What does it actually look like to optimize hormones the right way? Not just prescribing testosterone and calling it a day — but addressing the full picture of a patient’s health. This case study walks through one man’s journey from debilitating fatigue and low libido to renewed energy, strength, and cardiovascular protection.
The Patient: Where We Started
A 47-year-old male came in with a familiar set of complaints: persistent fatigue, difficulty making gains in the gym despite consistent effort, low libido, and a strong desire for cardiovascular disease (CVD) prevention. He wasn’t just looking for a quick fix, he was looking for long-term hormone optimization done right.
His relevant history painted a more complex picture. He had been cycling on his bike five days a week with long-distance rides but had never incorporated strength training. He had a significant family history of CVD (his father had a myocardial infarction, his paternal grandfather died of one at 68) and high blood pressure and cholesterol ran throughout the family. He’d been on blood pressure medication since age 31 and had been dealing with high chronic stress since his mid-30s. His job was sedentary. He’d tried supplements like tongkat ali and TestoPlex before seeking care, but neither provided any meaningful benefit for hormone support.
This was not a straightforward “low T, give testosterone” case. This was a patient with multiple overlapping systems in need of support.
Baseline Lab Work: What the Numbers Revealed
Initial labs showed a number of notable findings:
His fasting blood sugar was elevated at 100, flagging early blood sugar dysregulation. eGFR came in at 76 — low-normal, worth watching. Iron markers were high (iron 212 H, iron saturation 67 H) with a normal ferritin of 118, which pointed toward a possible hereditary hemochromatosis carrier status — later confirmed as the c.845G>A heterozygous variant. WBC was low at 3.2, and testosterone levels were clearly suboptimal: total testosterone 290.1, free testosterone 8.3, with SHBG at 17.2 and estradiol at 23.5.
Additional testing told the rest of the story:
- Positive hydrogen-dominant SIBO on breath testing
- High/normal total cortisol with low free cortisol on DUTCH testing — classic HPA axis dysfunction pattern
- Normal DHEA-s and thyroid labs
- Insufficiency dysbiosis (low lactobacillus, bifidobacterium, and akkermansia) with a mild-to-moderate gut immune response
- Pituitary hormones WNL, confirming primary hypogonadism rather than a secondary cause
- Calcium Score = 0, which was reassuring, but a CT angiogram was recommended given his strong family history
Key Findings Summary
Pulling it all together, the key clinical findings were:
- High fasting glucose
- Low/normal eGFR
- High iron markers with normal ferritin → hereditary hemochromatosis carrier
- Low WBC
- Hydrogen-dominant SIBO
- Insufficiency dysbiosis and gut immune response
- HPA axis dysfunction
- Hypogonadism
- Normal thyroid and pituitary hormones
- Calcium Score = 0
This patient wasn’t just dealing with low testosterone. He had gut dysfunction, cortisol dysregulation, blood sugar concerns, a genetic iron storage issue, and serious cardiovascular risk factors that needed to be addressed alongside hormone therapy,not ignored.
Phase One Treatment Plan
Rather than jumping straight to testosterone, the initial plan prioritized gut health first and built a foundation from there:
Gut first: Antimicrobial SIBO treatment and supportive gut therapy were implemented before starting hormone support. Gut dysfunction can significantly impair hormone metabolism and absorption — this step was non-negotiable.
Iron and hemochromatosis counseling: The patient was educated about his carrier status and counseled on reducing supplemental sources of iron to protect his organs long-term.
TRT initiated: Androgel 50 mg daily was prescribed as the starting point for testosterone support.
Adrenal and stress support: Given the HPA axis dysfunction, adaptogens were added to support cortisol dysregulation. Stress management was approached with a practical “one goal per month” framework to avoid overwhelming the patient.
CVD risk workup expanded: Additional CVD biomarkers were ordered, and a CT angiogram was recommended for a more complete cardiovascular picture given the family history.
Exercise prescription: Three days of strength training per week was recommended alongside NEAT (non-exercise activity thermogenesis) throughout the workday to counteract the sedentary job.
CGM: A continuous glucose monitor was added to help track and improve blood sugar patterns in real time.
