Many men with low testosterone report improved energy levels, sex drive, and mood after testosterone treatment. If testosterone is low, why not replace it?
Not so fast. A low testosterone level by itself doesn't need treatment. Testosterone replacement therapy can have side effects, and the long-term risks aren't known. Only men with symptoms of low testosterone and blood levels that confirm this as the cause of symptoms should consider testosterone replacement. Talking with your doctor is the only way to know if testosterone therapy is right for you.
What Is Testosterone Replacement Therapy?
Testosterone replacement therapy (TRT) is a shot, patch, or gel of the hormone testosterone to bring the level back to normal. Testosterone is produced in your testes (testicles), the sex organs in men, and is responsible for masculine traits.
The name for the condition where you don't produce enough testosterone is hypogonadism. Signs of hypogonadism in men and people with male anatomy include:
- Low sex drive
- Sparse facial and body hair
- Fewer spontaneous erections (such as while sleeping)
It's natural for testosterone to decline as you age and not necessarily a reason for TRT.
Testosterone replacement therapy for women
Women and people assigned female at birth do produce testosterone as well as estrogen, though the amounts of testosterone are much smaller than those produced by men. Most of the testosterone is produced in the ovaries. In women, testosterone plays a role in:
- Libido (sex drive)
- Bone health
- Energy and mood
- Fertility and the menstrual cycle
Testosterone does decline in women as they age, especially after menopause, but most of the time, TRT is not needed. If a woman is complaining of a low libido and wants that to change, experts usually recommend excluding other causes first, such as looking at current medications like SSRIs (taken for depression) or relationship issues.
A synthetic testosterone for women is only licensed in Australia. In other countries, testosterone is given to women off-label, usually at one-tenth the dose given to men. Women who've taken testosterone usually report an increase in sexual desire. There don't seem to be any benefits for women as far as energy, mood, or bone health.
Low Testosterone Causes
Causes of low testosterone include:
- Getting older
- Side effects from treatments like chemotherapy
- Injury to the testicles
- Testicular cancer
- Too much weight gain
- Problems with glands in the brain that control hormone production (The pituitary gland signals the testes to make testosterone.)
When do testosterone levels drop?
Testosterone levels are highest in men around age 17 and drop as they age, starting between ages 30 and 40. The drop is very gradual (about 1% per year) but increases as you get older. By age 70, the average man's testosterone is 30% below its peak, but it's usually still within the normal range. That's why many men in their 70s and beyond can father children.
You might confuse low testosterone (low T) with erectile dysfunction. While erectile dysfunction (ED) can be a symptom of low T, and having low T can lower your libido, some people with low T have no problem getting an erection, while others have ED with normal levels of testosterone.
Subtle Symptoms of Low Testosterone
The symptoms of low testosterone are sometimes obvious, but they also can be subtle. These include:
- Low sex drive
- Erectile dysfunction
- Fatigue and poor energy level
- Decrease in lean muscle mass
- Body and facial hair loss
- A hard time concentrating
- Depression
- Crankiness
- Low sense of well-being
- Low sperm count
- Increase in body fat
If you have symptoms of low testosterone and tests show you have an abnormally low testosterone level (below 300 nanograms per deciliter), your doctor may suggest treatment. If you have low testosterone levels but no symptoms, low testosterone treatment isn't recommended.
How Are You Tested for Low Testosterone?
If your doctor suspects your testosterone levels are low, they’ll give you a blood test, probably first thing in the morning. You may need to have your blood taken more than once and at different times of the day, since testosterone levels change. Once your results come back, your doctor may order other tests to rule out other reasons for your low T levels.
Daily testosterone cycle
Your levels go up and down during the day. Testosterone levels are highest at 8 a.m. and lowest at 9 p.m. Especially in older men, you'll want to have your level taken in the morning because a decline is more noticeable if blood is drawn at that time.
Blood test for testosterone levels
A nurse or technician will draw blood from a vein in your arm and collect it in a small test tube. It will be sent away for analysis. There are three types of blood tests to measure testosterone.
Total testosterone test. This is the usual test. It measures both testosterone attached to proteins in your blood and testosterone not attached to proteins (called free testosterone). Most testosterone is attached to proteins; the proteins control the amount of active testosterone in your body and prevent your tissues from using the hormone right away.
Free testosterone test. This measures the amount of free testosterone in your blood. It's given to diagnose certain medical conditions.
Bioavailable testosterone test. This measures free testosterone plus testosterone attached to a blood protein called albumin. This is not a common test, but it can be given to check for certain medical conditions.
What is a normal testosterone level?
A normal range of testosterone for men is anywhere from 300 to 1,000 nanograms per deciliter (ng/dL). But not everyone has symptoms at the same testosterone levels. Some may notice changes around 250 ng/dL, for instance. Others may not have symptoms until their level is at 150 or even 100.
