How to Get TRT: Step-by-Step Guide to Testosterone Therapy

Step 1: Recognize the Symptoms of Low Testosterone

Low testosterone does not always announce itself loudly. Fatigue that sleep does not fix, a libido that has quietly dropped over months, difficulty maintaining erections, and a gradual loss of muscle mass despite regular training are the signals most men notice first. Brain fog, depressed mood, and increased body fat, especially around the abdomen, round out the picture.

The American Urological Association (AUA) 2018 guideline on testosterone deficiency defines symptomatic hypogonadism as the combination of low serum testosterone AND clinical symptoms. [1] Symptoms alone are not enough, but they are the reason a clinician will order labs in the first place.

A validated questionnaire called the Aging Males' Symptoms (AMS) scale scores 17 items across somatic, psychological, and sexual domains. Scores above 37 suggest moderate-to-severe symptoms worth investigating. The AMS is not diagnostic on its own, but it helps quantify subjective complaints in a reproducible way.

Keep a two-week symptom log before your first appointment. Note energy levels in the morning versus afternoon, frequency of morning erections, sleep quality, and training performance. This log gives your clinician objective anchors rather than a vague complaint of "feeling off."

Step 2: Order the Right Lab Panel

A single testosterone draw is not enough. Get two fasting, morning draws on separate days.

The reason is straightforward: testosterone follows a circadian rhythm, peaking between 7 and 10 AM and falling by 20 to 40% through the afternoon. [2] A 2 PM draw on a stressed, sleep-deprived man can produce a falsely low result that leads to an unnecessary prescription. Two morning values below 300 ng/dL, collected at least one week apart, meet the laboratory threshold set by the Endocrine Society's 2018 Clinical Practice Guideline. [3]

Your baseline panel should include:

• Total testosterone (primary diagnostic marker)
• Free testosterone (calculated or equilibrium dialysis; relevant when SHBG is suspected to be elevated)
• Sex hormone-binding globulin (SHBG) (high SHBG lowers bioavailable testosterone even when total T looks normal)
• LH and FSH (distinguish primary hypogonadism, testicular failure, from secondary hypogonadism, pituitary or hypothalamic origin)
• Prolactin (elevated prolactin can suppress the hypothalamic-pituitary-gonadal axis)
• Complete blood count (CBC) (baseline hematocrit before starting therapy)
• PSA (baseline for men over 40 before starting testosterone)
• Comprehensive metabolic panel (liver and kidney function)
• Lipid panel (cardiovascular risk context)
• Estradiol (E2) (baseline estrogen; useful for monitoring aromatization on therapy)

Many telehealth platforms, including HealthRX, include this full panel in the intake process. If you are going through a primary care physician, ask specifically for LH, FSH, and prolactin because these are sometimes omitted from a routine "testosterone check."

Step 3: Get a Clinical Evaluation

Lab numbers do not exist in a vacuum. A clinician must correlate your values with your symptoms, medical history, and physical examination findings before prescribing.

The physical exam relevant to TRT is brief but specific. It includes testicular volume assessment (atrophied testes suggest primary hypogonadism), body hair distribution, gynecomastia screening, and a digital rectal exam (DRE) or PSA review in men over 40. The Endocrine Society guideline states: "We recommend measurement of morning testosterone on two separate occasions before initiating testosterone therapy." [3] That guidance reflects the dual requirement of biochemical AND clinical confirmation.

Several absolute contraindications must be ruled out before prescribing. These include:

• Prostate cancer or breast cancer (testosterone is contraindicated per FDA labeling [4])
• Hematocrit above 54% (polycythemia risk)
• Severe obstructive sleep apnea (untreated OSA worsens on testosterone)
• Active desire for fertility in the near term (see the fertility discussion below)
• Severe lower urinary tract symptoms (IPSS score above 19)

If your LH and FSH come back low or low-normal alongside low testosterone, your clinician needs to rule out a pituitary adenoma with an MRI before starting therapy. Elevated prolactin, typically above 20 ng/mL in men, is a red flag that warrants pituitary imaging regardless of LH levels.

Step 4: Choose Your Delivery Method

Testosterone is available in several FDA-approved formulations, each with a different pharmacokinetic profile, administration schedule, cost, and side-effect burden.

Testosterone Cypionate or Enanthate (Intramuscular or Subcutaneous Injection) The most commonly prescribed formulation in the United States. Cypionate is typically dosed at 100 to 200 mg every 7 to 14 days intramuscularly, or 50 to 100 mg weekly subcutaneously. Weekly subcutaneous dosing produces more stable serum levels and is increasingly preferred. Cypionate costs roughly $30 to $60 per month in generic form, making it the most affordable option.

