Two things change at once in this decade, and they get treated as one thing. Hormonal decline becomes measurable — testosterone falls roughly 1% a year while SHBG rises at a similar rate, so the usable fraction falls faster than the total. Separately, cardiovascular and metabolic risk begins to accumulate at a rate that will determine far more about the next thirty years than any hormone value.
The hormone question gets nearly all the attention, and it is the one with an entire industry attached. The cardiovascular and metabolic question carries more weight in the outcome data. A useful approach for a man over 40 has to handle both, and has to keep them in proportion.
The Verdict
The biomarker set that matters in this decade
Roughly 20 markers, split between the hormone picture and the risk picture. A standard annual physical covers perhaps half of them.
| Marker | Range or target | Why it matters here |
|---|---|---|
| Total testosterone | 300–1,000 ng/dL; thresholds of 300 (AUA) or 264 (Endocrine Society) define low | Falls roughly 1% a year from the thirties. Draw before 10am on two separate days — a single afternoon draw can read 20–25% lower |
| Free testosterone, calculated | 5–21 ng/dL (50–210 pg/mL); under about 6.5 ng/dL is commonly treated as low | The fraction that reaches the receptor, and the number that most often explains symptoms when total looks fine |
| SHBG | 10–57 nmol/L | Rises about 1% a year after 40. This is why free testosterone falls faster than total, and why a normal total can be misleading |
| LH and FSH | LH 1.7–8.6 IU/L; FSH 1.5–12.4 IU/L | Separates testicular from pituitary causes. Low LH with low testosterone is where the reversible causes live |
| Estradiol, sensitive LC/MS assay | 10–40 pg/mL in men | Order the sensitive assay by name. The standard immunoassay is validated at female concentrations and misreads male levels |
| PSA | Under 4.0 ng/mL; under 2.5 if under 50 | Baseline before any hormone therapy decision, then rechecked. A rise over 1.4 ng/mL in a year warrants urology input |
| Hematocrit, via CBC | 38.3–48.6% | The main safety lab on testosterone therapy. Above roughly 54%, most prescribers reduce the dose or pause |
| ApoB | Under 80 mg/dL for average risk | Counts atherogenic particles rather than the cholesterol they carry. The better cardiovascular marker, and rarely ordered by default |
| Lp(a), once in a lifetime | Under 75 nmol/L (about 30 mg/dL) | Genetically set. Identifies inherited risk in roughly one in five people that no intervention on this page will move |
| Fasting insulin and HbA1c | Fasting insulin under about 8 uIU/mL; HbA1c under 5.7% | Insulin resistance drives visceral fat, which raises aromatase activity, which lowers testosterone. The loop runs both ways |
| Full thyroid — TSH, free T4, free T3 | TSH roughly 0.4–4.0 mIU/L | Hypothyroidism produces the entire low-testosterone symptom set without moving testosterone much |
| Ferritin and transferrin saturation | Ferritin 30–300 ng/mL; saturation under 45% | High values screen for hemochromatosis, an uncommon but genuinely reversible cause of secondary hypogonadism |
| Prolactin | Under about 15 ng/mL | Elevated prolactin with low LH raises the question of a pituitary lesion. This is why low testosterone is not a prescription on its own |
| Home blood pressure | Under 120/80 mmHg | The most treatable major risk factor in this decade, and commonly undiagnosed |
Free testosterone is the entry worth understanding properly. Because SHBG climbs with age, a man can hold a flat total testosterone for fifteen years while the fraction reaching his tissues falls by a third. Calculated free testosterone — derived from total, SHBG and albumin — is more reproducible than most direct free-testosterone assays and is what a competent panel reports.
Interventions ranked by leverage
| Intervention | Leverage | Why it ranks here |
|---|---|---|
| Screen and treat sleep apnea | Very high | Untreated apnea suppresses the overnight LH pulses that drive testosterone production, and testosterone therapy can worsen it. Treating apnea can raise levels with no prescription |
| Resistance training, 2–3 sessions a week | Very high | Preserves the lean mass that declines from the thirties onward and improves insulin sensitivity, which reduces aromatization of testosterone to estradiol |
| Blood pressure control | Very high | Around half of adults with elevated blood pressure do not know. A home cuff costs under $50 and identifies the most treatable cardiovascular and cognitive risk factor |
| Reduce visceral fat | High | Adipose aromatase converts testosterone to estradiol, and the resulting estradiol suppresses LH. Roughly 10% weight loss has been associated with a meaningful rise in total testosterone |
| ApoB reduction where elevated | High | Cardiovascular events are the dominant cause of death in this decade. ApoB responds to diet, weight, exercise and, where indicated, medication |
| Medication review | High where it applies | Opioids, long-term glucocorticoids, some antifungals and finasteride each affect testosterone or the symptoms attributed to it. Frequently the whole explanation |
| Sleep duration and alcohol reduction | Moderate to high | One week of five-hour nights reduced daytime testosterone by 10–15% in healthy young men in a controlled study. Alcohol adds direct testicular effects |
| Testosterone therapy where genuinely indicated | High for the right man, low for the wrong one | Effective for sexual symptoms, bone density, lean mass and mood. Suppresses fertility, requires lifelong monitoring, and treats none of the causes above |
| Supplements marketed as testosterone boosters | Low | Correcting a measured vitamin D deficiency produces a small rise in deficient men. Most other products in this category do not have supporting evidence at consumer doses |
Sleep apnea sits at the top for a specific reason. The symptom overlap with low testosterone is close to total — daytime fatigue, low mood, poor concentration, weight gain, reduced libido — the condition directly suppresses overnight testosterone production, and testosterone therapy can worsen it if untreated. Any man who snores, carries weight around the neck and waist, or wakes unrefreshed should be screened before hormones enter the conversation.
