Normal testosterone levels but feeling awful: what TRT creators get wrong

What did @jeremygoodmanmd actually say?

The claim here is straightforward: a normal total testosterone reading does not mean your hormones are fine. He rattled off five alternative culprits, including low free testosterone, elevated prolactin, elevated estrogen, insulin resistance, and thyroid dysfunction, and argued that testing for these is necessary before concluding you are hormonally healthy. His closing pitch was to follow him for more guidance on interpreting labs.

This is a reasonable, clinically grounded argument. He is not selling a quick fix or pushing TRT as the default answer. He is, correctly, telling viewers that total T is an incomplete picture. That deserves some credit in a space where "low T" content usually skips straight to injection recommendations.

Does the science back this up?

Yes, with a few nuances worth spelling out. The science on free testosterone, thyroid dysfunction, hyperprolactinemia, and insulin resistance as independent drivers of fatigue and low-libido symptoms is well established, though the evidence quality varies by condition.

Free testosterone is the fraction not bound to sex hormone-binding globulin (SHBG) or albumin, and it is the biologically active portion. Studies have shown that SHBG levels vary significantly between individuals, meaning two men with identical total T can have very different free T levels. Travison et al. (2017, Journal of Clinical Endocrinology and Metabolism) confirmed that free T correlates more strongly with symptoms in some populations than total T does. Thyroid disorders, particularly hypothyroidism, produce a symptom cluster, fatigue, cognitive fog, low mood, that overlaps almost perfectly with hypogonadism. The American Thyroid Association estimates subclinical hypothyroidism affects roughly 4-8% of the general adult population. Hyperprolactinemia suppresses GnRH and can lower testosterone secondarily, a mechanism supported by endocrinology textbook physiology and confirmed in clinical case series (Melmed et al., 2011, New England Journal of Medicine). Insulin resistance and metabolic syndrome are associated with lower SHBG and altered testosterone metabolism, as documented in Corona et al. (2011, Journal of Sexual Medicine).

What did they get wrong (or right)?

Mostly right, but there is a precision problem with how he frames estrogen. He says "your estrogen might be high" as a standalone issue, which is technically true but undersells the complexity. Estrogen in men is primarily derived from aromatization of testosterone. High estrogen often signals high testosterone or high body fat, not a separate hormone dysregulation. Listing it alongside prolactin and thyroid as an independent cause of zombie-like symptoms without that context can mislead viewers into thinking estrogen is an external villain rather than a downstream signal worth interpreting carefully.

His point on free testosterone is well taken. Many standard panels do not include free T, and clinicians who only order total T are missing relevant data for symptomatic patients. His prolactin mention is also clinically appropriate because hyperprolactinemia is an underdiagnosed and treatable cause of sexual dysfunction and fatigue in men that gets far less attention than testosterone optimization in online wellness spaces.

The framing that these are all equally likely or easy to sort out with a few extra labs is a bit optimistic. Insulin resistance diagnosis, for example, involves fasting glucose, fasting insulin, and ideally a HOMA-IR calculation, not just a checkbox on a standard panel.

What should you actually know?

If you feel like, in his words, "a zombie" and your total T comes back in the normal range, do not stop at that result. A complete workup for these symptoms should include free testosterone with SHBG, TSH with free T4, prolactin, fasting glucose and insulin, and a full metabolic panel. Each of these can be treated effectively when diagnosed correctly, and none of them require testosterone therapy as a first response.

The Endocrine Society clinical practice guidelines on male hypogonadism (Bhasin et al., 2018) explicitly state that testosterone therapy should not be initiated based on symptoms alone, and that secondary causes of low T or low-T symptoms should be ruled out first. That is exactly the framework this creator is gesturing at, even if he does not go into that level of detail.

• Free testosterone and SHBG are frequently omitted from standard panels and are worth requesting specifically.
• Prolactin elevation can be caused by medications, a pituitary adenoma, or stress, and requires proper workup before any hormone intervention.
• Thyroid and metabolic issues are more common and more treatable than many TRT-focused content creators acknowledge.
• If a clinician dismisses your symptoms because "your T is normal," asking about these other markers is a reasonable, evidence-supported next step.