BHRT for Men: Andropause & Low Testosterone

Written by Empire Medical Training Editorial Team

Medically reviewed by Betsy Greenleaf, DO Board-Certified OB/GYN & Urogynecologist; Empire Director of Anti-Aging

Updated June 2026 ·12 min read

BHRT for men applies the same principle as bioidentical hormone therapy in women: replacing what the body is no longer making with hormones that are molecularly identical to the ones it produces naturally. In men, the central question is almost always testosterone, and the clinical backdrop is andropause — the gradual, age-related decline that leaves a substantial share of midlife and older men symptomatic. This guide is part of Empire's broader bioidentical hormone replacement therapy resource and draws on Dr. Betsy Greenleaf's clinical teaching.

It is written for clinicians who want an accurate, practical overview of how male hormone optimization is reasoned through, not a treatment recommendation. Nothing here is a protocol or a substitute for individualized medical judgment, current labeling, and proper monitoring.

Andropause: testosterone decline in men

Unlike menopause, which arrives relatively abruptly as the ovaries fail, the male hormonal change is slow and progressive. Dr. Greenleaf describes a natural decline in testosterone in men with age, and the numbers make the scale of it clear: roughly 38 percent of men over age 45 experience hypogonadism, compared with only about 7 percent of men under 40. Because the decline is gradual, men often attribute the symptoms to ordinary aging, stress, or overwork rather than to a treatable hormonal shift.

Hormones are chemical messengers produced by the endocrine glands — in men, the testes are the primary source of testosterone, supported by signaling from the hypothalamus and pituitary. As that axis weakens with age, the downstream effects reach well beyond libido, because hormone receptors are distributed throughout the body. Andropause is therefore best understood not as a single symptom but as a systemic change, which is exactly why it is worth identifying and, when appropriate, treating.

Symptoms of low testosterone in men

The clinical picture of low testosterone in men is broad. Drawing directly from Dr. Greenleaf's teaching, low testosterone in men can present as reduced sex drive, difficulty with erections, low sperm count, fatigue and poor energy, decreased muscle mass, increased body fat, decreased bone density, and mood changes. No single symptom is diagnostic on its own; it is the pattern that prompts evaluation.

• Energy and vitality: persistent fatigue and a general loss of drive that does not resolve with rest.
• Libido and sexual function: reduced sex drive and erectile difficulty are among the most commonly reported complaints.
• Mood: low mood, irritability, and changes in motivation; declining estrogen and testosterone can also influence neurotransmitter activity affecting mood and cognition.
• Body composition: decreased muscle mass alongside increased body fat — a shift that can become self-reinforcing, since excess fat tissue aromatizes testosterone into estrogen.
• Bone and long-term health: decreased bone density, which raises osteoporosis and fracture risk over time.

It is worth noting that decreased estrogen in men — not only low testosterone — can itself present as increased body fat, decreased sex drive, fatigue, depression, and osteoporosis, a reminder that male hormone health is not a single-hormone story.

Diagnosis: lab evaluation

Low testosterone is diagnosed by pairing the clinical picture with laboratory data, never by labs in isolation. The foundational measurements are total and free testosterone, interpreted together because a normal total can still mask a low bioavailable fraction. From there, the workup widens to a broader hormone review and to ruling out other drivers of the same symptoms.

Fatigue, low libido, and low mood are not specific to testosterone deficiency. A careful clinician rules out other causes — thyroid dysfunction, adrenal and cortisol patterns, sleep apnea, depression, anemia, and medication effects — before attributing everything to andropause. Dr. Greenleaf's guiding principle is that labs are supportive factors compared against the patient's presentation and symptoms: you treat the patient, not the number. This guide intentionally avoids citing specific cutoffs, because thresholds vary by assay and population and meaningful interpretation belongs in the clinical encounter and the training, not on a general reference page.

Testosterone replacement

When deficiency is confirmed and contraindications are excluded, testosterone replacement is the cornerstone of BHRT for men. Bioidentical testosterone restores levels toward a normal physiologic range, with the goal of relieving the symptom cluster above — energy, libido, mood, body composition, and bone density — rather than chasing a supraphysiologic target. Testosterone notably tends to create a feeling of wellness and energy, which is part of why patients respond to it subjectively as well as on labs.

The same guardrails apply here as elsewhere in hormone therapy: start low, go slow, and titrate against symptoms and follow-up labs. Pushing levels too high carries its own consequences — excessive testosterone can cause cardiovascular risk, elevated hematocrit, acne and oily skin, baldness, mood changes and aggression, fluid retention, testicular atrophy, and suppression of the body's own testosterone production. For a deeper treatment of indications, formulations, and monitoring, see our dedicated overview of testosterone replacement therapy.

Other hormones in men

One of the most useful lessons from Dr. Greenleaf's hormone review is that hormones convert into one another, so male optimization is rarely about testosterone alone. Evaluating and balancing the wider endocrine picture is what separates competent care from simply “adding testosterone.”

