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Testosterone Replacement Therapy Guidelines

testosterone replacement therapy guidelines

To benefit from testosterone replacement therapy (TRT), guys first need an accurate diagnosis of low testosterone—a.k.a. hypogonadism. Put simply, identifying the symptoms and confirming the lab work is job one.

The elephant in the room is distinguishing between normal age-related declines in testosterone and true hypogonadism. In layman’s terms, diagnosing hypogonadism boils down to two things: symptoms and numbers.

  • Physical signs: Several physical symptoms point to potential hypogonadism, including:
  • Reduced sexual function and libido. This involves problems with erections, ejaculations, sexual desire or activity.
  • Fatigue. Many men report unexplained exhaustion or lack of energy.
  • Decreased muscle mass. Loss of strength and muscle tone over time.
  • Diminished bone density. Higher risk of osteoporosis and fractures.

The caveat: Overlap exists between aging and hypogonadism. So symptoms alone don’t clinch a diagnosis. That’s where lab tests come in. Measuring three key hormone levels helps paint an objective picture:

  • The caveat: Overlap exists between aging and hypogonadism. So symptoms alone don’t clinch a diagnosis. That’s where lab tests come in. Measuring three key hormone levels helps paint an objective picture:
  •  Free testosterone: Reflects biologically active testosterone. May be more useful than total testosterone, especially for “functional hypogonadism.”
  • Luteinizing hormone (LH): Can indicate the cause (primary vs. secondary hypogonadism). May be high, normal or low.

A careful and holistic diagnostic approach based on symptoms, physical exam findings and robust laboratory testing represents the foundation of effective testosterone replacement therapy.

When TRT May Be Indicated 

Once hypogonadism has been diagnosed, clinicians must determine if testosterone replacement therapy (TRT) is appropriate. Candidates typically share two things in common:

Symptoms suggestive of testosterone deficiency

TRT should generally not be prescribed based only on low testosterone levels. Patients should exhibit clinical manifestations related to low testosterone, including:

  • Low libido and sexual dysfunction  
  • Fatigue   
  • Depressed mood    
  • Diminished muscle mass and strength
  • Decreased bone mineral density

Testosterone levels in the hypogonadal range

Diagnosis requires finding consistently low total and/or free testosterone levels. Measurements should ideally be taken in the morning for accuracy.

Specific patient populations that may benefit from TRT include: 

However, prescribing TRT solely based on testosterone levels in the aging male population remains unsupported by  definitive evidence and guidelines.  

Overall clinicians should weigh a patient’s:

  • Symptoms     
  • Comorbidities   
  • Risks versus benefits    
  • Life expectancy    
  • Patient preferences  

Before recommending TRT. When used judiciously and monitored closely, testosterone therapy represents an option that can significantly improve quality of life for men with classic hypogonadism or symptomatic age-related low testosterone.

When Not to Prescribe TRT

While testosterone replacement therapy (TRT) benefits many men with low testosterone, it’s not the right choice for everyone. Here are key groups that should generally avoid TRT:  

Untreated prostate and breast cancer: Testosterone can stimulate the growth of some cancers, including prostate and breast cancer. So TRT is contraindicated in men with untreated cases of these cancers.  

Several heart failure: Severe congestive heart failure is a relative contraindication due to theoretical concerns TRT could worsen symptoms. However, some research suggests these worries may be overblown.   

History of prostate cancer: Men with a prior history of treated prostate cancer should be closely monitored during TRT due to the theoretical risk of cancer recurrence or progression.    

Elevated PSA: Men with PSA levels over 4 ng/mL are generally not considered candidates for TRT until an urologist rules out prostate cancer.          

There are other potential “red flags” indicating a patient may not be a suitable candidate for TRT. These include:

  • Enlarged or indurated prostate on physical exam
  • Elevated hematocrit over 54% 
  • Obstructive sleep apnea
  • Active liver disease
  • Severe lower urinary tract symptoms  

Overall, clinicians should weigh the potential benefits versus risks of TRT for each unique patient presentation based on:

  • PSA levels
  • Digital rectal exam 
  • Imaging studies
  • Prostate biopsy results (if indicated)
  • Patient preferences

While TRT can considerably improve quality of life in select patients, it should generally be avoided in those with underlying conditions that could be exacerbated by testosterone therapy or those with an elevated risk of complication. An individualized approach is key.

Monitoring is Medication: Make Sure TRT Works For You

Correctly monitoring TRT means more than just checking testosterone levels—though that part is essential. Done right, consistent follow-up helps maximize benefits, reduce risks and ensure this treatment continues working for you over the long haul.   

Let’s unpack what proper monitoring of testosterone therapy involves:

Labs tests: Periodic measurement  (every 3-6 months) of total serum T levels ensures your medication dose is correctly adjusted to maintain levels in the mid-normal range. 

PSA test: Screening yearly to monitor for prostate issues    

Hematocrit:  Makes sure your red blood cell count doesn’t become elevated, increasing risk of blood clots   

Physical exams: Your doc should do checkups periodically (every 6-12 months) after starting TRT. They look to confirm:    

  • Normal prostate size     
  • No signs of prostatic abnormalities    
  • No underlying prostate conditions worsened  

Symptom check: Your physician will check in to see how you’re feeling and functioning. Are the benefits you hoped for actually materializing? And have any side effects developed? Honest feedback is crucial.

Treatment changes: Based on lab results, physical exams and your feedback, your doctor may need to:  

Adjust your dosage  – either higher or lower     

Change the route of testosterone administration (switching from gel to injections, for example)

Correct and consistent monitoring before, during and after starting TRT allows physicians to identify issues early, tweak your treatment plan as needed and give you the best chance for a safe and successful outcome. Don’t go it alone!