For females, the normal range is 15 to 70 ng/dL. A woman usually gets a testosterone test when the doctor suspects she has an abnormally high testosterone level (as opposed to a low level).
What is a low testosterone level?
The American Urology Association considers a low testosterone level in men to be anything below 300 ng/dL. Other professional organizations have higher or lower cutoffs, ranging from 350 ng/dL to 200 ng/dL.
Forms of Testosterone Supplements
Testosterone replacement therapy comes in several forms. All can improve testosterone levels:
Transdermal patch
This is a skin patch worn on the arm, upper body, or another place where you're not likely to sweat or apply pressure (like lie on it). The patch is applied once a day between 8 p.m. and midnight. You'll need to choose a different spot to apply it each time. Wait 7 days before going back to a spot you already used.
Testosterone gel
This may come in a foil packet or from a pump or twist-off bottle. Testosterone is absorbed directly through the skin when you apply the clear gel once a day. You usually rub this on your shoulders, upper arms, or thighs, depending on the instructions on the medication. Let the gel dry before you put clothes on top of it. Be careful about letting children or female loved ones touch the treated area or touch unwashed clothes that were in contact with the gel, as testosterone may get transferred to them.
One type of gel is applied to the inside of your nose via a dispenser pump. You usually apply this three times a day in each nostril, 6 to 8 hours apart. Don't blow your nose or sniff for 1 hour after using this nasal gel.
Testosterone mouth patch
This may look like a pill, but it sticks to your upper gums. Apply this patch by pushing it against your gums and to the left or right of your front teeth. Keep it in place by pushing on it from the outside of your mouth as well. The patch continuously releases testosterone into the blood through the oral tissues. Replace it after 12 hours, switching to the other side of your mouth.
Testosterone shots
A nurse or technician may give you testosterone as a shot directly into a muscle. You can also learn how to give the shot to yourself at home. You'll be shown which body parts you can use for the injection site, as they need to be rotated. The shot is usually given once a week.
Testosterone implants
A health care provider inserts these pellets under your skin (usually in the buttocks area) every 3 to 6 months. They do this by making a small cut in your skin and using a special tool to implant 10 pellets of testosterone. Your body slowly absorbs the testosterone into the bloodstream.
Oral testosterone
Why not a simple testosterone pill? Oral testosterone has been around since the 1980s but was not popular because it can cause problems for the liver. But there are now some new pills (Jatenzo, Tlando, and Kyzatrex) that bypass the liver and get testosterone into the blood directly, in the same way that skin patches, gels, and other treatments do. You usually take the pill twice a day with food.
One downside is that these pills are expensive and may not be covered by insurance, unless you've tried other methods of treatment and had no success or bad side effects.
Benefits of Testosterone Therapy
What can you expect from testosterone treatment? It's impossible to predict because every man is different. Many men report improvement in energy, sex drive, and quality of erections. Testosterone also increases bone density, muscle mass, and insulin sensitivity in some men.
Men also often report an improvement in mood from TRT. Whether these effects are barely noticeable or a major boost depends on the person.
Karen Herbst, MD, PhD, an endocrinologist, specializes in testosterone deficiency. She estimates about 1 in 10 men are "ecstatic" about their response to testosterone therapy, while about the same number "don't notice much." Most have generally positive but varying responses to testosterone replacement.
Is Testosterone Replacement Therapy Safe?
There are a few health conditions that experts believe testosterone therapy can worsen:
Benign prostatic hypertrophy (BPH). The prostate grows naturally under the stimulation of testosterone. For many men, their prostates grow larger as they age, squeezing the tube carrying urine (urethra). The result is a hard time urinating. This condition, benign prostatic hypertrophy, can be made worse by testosterone therapy.
Prostate cancer. Testosterone can stimulate prostate cancer to grow. Most experts recommend screening for prostate cancer before starting testosterone replacement. Men with prostate cancer or elevated prostate-specific antigen (PSA) should probably avoid testosterone treatment.
Sleep apnea. This condition can be worsened by testosterone replacement. It may be difficult for men to detect this themselves, but their sleeping partner can often tell. A sleep study (polysomnography) may be needed to make the diagnosis.
Blood clots. Some studies show testosterone can increase the risk of deep vein thrombosis and pulmonary embolism, a potentially life-threatening clot in the lungs.
Congestive heart failure.Men with severe congestive heart failure should generally not take testosterone replacement, as it can worsen the condition.
As with any medicine, the decision on whether the possible benefits outweigh any risks is up to you and your doctor.
