In short
- Treatment is considered, not assumed. Symptoms plus two low morning levels, and benefit is more likely below 200 ng/dL.
- What improves is modest. Libido and sexual activity clearly, mood and walking slightly, anaemia and bone density measurably.
- What does not improve. Vitality and cognition did not change in the trials, and blood sugar did not either.
- Real risks exist. More pulmonary emboli, more atrial fibrillation and more fractures in the largest trial, though no rise in heart attacks or strokes.
- Weight loss first, often. Obesity lowers testosterone reversibly and is far more common than age related deficiency.
Treatment Overview
When testosterone treatment is on the table
Only where there are symptoms of deficiency together with early morning testosterone below the normal range on at least two occasions.
Benefit is more likely the lower the level, particularly below 200 ng/dL. Men in the borderline band get less from treatment while carrying the same risks, which is the honest reason many are told no.
What the trials actually found
Two large studies define what is known. The Testosterone Trials treated 788 men over 65 with low levels for a year. TRAVERSE treated 5204 middle aged and older men with cardiovascular disease or risk factors for an average of 33 months.
| Outcome | Result |
|---|---|
| Sexual desire and activity | Moderate improvement, clinically meaningful |
| Erectile function | Improved to a lesser extent |
| Mood and depressive symptoms | Small improvement |
| Walking distance | Improved slightly across the whole group, not in the physical function trial alone |
| Unexplained anaemia | Clear benefit. 54 percent had a meaningful haemoglobin rise against 15 percent on placebo |
| Spine bone density | Increased 7.5 percent against 0.8 percent on placebo over a year |
| Vitality and energy scores | No significant improvement in the vitality trial |
| Memory and cognition | No improvement |
| Blood sugar | No improvement, and no reduction in progression from prediabetes to diabetes |
That table is worth reading twice, because it contradicts most of what is advertised. Testosterone does not fix energy, focus or metabolic health in older men with low levels.
The risks, from the same trials
- Major cardiovascular events were not increased. Heart attack, stroke and cardiovascular death occurred at similar rates.
- Pulmonary embolism and atrial fibrillation were more common on testosterone.
- Fractures were more common: 3.5 percent against 2.46 percent, most often ankles, wrists and ribs. That is despite bone density improving, which remains unexplained.
- Coronary plaque. In a substudy of 170 men, non calcified plaque volume increased more on testosterone over a year, though half already had severe atherosclerosis at the start.
- Prostate cancer occurred at similar rates, though men at high risk were excluded from the trial.
- Erythrocytosis was uncommon in both trials, because doses were kept within the normal range.
How the decision is made
- Confirm the diagnosis with correctly timed, repeated morning tests.
- Identify and treat the reversible causes first, especially obesity, sleep apnoea, alcohol and medication.
- Weigh the specific benefits you are hoping for against the specific risks that apply to you.
- If treatment goes ahead, minimise the risks: prostate assessment first, haematocrit monitored, dose kept in the normal range, and osteoporosis treatment where fracture risk is high.
Men who have had a previous blood clot are considered for preventive anticoagulation before starting.
Who Is a Good Candidate?
- You have symptoms of deficiency and two low morning testosterone values, ideally below 200 ng/dL.
- Reduced libido is one of your main complaints, since that is where the benefit is clearest.
- You have unexplained anaemia alongside low testosterone.
- You have low bone density and low testosterone.
- The reversible causes have been addressed and the symptoms remain.
- You want testosterone for energy, focus or blood sugar. The trials did not show benefit in any of those.
- You have a history of prostate cancer, or breast cancer.
- You have had a previous blood clot and have not discussed preventive anticoagulation.
- You are trying to conceive. Testosterone suppresses sperm production.
- Your levels are borderline and your weight, sleep and alcohol have not been addressed first.
What Happens During the Consultation
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1
The full picture
Symptoms and their timeline, with particular attention to libido and morning erections. Sleep and snoring, mood, alcohol, training, weight history and every medication.
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2
Correct diagnosis
Morning fasting testosterone repeated, LH and FSH, thyroid, prolactin, iron studies, blood count, HbA1c and lipids. A very low level in a younger man may prompt pituitary imaging.
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3
Reversible causes first
Obesity, untreated sleep apnoea, heavy alcohol and suppressive medication. Addressing these often raises testosterone without hormone therapy and avoids a lifelong treatment.
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4
A balanced decision
What you are hoping for, what the evidence says you would actually get, and which risks apply to you. Prostate assessment, baseline haematocrit and clot history before anything is prescribed.
Program Structure & Follow-Up
If treatment starts
- Two to three months. Testosterone level and symptoms, aiming for a mid normal value around 400 to 700 ng/dL rather than the top of the range.
- Three to six months. Haematocrit, and PSA at three months in men over 50 or over 40 at higher risk.
