- A low result is evidence whose value depends on how it was obtained, whether it repeats, and what symptoms accompany it; the conversation starts with those questions, not the number.
- Testicular, pituitary, medication, prior androgen, illness, sleep, and obesity causes all produce the same number by different mechanisms, and each changes the urgency, workup, fertility implications, and choices.
- Fertility is asked before anything else is decided, because prescription testosterone can switch off sperm production and a normal blood level says nothing about the semen.
- If treatment is chosen, the formulation is a tradeoff, the target range is Dr. Shusterman's practice rather than a rule, and monitoring goes on the calendar before the first dose because the monitoring is the treatment.
- A refill is a renewed decision; every six months or so the question is whether the reasoning still holds for this man, now.
The number is where I begin, not where I start
The result usually reaches a man before I do, flagged red in a portal, and it feels like the answer to everything he has struggled to name. My opening questions are about how the value came to exist, not the value itself: the hour the blood was drawn, whether anyone repeated it, what he hoped it would explain. Then I ask what has shifted in his sleep, weight, medicines, and life. A lab result is genuine evidence, but its worth depends on how it was obtained, whether it holds up on repeat, and which symptoms travel with it. The rest of the body still has a say.
Cause first, children before anything else
A testicular disorder, a pituitary disorder, a medication, earlier androgen use, illness, disrupted sleep, and obesity can each generate the same low value by a different mechanism, and each carries its own urgency, work-up, fertility implications, and options. Before any decision I ask about children, present and possible, because prescription testosterone can shut down sperm production even while the blood level reads normal, and that level tells you nothing about the semen. I also ask what he really wants changed: not "optimized," but a function he can name and we can follow.
Diagnosis before optimization is not a way of refusing treatment. It is what makes treatment defensible when treating is the right call.
When we do treat
We choose a formulation together as a set of tradeoffs, not a leaderboard. He learns the range I target and that it reflects my practice, not a rule. Monitoring is scheduled before the first dose, because the monitoring is the treatment rather than paperwork bolted onto it. He also hears that therapy may be long-term and that recovery, should he stop, comes with no promised date.
Roughly every six months, in my practice, we meet again to check whether the benefit he named persists, how his hematocrit, blood pressure, prostate, sleep, and mood are doing, whether his fertility plans have moved, and whether the label or the evidence has changed. A refill is a decision made again, not the absence of one.
One question, every time
This is how I actually work, and it does not steer every man toward the same product or even toward treatment. Some men I treat for years without regret; others I never start; some stop, and a few of those return. Each time the question is identical: does the reasoning still hold for this man, now? A testosterone consult exists not to convert a lab value into an identity but to convert it into the start of a careful investigation.
Common questions
My lab portal flagged my testosterone as low. Does that mean I have low T?
Not on its own. A single flagged value is evidence whose worth depends on when the blood was drawn, whether it has been repeated, and which symptoms go with it. Before I treat the number as meaningful, I ask what has shifted in sleep, weight, medicines, and life, and I look for a cause, since several different mechanisms produce the same result.
Is 'diagnosis before optimization' just a way of saying no to TRT?
No. The phrase is not an argument against treatment; it is what makes treatment defensible when treatment is right. I treat some men for years without regret, never start others, and watch some stop and later return. Confirming the number, locating the cause, asking about fertility, and naming a function to watch is the sequence that lets me say yes with confidence when yes is the answer.
What does ongoing TRT care look like in your practice?
Roughly every six months we sit down together. I want to know whether the benefit he named persists, how his hematocrit, blood pressure, prostate, sleep, and mood are doing, whether his fertility plans have moved, and whether the label or the evidence has changed. Monitoring is scheduled before the first dose, and each refill is a decision made again rather than the absence of one.