Testosterone Replacement Therapy: Different Methods, Similar Results

Several different methods exist for administering testosterone replacement therapy—and each has pros, cons and suitability for certain patients. The options include:  

Injections: Testosterone injections remain the most effective form of TRT, with higher testosterone levels and fewer side effects than other options. They’re given every 1-4 weeks, either by a health professional or self-administered at home.   

Skin patches: Testosterone patches adhere directly to the skin and slowly release the hormone into the bloodstream. Patches must be replaced daily and can cause skin irritation in some men.     

Gels: Testosterone gel is applied topically, usually to the upper arms and shoulders each morning. Absorption rates may vary and contact with others requires caution.     

Pellets: Tiny pellets containing testosterone are implanted subcutaneously every 3-6 months. After insertion, the pellets slowly release T into the body at a steady rate.    

Buccal system: A tablet is placed between the inside of the cheek and gum to deliver testosterone. Absorption can vary significantly between individuals.    

The important thing to remember is this: while the method of delivering testosterone differs,  the physiological effects—increased energy, libido, muscle mass, etc.—remain largely the same.   

You and your doctor should consider factors like:   

  • Cost  
  • Therapy adherence
  • Preferred method
  • Risk of side effects    
  • Partner/family concerns

When choosing the testosterone administration option that best suits your needs, lifestyle and specific situation. No single delivery system works best for all men—so discussing your preferences with an expert can help ensure you find the optimal treatment approach.

How Long Will Testosterone Therapy Last?

The optimal duration of testosterone replacement therapy remains somewhat unclear due to a lack of long-term studies. Here are the main considerations regarding the timeline of TRT:  

Trial period: Clinicians typically recommend an initial trial period of 3 to 6 months to determine how well a patient responds to testosterone therapy. This allows time for  benefits  to manifest and for side effects to develop.

Maintenance therapy:  For patients who experience clear benefits from TRT, guidelines recommend continuing therapy as long as the benefits outweigh the risks. This involves ongoing monitoring and adjustments as needed.   

Lifelong treatment: Some clinicians consider TRT a lifelong treatment for classically hypogonadal men for as long as their health allows. However, others argue benefits diminish over time and the risks may ultimately  outweigh rewards.

Cyclical therapy: Some emerging research indicates cyclical, “on-off” approaches may maximize benefits while minimizing side effects and costs over the long term. However, these strategies are not well studied.

Uncertainties of TRT DurationFor most men, TRT represents a long-term commitment with indefinite duration. Specific timelines for likely response and optimal continuation remain unclear due to factors such as variability in patient and treatment factors, lack of well-designed, long-term studies, and limited expertise and experience among providers.
Decisions on Therapy DurationDecisions regarding the appropriate duration of therapy must weigh a patient’s unique circumstances and goals, potential risks and benefits over time, treatment effectiveness and side effects, and expert opinion and clinical judgment.
Best ApproachThe best approach involves a frank and ongoing discussion between patients and their healthcare providers to personalize care and re-evaluate at appropriate intervals.

Certain Lifestyle Changes Can Boost the Effectiveness of TRT  

While testosterone replacement therapy is often necessary for men with classic hypogonadism, some lifestyle modifications can help you get the most out of your treatment:   

Exercise regularly: Weight-bearing and resistance training can significantly increase testosterone levels naturally. Keep working out even after starting TRT to maximize benefits.      

Maintain a healthy weight: Excess body fat converts testosterone into estrogen, lowering levels. So getting to a normal BMI through diet and exercise can optimize your response to treatment.

Eat a nutritious diet: A balanced diet high in lean protein, healthy fats, and low glycemic index carbs can  help boost testosterone while also supporting overall health.   

Reduce stress: Chronic stress suppresses testosterone levels, so practicing relaxation techniques, mindfulness and avoiding excessive worry can enhance TRT effectiveness.       

Get adequate sleep: Hormone production follows a natural circadian rhythm, so 7-8 hours of sleep per night  can help TRT work as intended by syncing your body clock.

Talk to your doctor: Lifestyle modifications are not one-size-fits-all and may interact with TRT in unknown ways. Discussing your plans openly with your provider will ensure you adopt a personalized, coordinated approach.   

While medication allows replacing missing testosterone, there are habitual changes within your control that could further optimize your levels, side effect profile and overall outcomes on therapy. 

Even small adjustments like exercising more or improving your diet could make a meaningful difference when combined  with TRT. However, always proceed cautiously and in close consultation with your healthcare team to prevent potential issues.

Stop Suffering the Effects of Low T: We Can Help

If you think you’re experiencing symptoms of low testosterone and suspect hypogonadism, Physicians Rejuvenation Centers provides a comprehensive, personalized evaluation and treatment approach to testosterone replacement therapy. 

Our team of experts will listen carefully to your concerns, review your medical history and run the appropriate laboratory and physical exams needed to determine if TRT is right for you.  

With years of experience treating patients for low testosterone, we understand it’s not a “one-size-fits-all” condition. Our goal is to partner closely with you to develop a customized treatment plan leveraging testosterone therapy, along with appropriate lifestyle changes and monitoring strategies, to optimize benefits while minimizing risks.  

Don’t continue to struggle with the symptoms of low testosterone. Contact Physicians Rejuvenation Centers today to schedule your initial consultation and take the first step toward regaining the energy, strength and quality of life you deserve. We look forward to helping you feel like yourself again.