Battling fatigue: Why veterans are at risk for hormone imbalance

Army sergeant Victor Estela struggled with a debilitating mental fog when he came home after serving in Iraq. It enveloped his life, leaving him exhausted by simple tasks such as reading or driving. Over time, the exhaustion morphed into gnawing suicidal urges.

"I didn't want to live if this was what life was going to be," the 53-year-old says softly.

Military members returning to life following deployment—particularly those who saw combat—often have devastating physical injuries and mental health issues that continue long after they retire from service, Hone Health explains.

Captain Dustin McClure endured both during his 12 years of active service in the U.S. Army.

There's the shattered disc in his lower back. A 7mm, semi-circular gunshot scar on the outside of his right knee. Migraines so bad his vision blurs and his speech slurs, symptoms of his traumatic brain injury. Twin hearing aids are a reminder that IED explosions are hell on the eardrums.

The Bronze Star recipient—in line to be awarded a Silver Star and Purple Heart—also had 

PTSD and erectile dysfunction.

Infantryman Mike Heusel's crippling depression arose following back-to-back tours in Afghanistan. "I was in a dark place. For years," admits the 33-year-old. "I couldn't keep a job, I was drinking too much, I was self-medicating."

"I didn't know what was next. I didn't care."

When they enlisted, Estela, McClure, and Heusel knew they might die defending their country. However, none knew it was possible to leave the military with an enemy combatant within their own body; a biological festering foe, strengthened only as a result of the repeated physical and mental stressors of combat.

Low testosterone.

The Perfect Storm

The average testosterone level in American men aged 15-39 years has plummeted by about 25% between 1999 and 2016. Up to 40% of men over 45 are testosterone deficient.

Veterans like McClure, Estela, and Heusel are particularly at risk.

Beyond the stress of being in combat, there's a lack of sleep, physical injuries, and lingering mental issues, each independently linked to low T, says urologist Joshua Calvert, M.D., who spent part of his residency at a Veterans Affairs (VA) hospital, and routinely sees veterans in his practice.

Our service members are subject to these salvos collectively. For years.

"Starting their careers, these guys are type-A adrenaline junkies and their testosterone levels are probably ahead of the curve," says Mike Simpson, M.D., a board-certified emergency medicine physician who served for over three decades as an Airborne Ranger.

"They sacrifice their bodies and health at the altar of mission accomplishment. When they get out, their T levels are below average."

A lack of education about the impacts of military service on hormone health and symptom stigma means most veterans don't find out they have low T for years, if ever.

In a Hone Health survey of 400 veterans and active service members with low testosterone, 43% said it took them more than two years of doctors' visits and tests to get diagnosed. 

"It's the perfect storm," says Simpson.

Internal Combat

Military personnel—especially men who see active combat—experience a range of physical and psychological factors that put them at risk for developing low testosterone. 

Stress

The roads in Afghanistan were strewn with trash when Heusel was stationed there in 2011. But 

it was the roadkill that unnerved him.

"They'd hide bombs in mangy dead dogs and goats," he says. "Every carcass you saw, you'd know 'this could blow me up.'"

"You'd be sent on a mission, knowing this could be your last night. There were times when I was trembling," Estela echoes. "Anyone who claims they didn't experience that is full of shit."

During episodes of acute stress, the body releases a deluge of hormones like adrenaline and cortisol that prime it for survival. When the threat passes, hormone levels fall. But when stress hormones flood the system for long periods—as in a combat zone—it can lead to metabolic changes that can increase the risk for low testosterone. 

The stress from intense military field training has been linked to up to a 47% decrease in testosterone. And the decline may begin in as little as 12 hours.

Chronic stress is also associated with depression, which is independently linked to low testosterone.

"If you have elevated cortisol combined with depression, it may lead to metabolic issues that put you at risk for low T," says family medicine doctor John Bissett, D.O., who served as a medical officer in the Navy from 2016 to 2021.

Lack of Sleep

"We slept outside the wires under the trucks and out in the open," says McClure. "We were so exhausted we'd just pass out."

"You're so sleep-deprived you hallucinate," Heusel adds, recalling 72 hours without sleep on some missions. "But if you go to sleep, you get killed."

An estimated 60% of service members sleep fewer than six hours per night. Veterans also get less deep restorative REM sleep, where the highest levels of testosterone are produced.

In one study, that sleep deficit reduced men's testosterone levels the same amount as aging 10 to 15 years. 

