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Androgen Receptor and Prostate Cancer Etiology

5a-Reductase, which converts testosterone into the more active androgen DHT activity, correlates with race, with low levels of activity in Japanese men and higher levels in African Americans and Caucasian 57 . Racial variations have also been found in the gene encoding 3b-hydrox-ysteroid dehydrogenase 2, which is involved in the breakdown of DHT, suggesting it may play a role in prostate cancer predisposition 58 .There has been much interest in possible racial differences in male testosterone levels however, studies have shown conflicting results 59,60 .

Oral Contraceptive Side Effects

Against primary and secondary osteoporosis (due to hypogonadism, glucocorticoid excess, immobilization, hyperthyroidism, diabetes mellitus, or primary hyperparathyroidism). Estrogen supplementation is the first choice for prevention and treatment of osteoporosis in women who are postmenopausal. The mechanism of action is thought to be decreasing bone resorption by inhibiting the synthesis of interleukins such as IL-6 as well as retarding the bone-resorbing effects of PTH. Estrogen is contraindicated in pregnancy, breast cancer, or active hepatitis. Side effects include breast tenderness, migraines, and vaginal bleeding spotting. Long-term adverse effects include gallstones, breast cancer, and thrombophlebitis. Estrogen alone also increases the risk of endometrial cancer, and progesterone is often added to decrease this risk.

Chapter Summary continued

Genomic imprinting refers to differential expression of genes based on chromosomal inheritance from maternal versus paternal origin. The classic examples are the mental retardation syndromes Prader-Willi syndrome (paternal deletion of chromosome 15 with obesity and hypogonadism) and Angelman syndrome (maternal deletion of chromosome 15 producing ataxia and inappropriate laughter characterized as happy puppet).

Transgenic Mice that Chronically Express MIS Gainof Function Study of the Transgenic Mouse

Most of the male MT-MIS transgenic mice were phenotypically normal and fertile. However, abnormal phenotypes were observed in a portion of the males (5 21) from the highest-expressing lines (Table 1). Externally, these transgenic males were feminized, exhibiting mammary-gland development. Internally, Wolffian-duct differentiation was arrested, and the testes were undescended (57). Serum testosterone levels of these transgenic mice were reduced, suggesting that a high level of MIS affected Leydig cell function (58). Further, more expression of steroidogenic proteins, such as P450 cholesterol side chain-cleavage enzyme and P450 hydroxylase C17-20 lyase, are down-regulated in transgenic male mice (14,15). The number of Leydig cells is also decreased

Hormonal fluctuations

Alongitudinal study of 39 women, followed from perimenopausal state until one year or more postmenopausal, found that these women had a significant decrease in frequency of sexual intercourse and fewer sexual thoughts or fantasies. They suffered more from lack of vaginal lubrication during sex and were less satisfied with their partners as lovers after menopause. While estradiol and testosterone levels showed significant declines, testosterone showed the most consistent association with coital frequency.20

Combined Radiotherapy and Hormone Therapy

The potential benefits of androgen deprivation have to be balanced against toxicity. Most patients experience hot flushes, fatigue, and impotence of varying degrees, which can impact significantly on quality of life. Other toxicities include loss of libido, weight gain, muscle wasting, and changes in texture of hair and skin. Longer-term concerns include the development of osteoporosis and the possibility that low testosterone levels may predispose to cardiovascular disease. There is no evidence yet that long-term hormone therapy increases non-prostate cancer mortality, but this is being investigated in the meantime, it is sensible to restrict the use of long-term hormone therapy to patient groups in which it has been shown to have an overall survival benefit.

Hormone Refractory Prostate Cancer

Hormone-refractory prostate cancer is defined as disease that progresses despite castrate testosterone levels, and is refractory to all hormonal manipulations including withdrawal of antian-drogen therapy. Until recently, there had been no standard chemotherapeutic approach for HRPC. Several agents had been evaluated in clinical trials, but many older studies suffered from methodological deficits such as small numbers of patients, heterogeneity of enrolled patients, and lack uniform response criteria 5 . Overall there have been very few recent phase III trials completed in HRPC (Table 4.1) making it difficult to draw firm conclusions about the efficacy of many regimens. However, it would appear that chemotherapy at a minimum does provide a palliative benefit.

