When TRT Is Appropriate
TRT is medicine, not optimization theater. It is appropriate when symptoms of hypogonadism are present AND lab work confirms low testosterone on two separate morning draws.
- Symptomatic threshold: Low energy, low libido, depressed mood, loss of morning erections, reduced muscle mass, brain fog
- Lab threshold: Total testosterone consistently below ~300 ng/dL with low or normal LH/FSH
- Two morning draws: Single low values can be artifacts of stress, sleep, or illness — confirm before treating
- Rule out reversible causes: Sleep apnea, obesity, opioid use, chronic stress, and SSRIs all suppress testosterone
Important
TRT shuts down endogenous production. If fertility matters now or in the future, talk to a specialist about HCG, enclomiphene, or fertility-preservation strategies before starting.
Lab Work That Matters
The diagnostic panel is broader than just total T. The number itself is meaningless without the supporting data.
Total Testosterone
Reference ~264–916 ng/dL. Symptoms matter more than the absolute number.
Free Testosterone
The bioavailable fraction. Often the more relevant value.
SHBG
Sex hormone binding globulin. High SHBG can produce symptoms even at normal total T.
Estradiol (sensitive assay)
Required — standard E2 assays are inaccurate at male levels.
LH / FSH
Distinguishes primary (testicular) from secondary (pituitary) hypogonadism.
Prolactin, TSH
Rule out pituitary tumors and thyroid contributions.
CBC + Hematocrit
Baseline before TRT and every 3–6 months — TRT raises hematocrit.
PSA
Baseline if over 40. Monitor annually on therapy.
Delivery Methods
Each delivery method has trade-offs in convenience, blood-level stability, and cost. There is no universally best option.
Subcutaneous injection (testosterone cypionate)
Twice-weekly small injections. Most stable levels with fewest peaks/troughs. Current best practice.
Intramuscular injection
Weekly larger injections. Higher peaks. Older standard, still common.
Topical cream / gel
Daily application. Stable levels but transfer risk to family members. SHBG often drops.
Pellets
Implanted every 3–6 months. Set-and-forget but inflexible if dose is wrong.
Oral (testosterone undecanoate)
Newer, expensive, requires dosing with fatty meals. Limited long-term data.
Standard Injection Protocol
A typical starting protocol for subcutaneous testosterone cypionate. Always work with a clinician — these are reference points, not prescriptions.
- 1Starting dose: 100–140 mg/week, split into two injections (e.g., Monday/Thursday)
- 2Needle: 27–30 gauge, 1/2 inch, subcutaneous in abdomen or thigh
- 3Trough labs at 6 weeks: Draw immediately before next injection — establishes lowest level
- 4Titrate by symptoms + labs: Most men feel best with total T 700–1100 ng/dL and free T in upper quartile
- 5Recheck every 6 months: CBC, lipids, PSA, hematocrit, E2 — adjust as needed
Estrogen Management
Estradiol is essential for libido, bone health, joint comfort, and cardiovascular function. The instinct to crush it with aromatase inhibitors is one of the most damaging trends in TRT.
- Don't treat numbers, treat symptoms: High E2 with no symptoms rarely needs intervention
- True high-E2 symptoms: Water retention, gynecomastia, emotional lability, nipple sensitivity
- Low-E2 symptoms (worse): Joint pain, low libido, depression, fatigue, dry skin, low HDL
- Aromatase inhibitors: Anastrozole only at very low doses (e.g., 0.25mg twice/week) and only if needed
- First-line approach: Reduce TRT dose, lose body fat, reduce alcohol — these lower E2 without medication
Monitoring & Side Effects
TRT is generally well-tolerated when monitored. The issues that emerge are predictable and manageable.
- Erythrocytosis (high hematocrit): Most common. Donate blood, hydrate, reduce dose if persistent above 54%
- Acne / oily skin: Usually resolves after 8–12 weeks as the body adapts
- Sleep apnea worsening: Get a sleep study if snoring increases or daytime fatigue persists
- Testicular atrophy: Universal. HCG (250–500 IU twice weekly) preserves size and intratesticular T
- Mood changes: Usually a sign of dose, frequency, or E2 imbalance — adjust before stopping
Implementation Checklist
- 1Confirm symptoms with a validated questionnaire (ADAM or AMS)
- 2Run two morning lab panels including SHBG, free T, sensitive E2, LH/FSH
- 3Address sleep, body fat, alcohol, and SSRIs first if present
- 4Choose a knowledgeable clinician — not every provider monitors correctly
- 5Establish a 6-week trough draw schedule
- 6Decide fertility strategy before starting (HCG, enclomiphene, or accept)
- 7Track symptoms in a simple journal — mood, energy, libido, sleep