Brain Trauma

Brain injuries, including concussions and traumatic brain injury, or TBI, are signature injuries of war. The blast of a roadside IED or a rocket-propelled grenade can easily cause brain bleeding, bruising, and other physical damage, as well as possible hormonal deficiencies.

Heusel's TBI diagnosis came during his first deployment to Afghanistan in 2009 when he was a gunner on top of a Humvee. "An RPG blew up next to my head and knocked me out. I don't remember much after that. I woke up in the back seat and couldn't hear a damn thing except the ringing in my ears."

Researchers don't fully understand how brain injuries impact hormones, but according to one study, as many as 80% of men with severe TBI experience low T following injury. One explanatory theory involves damage to the pituitary gland, which produces luteinizing hormone, which stimulates the testes to produce testosterone.

"Imagine that you have two skulls," says Simpson. "One surrounds your brain, and another tiny one, called the sella turcica, surrounds and protects your pituitary gland if you get hit or fall down. But it's not good at shielding it from blast waves from a bomb."

The pressure from a blast is like a wave that transmits through the bone, through the fluid around your brain, and into the soft tissue. "Every time you take a blow to the head, your pituitary gland smacks against the bone like a battle rope against a gym floor," says Simpson. The pituitary gland literally flattens from the impact.

PTSD

Estela was so jumpy, he slept with a gun under his pillow for years. "I'd wake in the middle of the night and freak for no reason," he says. "I still get flashbacks if I see a war movie on TV."

Heusel was plagued by nightmares of stepping on IEDs. "I'd wake up and not go back to sleep 

for hours. All I could think about was the war."

As many as 20% of veterans who served in Iraq and Afghanistan have post-traumatic stress disorder, or PTSD, a diagnosis that includes the flashbacks, nightmares, anger, and anxiety people can experience after exposure to trauma, such as physical harm or the threat of it. 

Post-traumatic stress disorder may diminish T levels in a number of ways. It can cause a lack of sleep, depression, and other metabolic changes associated with low testosterone. 

Some research suggests it may also impact the pituitary gland and be linked to lower levels of vitamin D, which may play a role in testosterone production.

The relationship goes the other way, too. Soldiers with low T may be more likely to develop PTSD than those who don't have testosterone deficiency.

Testicular Injury

Horrifyingly, Blunt Scrotal Trauma is common among service members. More than 1,400 U.S. troops suffered injuries to the genitals, including the penis, testicles, or bladder while serving in Afghanistan and Iraq, a number experts describe as "unprecedented." 

Injured testicles struggle to produce testosterone, says Calvert. T levels can bounce back on their own, and according to one study, did so within an average of five months. "But if the injury is severe, the impact may be permanent," says Calvert.

Don't Tell, Don't Ask

Symptoms of low T, such as low energy and fatigue, are embarrassing to talk about in general, but doubly so for military folks. 

"Not speaking up is part of the training," says McClure, especially for younger soldiers and those who have been hazed. "If you've been ridiculed about bedroom issues or you've gotten bashed about masculinity, that makes you shy about talking about symptoms," he says.

Simpson takes a broader view. "In the military, you judge yourself by: Am I an asset, or liability," he says. "When you've been trained to make physical performance your self-worth, and you start to lose your edge, you feel like a liability. That's tough."

If men knew that their wilting sex drive, energy, and focus were a medical issue, they might be more apt to speak up, Simpson says. 

The military educates men about the long-term effects of tobacco and energy drinks, he adds. 

"But they don't explain what it means for your hormones to burn the candle at both ends."

McClure, who had always had a healthy libido, was stymied by his sexual issues. Hormones didn't cross his mind until a cousin bragged about his own revved-up libido at the gym one day. "I asked him if he was on steroids. He said, no, it was TRT," says McClure, referring to testosterone replacement therapy.

Low T wasn't on Heusel's radar either. When his depression got so bad that his family urged him to see a doctor, a VA physician put him on antidepressants, which he says crashed him even harder. His doctor never mentioned hormones.

An Overwhelmed, Undereducated System

It would be easy to blame the VA for missing the diagnoses, except that's not fully fair.

"If a veteran goes to a psychiatrist at the VA, the doctor isn't likely thinking about whether the patient's struggles with mood are related to T levels.

Leonard Pogach, M.D., executive director for endocrinology and diabetes at the Veterans Health Administration, points out that many symptoms associated with low T, like depression, decreased energy, and lower libido, are also linked to other health issues and aging. "It is important for doctors to evaluate a patient for other health issues prior to initiating testosterone treatment," he adds. 

