Testosterone Therapy: What Men Should Understand Before Starting

Testosterone therapy is one of the most over-marketed and under-explained treatments in men's health. The "low T" billboards make it sound like a refill. It isn't.

TRT works. For the right patient, it can meaningfully improve energy, mood, body composition, sexual function, and quality of life. It's also a lifelong commitment with real tradeoffs that deserve a full conversation before the first injection.

This is the version of that conversation I want every patient to have.

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What testosterone actually does

Testosterone is an androgen produced primarily by the testes under signaling from the hypothalamus and pituitary — the HPG axis. It acts on receptors throughout the body, not just the reproductive system:

• Supports muscle mass and strength
• Maintains bone density
• Regulates libido and erectile function
• Influences mood, motivation, and cognition
• Supports red blood cell production
• Modulates fat distribution and insulin sensitivity

When testosterone drops — from age, chronic stress, sleep apnea, metabolic dysfunction, or medication effects — the symptoms can be diffuse and easy to dismiss as "just getting older."

They're not "just getting older." They're treatable. But how I treat matters.

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How TRT actually works (and what shuts off)

Exogenous testosterone tells your hypothalamus and pituitary that there's already plenty around. They respond by reducing LH and FSH — the signals that drive your testes to produce testosterone and sperm.

The result:

• Your endogenous testosterone production declines, often substantially.
• Sperm production declines and can stop.
• The testes shrink.

This is reversible in many men, but not all, and not predictably. Which is why fertility has to be a planned conversation, not an afterthought.

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Before you start: the conversation no one has with you

A good TRT workup answers these questions before the first injection:

1. Is this actually low testosterone — or something else? Sleep apnea, untreated diabetes, severe stress, opioid use, and several medications all suppress testosterone. Sometimes the right treatment isn't TRT.

2. What's your fertility plan? If children are in your future, TRT alongside hCG or enclomiphene protects the HPG axis differently than TRT alone. Plan first.

3. What's your baseline? Total testosterone, free testosterone, SHBG, estradiol, LH, FSH, prolactin, hematocrit, PSA (age-appropriate), lipid panel, fasting glucose/A1c, and a metabolic panel. "Total T" alone isn't enough.

4. Are you a candidate for restoring your own production instead? For some men, clomiphene or enclomiphene can raise endogenous testosterone without shutting the HPG axis off. It's not for everyone, but it should be on the table.

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Forms of TRT — real tradeoffs

There is no universally best form. Each has tradeoffs:

Injections (testosterone cypionate or enanthate) Most predictable serum levels. Twice-weekly small doses tend to feel better than weekly. Requires comfort with self-injection.

Topical gels and creams Daily application. Steady levels. Real transference risk to partners and children — needs to be taken seriously.

Pellets Implanted every 3–6 months. Convenient. But dosing is not adjustable once placed, and patients sometimes run "high" early and "low" late in the cycle.

Oral testosterone undecanoate Newer, viable for some patients. Different absorption profile and cost considerations.

The right form is the one that fits your life, your goals, and your tolerance for monitoring.

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What needs to be monitored

TRT isn't "set it and forget it." Reasonable monitoring includes:

• Total and free testosterone, SHBG — to confirm you're in a therapeutic range
• Estradiol — testosterone aromatizes to estrogen. Both too high and too low are problems.
• Hematocrit — TRT increases red blood cell production. Levels that climb too high raise cardiovascular risk and may require dose adjustment or therapeutic phlebotomy.
• PSA — baseline and on-treatment, age-appropriate.
• Lipids, glucose, blood pressure — TRT generally improves metabolic markers but should be tracked.
• Symptoms — energy, sleep, mood, libido, recovery. Numbers without symptom context are incomplete.

Quarterly monitoring is typical in the first year. Less frequent once stable.

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What about cardiovascular risk?

The older concern that TRT increases cardiovascular events has not held up in recent, better-designed studies. The TRAVERSE trial (2023) showed no increase in major adverse cardiovascular events with appropriately monitored TRT in men with hypogonadism.

What still matters:

• Don't let hematocrit climb unmonitored.
• Don't ignore sleep apnea — TRT can worsen it.
• Don't run estradiol either too high or too low.

Risk is managed, not eliminated, and that management is the job of the clinician you choose.

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Why I only offer TRT in five states

Testosterone is a Schedule III controlled substance. Prescribing requires an active DEA registration in the state where the patient lives. Mallory holds DEA registration in Indiana, Nevada, New Mexico, Pennsylvania, and Texas — and I only prescribe TRT in those states.

This isn't a limitation I apologize for. It's the rule, and any telehealth clinic prescribing controlled substances across states where it doesn't hold registration is doing something it shouldn't.

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The honest takeaway

If you're considering TRT, the most important thing isn't whether you do it. It's whether you do it with a clinician who is going to actually look at your labs, ask about your life, and adjust the plan as it unfolds.

That's a real visit. Not a five-minute form.