Testosterone replacement therapy side effects
TRT side effects often include:
- Rash, itching, or irritation where the testosterone is applied topically
- Acne or oily skin
- Breast enlargement
- Ankle swelling
- Smaller testicles
- Decrease in sperm count
- Increase in red blood cell count, raising the risk of blood clots
- Increase in prostate-specific antigen (PSA). TRT doesn't cause prostate cancer, but it can make the cancer grow faster.
The chance of a higher risk of heart attack or stroke with testosterone use prompted the FDA to put a warning label on testosterone replacement products. But in 2023, a large study showed there was no difference in the frequency of heart attacks, strokes, or death from any heart problems between a group of men who took TRT and those who took a placebo (dummy) drug.
But the study also found that men taking TRT had more cases of irregular heartbeat, blood clots in the leg or lungs, and kidney problems than the men who got the placebo. At this time, the warning label remains.
Testosterone Replacement vs. Performance-Enhancing Steroids
Some bodybuilders and athletes illegally take anabolic steroids to build muscle mass or to enhance their athletic abilities. (The word "anabolic" refers to body-building tissue). These steroids usually contain testosterone or chemicals that act like testosterone. So how does this differ from TRT?
The biggest difference is that the doses of testosterone used in TRT are small, designed to achieve natural levels of the hormone in the blood. The doses used by some athletes are as much as 10 to 100 times higher than those given medically. Also, the steroids are often combined ("stacked") with other substances like stimulants, pain relievers, and growth hormones to boost the overall muscle-building effect.
Some of the side effects of anabolic steroid abuse are:
- Increased aggression ("roid rage")
- Mood swings
- Psychotic episodes
- Higher cholesterol and blood pressure
- Liver problems
- Stunted growth in teenagers
- Acne and other skin rashes
You can also get addicted to anabolic steroids, even though they don't produce any "high."
How to Get Testosterone Replacement Therapy
You need a prescription from your doctor to access testosterone. But even if your doctor finds out that your testosterone levels are low, they may want you to try other remedies first – for instance, losing weight or seeing a psychologist for depression – before prescribing testosterone. Taking the drug is often a lifelong commitment (unless the low T is caused by a medical illness), so you'll need to be continually monitored by a doctor. They will also do a physical exam and ask whether you have the symptoms of low T before prescribing anything.
Testosterone replacement therapy clinics
Over the past 15 years or so, many clinics have sprung up that specialize in TRT. Some experts warn against them because they say the doctors who run them often overprescribe testosterone and are often not specialists in urology or endocrinology (the study of hormones). Some of these clinics accept insurance, while others are cash-only. Before going to a testosterone replacement therapy clinic, do some research to find a reputable one.
Once you start testosterone therapy, can you stop?
You can stop, but the symptoms of low testosterone will probably return. One study followed 151 men for 6 months after they stopped testosterone replacement therapy. The researchers found that for 92 patients (61%), the effects of TRT did not continue, but they did for the other 59 patients (39%). The researchers noted that the people is the second group had been on TRT longer than the people in the first group (10.7 months vs. 5) and they also exercised regularly.
If you do want to discontinue taking testosterone, don't stop cold turkey. Talk to your doctor so you can be weaned off gradually. During the time you're on TRT, your body stops making testosterone, so you'll want to give it time to start making its own male hormone again.
Testosterone replacement therapy cost
Costs vary a lot and depend on:
- Whether you have insurance and what your deductible and copays will be
- Whether the location you're using accepts insurance or is cash-only
- What type of TRT you're using – pills, patches, shots, gels, etc. (Shots are the most cost-effective.)
- How often you need to see the doctor and/or get lab work done
- Your geographic location
One study found the costs for evaluation plus 3 months of TRT ranged from $33 for a patient on Medicare using a medical center to $1,350 for a patient using a certain online telehealth platform with no insurance. A patient with basic insurance using a medical center paid around $500 for the evaluation, plus about $200 for follow-up and 3 months of treatment.
Takeaways
Many clinics and doctors offer testosterone replacement therapy, but you may not need it. Before prescribing testosterone, your doctor should check your testosterone levels and make sure your low T is not due to something else, like an illness. If your levels are low because of aging, you don't need TRT. If you start on TRT, you'll likely continue for life. Many men who take it find a lot of benefits.
Testosterone Replacement Therapy FAQs
What happens to your body when you start testosterone replacement therapy?
You may feel more energetic, less depressed, and have a higher sex drive. You might also notice you gain more muscle mass and lose body fat.
How long can you stay on testosterone replacement therapy?
If you stop TRT, the symptoms of low T usually come back, so you may have to stay on the drug for life – unless you decide you don't want to be treated anymore.
Does TRT raise blood pressure?
Some studies have found a link between TRT and higher blood pressure, while others have seen no effect or a link to lowered blood pressure. The effect on your blood pressure may depend on your own health, whether you have any heart disease or high blood pressure, and how much testosterone you take.