Veterans say that's a cop-out, especially when they ask about hormone testing.

"When you're diagnosed with PTSD, every VA provider who looks at your record sees it," says McClure, who notes his primary care doctor at the VA wouldn't test his T. "As soon as they do, that's their answer. They don't even want to look into anything else."

Heusel, who also had a PTSD diagnosis on file, says "it was like they were actively trying not to test my hormones," adding his primary care doctor brushed off every test request.

Estela was put on antidepressants by the VA and unsuccessfully cycled through multiple SSRIs for a decade. In 2015, after seeing an ad about low testosterone treatment online, he asked to have his hormones tested and his doctor complied. When she told him his testosterone was in a normal range, he didn't question it.

"Many veterans get frustrated because it seems like their doctor is looking for an excuse not to prescribe TRT," says Bissett. That apprehension toward TRT—both in the VA and outside it—likely stems from a 2014 FDA drug safety communication warning that the FDA was reassessing whether TRT could increase men's risk of cardiovascular problems. (A 2022 meta-analysis of 35 clinical studies ultimately found no significant risks of cardiovascular issues. A 2023 study published in the New England Journal of Health came to the same conclusion.)

However, Simpson has a theory: During active duty, testosterone was seen as a performance-enhancing drug. But TRT isn't trying to cheat time, or gain an unfair advantage, he says.

"I'm trying to maximize my time and why shouldn't medical science help me do that, especially since my levels would probably be higher if I hadn't been in the military?" says Simpson.

"The VA does not view TRT as a treatment to hold back aging," says Pogach. "The VA makes decisions based on what is best for the veteran, not based on cost or any stigma surrounding a certain course of treatment."

The Big Fight

If overcoming stigma and a lack of information are battles, getting treatment is the war.

Administrative burdens within the VA can make establishing care difficult, and staffing shortages can lead to fractured care.

That may be why 78% of men in our survey when seeking treatment for their symptoms went to a private practice physician or online clinic instead of the VA.

Simpson believes the military doesn't have enough doctors trained in hormone disorders. Pogach notes that primary care physicians within and outside the VA may be less confident about the diagnosis and treatment of these issues than specialists. He adds that VA primary care physicians can refer patients to a specialist, or to community care if an in-system specialist isn't available.  

That lack of knowledge is felt by patients. The majority of veterans we surveyed said they don't trust their physicians to correctly diagnose hormone imbalances.

And vets need to self-educate. In 2020, five years after Estela first requested hormone testing, he asked his primary doctor to test his T again. "I'd been reading more about low testosterone, and it just seemed to fit," he says.

This time, when told his levels were within range, he pushed for more information. He asked what normal was for his age, and if his levels were higher or lower than the test five years earlier. Every reply was the same: "Your numbers are normal."

Fed up, Estela ordered a test. His total testosterone was 200ng/dL, and he was highly symptomatic. A sexual function questionnaire indicated severe erectile dysfunction. He consulted with a doctor and started TRT.

He felt relieved. And pissed.

When contacted for this story, Estela asked for his specific numbers one last time. He was told his 2020 test indicated that his total T was 280 ng/dL and, per his provider, "within the 170-780 ng/dL range considered normal by VA Medical Center standards."

While still on active duty and symptomatic, Simpson, then 46, was tested by army physicians. They said his results were "low normal, but okay for your age" (he wasn't able to find the exact results for this story). "The active duty army hospital had nobody who knew how to address it, including endocrinologists and urologists," says Simpson.

One reason Estela and Simpson may not have been offered treatment: They fell into the testosterone gray area.

The Gray Area

Testosterone therapy guidelines come from several places, though the leading ones hail from the American Urological Association, and they state that symptomatic men with testosterone levels under 300 ng/dL should be considered for treatment. The Endocrine Society's guideline for low T is even lower: 264 ng/dL.

That doesn't mean TRT doesn't have any health benefits for men with levels above 300 ng/dL or above 400 ng/dL in some cases, Hone Health reports, noting total T is only one data point. Other factors should also be considered as part of a doctor's clinical decision-making process, including additional testing to shed light on whether low testosterone is causing a patient's symptoms, or whether the symptoms could be related to another condition.

Pogach agrees. "The prescription of testosterone is not based upon a single testosterone value but rather a clinical evaluation that may include multiple measures of total/free testosterone," he says.

That doesn't always happen in practice.

