Testosterone Replacement Therapy, considered.
TRT is medical treatment for a real condition that has, in parallel, become a wellness trend. The two contexts produce dramatically different outcomes. The diagnostic step is the most important step.
Who actually has low testosterone.
Hypogonadism is defined by total testosterone consistently below approximately 300 ng/dL on two morning fasted draws, accompanied by symptoms (low libido, fatigue, depressed mood, erectile dysfunction, loss of muscle mass). The lab number alone is not the diagnosis; symptoms alone are not the diagnosis. Both are required.
Men in the 300–500 ng/dL range with symptoms occupy a clinical gray zone. Some respond to lifestyle interventions (sleep, weight loss, resistance training, alcohol reduction) and recover endogenous T. Others benefit from therapy. Sequencing — lifestyle first, therapy second — is the conservative approach.
How TRT is administered.
Most common: testosterone cypionate or enanthate, intramuscular or subcutaneous, once or twice weekly. Twice-weekly protocols produce more stable levels and fewer mood/energy fluctuations.
Other delivery: topical gels (AndroGel, Testim), pellets (subcutaneous, every 3–4 months), patches. Injectables are dominant in practice because of cost, dose precision, and avoidance of partner skin transfer issues.
What proper monitoring looks like.
Baseline labs: total and free testosterone, estradiol (sensitive assay), SHBG, hematocrit, PSA, lipid panel, comprehensive metabolic panel. Repeat at 6 weeks, 3 months, 6 months, then every 6–12 months on maintenance.
Specific concerns to monitor: hematocrit (rises on T; over 54% requires dose adjustment or therapeutic phlebotomy), estradiol (manage symptoms, not the number), PSA (rule out prostate disease before initiation, monitor on therapy).
Fertility and exit considerations.
Exogenous testosterone suppresses LH/FSH and shuts down endogenous testosterone production and spermatogenesis. Men planning fertility should not start TRT without fertility-preservation protocols (HCG, sperm banking, or both).
Stopping TRT after years can produce a prolonged hypogonadal state during recovery. Some men recover full endogenous function in months; some take a year or more; some do not fully recover. Plan for chronic therapy or use restart protocols (hCG + clomid/enclomiphene) under specialist supervision.
Common questions.
Will TRT shrink my testicles?
Yes, mildly to moderately, in most men. Testicular volume decreases during exogenous testosterone use. Adding hCG (1–2 weekly injections) preserves testicular size and intratesticular function and is standard in fertility-preserving protocols.
Does TRT cause prostate cancer?
Long-debated; the current evidence does not support that TRT *causes* prostate cancer in men with normal pre-treatment screening. It can stimulate growth of an already-existing tumor. Pre-treatment PSA + DRE and ongoing surveillance are non-negotiable.
What about heart attack and stroke risk?
The TRAVERSE trial (2023) found no increased major cardiovascular event rate in symptomatic hypogonadal men on TRT vs placebo over 33 months. Earlier observational signals appear to have reflected confounding. The risk is not zero but it is no longer the field's leading concern.
Will my libido come back?
If low T is the cause of low libido, usually yes — within weeks to months. If low libido has other causes (relationship, medication, depression, vascular issues), TRT alone may not resolve it.
Telehealth TRT vs traditional clinic — which?
Telehealth has lowered access cost dramatically. The trade-off: variability in lab interpretation, monitoring discipline, and willingness to address complications. For straightforward cases, telehealth is appropriate. For complex cases (cardiovascular history, fertility plans, persistent estradiol issues), in-person specialist care is worth the additional cost.
Will I need it forever?
Most men who start TRT remain on therapy long-term. Restart protocols can recover endogenous function in some patients. Plan as if it is chronic therapy.