- One year. Prostate reassessment where indicated, and bone density reassessment after two years if it was low.
- Every 6 to 12 months once stable.
Full detail is on the testosterone replacement therapy page.
Judging whether it worked
The measure is whether the symptom that brought you in has changed, not whether the number moved.
If the level is now normal and libido, mood or anaemia have not improved, the honest conclusion is that testosterone was not the cause. The dose is not pushed higher in that situation, and stopping is discussed.
The non hormonal half of the plan
Regardless of whether testosterone is prescribed, these are worked on because they move the same symptoms.
- Weight around the middle, which affects testosterone directly and reversibly.
- Sleep, including formal assessment for apnoea where the history suggests it.
- Resistance training, which changes body composition and function independently of hormones.
- Alcohol.
- Blood pressure, lipids and glucose, treated on their own merits.
Benefits, Limits & Safety
What treatment realistically delivers
- Better libido and sexual activity, which is the most reliable benefit.
- Correction of unexplained anaemia in a majority of those affected.
- Improved bone density, particularly at the spine.
- Small improvements in mood and walking.
What it does not deliver
- Vitality and general energy did not improve in the vitality trial.
- Memory and cognitive function did not improve.
- Blood sugar did not improve, and progression from prediabetes to diabetes was not reduced.
The risks in plain terms
- Clots. More pulmonary emboli on testosterone. Men with a previous clot are considered for preventive anticoagulation first.
- Atrial fibrillation. More common on treatment.
- Fractures. More clinical fractures despite better bone density, most often ankles, wrists and ribs. Men at high fracture risk should also receive osteoporosis treatment.
- Prostate. Volume and PSA rise towards age expected values, and monitoring is done for that reason.
- Red cell concentration. Kept in check by keeping the dose within the normal range and measuring haematocrit.
- Fertility. Suppressed, and not guaranteed to recover quickly.
The regulatory position
After the cardiovascular results, the black box warning on testosterone products was removed. Approval for age related low testosterone specifically was still not granted, which tells you where the evidence sits.
What the trials showed
Clear benefit for libido, unexplained anaemia and spine bone density. Small gains in mood and walking. No improvement in vitality, cognition or blood sugar.
How treatment is followed
Testosterone and symptoms at 2 to 3 months, haematocrit at 3 to 6 months, PSA at 3 months and 1 year where age requires it, then every 6 to 12 months.
When it is not used
History of prostate or breast cancer, active desire to conceive, and men with normal levels. Previous blood clots require a plan before any treatment starts.
Cost & Program Investment
Cost depends on the tests required, whether treatment is prescribed, the preparation and the monitoring, so a single number on a website would be misleading. You get the full figure in the consultation before anything is started, and there are no charges you have not been told about.
Frequently Asked Questions
Probably not on its own. In the Testosterone Trials, vitality and energy scores did not improve significantly, and neither did memory or cognition. Libido, anaemia and bone density did improve. That gap between expectation and evidence is worth knowing before you start.
Benefit is more likely the lower the level, particularly below 200 ng/dL. In the borderline range the gains are smaller while the risks are unchanged, which is why many men in that band are advised against it.
In TRAVERSE, with 5204 men followed for an average of 33 months, major cardiovascular events were not increased. Pulmonary emboli and atrial fibrillation were more common. A smaller substudy found greater growth in non calcified coronary plaque over one year.
Bone density improved clearly, with spine trabecular density up 7.5 percent against 0.8 percent on placebo over a year. Confusingly, clinical fractures were more common on testosterone in TRAVERSE, mostly ankles, wrists and ribs. Men at high fracture risk should also be on osteoporosis treatment.
No. In a TRAVERSE substudy, testosterone did not improve glycaemia and did not reduce progression from prediabetes to diabetes. Weight loss does both.
Very often yes. Obesity lowers testosterone both by reducing the binding protein and by suppressing the pituitary signal, and that is reversible. Starting hormones instead of addressing it means a lifelong therapy for a fixable problem.
Testosterone suppresses sperm production and recovery is not guaranteed to be quick. If you may want children, that conversation happens before anything is prescribed.
Not specifically. After the cardiovascular safety results the black box warning was removed, but approval for age related hypogonadism was still withheld. That is an accurate summary of where the evidence stands.
By whether the symptom that brought you in has changed. If your level is normal and libido, mood or anaemia have not improved, testosterone was not the cause and the dose is not pushed higher.
Yes, and where a reversible cause was found and treated, stopping is planned deliberately. Where the deficiency is permanent, symptoms return after stopping.
If you are over 50, or over 40 with a first degree relative who had prostate cancer, yes. PSA and examination before treatment, then at three months and one year.
It depends on the tests, whether treatment is prescribed, the preparation and the monitoring, so a single figure would be misleading. You get the full cost in the consultation before anything starts.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.