Exploring testosterone replacement therapy
Testosterone replacement therapy (TRT) can give you a whole new lease on life. Our experts provide the personalised, life-changing treatment you need to feel your best.
Navigating the complex world of TRT can sometimes feel daunting, so we’re here to help. We’ve broken down the nuances of hormone levels, the personalised nature of treatment protocols, and the different forms of TRT available, into bite-sized chunks so you have all the information you need.
What are normal testosterone levels in men?
After the age of 30, testosterone levels naturally start to decline with age by roughly 1 to 2% each year. Scientific studies show that 1 in 4 men over the age of 30 may have abnormally low testosterone levels.
Levels of total testosterone higher than 12 nmol/L or free testosterone higher than 225 pmol/L are considered normal. Although studies have shown men may be symptomatic of low testosterone with levels below 15nmol/L. A simple blood test can determine whether your testosterone levels are within a normal range.
Exploring individuality in TRT protocols
Each person’s experience with low testosterone is entirely unique - we believe their treatment should be too. Lifestyle and genetic factors affect how each individual should be treated. Men also have different naturally occurring levels of sex hormones and molecules, like SHBG, which influence how certain medications act in the body - but we’ll get to those later.
As you can see, there’s no one-size-fits-all treatment protocol for low testosterone, the best protocol is one that’s tailored to your specific circumstances and that you can stick to consistently. Our TRT doctors will conduct a comprehensive diagnosis so that they can design a personalised, sustainable protocol for you which results in real improvements. Here’s how the diagnostic process works:
- Initial blood test: An initial at-home, finger-prick blood test measures 4 biomarkers including your total and free testosterone levels. You can access your results within 48 hours via your MANUAL account.
- Enhanced blood test: If the results of your first test indicate low testosterone levels, a comprehensive venous blood test (which measures 43 biomarkers) is required to confirm the initial blood test result, learn more about your health, and assess whether it’s safe to start TRT.
- Doctor consultation: You’ll have an in-depth discussion with one of our TRT doctors covering your medical history and lifestyle, your blood test results, your symptoms, the risks and benefits involved in TRT, treatment options (including costs), monitoring, and what to expect when you start treatment.
- Treatment starts: Your doctor will design a personalised treatment plan that works specifically for you, including the right medication at just the right dose to suit your individual needs.
TRT medication options
We’ve put together a rundown of the different TRT medication options, explaining their pros and cons. It’s also worth mentioning that if you’re planning to start a family you should start fertility treatment before starting TRT.
Injectables
Injectables are a popular choice, in fact, 98% of our patients use this method! Not only are they convenient - taking around 10 minutes to administer, once or twice per week - they’re also highly effective as they maintain steady testosterone levels over time. Having said that, not everyone likes the idea of having to inject themselves with medication, so they aren’t for everyone.
- How do injectables work?
Testosterone injections, like testosterone Enanthate and Sustanon, work by supplementing the body’s low testosterone levels with synthetic testosterone. A chemical compound called an ester is attached to the hormone to slow down its release into the bloodstream, so that it’s absorbed gradually over an extended period.
Because injectables make it easy for doctors to implement changes in dosage based on blood test results, they tend to have more success at reaching target levels than other methods. Another benefit of injectables is that there’s no risk of transference to women or children which is a risk with topical medication.
Enanthate is a medium-acting ester, so it’s injected on a weekly or bi-weekly basis. Sustanon is another medium-acting formulation containing 4 different testosterone esters and it’s administered once a week. Depending on your personal needs and preferences, your doctor may recommend other long-acting testosterone injections that only have to be administered monthly.
- How effective are injectables?
Testosterone injections have been proven to be effective, with 90% of our patients seeing an improvement in their symptoms after 6 weeks.
- Are injectables safe?
Testosterone replacement therapy is completely safe if you’re treated by a specialist doctor who regularly monitors your testosterone levels along with any side effects. If you have low testosterone symptoms that are impacting your daily life, the benefits often outweigh the risk of side effects.
