What is TRT?
Testosterone replacement therapy (TRT) restores testosterone in men diagnosed with hypogonadism — confirmed by symptoms (low libido, fatigue, depressed mood, reduced muscle mass) plus two morning total testosterone measurements below the laboratory reference range (Endocrine Society 2018 Guideline; AUA 2018 Guideline).
How is low testosterone diagnosed?
Diagnosis requires two morning blood draws (before 10am) showing total testosterone below 264 ng/dL (laboratory cutoff varies), plus clinical symptoms. A single low reading is insufficient because testosterone fluctuates 30-40% across the day (Endocrine Society 2018).
What are the symptoms of low testosterone?
The most specific symptoms are reduced libido, erectile dysfunction, loss of body hair, and reduced spontaneous erections. Less specific symptoms include fatigue, depressed mood, irritability, reduced muscle mass, and decreased exercise tolerance (AUA 2018).
What forms of testosterone do you prescribe?
Three options: (1) injectable testosterone cypionate — the most studied, dosed weekly or twice weekly; (2) oral testosterone undecanoate (Kyzatrex/Tlando) — taken twice daily with food; (3) enclomiphene citrate — a selective estrogen receptor modulator that raises endogenous testosterone by stimulating LH and FSH, preserving fertility.
What is enclomiphene and why might I choose it over TRT?
Enclomiphene blocks estrogen feedback at the pituitary, raising LH and FSH, which signals the testes to produce more testosterone naturally. It preserves testicular size and fertility (unlike injectable/oral testosterone, which suppress both). It's a good choice for men under 40 planning future fertility (multiple studies in J Urol, Fertility & Sterility 2014-2020).
Will TRT make me infertile?
Exogenous testosterone (injectable or oral) suppresses the HPG axis, reducing sperm production. Most men on TRT for 6+ months become functionally infertile while on therapy. Fertility usually returns 3-12 months after stopping. If you want children in the next 1-2 years, enclomiphene is the better choice.
Will TRT shrink my testicles?
Yes, mildly. Exogenous testosterone suppresses LH, which reduces testicular function and can cause measurable shrinkage (5-15% volume) over 6-12 months. This is reversible after stopping TRT, or can be partly mitigated by adding HCG to your protocol.
How fast will TRT start working?
Energy and mood improvements often appear within 2-4 weeks. Libido and erectile function improve in 3-6 weeks. Muscle mass and strength changes are slower — 3-6 months. Body fat reduction is gradual over 6-12 months. Hematocrit (red blood cell count) should be re-checked at 8-12 weeks to ensure it stays in the safe range.
What are the side effects of TRT?
Common: acne, mild fluid retention, increased red blood cell count (hematocrit), reduced testicular size, decreased sperm production. Less common: gynecomastia (breast tissue growth — from testosterone converting to estradiol), sleep apnea worsening, mood changes. Most are managed with dose titration or adjunct medications (anastrozole, HCG) when warranted.
Does TRT cause prostate cancer?
Current evidence does not support a causal link. The AUA 2018 Guideline states TRT does not appear to increase the risk of prostate cancer development. Men with active or recent prostate cancer are screened out at intake. PSA is monitored throughout therapy as standard surveillance.
Is TRT safe long-term?
Long-term TRT in men with confirmed hypogonadism has a favorable safety profile when monitored. Major studies (T-Trials 2016, TRAVERSE 2023) showed no increased cardiovascular risk over 3-4 years in older men with low testosterone. Hematocrit, PSA, and lipid panel are tracked throughout.
Will TRT affect my cardiovascular health?
The 2023 TRAVERSE trial (NEJM) — the largest cardiovascular safety study to date, in 5,200+ men over 3 years — found TRT was non-inferior to placebo for major adverse cardiac events. Older concerns from smaller observational studies have not been confirmed in randomized trials.
Do you offer HCG with TRT?
Yes, when clinically indicated — typically for men who want to preserve testicular size, future fertility, or who develop testicular atrophy on TRT. HCG (human chorionic gonadotropin) mimics LH to keep testicular function active. Discussed during intake based on your goals.
How often do I need bloodwork on TRT?
Baseline panel before starting, then re-check at 6-8 weeks for initial titration. After that, every 6 months: total testosterone, free testosterone, SHBG, hematocrit, hemoglobin, PSA (in men over 40), estradiol, and lipids. More frequent if dose changes are needed.
Who shouldn't take TRT?
Contraindications: active or recent prostate cancer, untreated severe sleep apnea, hematocrit above 54%, severe heart failure, breast cancer in men, untreated obstructive sleep apnea, and men actively trying to conceive (enclomiphene is the alternative for that case).
How much does TRT cost?
TRT is $169 every 4 weeks for testosterone plus anastrozole, or $189 every 4 weeks for the enclomiphene pathway. Initial labs are $50, and gonadorelin can be added for $35 every 4 weeks. Bloodwork is optional at $196 for the 80+ biomarker panel. Intake and clinician review are free — you only pay if you qualify and decide to start.
Can I take TRT with my other medications?
Most medications are compatible with TRT, but disclose everything at intake. Blood thinners (warfarin) may need dose adjustment because testosterone can affect coagulation. Insulin and oral diabetes medications may need adjustment as TRT improves insulin sensitivity.
What happens if I stop TRT?
Within 2-4 weeks of stopping, testosterone drops back to your pre-treatment baseline (which was low — that's why you started). Symptoms return. Natural testosterone production resumes over 3-12 months, but for older men with primary hypogonadism it may not fully recover.
