"A low number is a finding, not a diagnosis," says the Las Vegas longevity expert. "Sometimes the answer is testosterone therapy. Sometimes it is a sleep study. You cannot know which without looking."
Las Vegas, Nevada, United States, 4th Sep 2026 — A 49-year-old man returns a testosterone result of 340 ng/dL and has a decision to make. What Dr. John Spencer Ellis wants him to understand is that he does not yet have enough information to make it.
"A low number tells you the level. It does not tell you the cause," said the internationally recognized authority on men's health, longevity and human performance. "In medicine that is called a differential diagnosis, and low testosterone has one. Six things suppress it besides age. Knowing which apply to you is what turns a guess into a decision."
He is emphatic about what he is not saying.
"I am not telling men to avoid TRT. It is an FDA-approved therapy, it works, and the 2023 TRAVERSE trial of 5,246 men found it noninferior to placebo for major adverse cardiac events — which settled a decade-old cardiovascular controversy and led the FDA to remove the warning from testosterone labeling in 2025. For men who genuinely need it, it is excellent medicine. I am saying: work the differential first."
The six
1. Sleep. The most direct evidence in the field, and the most overlooked. A JAMA paper by Leproult and Van Cauter states plainly that the majority of the daily testosterone release in men occurs during sleep. The researchers restricted ten healthy young men to under five hours nightly for one week and measured significantly lower testosterone — a reduction commonly cited at 10 to 15 percent, in men in their twenties, from seven days.
"Extrapolate that to four years of six broken hours in a 50-year-old," said Dr. Ellis. "The paper's senior author called short sleep an endocrine disruptor. That is not rhetoric."
2. Obstructive sleep apnea, which is separately associated with reduced testosterone, is common in men over 40, is treatable, and is diagnosed in a fraction of the men who have it. "If you snore or wake unrefreshed, get screened. For some men that is the whole answer, and they will never find it by reading a supplement label."
3. Visceral fat. Abdominal adipose tissue contains aromatase, the enzyme that converts testosterone directly into estrogen. "This is the mechanism nobody explains. Belly fat does not accompany low testosterone. It produces it. And it produces a loop — cortisol drives the fat, the fat converts the testosterone, low testosterone removes the drive to train, and less training means more fat."
4. Alcohol, which suppresses production directly while fragmenting the sleep that generates most of it. Increased intake is repeatedly identified in the literature as a male-typical response to sustained stress, meaning it climbs quietly when self-monitoring is weakest.
5. Chronic stress. Cortisol and testosterone move inversely; sustained elevation of one suppresses the other.
6. Nutrition, training load and medications. Chronic energy deficit while training hard suppresses the entire hypothalamic-pituitary-gonadal axis, as does chronically low dietary fat. Excessive training volume without recovery lowers the testosterone-to-cortisol ratio. And opioids, glucocorticoids and several other drug classes suppress testosterone outright.
"That last one is a five-minute conversation with your physician that occasionally explains the entire result," said Dr. Ellis.
What the panel needs that most panels omit
Dr. Ellis flags a specific gap in direct-to-consumer testing.
"Ask for LH and FSH. Those two distinguish primary hypogonadism — the testes — from secondary, meaning the pituitary or hypothalamus. That distinction determines everything that follows, and it is routinely left off. A total testosterone number by itself is nearly uninterpretable."
He also stresses the draw conditions the Endocrine Society guideline actually specifies: two separate fasting morning draws, at least 48 hours apart, in a man with genuine symptoms, with the treatment threshold at 300 ng/dL.
"Testosterone peaks in the early morning and declines through the day. Food lowers it acutely. It varies day to day with sleep, illness and alcohol. One low afternoon reading is not a diagnosis — it is a data point collected badly."
His recommended panel: total and free testosterone, SHBG, LH and FSH, prolactin, estradiol, hematocrit, PSA, lipids, HbA1c, thyroid and vitamin D.
Why working the differential helps either way
Dr. Ellis argues this approach improves the outcome regardless of which direction it points.
"Correct the reversible factors for ninety days and retest under identical conditions. If the number rises, you were functionally suppressed — and you have avoided a therapy that suppresses fertility, is effectively permanent, and requires indefinite hematocrit and blood pressure monitoring.
"And if it does not rise, you are a better candidate than you were. You now have a well-characterized case with the confounders already removed. Your physician can act on that with far more confidence, and a man who starts TRT sleeping seven hours with lower visceral adiposity gets more out of it than one who starts while everything else is still working against him."
He names one exception. "If the number is markedly low, or LH and FSH indicate a pituitary issue, that is a prompt medical matter — not a ninety-day project. Take an abnormal result to a physician immediately."
The program
The Health, Longevity and Aesthetic Optimization Program for Men 40+ is a 90-day personalized engagement designed to execute this sequence properly: comprehensive intake covering sleep, stress load, alcohol intake and medications; bloodwork guidance alongside the client's own physician; a protocol across training, nutrition, sleep architecture and stress physiology, sequenced so sleep and alcohol stabilize before training load increases; and twelve weekly one-on-one coaching sessions.
"Ninety days is exactly long enough to abandon halfway with nobody noticing," said Dr. Ellis. "And a retest is worthless if the protocol was never actually run."
Dr. Ellis is a coach and educator, not a physician or endocrinologist. He does not diagnose, treat or prescribe, does not order or interpret laboratory tests, and does not prescribe, supply or advise on testosterone replacement therapy. Hypogonadism is a medical diagnosis and TRT is a prescription decision belonging entirely to a qualified physician. He holds no financial interest in any testing service, supplement or hormone therapy.
Program details are available at https://johnspencerellis.com
About Dr. John Spencer Ellis
Dr. John Spencer Ellis has been an award-winning health expert and entrepreneur since 1992. He is a Personal Trainer Hall of Fame inductee, named among the Top 100 Most Influential Personal Trainers of All Time, and a Quilly Award winner. He holds two bachelor's degrees, an MBA and a doctorate in education, plus 14 months of doctoral-level naturopathic health education study, alongside 15 professional certifications, a license in radiological technology, and a medical assisting certification with phlebotomy.
His programs have been used by Cirque du Soleil, the Army, Navy, Air Force, Marines, U.S. Secret Service and Coast Guard. His work has been featured on Oprah Radio, ABC, NBC, CBS, PBS, FOX and ESPN.
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