Men’s Testosterone Therapy

Diagnosis requires more than one number. Testosterone peaks in the morning and varies substantially day to day, so a single low reading — particularly one drawn in the afternoon — is not a diagnosis. We need at least two fasted morning samples genuinely below range, alongside symptoms that fit: reduced libido, erectile difficulty, loss of morning erections, falling muscle mass, low energy and flattened mood. LH and FSH tell us whether the problem originates in the testes or the pituitary, which occasionally uncovers something that needs investigating in its own right.

Symptoms alone are a poor guide because so much overlaps with other conditions. Obesity, untreated sleep apnoea, poor sleep, heavy alcohol use, depression, thyroid disease, iron deficiency and opioid use all lower testosterone or mimic deficiency. In a meaningful proportion of men, treating sleep apnoea or losing significant weight raises testosterone without any prescription at all. Skipping that step means committing to lifelong therapy for a reversible problem.

Where treatment is indicated, we aim for the middle of the physiological range — not the top of it, and certainly not above. Supraphysiologic dosing raises haematocrit and cardiovascular risk without improving symptoms further. Injections, gels and creams all work; injections are cheaper and more consistent, gels avoid needles but transfer to partners and children on skin contact, which matters in households with young kids.

Two consequences need stating before you start rather than afterwards. Exogenous testosterone suppresses sperm production and can cause infertility, sometimes persistently — if you may want children, this changes the plan and there are alternatives that preserve fertility. And therapy is generally long-term: stopping usually returns symptoms, often temporarily worse, because your own production has been suppressed. Starting is a durable commitment, and we would rather you understood that at the outset.