What to rule out before hormone therapy
Low testosterone in a man over 40 is usually secondary, meaning the pituitary signal is down rather than the testes failing. That is where the reversible causes live, and LH on the panel is what tells you which situation you are in.
- Obstructive sleep apnea. Screen with a home sleep test if there is snoring, witnessed apneas or daytime sleepiness.
- Excess visceral fat. Aromatase in adipose tissue converts testosterone to estradiol, and the estradiol suppresses LH.
- Opioids and long-term glucocorticoids. Both suppress the axis, often entirely accounting for the picture.
- Thyroid disease. Produces the full symptom set without moving testosterone much.
- Prolactin excess. Check prolactin, particularly with low LH or a very low total testosterone.
- Iron overload. Ferritin and transferrin saturation screen for hemochromatosis.
- Heavy alcohol use and chronic short sleep. Both measurable, both reversible.
- Prior anabolic steroid or SARM use. Disclose it. The recovery protocol differs and the baseline is not interpretable without that history.
Platform options
Two categories. Diagnostic platforms give data and leave interpretation to you or your own physician. Physician-led programs include a clinician who manages care and can prescribe. Both lists are alphabetical; ordering carries no editorial meaning.
Diagnostic-only platforms, alphabetically
| Platform | Price | What you get | What it does not include |
|---|---|---|---|
| Function Health | ~$499/yr membership | 100+ biomarkers with retesting built into the year | No clinician manages care; confirm hormone markers are included at the tier you buy |
| InsideTracker | ~$249–$589 per test | Pay per test with a recommendation engine, no membership | Narrower base panel at the entry tier |
| Superpower | ~$499/yr membership | 100+ biomarkers presented through a consumer app | Same structural limit — interpretation and any prescription are elsewhere |
Physician-led programs, alphabetically
| Program | Price | Model | What differentiates it |
|---|---|---|---|
| Fountain Life | $19,500+/yr | In-person concierge with imaging and a broad diagnostic panel | Screening breadth and clinic access; the highest price and time cost here |
| Hone Health | ~$540–$2,640/yr | Telehealth hormone care with at-home collection | The lowest entry price among these; hormone-focused scope |
| Lifeforce | ~$1,900/yr | Telehealth optimization with a bundled panel and scheduled retests | Hormones read inside a broader panel |
| Marek Health | $2,500–$6,000/yr | Telehealth with an a la carte lab menu and hormone depth | Wide lab menu; cost scales with how much you order |
| Maximus | ~$1,800–$3,600/yr plus labs | Telehealth hormone protocols including a SERM-first pathway | Relevant where fertility preservation is a priority; labs generally billed separately |
| Opt Health | ~$3,000/yr | Telehealth optimization, physician-led, with scheduled reassessment | Hormones read inside a broader panel |
How to pick
- Start with your existing physician. Most of the panel is orderable and often covered when symptoms are documented. Ask for free testosterone, SHBG, ApoB and a one-time Lp(a) by name.
- If you want breadth and will interpret it yourself, a diagnostic platform gives a wider panel and a retest cadence at a lower price than any clinician-inclusive option.
- If fertility is a live concern, that narrows the field considerably. A SERM-first or hCG-inclusive pathway is a different conversation from testosterone, and not every program offers it.
- If you want labs, interpretation and prescribing in one place, a telehealth physician-led program consolidates three relationships into one. Compare the baseline panel contents and the retest cadence, not the headline fee.
- Choose in-person concierge only if imaging breadth and clinic access are what you are buying, and the cost and travel are genuinely available.
- Confirm you can leave. Record portability and outside-pharmacy prescribing determine what switching later costs you.
What men in this decade most commonly get wrong
- Testing total testosterone alone. Without SHBG, the most common pattern in this age group is invisible.
- Drawing at the wrong time. An afternoon draw can read 20–25% below a morning one in the same man, and a single draw is not a diagnosis.
- Skipping the sleep apnea screen. Common, directly suppressive, and treatable without a prescription.
- Treating the hormone and ignoring ApoB and blood pressure. The two markers that carry the most mortality weight in this decade get the least attention.
- Starting therapy without asking about fertility. The one decision here that cannot be revisited later.