Is the Case for Immediate Treatment Proved

On the other hand, are there problems with immediate treatment The immediate side effects of impotence, hot flushes, and so on have been long recognized. However, just as studies have started to show that clear benefits may result from immediate treatment, so has the possibility emerged that serious harmful effects may result from androgen treatment. Some of these are specific to particular therapies, such as cardiovascular complications of estrogens, and liver toxicity of antiandrogens. However, testosterone deficiency, including androgen deprivation from orchiectomy or LHRH analogues, long considered safe options, is now recognized to cause weight increase, loss of muscle mass, and loss of energy 26 . Anemia may be a particular problem in patients treated with combined androgen blockade 27 . Osteoporosis has been


Thus circulating testosterone may be the androgen of choice to measure indeed, its circulating levels may offer better discrimination between a control population and the affected population with PCOS. A 14 overlap in elevated androgen levels was noted between women with PCOS and a prospectively recruited cohort of cycling control women (34), versus a 20 to 30 overlap of polycystic ovaries in an normal population (35,36). A circulating total testosterone level was found to be the best hormonal correlate of the combined syndrome of hyperandrogenic chronic anovulation and polycystic ovaries (37). Many prefer either a free testosterone or a bioavailable testosterone level, as that better reflects the suppressive effects of hyperinsulinemia on SHBG (38). Assays are reproducible and eliminate any observer bias in identifying women with androgen excess. However given the interassay variability, it is difficult to assign a uniform and specific level of circulating testosterone as the cutoff...

Exercise Lifestyle Modification

There is some evidence that lifestyle modification (diet and exercise) may be an effective adjunct to the treatment of PCOS. The use of hypocaloric diets improves the metabolic derangements in those patients, and low-calorie, low-fat diets have been shown to improve clinical parameters and lower insulin and testosterone levels in PCOS patients (169,170). Weight reduction has also been shown to increase noradrenalin sensitivity in PCOS patients, as PCOS patients have a marked reduction in the lipolytic effects of noradrenalin owing to a decreased number of noradrenalin receptors on fat cells (171), resulting in dyslipidemia. Metformin, in addition to a hypocaloric diet, improves hirsutism, menstrual function, visceral adipose tissue, and glucose-stimulated insulin secretion (172,173). Thus, it appears that diet and medication in combination may be helpful in patients with PCOS.

Targeted Disruption of the FSHfi Gene

Disruption of the FSHp gene has led to both anticipated and unexpected findings regarding its role in reproductive function. Female mice lacking FSH are infertile because of an arrest of folliculogenesis at the preantral stage, and display reduced uterine size caused by the loss of significant estrogen synthesis by the ovary (18). These mice pheno-copy a form of primary amenorrhea in women that results from a point mutation in the FSH receptor (19). Surprisingly, male mice lacking FSH are fertile, despite a reduction in testis size and sperm count (18). Similar effects are observed in human males lacking appropriate FSH signaling following a mutation in its cognate receptor (20). Using another approach to assess FSH function, Sassone-Corsi and colleagues specifically ablated the allele for the FSH receptor in mice. Similar to the FSHp knockout, the female mice are infertile, while males have reduced fertility caused by smaller testis size and reduced sperm count (21). These male mice...