Transdermal Gels (AndroGel 1%, AndroGel 1.62%, Testim, Vogelxo) Applied daily to shoulders, upper arms, or abdomen. AndroGel 1.62% is dosed at 20.25 to 81 mg per day. Gels produce steady daily levels without injection peaks and troughs, but transference to partners or children through skin contact is a documented risk. The FDA issued a black-box warning on gel transference in 2009. [4]

Testosterone Pellets (Testopel) Implanted subcutaneously in the upper buttock every 3 to 6 months. Each pellet delivers 75 mg of testosterone. The in-office procedure takes about 10 minutes. Pellets provide the most stable long-term levels but cannot be quickly adjusted if a problem arises.

Topical Nasal Gel (Natesto) Dosed at 11 mg (5.5 mg per nostril) three times daily. It produces normal serum testosterone levels while partially preserving the LH pulse and, in some studies, sperm production. A 2019 study by Ramasamy et al. found that 90% of men on Natesto maintained sperm concentrations above 15 million/mL at 6 months, compared with near-universal azoospermia in men on injectable testosterone. [5] This formulation is worth considering in younger men who may want biological children.

Testosterone Undecanoate (Aveed, Jatenzo) Aveed is a long-acting intramuscular injection given at 0, 4, and 10 weeks, then every 10 weeks thereafter. Jatenzo is an oral capsule taken twice daily with food. Oral testosterone carries a boxed warning for blood pressure increases; in the key trial, diastolic blood pressure rose by a mean of 3.9 mmHg. [6]

The table below summarizes which delivery method suits which clinical profile. Use it as a starting discussion point with your clinician.

| Delivery Method | Dosing Frequency | Stable Levels | Fertility-Sparing | Cost/Month | |---|---|---|---|---| | Cypionate/Enanthate IM/SC | Weekly | Moderate | No | $30 to $60 | | Transdermal Gel | Daily | High | No | $100 to $400 | | Pellets (Testopel) | Every 3 to 6 months | Very high | No | $400 to $800 | | Natesto nasal gel | 3x daily | Moderate | Partial | $350 to $500 | | Aveed (IM undecanoate) | Every 10 weeks | High | No | $500 to $900 | | Jatenzo (oral) | 2x daily with food | Moderate | No | $500 to $900 |

Step 5: Understand Fertility Implications Before Starting

Exogenous testosterone suppresses the hypothalamic-pituitary-gonadal (HPG) axis. LH drops, FSH drops, and intratesticular testosterone, which is 50 to 100 times higher than serum testosterone and is required for spermatogenesis, falls sharply. The result is oligospermia or azoospermia in the majority of men within 90 days of starting treatment. [7]

This is not a minor footnote. A 2021 review in Fertility and Sterility noted that testosterone is the most commonly used hormonal contraceptive in men, with contraceptive efficacy comparable to female oral contraceptives when azoospermia is achieved. [7] If you have any chance of wanting biological children in the next two to three years, discuss alternatives with your clinician before your first injection.

Options for hypogonadal men who want to preserve fertility include:

• Clomiphene citrate (Clomid, 25 to 50 mg every other day): A selective estrogen receptor modulator that blocks negative feedback at the hypothalamus, raising LH and FSH and thereby stimulating endogenous testosterone production. It preserves spermatogenesis because endogenous production is maintained.
• Human chorionic gonadotropin (hCG, 500 to 1 to 500 IU two to three times weekly): Mimics LH, directly stimulating Leydig cells and maintaining intratesticular testosterone. Often combined with low-dose testosterone.
• Enclomiphene (Androxal): The active trans-isomer of clomiphene; has shown efficacy in raising testosterone while preserving sperm counts in phase III studies.

Bank sperm before starting TRT if there is any ambiguity about future fertility plans.

Step 6: Start Therapy, Titrate, and Monitor

Once you and your clinician agree on a delivery method and starting dose, therapy begins. The first dose is not the final dose. Virtually every man requires at least one dose adjustment in the first three to six months.

Monitoring timeline:

• 6 to 8 weeks after starting: Draw a mid-cycle (for injections, a trough level drawn just before the next injection) or steady-state (for gels, drawn 2 to 4 hours after application) testosterone level. Target trough for injections is 400 to 700 ng/dL. The Endocrine Society specifies a target of 400 to 700 ng/dL for mid-range physiological replacement. [3]
• 3 months: Recheck testosterone, hematocrit, PSA. Hematocrit above 54% requires a dose reduction or dose-interval extension, phlebotomy, or both.
• 6 months: Repeat full panel including lipids, metabolic panel, testosterone, hematocrit, PSA.
• 12 months: Bone density (DEXA scan) is recommended in men with osteoporosis risk factors or baseline low bone density.
• Annually thereafter: Testosterone, hematocrit, PSA, and lipids at minimum.

The T-TRIALS (Testosterone Trials), a coordinated set of seven randomized, placebo-controlled trials in 788 hypogonadal men aged 65 and older, found that testosterone treatment for one year significantly improved sexual function, physical capacity, and bone mineral density compared with placebo. [8] These trials remain the most rigorous evidence base for TRT efficacy in older men.