As with all medications, some people may experience side effects - however, they’re easily controlled and generally avoided with sensible doses and regular monitoring. Some possible milder side effects include fluid retention, acne, and increased urination. More severe potential side effects include gynecomastia (the growth of male breasts), worsening of existing sleep apnea, increased cholesterol levels, increased blood pressure, increased oestrogen levels, decreased sperm count, infertility, and an increased number of red blood cells. There’s also a risk of infection so it’s important that you administer the injections safely.
Testosterone injections may increase your risk of certain health problems, such as heart attack, stroke, blood clots or a worsening of pre-existing prostate tumours or benign prostatic hyperplasia (enlarged prostate). However, these side effects can mostly be avoided or controlled through regular monitoring and other medications.
- How do I administer testosterone injections?
It’s easy to learn how to administer testosterone injections, and we’ll provide all the training you need so that you feel confident and comfortable using your medication safely. And don't worry, most of our customers are surprised at how easy and painless it is!
Testosterone Enanthate is usually injected subcutaneously into a layer of fat just under the skin of the thigh, glute or abdomen. Sustanon is administered via intramuscular injection which is a little deeper than a subcutaneous injection. We recommend using the glutes or thighs for intramuscular injections.
Topical
Topical testosterone treatments are a great option for those who prefer a needle-free approach, as they come in the form of a cream or gel. They’re applied daily and although they work well for some men, the overall outcome of the treatment can be affected if they’re not absorbed properly.
Topical treatments tend to have a moderate impact on your lifestyle as it’s important to adhere carefully to your application schedule. They also carry the risk of testosterone transmission to women and children, posing potential dangers such as changes to women’s menstrual cycles. For this reason, this form of treatment may not be suitable for a lot of men.
- How do topical treatments work?
Topical testosterone treatments, like Testogel, deliver testosterone through the skin via a cream or gel. Testosterone is absorbed into the bloodstream, helping increase overall testosterone levels. As they have a short half-life, topical treatments have to be applied daily.
- How effective are topical testosterone treatments?
When they are fully absorbed into the bloodstream topical testosterone treatments can be effective, but generally speaking, they are less effective than injectables.
- Are topical testosterone treatments safe?
Testosterone replacement therapy is completely safe if you’re treated by a specialist doctor who regularly monitors your testosterone levels along with any side effects. If you have low testosterone symptoms that are impacting your daily life, the benefits often outweigh the risk of side effects.
As with all medications, some people may experience side effects - however, they’re easily controlled and generally avoided with sensible doses and regular monitoring. Some possible milder side effects include fluid retention, acne, and increased urination. More severe potential side effects include gynecomastia (the growth of male breasts), worsening of existing sleep apnea, increased cholesterol levels, increased blood pressure, increased oestrogen levels, decreased sperm count, infertility, and an increased number of red blood cells. However, these side effects can mostly be avoided or controlled through regular monitoring.
- How do I administer topical testosterone treatments?
Topical testosterone treatments like Testogel are easy to use as they just need to be applied to your arms once every morning. You should allow the gel or cream to dry completely before putting clothes on top of it, wash your hands thoroughly after applying the treatment, and avoid showering, bathing, swimming, as well as any vigorous exercise, for several hours after application. We recommend that you shower before any physical contact with others to prevent potential testosterone exposure risks.
Oral
In cases where injections or topical treatments aren’t suitable, oral testosterone treatments might be prescribed. This method of treatment is incredibly convenient since it involves taking just one daily tablet, and has the added perk of not requiring any injections. This form of treatment helps to maintain fertility whilst increasing testosterone levels, but isn’t effective for some men.
- How do oral testosterone treatments work?
Oral testosterone treatments, like Clomid, work differently to other TRT treatments in that they don’t provide your body with a form of testosterone. Instead, they stimulate the release of hormones in the brain, like luteinizing hormone (LH) and follicle-stimulating hormone (FSH). This results in an increase in the production of testosterone.
- How effective are oral testosterone treatments?
Research shows that although some men achieve an increase in testosterone levels, oral testosterone treatments are not as effective for symptom relief as other testosterone TRT methods.
- Are oral testosterone treatments safe?
Oral testosterone treatments are completely safe if you’re treated by a specialist doctor who regularly monitors your testosterone levels along with any side effects. If you have low testosterone symptoms that are impacting your daily life, the benefits often outweigh the risk of side effects.