Pituitary Gonadotropin Gene Expression

Similar to the GSE, a site for the bicoid-related, homeodomain-containing protein, Pitx1 (Ptx1, P-Otx), has been identified within the bovine promoter using cell-culture paradigms (66,67). Mutation of this site in the context of the full-length LHp promoter in transgenic mice reduces activity to nondetectable levels (CC Quirk et al., 2001 in press), confirming its importance for appropriate expression of the LHp gene. In addition, targeted disruption of the Pitx1 gene in mice results in a diminution of gonadotropes, as well as a reduction in LHp gene expression (68). A similar protein, Otx1, has also been knocked out in mice. These mice present with transient dwarfism and hypogonadism that

Gonadotropinreleasing Hormone Deficiency

GnRH exerts its effects by binding to cell-surface receptors (GnRH-R) on gonadotropes. The GnRH-R is a member of the seven-transmembrane-spanning, G-protein-coupled receptor family, but is unique in lacking a C-terminal cytoplasmic domain (17). Because mice and humans appear to have only one GnRH-R gene, null mutations in this gene may phenocopy the hpg mouse in terms of FSH and other reproductive deficits. Mutations in the human GnRH-R lead to hypogonadotropic hypogonadism (18). To date, there are no published reports of naturally occurring null mutations in the murine GnRH-R gene, and null mutants have not been generated by targeted deletion in ES cells.

Fertility and Gonadal Function

Spermatogenesis is impaired in a substantial proportion of patients presenting with germ cell cancer. In normospermic men who undergo combination BEP chemotherapy, a reduction in fertility is apparent postchemotherapy, although for most individuals sperm counts will recover over a period of years 50 . Of note, a good prechemotherapy sperm count is associated with a increased likelihood of recovery of spermatogenesis. With regard to hormonal function, a comparison of patients treated with surgery alone or surgery plus chemotherapy suggests that standard-dose BEP chemotherapy does not seem to contribute additionally to a significant impairment in Leydig cell function 51 . In contrast, higher doses (> 400mg m2 cisplatin) may be associated with a significant and persistent impact in Leydig cell function with a consequent reduction in mean testosterone levels.

Biology and Genetics

The majority of LCTs are sporadic, and the etiology of these tumors remains largely unknown. In the minority of cases associated with underlying predisposing conditions (mentioned above), there is an increased risk of Leydig or mixed Sertoli-Leydig tumors, and these usually present as multiple lesions bilaterally. It has previously been reported that inactivation of the luteinizing hormone receptor (LHR) gene on chromosome 2p may result in Leydig cell hypoplasia and male hypogonadism 145 . Studies examining a small number of LCTs have reported the presence of activating mutations of the LHR gene in these tumors 146,147 . However, their results have not been confirmed by other studies 148 , and thus further validation of these findings in large-scale studies of LCTs is required.

Psychological aspects of menopause Menopause as a transition

Decline in coital frequency has been associated with reductions in testosterone levels, and cross-sectional studies have found less evidence of an effect of menopausal status (including specific gonadal hormonal levels) on sexual function, the effects being some reduction in enjoyment of sexual activity and desire.40 Overall, this suggests that reduction of libido and frequency of sexual activity and orgasm may accompany the menopause. However, satisfaction with sexual relationship remains largely unaffected in the majority of

Antral Follicle Development Sensitivity To Extra Ovarian And Intra Ovarian Regulation

Defects in the hypothalamic-pituitary-gonadal axis have a dramatic effect on antral-follicle development, and there are multiple mouse models that exhibit infertility or subfertility because of defects at the levels of the hypothalamus and pituitary (Table 5). Loss of pituitary stimulation by hypothalamic GnRH because of a gene deletion, as in the hypogonadal (hpg) mouse (65), or resulting from migration arrest of GnRH neurons and tumor formation, as in the GnRH-SV40 T-antigen transgenic mouse (66), prevents release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In the GnRH mouse models, follicles progress normally to the multilayer preantral-follicle stage, but are unable to form significant antra, similar to the FSH -defi-cient mouse model (47). Additionally, the ovaries are very small, with little interstitial tissue, which may be caused by the lack of LH or a direct effect of GnRH on the ovary. Mutations in the GnRH receptor (67) also cause recessively...