The AUA guideline recommends against prescribing testosterone to men with a hematocrit above 54% and advises withholding therapy in men with PSA above 3.0 ng/mL until urology evaluation is complete. [1]

Step 7: Manage Common Side Effects

Side effects on TRT are real, predictable, and mostly manageable when monitored properly.

Erythrocytosis (elevated red blood cell count) is the most common laboratory abnormality. Injections carry a higher risk than gels because of higher peak testosterone levels. If hematocrit exceeds 54%, standard options are dose reduction, switching delivery method, therapeutic phlebotomy (donating blood), or, less commonly, adding low-dose aspirin. The TRAVERSE trial (N=5,204), a cardiovascular safety trial of testosterone undecanoate published in the New England Journal of Medicine in 2023, found a significantly higher incidence of pulmonary embolism in the testosterone group (0.9% versus 0.5%, P<0.05), highlighting the importance of monitoring hematocrit. [9]

Estradiol elevation occurs because aromatase converts testosterone to estradiol, particularly in adipose tissue. Symptoms include nipple sensitivity, water retention, and mood changes. An estradiol above 40 pg/mL with symptoms may prompt a discussion about aromatase inhibitors (anastrozole 0.25 to 0.5 mg twice weekly is the typical starting dose), though routine use of aromatase inhibitors in TRT is not endorsed by the Endocrine Society because excessive estrogen suppression negatively affects bone density, libido, and cardiovascular lipid profiles.

Testicular atrophy is common and expected. Adding hCG at 500 IU two to three times weekly can preserve testicular volume in men bothered by this side effect.

Skin and injection-site reactions are minor with subcutaneous injections. Rotating injection sites (lateral thigh, abdomen, deltoid) reduces localized irritation.

Sleep apnea worsening has been reported, particularly in men with pre-existing OSA. Screen for new or worsening sleep apnea symptoms at each follow-up visit.

Step 8: Know When TRT Is Not the Right Answer

Not every man with a testosterone level below 300 ng/dL needs TRT. Obesity, sleep deprivation, chronic illness, excessive alcohol, and opioid use all suppress testosterone, sometimes dramatically. A man with a BMI of 38 and total testosterone of 280 ng/dL may see his level rise to 420 ng/dL after losing 15% of his body weight. A 2014 study in the European Journal of Endocrinology found that weight loss of 10% or more restored testosterone to normal ranges in 50% of obese hypogonadal men without any exogenous hormone. [10]

Before committing to a lifelong prescription, address modifiable contributors:

• Sleep 7 to 9 hours per night (sleep restriction below 5 hours drops testosterone by 10 to 15% after one week [11])
• Reduce alcohol to fewer than 14 units per week
• Treat obstructive sleep apnea with CPAP
• Reduce BMI to below 30 if possible
• Discontinue opioids if clinically feasible
• Review all medications; glucocorticoids, ketoconazole, and certain antidepressants suppress the HPG axis

If testosterone remains below 300 ng/dL after addressing these factors for three to six months, the case for TRT becomes considerably stronger.

How to Access TRT: In-Person Clinic vs. Telehealth

Both pathways lead to a legal prescription. The differences are cost, convenience, and depth of examination.

An endocrinologist or urologist visit involves an in-person physical exam, which is the standard of care for initial evaluation. Wait times range from two to eight weeks in most metropolitan areas. This pathway is appropriate for men with secondary hypogonadism (low LH, pituitary concerns), very high PSA values requiring urological workup, or significant comorbidities.

Telehealth TRT clinics, including HealthRX, can complete intake labs, a video or asynchronous clinical evaluation, and a same-week prescription for straightforward primary hypogonadism. The Endocrine Society notes that testosterone therapy is appropriate when initiated and monitored by "any trained clinician," not exclusively by subspecialists. [3] Telehealth is a reasonable starting point for otherwise healthy men with straightforward low testosterone and no contraindications.

Regardless of pathway, the physician who signs your prescription is legally and ethically responsible for reviewing your lab work, confirming the absence of contraindications, and establishing a monitoring schedule. A service that ships testosterone without labs or a clinician review is operating outside medical and legal standards.

What Does TRT Actually Cost?

Cost varies widely by formulation, insurance coverage, and whether you use a telehealth or brick-and-mortar provider.

• Generic testosterone cypionate: $30 to $60 per month through most pharmacies, often covered by insurance when the diagnosis is documented.
• Transdermal gels (brand): $200 to $400 per month without insurance; generic gels are approximately $50 to $100.
• Pellets (Testopel): $400 to $800 per insertion procedure, usually every 4 to 6 months.
• Aveed: Typically requires specialty pharmacy; cost can reach $900 per month without coverage.
• HealthRX monthly membership: Includes provider visits, monitoring guidance, and prescription coordination. Verify current pricing at healthrx.com.

GoodRx coupons routinely bring generic cypionate below $40 per month at major pharmacy chains, making injectable testosterone the most accessible option on cost grounds alone.