As with all medications, some people may experience side effects - however, they’re easily controlled and generally avoided with sensible doses and regular monitoring. Some possible side effects include hot flashes, changes in mood, headaches, nausea, blurry vision, and sore breast tissue. However, these side effects can mostly be avoided or controlled through regular monitoring.
- How do I use oral testosterone treatments?
Oral testosterone treatments are by far the simplest and most convenient way to treat low testosterone, as you only have to take one tablet a day.
Treatment adjustment & monitoring
You’re probably starting to see that low testosterone is a tricky condition to treat. There are a lot of physiological factors at play, plus your lifestyle has to be taken into careful consideration when choosing the right protocol.
A personalised, bespoke treatment is key to TRT as no one responds in the same way to the same treatment method, dosing or dosing frequency. Whilst most patients start on similar protocols, it’s essential that treatment is adapted to your unique needs. That’s why regular follow-ups and blood analysis are so important.
After you’ve started your TRT protocol, we’ll test your blood at 6 weeks, 3 months, 6 months, and 12 months, and you’ll receive direct feedback and counselling from a doctor after each test. These test results will allow your doctor to effectively monitor your progress and make incremental adjustments to your protocol (adding different medications if required) to ensure that your body gets the right amount of testosterone to put your levels within a healthy physiological range. Patience is key here. It can take a few months up to a year in some cases, but it’s important to trust the process to achieve the best results.
Understanding physiological factors in TRT
Aside from your individual testosterone levels, there are other physiological factors at play that can influence the response of TRT. Sex hormone binding globulin (SHBG) levels, oestrogen levels, and androgen receptor type vary between men, so it’s important to tailor treatment with these in mind.
Sex Hormone Binding Globulin (SHBG)
SHBG is a protein which binds to three hormones - testosterone, oestrogen, and dihydrotestosterone (DHT) - in order to transport them through the bloodstream. When SHBG binds to testosterone it reduces the amount of the hormone available in the blood.
SHBG levels are affected by age, insulin sensitivity, liver health, and alcohol consumption, among other things. Using different dosing strategies (including adding certain medications alongside TRT) can help to treat men with high or low SHBG levels.
Oestrogen (oestradiol)
Oestrogen (specifically oestradiol) levels vary in men due to the amount of aromatase found in their bodies. Aromatase is an enzyme which shears off part of the testosterone molecule, converting it into oestrogen. Factors such as genetics, body fat, diet, and alcohol intake contribute to these variations.
Androgen receptors
Androgen receptors are proteins which play a crucial role in shaping male sexual characteristics and the regulation of muscle and bone growth. When sex hormones such as testosterone activate them, they bind to specific DNA regions and essentially regulate the activity of certain genes.
Androgen receptor type is probably more important than the levels of testosterone in your body - two men with the same testosterone levels can see variations in the effect on things like muscle mass or bone density.
These variations in physiology highlight the importance of tailoring TRT protocols to each individual.
Complementary therapies in TRT
Successful hormone therapy involves administering the right medications at just the right doses for your individual needs. Additional treatments, such as human chorionic gonadotropin (HCG) and aromatase inhibitors work in tandem with TRT to optimise your hormone balance.
HCG
Human chorionic gonadotropin (HCG) is often administered to men on TRT as it plays an important role in maintaining fertility and natural testosterone production. It’s a luteinising hormone (LH) analogue, so it replicates the LH's role in hormone regulation, preventing testicular shrinkage and sustaining testosterone production in men on TRT.
Those with primary hypogonadism will produce less testosterone when using HCG compared to those with secondary hypogonadism. It is, however, difficult to predict the effect that HCG will have on an individual’s testosterone production so adjusting HCG and testosterone doses based on follow-up blood tests is essential.
Aromatase inhibitor
Aromatase inhibitors are commonly used during TRT to limit the conversion of testosterone into oestrogen. They work by binding to the aromatase enzyme, reducing oestrogen production.
While generally best avoided due to potential side effects which affect bone density, joint health, epithelial health, and lipid profile, they may be necessary for men with excess body fat or a genetic susceptibility to raised oestrogen levels (which can be identified through blood or genetic testing). Adjusting the dosage offers an alternative for managing oestrogen levels in other cases.