Growth Factors

Epidermal growth factor and transforming growth factor-a (TGF-a) are two related peptide growth factors that signal through the same EGF receptor (EGFR), a transmembrane tyrosine kinase. They are found in normal and cancerous prostate cells. In the nondiseased prostate, EGF appears to be an important regulator of growth 63 . Its expression is regulated by androgen castrated mice and rats have reduced EGF expression that can be restored by the administration of testosterone 64,65 The EGFR, however, is negatively regulated by androgen 66 . In prostate cancer cell lines, EGFR expression is upregulated with progression however, results from immunohistochemistry of human tumors have been inconclusive. Upregulation of EGF and TGF-a has been observed in prostate cancer specimens 65 , which correlates with tissue testosterone levels, suggesting they may be significant in pathogenesis. Increased EGF expression may also be associated with the invasive ability of prostate cancer cells 67 .


Increased testosterone levels in males can be caused by adrenal hyperplasia and adrenocortical or testicular tumors. Young men with an excess of this hormone may display precocious puberty and sexual behavior. Ovarian and adrenocortical tumors, adrenocortical hyperplasia, and polycystic ovaries may cause elevated testosterone levels in females. Excessive amounts of testosterone usually lead to the masculiniza-tion of females as evidenced in hirsutism, cessation of menstrual periods, and development of other male secondary sex characteristics. Decreased testosterone levels in males are associated with cryptorchidism, hypogonadism (a deficiency in the secretory function of the testes) and Klinefelter's syndrome. Interfering Circumstances. Drugs that may increase testosterone levels include anticonvulsants, barbiturates, estrogens, and oral contraceptives. Decreased testosterone levels are associated with alcohol, steroids, digoxin, and androgens.


The primary cause of germ-cell loss in Bclw mutants does not appear to be caused by endocrine effects, as gonadotropin levels were initially equivalent in Bclw mutants and controls and, as expected, FSH levels were elevated during the period of protracted germ-cell loss (147). Additionally, weights of seminal vesicles, a testosterone-sensitive tissue, were similar in young mutants and controls, suggesting that testosterone levels were not significantly affected (146,147).


In 1994, the genetic mutation causing massive obesity in ob ob mice was described (123). The gene encodes an adipocyte-derived hormone known as leptin, which acts primarily on the hypothalamus as a lipostat, thus tending to adjust the size of the body's energy stores. Mice homozygous for the ob mutation completely lack the presence of circulating leptin these animals develop severe, early-onset obesity, with many associated metabolic and hormonal abnormalities including hyperphagia, defective ther-mogenesis, infertility, and type 2 diabetes. The next experiments demonstrated that these metabolic and physiologic abnormalities were rapidly corrected by leptin administration, which caused significant reductions in food intake and increased energy expenditure resulting in weight loss after only a few days of leptin administration (124-126). These findings led to optimism that leptin therapy might be important for treating human obesity. The human gene encoding leptin has been screened in...

Treatment Of Pcos

We are currently changing from a symptom-oriented treatment approach to PCOS, which often focused alternatively on either suppression of the ovaries (for hirsutism and menstrual disorders) or stimulation of the ovaries (for infertility), to one that improves insulin sensitivity and treats a variety of stigmata simultaneously (111). Multiple studies have shown that improving insulin sensitivity, be it from lifestyle modifications or from pharmacologic intervention, can result in lowered circulating androgens (primarily mediated through increased SHBG and less bioavailable androgen but also through decreased total testosterone), spontaneous ovulation, and spontaneous pregnancy.

Anti Obesity Drugs

It also induced a reduction of testosterone levels, which is consistent with the reduction of testosterone levels in overweight women with PCOS after weight loss by dietary changes and exercise (139). However, it is difficult to assess the long-term clinical efficiency of the medications because the literature is rather inconclusive (small number of patients and short-term studies). Common side effects (headache, insomnia) and potentially serious cardiovascular effects (hypertension, arrythmias, etc.) limit the widespread use of sibutramine, and although orlistat generally has a safer side-effect profile, the frequent adverse effects on bowel habits (flatulence, steatorrhea, GI discomfort) are also significant hurdles to its use.

