Injectable testosterone suppresses natural production, causing infertility. New protocols use shorter-half-life oral/topical testosterone combined with enclomiphene (which blocks estrogen feedback) to increase T-levels while maintaining the body's own production, making it a viable option for younger men concerned about fertility.

Androgen deprivation therapy induces metabolic syndrome-like effects, increasing cardiovascular risk. It is the medical oncologist's responsibility to perform a baseline CV risk assessment using tools like the STAMP questions and to engage cardiology partners when needed for risk mitigation.

Creatine helps normalize testosterone's conversion pathway, shifting it toward DHT and away from estrogen. For individuals with low 5-alpha reductase activity, it restores a natural balance rather than creating a supraphysiological state that could accelerate hair loss.

Shifting the view of prostate cancer from "androgen-driven" to "androgen receptor-driven" provides a new framework. In curative settings, after the androgen receptor is targeted for a defined period, restoring testosterone is seen as logical to improve patient quality of life once the cancer is destroyed.

Transdermal estradiol is gaining renewed attention as an ADT option. Recent trials show it is non-inferior to standard LHRH analogs, offering a different side effect profile. This allows clinicians to trade side effects like hot flashes for gynecomastia, enabling more personalized treatment decisions.

Patients can successfully request hormone tests by describing subjective declines in energy, focus, or athletic performance compared to their past selves. This provides the necessary clinical justification for the lab work without requiring a pre-existing diagnosis.

The body has different estrogens: E1 (pro-inflammatory) and E2 (protective). Current breast cancer therapies are blunt instruments, blocking both types. This indiscriminate blocking contributes to negative side effects like cardiometabolic dysfunction, highlighting a need for more targeted future treatments.

Instead of relying on supplements, performance medicine uses FDA-approved drugs off-label to optimize health. The predicted stack includes testosterone (muscle), tirzepatide (fat loss), tesamorelin (recovery/sleep), tadalafil (blood flow), and oxytocin (stress), each drastically outperforming its supplement counterpart for a specific health goal.

When addressing hormone imbalances, start at the base of the "hormone pyramid." Optimizing foundational hormones like cortisol (stress) and insulin (blood sugar) is essential, as they directly impact thyroid function and sex hormones like estrogen and testosterone.