Such patients have also been shown to have mild anaemia, low bone mineral density (BMD) in the arms and ribs, and increased adiposity when compared with eugonadal type 2 diabetics (44,45). There is no relation between the degree of hyperglycaemia and testosterone concentration (40,43). Low testosterone concentrations are known to occur in association with type 2 diabetes. Data from the MMAS have demonstrated that there is a strong, positive relationship between HDL and testosterone in men with cardiovascular disease (low total or free testosterone correlates with low HDL cholesterol) (31). The relationship between testosterone and HDL is confounded by the fact that both HDL and testosterone are inversely related to BMI.
Even the sexual symptoms can be due to many other conditions, including vascular disease, chronic alcohol use, and depressive disorders. Their data support the idea that "the decline in serum T with male ageing is a non-specific effect of the common co-morbidities that accumulate during ageing" (5). One small study investigated this question by looking at groups of men across different age groups who were in "very good or excellent health" (5).
Adam S. Baumgarten, M.D., assistant professor in the University of Alabama at Birmingham Department of Urology, shares insights on the causes, symptoms and treatment options for low testosterone in men. Low testosterone, or hypogonadism, in men can often go unnoticed without an understanding of the symptoms and causes. Modulating these enzymes may therefore impact the levels of testosterone and estrogens circulating in the body. For instance, high-intensity interval training has been found to increase free testosterone in older, sedentary men10 as well as masters athletes.11 In addition, a 2022 systematic review found that exercise training of any intensity increased basal levels of testosterone in older adults.12Studies also suggest that alcohol consumption may reduce circulating concentrations of total testosterone.13 In the following video, IFM educator Mark Holthouse, MD, FAAFP, IFMCP, discusses the functional medicine approach to optimizing testosterone levels naturally. An age-related guideline for referral if PSA levels exceed 2.5 ng/ml in males under 60 years or 4 ng/ml in men over 60 years is often used (97). It is important to mention that the occurrence of prostate cancer in patients with type 2 diabetes is lower than that seen in the general population.
Figure 2 illustrates the main hypogonadal-obesity-insulin resistance connections and also includes other factors such as TNF-α (an adipokine), which is elevated in obese males (42,51,57,58). Thus, adiposity potentially leads to hypogonadism, which itself promotes further adiposity. The estradiol produced by aromatisation also provides negative feedback on the HPG axis, further reducing testosterone. Thus, the degree of hypogonadism is positively correlated to the degree of obesity in obese men (51,52). This is not a rigid rule as BMI does not directly measure body fat, so athletes, for example, may have high BMIs even though they are not overweight (49). Utilising data from the NHANES III survey, it was found that men in the lowest free testosterone tertile were four times as likely to have diabetes as those in the highest free testosterone tertile (47). Interestingly, low testosterone concentrations predict the development of type 2 diabetes.
It’s natural to be concerned about lower testosterone levels. Some research also suggests that high levels of prenatal testosterone levels may be linked to autism in children. A 2018 study in 60 children found that testosterone levels in the womb may also affect how your right and left brain function. Testosterone levels may start to decline after age 30 years in males and between ages 45 and 55 years in females. When most boys transition through puberty, they can credit an increase in the male sex hormone testosterone for their lower voices, hairier bodies, amplified sex drive, sperm production, and more - just in time to make them feel gangly and awkward. At UAB, men who require testosterone replacement therapy can access a full range of services through the Men’s Health Clinic, which offers various treatment options including injections, gels or creams, subcutaneous pellets, and oral medications.
However, when given as a transdermal gel to hypogonadal men, there is either no significant change or only minor changes in HDL levels (28,31,32). Vascular tissue (including endothelium and vascular smooth muscle cells) contains androgen receptors, so it is to be expected that testosterone (or its metabolite, oestrogen) is likely to affect the cardiovascular system. There appears to be no consistent evidence that the prevalence of hypogonadism differs between racial and ethnic groups (24–26). Likewise, measurement of symptoms alone is not reliable, as hypogonadal symptoms are non-specific. In the Baltimore Longitudinal Study on Ageing, it was found that 19% of men over 60 years had low testosterone. In general, however, the term mixed hypogonadism is not used in clinical practice in the US and is considered part of secondary hypogonadism. This is found in men with sickle-cell disease, thalassemia, alcoholism, glucocorticoid treatment, and in older men (2).
Certain medications and illnesses can also affect the hypothalamic–pituitary system resulting in hypogonadism (17). Primary hypogonadism is caused by testicular failure and is characterised by low serum testosterone and high LH and FSH concentrations. Apart from the vital role that it plays during puberty in stimulating the development of male secondary sexual characteristics and their maintenance thereafter, it has multiple other physiological effects. The Sertoli cells of the testes, in addition to stimulating spermatogenesis, also secrete the glycoprotein hormone inhibin, which provides negative feedback to the pituitary, inhibiting the secretion of FSH (11). Only 1–2% of testosterone circulates free in the blood; the remaining 98–99% is bound to albumin (40–50%) and to sex hormone binding globulin (SHBG) (50–60%).

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