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Materials and methods The meta-analysis was conducted per instructions outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Reference Higgins, Thomas and Chandler13) and the Grading of Recommendations Assessment, Development, and Evaluation Handbook (Reference Schunemann14)

By age 50-60, many men experience clinically significant testosterone deficiency, presenting as: Persistent fatigue and reduced motivation Loss of muscle mass and strength Increased body fat, particularly visceral (abdominal) fat Decreased libido and sexual function Mood changes including irritability and mild depression Reduced bone mineral density Growth Hormone Decline Growth hormone secretion declines approximately 14% per decade after age 30, a process termed somatopause (2)

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These include environmental factors, such as ultraviolet (UV) radiation and environmental pollutants, including ozone and cigarette smoke (115, 116)