Rosenheimer Str. 6-8, 83043 Bad Aibling, Germany · info@clinicum-stgeorg.de
Hormone Optimization
St. George Hospital runs a full male hormone panel before any prescription: total and free testosterone, SHBG, DHT, estradiol, DHEA-S, cortisol, thyroid and metabolic markers, drawn fasting in the morning and repeated when a single value could mislead. Where a deficiency matches your symptoms, we treat it with bioidentical testosterone and monitor hematocrit and PSA on a fixed schedule.
Sleep is shallower. The belly fat arrived without an invitation. You are quicker to snap at people you love. A testosterone test came back "low-normal" and the conversation ended there, or ended with a prescription and no plan for what comes after. Hormone assessment is one part of our men's health program, and it starts with a panel read by a physician.
From the mid-thirties, men produce gradually less testosterone, DHEA and growth hormone. The decline is slow in healthy men and faster with obesity, sleep apnea, type 2 diabetes, chronic illness and some medications. It is also happening across generations: a study of American men found serum testosterone falling from one birth cohort to the next, independent of age (Travison et al., Journal of Clinical Endocrinology and Metabolism, 2007). Fatigue, loss of muscle, abdominal fat, low mood, poor concentration and reduced libido are the symptoms; sometimes the cause is testosterone, sometimes it is the sleep apnea that lowered it.
Our program does not wait for a value to fall far below the reference range before looking, and it does not prescribe on a single value either. The panel below is drawn fasting in the morning, repeated if borderline, and read against your symptoms and your metabolic picture before a physician decides whether a hormone is the cause.
The program is supervised by Julian Douwes M.D. and Daniela Hudi M.D., with laboratory analysis through our laboratory and immune testing.
Men tend to file these symptoms under age, stress or work. Several of them are also the symptoms of depression, sleep apnea, hypothyroidism and iron overload, which is why the panel is wider than testosterone alone.
The panel evaluates production, transport, metabolism and the systems that interact with testosterone. It is drawn between 07:00 and 09:00, fasting, on day one, and the testosterone fraction is repeated on day two when the first value is borderline. Physiological measurements (body composition, sleep screening, fitness test) belong to functional diagnostics and are read together with the blood work in the functional medicine consultation.
From the results, the physician writes a plan that may include one or more of the components below. Testosterone is prescribed only for confirmed hypogonadism: symptoms plus a low morning testosterone on two occasions. The practical details of routes and monitoring are on the hormone therapy page.
Transdermal gel or injectable testosterone, dosed to bring the value into the mid-normal range and no higher. Hematocrit and PSA are checked at baseline, after three to six months and then yearly; the dose is adjusted on symptoms and values together.
Precursor hormones of the adrenal cascade. We replace DHEA only when DHEA-S is clearly low and symptoms fit; in older men without a deficiency the evidence that it helps is limited.
Where the panel shows hypothyroidism, levothyroxine or, in selected cases, a T4/T3 combination. Treating the thyroid first often changes what the testosterone values look like six weeks later.
Estradiol that is high relative to testosterone is addressed first through fat loss, zinc repletion and, where needed, a change in testosterone route or dose. Aromatase-inhibitor drugs are not used routinely in men because of their effect on bone.
Insulin sensitivity, sleep apnea treatment, resistance training, protein intake, vitamin D and magnesium. In some men these raise testosterone enough that replacement is not needed, which is the better outcome.
Testosterone therapy relieves symptoms in men with confirmed hypogonadism, and that evidence is strong. Without a clear deficiency it is limited: no trial shows better energy, cognition or longevity at normal or low-normal values.
The evidence that testosterone therapy relieves symptoms in men with confirmed hypogonadism is strong. In the Testosterone Trials, 790 men aged 65 and older with a serum testosterone below 275 ng/dL and symptoms received testosterone gel or placebo for one year. Treatment raised testosterone into the mid-normal range of young men and improved sexual activity, sexual desire and erectile function; the effect on walking distance was significant only when all participants were analyzed together (Snyder et al., New England Journal of Medicine, 2016). The Endocrine Society guideline builds on these and earlier trials: diagnose only with symptoms and two low morning values, treat with the aim of mid-normal levels, and monitor hematocrit and PSA (Bhasin et al., Journal of Clinical Endocrinology and Metabolism, 2018).