- Chasing a target number rather than a symptom response. There is no consensus optimal level, and pushing above the reference range raises hematocrit without a matching benefit.
- Taking an aromatase inhibitor by default. Men need estradiol for bone, libido and mood. Suppressing it to treat a number from a non-sensitive assay causes its own problems.
Realistic budget
| Spend | What it buys | What you actually get |
|---|---|---|
| $0–$200 one-off | Home blood-pressure cuff, gym access or basic equipment | The highest return per dollar at any budget in this decade |
| $0–$300/yr | A baseline panel through primary care, with free testosterone, SHBG, ApoB and Lp(a) requested by name | Most of the panel above, often covered when symptoms are documented |
| $250–$600/yr | A direct-to-consumer broad panel with a retest | Breadth and a trend line, with interpretation left to you |
| $540–$6,000/yr | A telehealth physician-led program with scheduled retesting and prescribing | Labs, interpretation and prescriptions in one place. The range reflects scope, not quality |
| $30–$100/mo on top | Generic injectable testosterone, if therapy is indicated | Almost never included in an advertised membership price |
| $19,500+/yr | In-person concierge with imaging | Screening breadth and clinic access, at the highest cost and time commitment |
See a physician rather than any subscription program for total testosterone under 150 ng/dL, visual field changes or new persistent headaches, nipple discharge, testicular pain or shrinkage, an abnormal baseline PSA, or chest pain and breathlessness on exertion. Each points at something a hormone prescription would obscure rather than treat.
Frequently Asked Questions
What should men over 40 actually test?
Total and free testosterone with SHBG, LH, FSH, sensitive estradiol, prolactin and PSA for the hormone picture. ApoB, a one-time Lp(a) and home blood pressure for cardiovascular risk. Fasting insulin and HbA1c for metabolic drift. A full thyroid panel, ferritin with transferrin saturation, and a CBC for the conditions that mimic low testosterone. Roughly 20 markers. Standard annual physicals cover perhaps half.
Should men over 40 start testosterone therapy?
Only with symptoms plus two low early-morning draws on separate days, and only after working through the reversible causes: sleep apnea, excess visceral fat, opioids, long-term glucocorticoids, heavy alcohol use, thyroid disease, iron overload and prolactin excess. Several of these are correctable, and correcting them can move levels enough that lifelong therapy stops being the question. Starting therapy suppresses your own production, which is the reason the sequence matters.
Which platforms should men over 40 consider?
For diagnostics without a clinician, the options reviewed here are, alphabetically, Function Health, InsideTracker and Superpower. For a physician who manages care and can prescribe, the programs reviewed here are, alphabetically, Fountain Life, Hone Health, Lifeforce, Marek Health, Maximus and Opt Health, ranging from roughly $540 to $19,500 a year. They differ in panel breadth, prescription pathway, retest cadence, whether labs are bundled, and price. Each is reviewed against the same rubric.
Why does my testosterone read normal when I have every symptom?
Most often because SHBG was never measured. Roughly 98% of circulating testosterone is bound and cannot act on tissue, and SHBG rises about 1% a year after 40. A man at 540 ng/dL total with SHBG of 62 nmol/L can calculate to a free testosterone below the threshold most clinicians treat as low. Total alone cannot show that. The other common explanations are thyroid disease, iron deficiency, sleep apnea and depression, all of which produce the same symptoms at any testosterone level.
What does the whole thing cost in a year?
Under $500 covers a blood-pressure cuff, gym access and a baseline panel through primary care. A direct-to-consumer broad panel with a retest runs $250 to $600. Telehealth physician-led programs run roughly $540 to $6,000 a year depending on scope, with medication almost always separate — generic injectable testosterone is $30 to $100 a month. In-person concierge with imaging starts around $19,500. The cost driver is whether a clinician is included and how often you retest, not biomarker count.
Is testosterone therapy safe for the heart?
Better established than it was, and not fully settled. The TRAVERSE trial, published in 2023, randomized roughly 5,200 middle-aged and older men with hypogonadism and cardiovascular risk to transdermal testosterone or placebo and found no increase in major adverse cardiac events. It did find higher rates of pulmonary embolism, atrial fibrillation and acute kidney injury on testosterone. Therapy also requires baseline and ongoing hematocrit and PSA monitoring, and is not appropriate with several specific contraindications.
What do men in this decade most commonly get wrong?
Testing total testosterone alone, getting a normal number, and stopping. After that: skipping the sleep apnea screen, which is both common and directly suppressive; treating the hormone while ignoring ApoB and blood pressure, which carry far more mortality weight in this decade; and starting therapy without asking about fertility, which is the one decision on the list that cannot be revisited later.
Related
- Men's health hub — the full hormone and TRT section
- Signs of low testosterone — which symptoms actually track the numbers
- Free vs total testosterone — how SHBG changes the answer
- TRT clinics compared — six physician-led programs on one rubric
- Doctor-led options — every physician-supervised platform on one rubric