Despite his VA testosterone results being 20 points under the AUA's cutoff, Estela says he wasn't offered additional testing. Neither was McClure, who pushed for testing and discovered his T levels were above 400 ng/dL. (Heusel's Hone test revealed his T was just 183 ng/dL, well below the threshold.)

Jim Staheli, D.O., medical director of Broad Health, Hone Health's affiliated medical practice, says additional elements need consideration, like symptoms.

"Men can be symptomatic at 240 ng/dL or 400 ng/dL," Staheli says. "In addition to a full workup, Hone-affiliated physicians review three screening questionnaires, including a qADAM score, to help identify potential symptoms associated with low testosterone."  

Doctors should also be looking at additional labs to get a clearer picture of what's going on in a man's body, Staheli notes. "Physicians should be looking at other labs including free T, sex hormone binding globulin, or SHBG, and several other biomarkers," says Simpson, especially for veterans in the gray area. 

"There's a huge conflation between normal and average," says Simpson. "Veterans know what it feels like to operate at a certain level. If they have a testosterone level of 350 and feel like shit, that's an issue."

A study published in 2022  on veterans has found that TRT was beneficial for men with T levels at the low end of normal.

Understanding T

Testosterone is found in the bloodstream in two main forms: bound T and free T.

Bound T makes up the bulk of testosterone in the body. It's bound to proteins like albumin and sex hormone binding globulin , which helps transport testosterone but prevents the body from using it right away. Testosterone not attached to proteins—free T—is readily available for cells to use.

"You can have a normal total testosterone level, but still suffer from symptoms of low T if your free testosterone is low," says Staheli. In fact, some research suggests that free T levels are a better predictor of symptoms of low T than total testosterone levels.

But even determining free T just scratches the surface. "If free testosterone is too low, or SHBG is too high, patients can experience the effects of low testosterone like irritability, low libido, and fatigue," says Staheli.

Strategic Offense

All of the veterans in this story ended up getting treatment for low T. Their symptoms—the low libido, the brain fog, the depression, the suicidal urges—have vastly improved. 

McClure's libido is back to what it was in his 30s. Estela's brain is happily firing on all cylinders. Heusel has seen a 180 in his mood. Even his PTSD has diminished. "I still think about Afghanistan for about 70% of my day, but now I can put it in its place," he says.

Not all veterans are so lucky.

Hone leadership and physicians within and outside the VA are advocating for that to change. Here's what that might look like. 

Screening

"There's a lot of screening starting your service, and testosterone should absolutely be added," says Simpson. "We should get baseline testosterone levels for every guy in their initial physical, and measure it regularly."

Veterans agree. 86% of the men in our survey said they thought the military should do hormone testing to establish baseline T levels before enlistment.

It would help researchers better understand how military service impacts hormone levels. It would also allow physicians to offer TRT quicker, if needed.

Individual Education

Simpson would like the military to provide information on testosterone and how active duty can impact it. Estela agrees. "Having a chart or something that shows the consequences of serving on your hormones might help guys understand the impact," he says. 

Educating the chain of command is also critical. "If we're treating soldiers as commodities, commanders need to understand the downstream effects," says Simpson.

Physician Education

"Doctors who treat veterans—inside the VA and in private hospitals—need to get up to speed about testosterone therapy. Instead of only treating symptoms like erectile dysfunction with Viagra, physicians should take a more holistic approach, which includes hormonal health," reports Hone Health.

More Gray

Staheli's biggest hope: less fixation on the 300 ng/dL cutoff. "As technology leads to more precise testing and researchers gain a better understanding of how our diets, exercise, sleep patterns, genetics, environmental toxins, and stress—in a combat zone or at a desk job—impact testosterone levels, guidelines, and patient care will continue to, and should, change."

"With This Hindsight, Would You Serve Again?"

The big question, right? For McClure, a third-generation Army Infantry Airborne Ranger, the answer is an immediate yes. He cites a quote (not his): "We wrote a blank check made payable to The United States of America, for an amount up to and including our lives."

Heusel echoes that, even if he knew, he still would've gone into the military. "My advice for people joining the military is to learn from the past mistakes made on our government's behalf," he says. "I hope the VA and our military will be more aware of how deployment and stress truly affect us."

While 85% of veterans in our survey said that even if they knew more about how serving could negatively impact their hormones, they would have still enlisted. Not Estela.

"I wouldn't enlist again knowing what I know now," says Estela. "I had the testosterone of a man in his 70s when I got out. You sign up, you take your oath, and it is about your country."

"But our country is not really watching out for us. If we sacrifice our hormones, they don't take care of us."