• Estradiol balance: through aromatization, testosterone — and androstenedione — can convert into estrogen via the enzyme aromatase, and excess fat tissue accelerates this. Men need some estradiol for bone, mood, and libido, but an unfavorable shift toward high estradiol matters. When indicated, conversion can be modulated; aromatase inhibitors such as anastrozole, letrozole, or exemestane are options, and zinc, chrysin, and grapeseed extract are described as having anti-aromatase activity.
• DHEA: an upstream adrenal hormone that feeds into the testosterone and estrogen pathways. Low DHEA frequently appears alongside low testosterone on a full panel and is a common part of the assessment.
• Cortisol: chronic stress drives cortisol patterns that blunt the morning rise and steal resources from reproduction and repair. A flattened cortisol curve can mimic or compound low-testosterone symptoms, so the adrenal picture is worth assessing.
• Thyroid: thyroid hormone regulates metabolism, and untreated thyroid dysfunction produces fatigue, weight gain, and low mood that overlap heavily with andropause — another reason thyroid is reviewed before crediting symptoms to testosterone alone.

Delivery options & pellets

Bioidentical testosterone can be delivered by several routes, each with its own trade-offs in convenience and the stability of resulting levels. Many methods produce the familiar peaks and troughs of hormone levels between doses. Hormone pellets are designed to address that: small, tablet-like compounds placed under the skin that release hormone slowly over time, with high bioavailability, typically replaced every three to six months.

For men specifically, pellets offer convenience and steadier delivery, and andropausal men are among the populations for whom pellet therapy is considered. As with any route, the goal is physiologic restoration, careful monitoring of response, and attention to aromatization. The pellet insertion technique, the candidacy specifics, and the dosing reasoning are covered in depth in Empire's training; see our overview of hormone pellet therapy for the full picture.

Benefits of treatment

When BHRT for men is well selected and well managed, the benefits track the symptoms it treats. Patients frequently report improved energy and a restored sense of wellness, recovery of libido and sexual function, and better mood and motivation. Over a longer horizon, restoring testosterone toward a normal range supports muscle mass and body composition and helps protect bone density, countering the osteoporosis risk that accompanies decline.

These benefits are real but not automatic. They depend on accurate diagnosis, appropriate candidate selection, restraint in dosing, and attention to the whole hormonal picture — including keeping estradiol in a healthy range so that the gains are not undercut by aromatization. Dr. Greenleaf's experience underscores that the best outcomes come from matching treatment to symptoms and reassessing over time, not from a one-time fix.

Safety considerations

The reassuring headline from the data Dr. Greenleaf reviews is that medical complications in men related to hormone usage have generally been small — for myocardial infarction, prostate cancer, DVT, stroke, and total complications — in appropriately selected patients. That said, several safety domains define responsible male hormone care.

• Prostate: testosterone can stimulate prostate tissue, although the relationship between testosterone and prostate cancer is not fully understood. Active prostate cancer is a contraindication, men should be current on prostate screening, and the digital rectal exam should be normal before initiating therapy.
• Cardiovascular: testosterone can contribute to fluid retention, raise cholesterol, and add to heart disease risk, and severe heart disease is a contraindication. Cardiovascular status must be weighed before and during treatment.
• Polycythemia: testosterone can increase red blood cell count, so a high red blood cell count (elevated hematocrit) is a contraindication and a parameter to monitor on therapy.
• Fertility: exogenous testosterone suppresses the body's own production and can lower sperm count, causing reduced fertility — an essential conversation for any man who may wish to father children.
• Other contraindications: breast cancer, severe liver or kidney disease, and untreated sleep apnea (which testosterone can worsen). Therapy should be stopped if any contraindicated condition develops.

Candidacy & monitoring

The ideal candidate is a symptomatic, andropausal man with lab-confirmed deficiency and no contraindications — the patient whose history and labs agree. Men with osteoporosis or documented hypogonadism are also appropriate candidates. Patient history must be evaluated carefully: certain cardiac histories, untreated sleep apnea, an elevated red blood cell count, or active hormone-sensitive cancer move a man out of the candidate pool. Before initiation, patients should be up to date on recommended screenings — including prostate evaluation and colonoscopy — and have a normal digital rectal exam.

Monitoring is continuous, not a one-time check. Follow-up combines symptom review with labs to confirm response, keep testosterone in a physiologic range, watch hematocrit for polycythemia, and track estradiol so aromatization stays balanced. Health screening continues, and patients are followed for any change in condition. The specific cadence, target ranges, and titration logic are exactly the kind of individualized detail that belongs in structured training rather than a public summary — which is why dosing and protocols stay in Empire's course.

Provider training

Delivering BHRT for men well requires more than a prescription pad. A competent provider understands male hormone physiology, interprets total and free testosterone in context, rules out mimicking conditions, manages aromatization and estradiol balance, screens contraindications, and monitors over time — and, for those offering pellets, performs the insertion procedure safely. Empire's curriculum is built around that practical judgment, taught by Dr. Betsy Greenleaf and situated within the broader science of bioidentical hormone replacement therapy.