Follow-Up Labs: Round One (With Androgel)
The initial results on topical testosterone were underwhelming:
| Marker | Result |
| Total Testosterone | 341.8 |
| Free Testosterone | 8.5 |
| SHBG | 17.3 |
While the SIBO breath test had normalized and eGFR, cystatin C, and BUN had improved, the testosterone numbers barely budged. Total T had risen only modestly, free T was nearly unchanged, and the patient wasn’t reporting meaningful symptom improvement. The CT angiogram revealed moderate soft plaque in areas of concern — an important finding that would shape the cardiovascular arm of his treatment going forward.
Topical Androgel simply wasn’t absorbing well enough for this patient.
Phase Two Treatment Plan: Adjusting Course
When the data doesn’t support the intervention, you consider changing the intervention. The plan was updated:
Switched to daily low-dose TRT injections: 12 mg injected daily (84 mg/week) to mimic the body’s natural diurnal testosterone production pattern. This approach avoids the peaks and troughs of weekly injections and tends to keep estradiol and hematocrit more stable. While traditionally administered 1-2 times weekly in larger doses, I have found low dose daily injections also work well for some patients, especially with a low SHBG.
Environmental toxin testing: Given that the patient wasn’t eating organic, lived adjacent to a golf course (pesticide exposure risk), and had a history of mold in his home, a full environmental toxin panel was ordered. This is often an underappreciated contributor to hormonal and metabolic dysfunction.
Added creatine and short-chain fatty acids (SCFA): Creatine for muscle support and SCFA for gut microbiome recovery.
CVD intervention: After counseling on risk and options, the patient chose to start low-dose Crestor (rosuvastatin) to address the moderate soft plaque findings on his CT angiogram.
Follow-Up Labs: Round Two (With Daily Injection TRT)
The difference was dramatic:
| Marker | Result |
| Total Testosterone | 760.4 |
| Free Testosterone | 22.5 H |
| SHBG | 12.1 L |
| WBC | 3.9 |
| RBC | 5.43 |
| Hgb | 16.8 |
| Hct | 50.6 |
| Platelets | 207 |
| PSA | 1.4 |
| Estradiol | 28.3 |
Total testosterone more than doubled. Free testosterone reached therapeutic levels. WBC improved. Estradiol remained stable and within a healthy range. Hematocrit was climbing slightly (50.6) and was being monitored closely, an expected response to TRT that warrants ongoing attention. Cortisol balance had also normalized on follow-up DUTCH testing.
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Clinical Outcomes: Where He Landed
At the 3 and 6 month follow-ups, the picture was clear: this approach worked.
- Improved libido — one of his chief complaints, now resolved
- Better energy and strength — gym performance finally moving in the right direction
- Patient was very happy with his response to testosterone injections
- RBC and estradiol remained steady across both follow-up labs
- Strength training, NEAT, and grounding had become a sustainable daily routine
- Cholesterol and CVD risk markers normalized
- Gut health restored — SIBO treated, iron normalized, dysbiosis imbalances improved
- Environmental burdens identified and addressed
- CGM levels improved alongside the full treatment plan implementation
What This Case Teaches Us
This case is a perfect example of why testosterone therapy alone is rarely the complete answer, why it deserves to be individualized and why thorough, systems-based evaluation matters before and during treatment.
A few key takeaways:
Delivery method matters. This patient had minimal response to topical Androgel but responded exceptionally well to daily low-dose injections. Not every patient absorbs topical testosterone adequately, and lab work plus symptom monitoring should guide any decision to stay the course or pivot.
Treat the gut before the hormones. Gut dysfunction affects hormone metabolism, absorption, and overall inflammation. Clearing the SIBO first created a better environment for the TRT to work.
Don’t ignore cardiovascular risk. Family history is a major flag. The CT angiogram finding of moderate soft plaque would have gone undetected without proactive testing and the decision to add low-dose statin therapy was an individualized decision made with the patient and well-supported by the data.
Genetics inform the plan. Identifying the hemochromatosis carrier variant allowed for targeted counseling on iron sources, something that could potentially have led to other health issues being unaddressed.The full picture matters. Stress, sleep, environmental toxins, exercise prescription, blood sugar monitoring, all of these played a role in this patient’s outcomes. Hormone optimization doesn’t happen in a vacuum.
