Testosterone Replacement Therapy

Testosterone replacement therapy (TRT) is a vital treatment for men with clinically low testosterone, helping restore energy, libido, muscle mass, mood, and cognitive function. Research shows TRT not only improves physical strength and mental clarity but may also reduce visceral fat, enhance sleep quality, and even lower the risk of heart disease. For men truly in need, TRT isn’t just about feeling younger—it’s about reclaiming overall health, confidence, and quality of life.

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Clinical screening tools like the ADAM questionnaire:

(Androgen Deficiency in Aging Males)

Low Testosterone Self-Check Questionnaire

Answer YES or NO to each question:

Do you have a decrease in sex drive (libido)?
Do you have a lack of energy or persistent fatigue?
Have you noticed a decrease in strength or endurance?
Do you feel a decrease in enjoyment of life?
Are you sad or grumpy more often than before?
Have you noticed a recent decline in your ability to concentrate or memory?
Have you noticed a decrease in muscle mass or increased body fat?
Do you have fewer or weaker erections, including morning erections?
Do you fall asleep more easily after dinner or feel excessively sleepy in the evening?
Have you noticed a decrease in work performance or motivation?
Have you experienced infertility or difficulty having children?
Do you have osteoporosis or a history of low-trauma fractures?

🔎 Scoring:

If you answered YES to questions 1 or 7, or to three or more questions total, you may have symptoms of low testosterone.

How Lab Tests Help Diagnose Low Testosterone

When men have symptoms like low energy, reduced sex drive, or loss of muscle, doctors often check testosterone levels through a blood test. But not all testosterone in the body works the same way—so we look at a few key numbers to get the full picture:

1. Total Testosterone

This is the main number we test first. It measures all the testosterone in your blood—both the active and inactive forms.

Normal Range: 300–1000 ng/dL
If your level is below 300 ng/dL on two separate mornings (7–10 AM), and you have symptoms, treatment may be recommended.

2. Free Testosterone

This is the active form of testosterone that your body can actually use. Sometimes, total testosterone looks okay, but free testosterone is still too low—especially if your body makes too much of a protein called SHBG (see below).

Normal Range: Around 5–15 ng/dL (varies slightly by lab)
If your free testosterone is low, even with normal total testosterone, treatment may still be appropriate.

3. SHBG (Sex Hormone-Binding Globulin)

This is a protein in your blood that binds to testosterone, making it inactive. If SHBG is too high, it can "lock up" too much testosterone, leaving you with less free testosterone.

SHBG is tested when total T is borderline or doesn’t match your symptoms.
High SHBG = less free testosterone, even if total T looks okay.

Simple Analogy

Think of total testosterone like all the money in your bank account, but free testosterone is the cash in your wallet. SHBG is like the bank’s security lock—it keeps the money safe, but you can’t spend it. If the lock is too tight (high SHBG), you may have plenty in the bank, but not enough to use!

Indications for Testosterone Replacement Therapy

1. Low Testosterone Levels

Total testosterone < 300 ng/dL on two separate morning blood tests
OR Low free testosterone, especially if SHBG is abnormal or symptoms are strong

2. Presence of Clinical Symptoms

At least one or more of the following:

Low sex drive or erectile dysfunction
Fatigue or low energy
Loss of muscle mass or strength
Depressed mood or irritability
Poor concentration or memory (brain fog)
Loss of body hair or increased body fat
Decreased bone density (osteoporosis or fractures)

What to Do When Total Testosterone is Normal but Symptoms Exist

1. Check Free Testosterone

Total testosterone includes both active (free) and inactive (bound) testosterone.
In many men—especially older adults or those with high SHBG—total testosterone may look normal, but free testosterone is low.
Free T is the portion your body can actually use.

Action: Order free testosterone and SHBG blood tests to assess actual hormone availability.

2. Check SHBG (Sex Hormone-Binding Globulin)

SHBG binds testosterone and reduces the amount that’s available.
High SHBG (common in aging, thyroid disease, liver disease, or certain medications) = lower free testosterone.

3. Evaluate Other Causes

Symptoms like fatigue, low libido, or mood changes can also come from:
- Depression or anxiety
- Thyroid dysfunction
- Chronic illness
- Sleep disorders
- Nutritional deficiencies (like vitamin D or B12)

Nebido – Long-Acting Injection

How it works:
Nebido is injected into a muscle by a doctor every 10–14 weeks (about 4 times a year).

Pros:

Very convenient – no daily routine
No worry about skin contact with others
Stable levels after the first few doses

Things to consider:

Requires an injection at the clinic
May cause mild discomfort at the injection site
Cannot easily stop or adjust once it’s injected
Takes a few weeks to reach full effect with the first dose

When Testosterone Therapy Is NOT Recommended

Testosterone replacement can offer powerful benefits, but it’s not safe or suitable for everyone. There are certain medical conditions where TRT should be avoided, as it may cause harm.

Absolute Contraindications (Do NOT use TRT):

Prostate cancer (active or suspected)
TRT can potentially stimulate prostate tissue growth, including cancer cells.
Male breast cancer
Although rare, testosterone can worsen this condition.
Very high red blood cell count (hematocrit >54%)
TRT can increase the risk of blood clots, stroke, or heart attack.
Severe untreated sleep apnea
TRT may worsen breathing issues during sleep if this condition is not managed.
Severe heart failure
TRT may cause fluid retention and worsen the condition.
Allergy to testosterone or its components
Especially important for gel or injection forms (e.g., castor oil in Nebido).

