TRT (Testosterone Replacement Therapy)
Testosterone replacement therapy has evolved from a niche treatment to mainstream medicine as understanding of male hormonal health has advanced. Recognising when TRT might help requires understanding both the condition and treatment realities.
Understanding Low Testosterone
The Decline Pattern
Testosterone naturally declines approximately 1-2% yearly after age 30. However, significant deficiency isn't inevitable with ageing. Some 80-year-olds maintain higher levels than some 40-year-olds. Individual variation is substantial.
Total testosterone below 12 nmol/L generally indicates deficiency, though symptoms matter more than numbers. Some men experience symptoms with "normal" levels, while others function well with lower levels.
Recognising Hypogonadism
Male hypogonadism presents variably. Sexual symptoms often appear first:
Reduced libido
Erectile dysfunction
Decreased morning erections
Reduced ejaculate volume
Physical changes develop gradually:
Loss of muscle mass
Increased abdominal fat
Reduced body hair
Breast tissue development
Decreased bone density
Psychological effects significantly impact life:
Low mood or depression
Irritability
Poor concentration
Reduced motivation
Fatigue despite rest
Diagnosis Beyond Blood Tests
Comprehensive Testing
Diagnosis requires more than single testosterone measurement:
Two early morning testosterone levels
Free testosterone calculation
LH and FSH (determining primary vs secondary)
Prolactin levels
Full blood count
Metabolic panel
Additional tests may include morning cortisol, thyroid function, and ferritin.
Clinical Assessment
Symptoms combined with biochemistry guide diagnosis. Standardised questionnaires like ADAM or AMS help quantify symptoms. Physical examination assesses body composition, hair distribution, and testicular volume.
TRT Treatment Options
Gel Preparations
Testosterone gel remains the most prescribed TRT in the UK:
Daily application to shoulders/abdomen
Steady hormone levels
Easy dose adjustment
Quick reversibility if needed
Disadvantages include transfer risk to partners/children and daily application requirement.
Injection Therapies
Short-acting injections (Sustanon):
Every 2-3 weeks
Fluctuating levels
Peak-and-trough symptoms
Long-acting injections (Nebido):
Every 10-14 weeks
Stable levels
Convenient dosing
Requires loading phase
Alternative Delivery
Patches: Daily application provides consistent levels but may cause skin irritation.
Pellets: Surgically implanted, lasting 4-6 months. Not widely available in UK.
Oral preparations: Newer formulations avoid liver toxicity of older oral steroids.
Expected Benefits
Timeline of Improvement
TRT benefits appear progressively:
Weeks 3-4: Improved libido and mood Weeks 6-8: Enhanced morning erections Months 2-3: Increased muscle mass begins Months 3-6: Full sexual function improvement Months 6-12: Body composition changes Year 2+: Bone density improvement
Patience is essential - full benefits take months to manifest.
Realistic Expectations
TRT isn't a fountain of youth. It treats deficiency, not normal ageing. Benefits for truly deficient men are significant, but TRT won't turn back the clock or create superhuman performance.
Safety and Monitoring
Initial Monitoring
First year requires careful monitoring:
Testosterone levels at 3, 6, 12 months
Haematocrit (blood thickness)
PSA (prostate marker)
Liver function
Lipid profile
Dose adjustments optimise levels while maintaining safety.
Long-term Surveillance
Annual monitoring continues indefinitely:
Digital rectal examination
PSA velocity
Haematocrit
Cardiovascular risk assessment
Bone density (if indicated)
Managing Side Effects
Common side effects are usually manageable:
Acne: Topical treatments
Oily skin: Hygiene adjustment
Fluid retention: Usually temporary
Mood changes: Dose adjustment
Serious complications are rare with appropriate monitoring.
Contraindications and Cautions
Absolute Contraindications
TRT is inappropriate with:
Prostate cancer
Male breast cancer
Severe heart failure
Polycythaemia
Severe sleep apnoea
Relative Contraindications
Careful consideration needed with:
Elevated PSA
Strong family history of prostate cancer
Fertility desires
Moderate cardiovascular disease
Risk-benefit discussion guides decisions.
Fertility Considerations
TRT suppresses sperm production. Men desiring fertility need alternatives:
HCG monotherapy
Clomiphene citrate
FSH with HCG
Temporary TRT cessation
Fertility usually recovers after stopping TRT, though timeline varies.
Lifestyle Optimisation
TRT works best with healthy lifestyle:
Resistance training maximises muscle benefits
Weight loss improves testosterone utilisation
Sleep optimisation enhances hormone production
Stress management supports hormonal balance
These measures may improve testosterone naturally, potentially avoiding TRT need.
Considering TRT? Book your online GP consultation via WhatsApp for comprehensive assessment and personalised treatment planning from experienced doctors.
