TRT for Men: Candidacy, Benefits, and Monitoring

Diagnosis

Who Actually Qualifies for TRT

The Endocrine Society and AUA define hypogonadism as consistently low testosterone (typically two morning total T measurements below 300 ng/dL, plus free T) plus clinical symptoms — low libido, ED, fatigue, loss of morning erections, mood changes, decreased body hair, reduced lean mass.

Either alone is not enough. Low T without symptoms generally does not need treatment. Symptoms with normal T need evaluation for other causes (sleep apnea, depression, thyroid disease, medication side effects).

Secondary work-up: LH, FSH, prolactin, SHBG, estradiol, ferritin, PSA, hematocrit, CMP. Pituitary imaging if LH/FSH are inappropriately low.

What it does

What TRT Actually Improves

In confirmed hypogonadism, TRT reliably improves libido and sexual function, energy and mood, lean body mass and strength, bone mineral density, and red blood cell production.

The TRAVERSE trial (2023, ~5,200 men) showed no significant difference in major adverse cardiac events between TRT and placebo over ~22 months — addressing the older concern raised by smaller studies.

What it doesn't fix

What TRT Does Not Fix

TRT does not reliably treat fatigue, weight, mood, or libido issues in men with normal testosterone. A meaningful share of men prescribed TRT by online clinics have normal labs and symptoms with other causes — sleep deprivation, untreated sleep apnea, chronic stress, depression, alcohol use, obesity, untreated diabetes.

Starting TRT in a man with normal T to chase a symptom rarely solves the underlying problem and commits him to lifelong therapy.

Forms

Delivery Forms

• ·Injectable testosterone cypionate/enanthate — weekly or twice-weekly IM or SC; the most common and the form with the most consistent dosing data.
• ·Topical gels and creams — daily application; transfer risk to partners and children.
• ·Subcutaneous pellets — 3–6 month implants; convenient but harder to dose-adjust.
• ·Nasal gel — multi-dose daily; preserves fertility better in some patients.
• ·Oral testosterone undecanoate — twice-daily oral; newer.

Monitoring

Monitoring — What a Good Program Tracks

• ·Baseline: total and free T, SHBG, estradiol, hematocrit, PSA, lipid panel, CMP.
• ·3 months: trough total T, hematocrit, estradiol, PSA.
• ·6 months: repeat plus symptom review and dose adjustment.
• ·Annually thereafter: full panel, PSA, hematocrit, DRE in appropriate patients.

A clinic that hands out testosterone with one initial lab and no follow-up is not running a TRT program — it is running a subscription.

Risks

Real Risks and Common Side Effects

• ·Fertility suppression — exogenous T suppresses LH/FSH and shuts down sperm production. Discuss hCG, clomiphene, enclomiphene, or sperm banking before starting.
• ·Polycythemia — elevated hematocrit may require dose reduction or phlebotomy.
• ·Estradiol elevation — gynecomastia, fluid retention; routine aromatase inhibitors are over-prescribed.
• ·Acne, oily skin, scalp shedding in predisposed men.
• ·Sleep apnea worsening in predisposed patients.
• ·TRT does not cause prostate cancer per current evidence, but can drive growth of existing undiagnosed cancer — why baseline and follow-up PSA matter.