Nuclear Receptors

An inhibitor of SF-1, Dax-1 (or Ahch) is also an orphan member of the nuclear receptor superfamily. Patients with Dax-1 mutations present with adrenal hypoplasia congenita and hypogonadotropic hypogonadism (114,115). This finding suggests that Dax-1 may play an important role in maintaining gonadotropin gene expression. Surprisingly, mice deficient in Dax-1 have normal serum gonadotropin levels and hence normal gonadal steroids (116). Females are fully fertile however, males are infertile as a result of progressive degeneration of the testicular germinal epithelium (116). These results implicate Dax-1 as a crucial regulator of spermatogenesis in mice. The differential impact of the loss of Dax-1 between mice and humans suggests that there are significant species-specific differences in its mechanism of action. Importantly, Dax-1 does not


The phenomenon of imprinting refers to the fact that a small number of human genes are transcriptionally active only when transmitted by one of the two sexes. A good example is provided by Prader-Willi syndrome, a disorder characterized by moderate mental retardation, hypogonadism, small hands and feet, and obesity. Most cases of Prader-Willi syndrome are caused by a deletion of 4 million bases (4 megabases or Mb) on the long arm of chromosome 15. However, the deletion produces this syndrome only if it is transmitted by the father. If the same deletion is


In most of the established GH-transgenic lines, the males are fertile although their reproductive performance may be quantitatively reduced indicated by increased intervals from pairing them with females until conception, reduced proportion of females impregnated within a given period of cohabitation, and reduced proportion of males exhibiting various elements of sexual behavior (mounting the females, intromitting, and ejaculating) during a 1-h period of observation in the presence of ovariectomized (OVX) females brought into behavioral estrus by treatment with estradiol and progesterone (58,60). Plasma testosterone levels in GH-transgenic males are usually normal, as is the release of testosterone from incubated testicular tissue in vitro, and testosterone responses to LH stimulation in vivo or in vitro (58,60). Daily sperm production per g of testicular

Igf1 in Reproduction

Igfl-null mice that survive the first postnatal week appear quite healthy and active, but both sexes are infertile (21). Males have testosterone levels l8 of normal, and spermatogenesis is reduced to a similar extent. Mating behavior is absent, and distal portions of the reproductive tract (i.e., the vas deferens, seminal vesicles, and prostate) are hypoplastic, consistent with the reduced testosterone levels (21,22). The molecular cause of the reduced testosterone biosynthesis in the male Igfl-null mouse remains unclear, although Leydig-cell size and numbers are decreased (21).

Physical Examination

A careful general physical examination is useful in the evaluation of the obese child. Such an examination yields identification of physical findings that may suggest an underlying endocrine syndrome or genetic disorder. The physical examination should include an overall assessment of the child's body habitus and notation of the pattern of fat distribution. Careful measurement of the height and weight of the child is important to rule out underlying short stature, which may indicate an associated endocrine or genetic abnormality. The presence of a buffalo hump, moon facies, short stature, and hypertension may suggest Cushing's syndrome (although many normal obese children have extra fat deposition over the upper back). Hypogonadism is present in a number of syndromes (Prader-Willi, Bardet-Biedl, and others). Short stature, short metacarpals and metatarsals, subcutaneous calcifications, and mental retardation are present in pseudohypoparathyroidism. The presence of acanthosis nigricans...

Klinefelter Syndrome

This is the most common single cause of hypogonadism and infertility, occurring in 1 500-1 1000 newborn boys. 47,XXY is the most common pattern. Patients tend to have low IQ. Behavior problems and immaturity are early manifestations, arising in childhood well before adolescence and hypogonadism. Fire-setting behavior has been reported. Patients tend to be tall and slim with long limbs. They may be obese as adults. Hypogonadism and a small penis are observed cryptorchidism or hypospadias may occur. Gynecomastia occurs in 40 of patients, and there is an increased incidence of breast cancer. The diagnosis is made by demonstrating an X chromatin-positive male. Therapy consists of testosterone replacement at 11-12 years.

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