The evidence on cardiovascular safety is now strong. The TRAVERSE trial randomized men with hypogonadism and pre-existing or high cardiovascular risk to testosterone gel or placebo, with a mean follow-up of 33 months. A major adverse cardiac event occurred in 7.0% of the testosterone group and 7.3% of the placebo group, meeting the non-inferiority criterion. Atrial fibrillation, pulmonary embolism and acute kidney injury were more frequent with testosterone (Lincoff et al., New England Journal of Medicine, 2023). Those three findings are why we screen for arrhythmia, clotting risk and kidney function before prescribing.
The evidence for DHEA and for low-dose testosterone in men without clear deficiency is limited. A two-year placebo-controlled trial in elderly men found no physiologically relevant benefit of either on body composition, physical performance, insulin sensitivity or quality of life (Nair et al., New England Journal of Medicine, 2006).
What the evidence does not show: no trial has shown that testosterone therapy in men with normal or low-normal values improves energy, cognition or longevity.
Day one: fasting panel at 07:00 to 09:00, prostate examination, body composition and sleep screening. Day two: repeat testosterone if borderline, results discussion when the laboratory reports. If replacement is indicated it starts on the ward, so that the first response and any side effects are seen by a physician before you travel. At discharge you receive the prescription, the monitoring schedule (hematocrit and PSA at three to six months, then yearly) and a letter for your own physician.
Three articles from our journal go deeper: a medical guide to hormone replacement therapy for men, why the testosterone-to-estrogen balance matters, and progesterone in men.
Costs are individual: a package price plus individual add-ons. After a physician has reviewed your findings, you receive a written, itemized cost overview: a package price plus individual add-ons. Treatment is self-pay; the invoice is itemized in English with diagnoses and procedure descriptions for out-of-network review. See Costs and insurance and, for the video consultation before you travel, Information for international patients.
Related pages
The hub: hormones, prostate and urinary function assessed in one stay.
PSA, imaging and treatment options for benign enlargement and prostate cancer.
Frequency, urgency, nocturia and weak stream: how we find the cause.
Routes, doses, monitoring schedule and contraindications for bioidentical replacement.
Thyroid, adrenal and sex hormones in the longevity program, for men and women.
Used alongside hormone therapy when mitochondrial markers and energy are low.
The TRAVERSE trial followed men with hypogonadism and high cardiovascular risk for about three years and found that testosterone gel was non-inferior to placebo for major cardiac events. It also found more atrial fibrillation, pulmonary embolism and acute kidney injury in the testosterone group. We screen for these risks before and during therapy.
Endocrine guidelines require symptoms plus an unequivocally low morning total testosterone on at least two occasions, with free testosterone checked when SHBG is abnormal. A single low-normal value after a bad night is not a diagnosis. We repeat the sample on the ward under the same conditions before deciding.
Randomized trials to date have not shown that testosterone replacement at physiological doses causes prostate cancer, but it is not given to men with known prostate cancer, a PSA above 4 ng/mL, or an abnormal prostate examination. PSA and a digital examination are part of the baseline and of every follow-up.
Not necessarily. Testosterone suppresses your own production while you take it, so stopping needs a plan. Weight loss, sleep apnea treatment, resistance training and correcting thyroid or iron problems raise testosterone in some men enough to stop. We review the need at each follow-up rather than renewing by default.
Costs are individual: a package price plus individual add-ons. After a physician has reviewed your findings, you receive a written, itemized cost overview: a package price plus individual add-ons. Treatment is self-pay; the invoice is itemized in English with diagnoses and procedure descriptions for out-of-network review.
If you have a testosterone result already, send it with the time of day it was drawn and a short history. A physician reads it before the video consultation and tells you whether a repeat panel or a therapy is the next step.
The initial inquiry is free of charge. The International Office reviews your message and your case directly and gets back to you.
Munich Airport (MUC), about 60 minutes by car.
