Testosterone is a key hormone that influences nearly every aspect of a man’s physical and emotional wellbeing. From libido and muscle mass to energy levels and cognitive clarity, it plays a central role in male health. Yet for many men, testosterone levels decline gradually with age or due to underlying medical conditions, leading to a constellation of symptoms that can significantly affect quality of life. Testosterone replacement therapy (TRT) offers a targeted solution, but it’s essential to understand who it’s for, how it works, and how to do it safely.
Understanding Testosterone Deficiency
Testosterone deficiency, or hypogonadism, occurs when the body no longer produces enough testosterone to support normal physiological functions. This condition is diagnosed through a combination of clinical symptoms and laboratory testing. Typically, a total testosterone level below 300–350 ng/dL or a free testosterone level below 65–100 pg/mL indicates deficiency, though specific thresholds may vary slightly depending on the laboratory.
Men with low testosterone often experience a decline in sexual desire and performance, including erectile dysfunction. Fatigue, decreased motivation, and mood disturbances such as irritability or low mood are also common. Many report “brain fog,” difficulty concentrating, and memory issues. Physical symptoms can include reduced muscle mass, increased abdominal fat, poor sleep, and even hot flashes or reduced shaving frequency due to slowed hair growth.
Diagnosis and the Importance of Testing
Diagnosing low testosterone is not as simple as running a single blood test. Timing matters — testosterone should be tested in the early morning when levels are at their peak. Multiple readings may be needed to confirm deficiency. In addition to testosterone, a complete evaluation should include markers such as estradiol (E2), DHEA-S, SHBG (sex hormone-binding globulin), and prolactin. These offer valuable insights into the hormonal landscape and help tailor therapy appropriately.
Before starting TRT, it’s crucial to rule out contributing factors such as sleep apnoea, chronic illness, or certain medications like opioids or corticosteroids, which can suppress testosterone production.
What Are Your Treatment Options?
There are several methods of testosterone delivery, and the best option depends on the individual’s medical history, lifestyle, and personal preferences. Topical testosterone, in the form of gels or creams, is one of the most commonly prescribed. It mimics the body’s natural diurnal hormone rhythm and is applied daily to areas like the shoulders, arms, or thighs. While convenient and effective for many, it does carry a risk of hormone transfer through skin contact and may cause mild irritation in some users.
Injectable testosterone offers another route, with options ranging from short-acting weekly injections to longer-acting formulations like Nebido, which is administered every 10–14 weeks. While injections can deliver consistent results, they may cause hormonal fluctuations, particularly if dosing isn’t tailored properly. Some men also experience discomfort at the injection site, though this can often be managed with technique adjustments or switching to subcutaneous injections.
In some cases, compounded testosterone creams may be prescribed — especially for individuals with absorption issues or allergies to excipients found in standard preparations. These bespoke formulations may also include ingredients like Chrysin, a natural aromatase inhibitor, to help maintain optimal estrogen-testosterone balance.
Is Testosterone Therapy Right for Everyone?
While testosterone therapy can be highly beneficial, it is not appropriate for everyone. Men with active or recent prostate or breast cancer should not undergo TRT. Other contraindications include elevated haematocrit levels (above 52%), uncontrolled sleep apnoea, recent heart attack or stroke, and unexplained PSA (prostate-specific antigen) elevations. A thorough review of medical history, family history (particularly of prostate cancer or clotting disorders), and lifestyle factors is essential before starting treatment.
Ongoing Monitoring Is Key
One of the most important aspects of TRT is ongoing monitoring. Blood tests should be repeated 6 to 8 weeks after initiating treatment to assess trough testosterone levels (measured just before the next dose), as well as key safety markers like haematocrit and PSA. Estradiol should also be tracked, ideally kept within the optimal range of 30–35 pg/mL using an LC-MS/MS assay. In some cases, saliva testing may also be recommended — particularly when using topical formulations — to monitor absorption and effectiveness.
As treatment continues, follow-ups are typically scheduled at three months and then every six months once stable. Adjustments may be needed based on symptoms, lab values, and patient feedback. If there’s no improvement after six months, it’s important to re-evaluate and investigate other potential causes of symptoms.
Alternatives to TRT: Preserving Fertility
For men wishing to maintain fertility, testosterone therapy may not be ideal since it suppresses sperm production. In these cases, alternatives like clomiphene citrate or human chorionic gonadotropin (hCG) can be considered. Clomiphene works by stimulating the hypothalamic-pituitary-testicular axis to increase endogenous testosterone while preserving spermatogenesis. It is typically taken in low doses (25–50 mg every other day) and is often well-tolerated.
hCG mimics luteinising hormone (LH), stimulating the testes to maintain both testosterone production and testicular volume. It is often used alongside TRT to prevent testicular shrinkage or independently in cases of secondary hypogonadism. Both medications are considered off-label for male hormone management in the UK but are commonly prescribed in private practice with proper clinical justification and informed consent.
Natural Supplements That May Help
Some men prefer to explore natural strategies to support testosterone levels, especially in borderline cases. Supplements such as Shilajit, Quercetin, Fenugreek, Tongkat Ali (Eurycoma longifolia), and Zinc have shown some potential in boosting testosterone or supporting hormonal balance. Others, like DIM (Diindolylmethane), help with estrogen metabolism and may be beneficial in men with elevated estradiol. While these natural options can be useful, they should not replace clinical evaluation or be used without guidance, particularly in men with more significant hormonal imbalance.
The Benefits and Risks of TRT
When prescribed correctly, testosterone therapy can dramatically enhance a man’s quality of life. Benefits often include improved libido, stronger erections, increased energy, sharper cognition, and better mood. Physically, many men experience increases in lean muscle mass, reductions in body fat, and improved exercise recovery. TRT has also been linked to better bone density and may support metabolic health by improving insulin sensitivity and reducing waist circumference in men with type 2 diabetes or metabolic syndrome.
However, like any medical treatment, TRT comes with risks. These can include acne, fluid retention, breast tenderness (gynecomastia), increased red blood cell count (polycythaemia), and — in some cases — elevated PSA or worsening urinary symptoms in men with prostate issues. The key to safe and successful treatment lies in careful candidate selection, proper dosing, and regular monitoring.
Final Thoughts
Testosterone therapy isn’t about chasing youth — it’s about restoring balance. For men with confirmed testosterone deficiency, TRT can offer significant improvements in physical, emotional, and sexual health. However, it must be approached with care, clinical oversight, and a personalised treatment plan. If you’re experiencing symptoms of low testosterone, the first step is to speak with a qualified clinician who can guide you through testing and discuss whether treatment is appropriate for you.
