Testosterone Replacement Therapy: What Is It? Who Needs It? How to Do It.

What is it? Testosterone levels begin to decline around age 30 and with that decline comes a constellation of unwanted symptoms that are too often attributed to aging itself. Testosterone replacement therapy (TRT) is used to optimize testosterone levels and return men to some prior level of functioning when testosterone levels were naturally higher. It is important to note that TRT is not used to achieve supra-physiologic levels (as is often the case in instances of abuse) but rather to restore what would have been normative in earlier years.

Who needs it? Most middle-aged men experiencing symptoms of testosterone deficiency qualify for testosterone replacement therapy. A thorough history and laboratory evaluation are needed to determine if a man is a candidate for therapy, but more often than not if a man is experiencing symptoms his testosterone has dropped to a level that warrants optimization. It is important to remember that symptoms can be vague in nature and often manifest as low energy, loss of motivation, etc. early on. By the time sexual symptoms begin to manifest testosterone levels are generally quite low. If TRT is started at a younger age, men can experience its benefits for an extended amount of time and potentially mitigate many age-related issues like weight gain, muscle loss, decreases in bone density, etc.

How to do it? Testosterone is best administered in two ways, either with an injection or topical cream. There are other formulations available, but they tend to be less effective and/or increase the risk of adverse events. Injections can be given either in the muscle (IM) or in the subcutaneous (SQ) fat. Injections given IM are generally done 1x/week whereas ones given SQ are generally 2-3x/week. IM injections are more convenient considering they only need to be done once a week, but they can be painful and difficult to do on yourself. Because of this, men often need to visit a clinic weekly to receive their injections. SQ injections are given with very small needles and quite easy to do on oneself (think of it like giving insulin) and even though they need to be done multiple times a week men tend to find them quite convenient since they can be done at home. The other benefit to giving multiple injections per week is that it more closely mimics the natural release of testosterone producing greater effects and decreased adverse effects (because it is given in lower doses). The cream is an alternative to injections for those who prefer to avoid injections or are at greater risk of adverse effects. The cream reduces the chance of adverse effects even more than SQ injections because of the way it is processed in the body. The drawback of the cream is that it needs to be given twice a day. At first glance, this seems like a lot but with time men tend to work it into their morning and evening routines barely noticing the addition. In any case, therapy should not be approached in a one-size-fits-all manner but rather customized to the patient's specific history, goals, and preferences.