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Testosterone Replacement Therapy Options Explained

Testosterone replacement therapy (TRT) is available as injectable, topical gel or cream, transdermal patch, buccal tablet, or subcutaneous pellet. Each delivers testosterone by a different route with trade-offs in convenience, cost, and the steadiness of levels. An endocrinologist or urologist selects the right form based on labs, symptoms, and health history.

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Who is testosterone replacement therapy for?

TRT is prescribed for hypogonadism — a condition in which the body does not produce enough testosterone. Symptoms can include fatigue, decreased sex drive, difficulty concentrating, loss of muscle mass, and mood changes. Diagnosis requires more than one low morning testosterone blood test, along with symptoms that match. The American Urological Association and the Endocrine Society both recommend confirming low levels on at least two separate occasions before starting treatment 12.

What are the main delivery methods?

Intramuscular or subcutaneous injections are typically given every one to two weeks (short-acting formulations such as testosterone cypionate or enanthate) or every ten weeks (long-acting testosterone undecanoate). Injections tend to be less expensive but can produce a cycle of higher levels shortly after the injection and lower levels near the next dose.

Topical gels and creams are applied daily to the shoulders, upper arms, or abdomen. They produce more stable day-to-day levels than injections but carry a transfer risk — the gel can be passed to a partner or child through skin contact before it dries.

Transdermal patches are applied to the skin each day. They offer steady absorption but can cause skin irritation at the application site.

Buccal tablets adhere to the gum twice daily and release testosterone through the oral mucosa.

Subcutaneous pellets are implanted under the skin every three to six months in an outpatient procedure. Levels are generally stable between placements.

Your clinician's choice depends on your lifestyle, preference for injection, skin sensitivity, and whether a partner or child might have skin contact.

What does TRT actually do in the body?

Testosterone binds to androgen receptors in muscle, bone, brain, sexual organs, and other tissues. Replacement brings low levels back into a physiological range and can improve symptoms of hypogonadism — energy, mood, libido, muscle strength, and bone density. It does not reverse all causes of low testosterone, and response varies among individuals. The goal is the lower-normal range for age, not supraphysiologic levels.

What are the risks and side effects?

TRT suppresses the body's own testosterone production and can reduce sperm production, which matters for men who want to father children. Other possible effects include:

  • Increased red blood cell count (erythrocytosis), which requires monitoring
  • Acne or oily skin
  • Fluid retention
  • Breast tissue enlargement (gynecomastia)
  • Sleep apnea worsening
  • Skin irritation at application sites (gels, patches)

Cardiovascular safety has been studied extensively. A 2024 meta-analysis of randomized trials found no significant increase in major adverse cardiovascular events with TRT in hypogonadal men, though the picture continues to evolve and patients with established cardiovascular disease require individualized risk discussion 3.

Prostate considerations: TRT is contraindicated in men with known or suspected prostate cancer. PSA and hematocrit are typically monitored after starting therapy.

What about fertility?

Exogenous testosterone suppresses the pituitary signals (LH and FSH) that drive sperm production. For men who want biological children, this is an important consideration. Alternative approaches — such as human chorionic gonadotropin (hCG) or clomiphene — can raise endogenous testosterone levels while preserving sperm production. A urologist or reproductive endocrinologist can discuss these options 2.

How is TRT monitored?

Once therapy starts, follow-up blood work typically checks testosterone levels, hematocrit (red blood cell concentration), and PSA at regular intervals — often at three and six months and then annually. Dose or delivery method adjustments are common in the first year as clinician and patient find the right balance. Self-adjusting doses or skipping monitoring is not advisable.

Where does Gale fit in?

TRT is managed by a specialist — typically an endocrinologist or urologist. Gale can help you prepare for that appointment: understanding your lab values, thinking through questions to ask, and knowing what information to bring. If you are not sure which specialist to see first, a Gale primary care clinician can help with initial evaluation and a referral.

Common questions

Is TRT the same as anabolic steroid use?

No. TRT replaces testosterone to a normal physiological range in men who are genuinely deficient. Anabolic steroid use involves much larger supraphysiologic doses, typically without a medical diagnosis of deficiency, and carries different and greater health risks.

Will I need to be on TRT forever?

Many men who start TRT continue it long-term because the underlying condition does not resolve on its own. Some men with secondary hypogonadism (caused by a correctable problem elsewhere) may be able to discontinue. Stopping abruptly is not recommended — your clinician will guide any taper.

Can TRT cause prostate cancer?

Current evidence does not confirm that TRT causes prostate cancer in men without pre-existing disease, but it is contraindicated if prostate cancer is known or suspected. PSA monitoring during treatment is standard practice.

Does insurance cover testosterone therapy?

Coverage varies. Injections are generally the least expensive option and are widely covered when hypogonadism is confirmed. Gels and pellets vary by plan. Your clinician's office can help with prior authorization if needed.

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When to contact your clinician

  • —Chest pain, shortness of breath, or leg swelling after starting TRT
  • —Significant difficulty breathing or new or worsening snoring — TRT can worsen sleep apnea
  • —Symptoms of high red blood cell count: headache, flushing, dizziness, or vision changes
  • —Pain, redness, or swelling at an injection site that does not resolve
  • —New urinary symptoms — difficulty urinating or weak stream

If you develop chest pain, trouble breathing, or signs of stroke (face drooping, arm weakness, speech difficulty), call 911.

This article provides general health information and is not a substitute for personalized medical advice. Testosterone replacement therapy is a prescription treatment that requires a diagnosis, individualized risk discussion, and ongoing monitoring by a qualified clinician.

References

  1. 1.Mulhall JP, Trost LW, Brannigan RE, Kurtz EG, Redmon JB, Chiles KA, Lightner DJ, Miner MM, Murad MH, Nelson CJ, Platz EA, Ramanathan LV, Lewis RW (2018). Evaluation and Management of Testosterone Deficiency: AUA Guideline. Journal of Urology. doi:10.1016/j.juro.2018.03.115 ✓Diagnosis of hypogonadism requires confirmed low testosterone on two occasions with compatible symptoms
  2. 2.Bhasin S, Brito JP, Cunningham GR, Hayes FJ, Hodis HN, Matsumoto AM, Snyder PJ, Swerdloff RS, Wu FC, Yialamas MA (2018). Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism. doi:10.1210/jc.2018-00229 ✓Endocrine Society guidance on delivery methods, monitoring, fertility considerations, and fertility-preserving alternatives
  3. 3.Jaiswal V, Sawhney A, Nebuwa C, Borra V, Deb N, Halder A, Rajak K, Jha M, Wajid Z, Thachil R, Bandyopadhyay D, Mattumpuram J, Lavie CJ (2024). Association between Testosterone Replacement Therapy and Cardiovascular Outcomes: A Meta-analysis of 30 Randomized Controlled Trials. Progress in Cardiovascular Diseases. doi:10.1016/j.pcad.2024.04.001 ✓2024 meta-analysis of 30 RCTs found no significant increase in major adverse cardiovascular events with TRT

3 sources, numbered by first appearance. General health information, not medical advice — synthetic demonstration content.