Relative Contraindications (Use with Caution or Under Specialist Supervision):

Elevated PSA or enlarged prostate (needs evaluation first)
Fertility concerns – TRT can suppress sperm production
History of heart attack or stroke – requires close monitoring
Blood clotting disorders or history of DVT/PE
Uncontrolled diabetes or obesity – need to address underlying risk factors

What to Monitor During Testosterone Therapy

Regular monitoring is essential to make sure testosterone therapy is working well without causing side effects. Your doctor will track your hormone levels, blood health, and prostate safety throughout treatment.

🔍 1. Testosterone Levels

Why: To make sure levels are in the healthy, therapeutic range—not too low or too high.
When:
- Before starting treatment
- 6–8 weeks after starting or changing dose
- Then every 3–6 months once stable

2. Hematocrit and Hemoglobin

Why: TRT can increase red blood cell count, which may raise the risk of blood clots.
When:
- Before starting
- 3 months after starting
- Then every 6–12 months
- If hematocrit >54%, therapy may need to be paused or adjusted.

3. PSA (Prostate-Specific Antigen)

Why: To monitor for prostate growth or signs of prostate cancer.
When:
- Before starting (baseline)
- 3–6 months after starting
- Then annually

5. Symptoms and Side Effects

Why: To track improvements (e.g., energy, libido, mood) and watch for side effects like acne, hair loss, or mood swings.
When: At every visit

Does Testosterone Replacement Therapy (TRT) Cause Cancer?

The short answer, based on current scientific evidence, is:

There is no strong evidence that TRT causes prostate cancer or increases overall cancer risk in men.

What the Research Says:

1. Prostate Cancer

In the past, it was believed that testosterone “feeds” prostate cancer. This came from early studies in the 1940s that showed prostate cancer slowed down when testosterone was removed.
However, modern research paints a more nuanced picture.

A large review published in European Urology (2016) found no increased risk of prostate cancer in men undergoing TRT.

The Testosterone Trials (TTrials) and studies in JAMA (2017) also found no rise in aggressive prostate cancer in men treated with testosterone.

Fun Fact:

Most prostate cancers occur in older men with low testosterone, not high.

2. Other Cancers

There is no clear evidence linking TRT to cancers like colon, lung, or breast cancer in men.
However, TRT is absolutely contraindicated in men with active prostate or breast cancer, as a precaution.

Why the Fear?

Testosterone can cause prostate tissue to grow, so it can enlarge the prostate (BPH), which causes urinary symptoms—but this is not cancer.
That’s why we monitor PSA (prostate-specific antigen) regularly during therapy.

Bottom Line for Patients:

TRT does not cause prostate cancer, but we screen and monitor carefully to keep you safe. In fact, some men with low testosterone may actually feel better, live stronger, and have better quality of life with proper, monitored treatment.

Nebido – Long-Acting Testosterone Injection

Nebido is a slow-release testosterone injection given every 10–14 weeks. It’s ideal for men who prefer not to apply a daily gel and want long-term hormone stability with fewer clinic visits.

What is Nebido?

A testosterone undecanoate injection given deep into a muscle (usually buttock) by a healthcare professional
Delivers testosterone slowly over time to keep hormone levels stable
Injection every 10–14 weeks (about 4 times per year after initial loading dose)

How Does It Work?

After injection, the testosterone is slowly absorbed over many weeks
This provides a steady, long-lasting hormone level without the need for daily treatment
It's great for men who want convenience and consistency

Dosing Schedule

Initial phase: Two injections 6 weeks apart
Maintenance phase: One injection every 10–14 weeks, depending on response and lab results

Benefits of Nebido

No daily routine or messy application
No risk of skin-to-skin transfer
Fewer fluctuations in testosterone levels
Only 4 injections per year after stabilization

Common Side Effects & What to Do

Injection site discomfort or swelling:
- Mild soreness for 1–3 days is normal
- Apply a warm compress or massage area gently
- Inform the clinic if there’s redness, severe pain, or swelling
Mood changes (irritability or emotional shifts):
- Some men feel emotionally sensitive during hormonal peaks
- Keep track and share with your doctor—it may require adjusting the interval between injections
Increased red blood cell count (high hematocrit):
- May cause headaches, flushing, or fatigue
- Will be checked regularly in blood tests
- If levels are too high, your dose or frequency may be adjusted
Mild fluid retention or weight gain:
- Monitor salt intake and blood pressure
- Report swelling in legs or feet to your doctor
Delayed onset of effect with first dose:
- Because it’s slow-acting, it may take a few weeks to feel full results after the first injection
- Your doctor might add a short-term boost or schedule the second injection earlier (at 6 weeks)

What to Monitor

Testosterone levels: Before and during treatment
Hematocrit and hemoglobin: To monitor red blood cells
PSA test: To monitor prostate health
Mood, energy, libido, and physical changes: Track symptoms and improvement

When to Contact the Clinic

Painful or inflamed injection site
Trouble urinating or prostate symptoms
Mood swings or unusual emotional changes
No symptom improvement after 3 months

How Often Should Nebido Be Injected – Every 10, 12, or 14 Weeks?

The ideal injection interval for Nebido varies by person and depends on both your symptoms and your blood test results. Here's how to decide:

What Determines the Injection Schedule?

Standard maintenance: One injection every 10 to 14 weeks
If symptoms return early (e.g., low energy, poor sleep, low libido, irritability):
→ Injection may be needed sooner, such as every 10–12 weeks
If you feel stable and symptom-free throughout the full period:
→ Injection may be extended to 14 weeks

What Lab Tests Help Decide?

Testosterone level (before your next injection):
- If still within target range → current schedule is fine
- If too low → shorten the interval
Hematocrit (red blood cell count):
- If higher than 54% → injections may need to be spaced out further or dose adjusted