TRT Guide: What Patients Need to Know Before Starting

TRT (testosterone replacement therapy) can meaningfully improve symptoms in men who truly have low testosterone, but it is a long-term medical treatment with real trade-offs, including suppressed fertility, rising red blood cell counts and the need for ongoing monitoring. Before starting TRT, you should have a confirmed diagnosis based on symptoms and repeated morning labs, a search for reversible causes, and a clear conversation about your goals.

Who TRT is actually for

Testosterone naturally declines gradually with age, and many symptoms attributed to "low T," such as fatigue, low motivation, weight gain or reduced libido, have other common causes. Guidelines from the Endocrine Society recommend diagnosing hypogonadism only when a man has:

• Consistent signs and symptoms, such as reduced libido, erectile dysfunction, loss of morning erections, low energy, reduced muscle mass, or low bone density; and
• Unequivocally low testosterone, confirmed on at least two separate early-morning, fasting blood draws.

Testosterone varies through the day and drops temporarily after illness, poor sleep, heavy training or caloric restriction. A single afternoon value is not enough to make a decision that may last for years.

The workup before starting TRT

In my practice, I start with labs and a full history. A thoughtful evaluation typically includes:

• Total testosterone, and free testosterone when sex hormone-binding globulin (SHBG) is abnormal, as often happens with obesity, aging or thyroid disease
• LH and FSH, to distinguish testicular causes (primary hypogonadism) from pituitary or hypothalamic causes (secondary hypogonadism)
• Prolactin and iron studies when secondary hypogonadism is suspected, and sometimes pituitary imaging
• Hematocrit, because testosterone raises red blood cell production
• PSA and a prostate risk discussion, for men in age-appropriate groups
• Metabolic labs: glucose, HbA1c, lipids, liver and kidney function
• Screening for sleep apnea, which both lowers testosterone and can worsen on therapy

Equally important is looking for reversible causes: excess body weight, untreated sleep apnea, heavy alcohol use, opioid or other medications, chronic illness, and under-fueling relative to training. Treating these can raise testosterone on its own.

TRT and fertility: the conversation many men miss

This is the single most important counseling point. Testosterone from outside the body signals the brain to reduce LH and FSH. Because sperm production depends on those signals, TRT can markedly lower sperm counts, sometimes to zero. Recovery after stopping is common but can take many months and is not guaranteed.

If you want children now or in the next few years, TRT is usually not the right first choice. Options that work by stimulating your own production, such as hCG or selective estrogen receptor modulators, are discussed in our articles on hCG for fertility and testosterone support and enclomiphene vs TRT. Note that enclomiphene is not FDA-approved.

Risks and side effects of TRT

TRT is generally well tolerated when properly monitored, but the known risks include:

• Erythrocytosis (high hematocrit), which thickens the blood; it is one of the most common reasons to adjust therapy
• Acne and oily skin
• Worsening of untreated sleep apnea
• Fluid retention
• Breast tenderness or enlargement
• Testicular shrinkage and reduced fertility
• Urinary symptoms in men with prostate enlargement

Situations where TRT is generally avoided or needs specialist input include prostate or breast cancer, a markedly elevated hematocrit, untreated severe sleep apnea, uncontrolled heart failure, a recent heart attack or stroke, and active plans for conception.

What we know about TRT and the heart

For years, the cardiovascular safety of testosterone was debated. The TRAVERSE trial, published in the New England Journal of Medicine in 2023, randomized more than 5,000 men aged 45 to 80 with hypogonadism and existing cardiovascular disease or high cardiovascular risk. Testosterone was noninferior to placebo for major adverse cardiac events. However, the testosterone group had a higher incidence of atrial fibrillation, acute kidney injury and pulmonary embolism.

Forms of TRT

Testosterone is available as injections, topical gels, long-acting pellets, and oral and nasal formulations. FDA-approved products have labeled dosing, but the right formulation and dose depend on your labs, lifestyle, skin sensitivity, fertility goals and how your body responds. Gels, for example, carry a risk of transfer to partners and children through skin contact. Dosing is individualized and set only after evaluation.

Monitoring: TRT is a commitment

Guidelines recommend checking testosterone levels, hematocrit and symptoms within the first several months after starting, and at least yearly after that, with PSA monitoring in appropriate men. Stopping TRT often means a period of low testosterone while your own production recovers. Our TRT monitoring guide walks through what we track and why.

How I approach TRT at Laeeq M.D.

At Laeeq M.D., TRT is part of a broader internal medicine evaluation rather than a stand-alone prescription. We confirm the diagnosis, look for causes, address sleep, weight, training and nutrition, and discuss fertility before any decision. If therapy is appropriate, we agree on a monitoring schedule and on what would prompt a change or a stop.

Sources

• Bhasin S, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism, 2018. https://pubmed.ncbi.nlm.nih.gov/29562364/
• Lincoff AM, et al. Cardiovascular Safety of Testosterone-Replacement Therapy (TRAVERSE). New England Journal of Medicine, 2023. https://www.nejm.org/doi/full/10.1056/NEJMoa2215025
• FDA Issues Class-Wide Labeling Changes for Testosterone Products. U.S. Food and Drug Administration, 2025. https://www.fda.gov/drugs/drug-safety-and-availability/fda-issues-class-wide-labeling-changes-testosterone-products

Book a Consultation

If you think you may have low testosterone, a careful evaluation is the right starting point. You can book a consultation for a 60-minute visit with Dr. Laeeq, virtually or in Reston, VA, to review your symptoms, labs and goals, including fertility, before any treatment decision.

This article is for educational purposes and is not medical advice. Discuss any treatment with a licensed physician who knows your history.