Treating Low Testosterone: Options and Expectations

Testosterone therapy works, and for the right man it can make a real difference. It works best, though, when you know what it's likely to change before you start.

So start by naming what you want fixed. Maybe it's a sex drive that has faded, or muscle that's harder to hold onto. Whatever it is, that's what treatment should be judged against, not just a number on a lab report.

What Testosterone Can Change, and What It Can't Promise

Testosterone's most reliable effects are on sex drive and the body itself. In the Testosterone Trials, older men with low testosterone saw more sexual desire and activity. Hemoglobin also rose, which helps men who are mildly anemic. [3] Lean mass tends to go up and fat mass to come down, and those changes build steadily over time. [1]

The less predictable effects are often the ones men care about most. In the same trials, testosterone didn't improve energy, and mood improved only slightly. Across pooled trials, the effect on erections was small. [3,4] That doesn't mean no one feels more energetic on treatment. It means energy alone is a weak reason to start, and erection problems often respond better to other treatments. Testosterone hasn't been shown to improve memory or thinking. [3]

Timing matters too. Changes in sex drive usually show up within about three weeks and level off by six. Erections can take up to six months. Body composition shifts over three to four months. [5] A fair verdict takes a few months, not a few weeks.

Why this matters: If low energy is your main complaint and your testosterone is borderline, testosterone may not be the answer. A good evaluation should tell you that before you start, not six months in.

Your Options

There's more than one way to raise testosterone, and the right one depends on your body, your goals and your plans for children.

• Injections are the most common and most flexible route. How often you inject matters as much as how much. Some men clear testosterone quickly, often because their SHBG is low. Smaller, more frequent doses keep their levels steadier and avoid big peaks and crashes.
• Topical cream is a real alternative, not a weaker one. It suits men who dislike needles or don't do well on injections. It can be applied to several sites, including the scrotum. Absorption there is much higher, so the site is set as part of your prescription. The tradeoff is transference, since cream can rub off onto a partner or child. That makes it a poor fit if your partner is pregnant or trying to conceive, or if you're in close skin contact with young children.
• Enclomiphene and hCG raise your own testosterone instead of replacing it, so your testes keep producing. They suit men who want to protect fertility or keep their natural production running, as long as the testes can still respond. Why Is My Testosterone Low, and What Comes Next? explains how they work.
• Treating the cause at the same time. If excess weight is part of the picture, GLP-1 medication and testosterone therapy can run together. One works on the cause while the other works on how you feel.

If kids are on the table, now or in the next few years, we recommend a baseline semen analysis before starting any treatment. Testosterone therapy suppresses sperm production, and knowing your starting point makes every decision after it clearer. hCG can be added to testosterone therapy to help protect fertility. Repeat semen testing can show whether it's working. Coming off therapy to conceive is its own process. [6] Whatever your plans for children, raise them with your doctor before you start. We'll go deeper on testosterone and fertility in a future article.

How Treatment Should Be Run

Starting testosterone is the easy part. Running it well is where most of the difference lies.

Your dose should be built around you, not a template. Men who carry more weight around the middle convert more testosterone into estrogen, so they often do better starting lower and building up. Labs should be timed to your dosing schedule. With injections, that means drawing at the low point right before your next dose, so a peak level doesn't make a reasonable dose look like an overdose. And changes should come one at a time, so it's clear what actually helped.

When something isn't working, the answer usually isn't more testosterone. A man who seems to need more and more usually has something else going on. It might be mistimed labs, the wrong dosing schedule, untreated sleep apnea or uncontrolled weight. Those deserve attention before the dose climbs.

There's also a point to stop and reassess. Sometimes your levels get where they should be and your symptoms still haven't improved after three to six months. When that happens, the honest move is to question whether testosterone was the problem, not to keep raising the dose. [2] Chasing a higher number isn't the same as getting better.

Keeping Treatment Safe

For most men, testosterone therapy is safe. The heart is the worry men raise most often, and it's where the evidence is most reassuring.

The largest trial to date followed more than 5,000 men with low testosterone who already had heart disease or a high risk of it. These are the men you'd expect to be most vulnerable. Even so, testosterone didn't increase their risk of heart attack, stroke or death from heart disease. A few less common problems, such as an irregular heart rhythm, were slightly more frequent. That's part of why treatment is monitored. [7]

The other side effects worth watching are predictable. Routine labs and checkups catch them early:

• Red blood cell count (hematocrit). Testosterone raises red blood cell production, which is expected. If the count runs too high, the usual fix is adjusting the dose and finding the reason, not routine blood donation. [1]
• Blood pressure and snoring. Testosterone can raise blood pressure slightly. In the studies the FDA requires, the top number rose by about 3 to 5 points on average. [9,10] Men who already have high blood pressure may need closer monitoring, but treatment can still be done safely. New or louder snoring is a cue to check your sleep.
• Prostate. PSA is checked before you start and during treatment, the same kind of screening used in the largest trial to date. In that trial, prostate cancer was rare, with no meaningful difference between testosterone and placebo. Urinary symptoms didn't get worse either. [8]
• Estrogen. Some testosterone naturally converts to estrogen, and that's normal. A higher estrogen number alone isn't a reason to add an estrogen blocker like anastrozole. If it does cause symptoms, adjusting how testosterone is dosed usually takes care of it.

Monitoring isn't a sign that treatment is dangerous. It's what keeps it safe.

Is It for Life?

That depends on the cause. When something reversible was driving low testosterone, treatment may not need to be permanent. Coming off still takes planning, because your own production can take time to restart. When the cause can't be fixed, treatment usually continues, with the same monitoring that makes it safe.