6 types of testosterone therapy

In this article:

• What is testosterone replacement therapy (TRT)?
• How to get TRT
• Types of testosterone replacement therapy (TRT )
• How much does TRT cost?
• Risks of TRT
• Alternatives to TRT
• Bottom line

In this article

• What is testosterone replacement therapy (TRT)?
• How to get TRT
• Types of testosterone replacement therapy (TRT )
• How much does TRT cost?
• Risks of TRT
• Alternatives to TRT
• Bottom line

Are you feeling sluggish, experiencing mood swings, or struggling to maintain muscle mass? It may be a good idea to have your testosterone levels checked. Testosterone naturally declines in men, starting around the age of 30 to 40. And although decreased testosterone is a normal part of aging, levels that dip too low can significantly impact your day-to-day life. Symptoms of low testosterone include a low sex drive, sexual dysfunction (erectile dysfunction), decreased muscle mass, increased body fat, loss of bone density, and insomnia, among others.

If you’re experiencing symptoms of testosterone deficiency, there’s good news! If your testosterone lab work shows a low testosterone level, treatment options like androgen replacement therapy can restore your testosterone levels to a normal range. Keep reading to learn more about testosterone treatment therapy for low T, including treatment options, benefits, and risks.

What is testosterone replacement therapy (TRT)?

Testosterone replacement therapy (TRT) is a form of hormone replacement therapy approved by the U.S. Food and Drug Administration (FDA) to treat males with low testosterone hormone levels associated with hypogonadism. Hypogonadism occurs when the gonads (the testicles), which are the primary reproductive organs, produce sex hormones less than the normal range.

“The therapy aims to restore normal testosterone levels, alleviating symptoms such as fatigue, decreased libido, erectile dysfunction, mood changes, and loss of muscle mass,” says Sunjya Schweig, MD, an integrative and functional medicine practitioner, founder and president of the California Center for Functional Medicine in Oakland. Testosterone therapy is available as capsules, injections, patches, gels, or pellets implanted under the skin.

It’s important to note that not all cases of low testosterone should be treated with TRT. According to Linda Khoshaba, NMD, founder of Natural Endocrinology Specialists (NES) in Scottsdale, Arizona, good candidates for TRT include:

• Men with lab-confirmed hypogonadism, which causes symptoms like erectile dysfunction, loss of muscle mass, and depression.

• Men with secondary hypogonadism, which occurs due to dysfunction of the pituitary gland or a part of the brain called the hypothalamus.

• Men with testosterone levels below the normal reference range (lower than 300 ng/dL) warrant investigation and possible treatment if they are symptomatic.
• Men with specific conditions like delayed puberty, certain cancers, or chronic illnesses impacting levels of testosterone.

Benefits of TRT

Within a few weeks of TRT, men may notice a pickup in energy, motivation, and libido, says Vinita Tandon, MD, a board-certified endocrinologist and medical director at Lifeforce, a telehealth service focused on hormones. “Within a few months, they may notice changes in body composition with improved lean muscle mass and reduced fat mass,” says Dr. Tandon, adding that once hormone levels have been optimized within the normal range, men often feel like the best version of themselves.

How to get TRT

A prescription from a healthcare provider is necessary to obtain TRT, Dr. Schweig says. First, the provider will perform a medical evaluation to assess symptoms and medical history. If low testosterone is suspected, blood tests are performed to provide confirmation, he explains.

Based on this evaluation and lab results, the provider will prescribe an appropriate form of testosterone. Dr. Schweig emphasizes the importance of avoiding online prescriptions that do not require medical supervision, “Proper monitoring by a healthcare provider is essential to ensure safe and effective treatment, adjust dosages, and monitor potential side effects.”

Types of testosterone replacement therapy (TRT )

Different testosterone medications approved for TRT are classified based on their route of administration. Typically, a testosterone treatment plan may involve about six months of therapy per prescription. Patients’ satisfaction with these methods will vary depending on factors like ease of use, cost, symptom improvement, and side effects.

Injectable testosterone

Testosterone comes in injectable forms, such as testosterone cypionate and testosterone enanthate. The standard route for administering these testosterone shots was intramuscular. Still, recent studies have shown that the subcutaneous route offers as much effectiveness and safety as intramuscular testosterone injections and is an accepted alternative. A typical dose for testosterone injections is 200 mg/mL, administered every two weeks. The long-acting testosterone undecanoate, which the FDA approved in 2014, is typically dosed at 750 mg once, another 750 mg four weeks later, and subsequently 750 mg every 10 weeks. Testosterone injections are often performed by the patient themselves and are usually the least expensive way to receive testosterone replacement. 

Transdermal testosterone (topical gels, patches, and solutions)

Transdermal TRT involves applying gels containing testosterone (5–10 mg daily of 1% gel containing 50–100 mg testosterone) or testosterone patches, such as Androderm (2 or 4 mg every night), to the skin of the upper arms, back or thighs. Axiron is a 60 mg topical testosterone solution. The recommended dose is two pumps applied to the underarms once daily. Providers can adjust the dose based on serum testosterone levels measured 14 days after the start of the therapy. Gels are commonly recommended for convenience, cost-effectiveness, and minimal hormonal level variability. Alcohol-based gels are flammable. Avoid fire, flames, or smoking until the gel is dry. Testosterone may be transferred to another person when there’s skin-to-skin contact with the application site. The patient should thoroughly wash hands after application and cover the application site with clothing once dried. 

Subcutaneous testosterone pellet

Testosterone pellets are grain-sized dissolvable implants (600-1200 mg, every 4-6 months) inserted under the skin to release hormones gradually over time. However, pellets are only sometimes used due to insufficient data on how to maintain testosterone concentrations during treatment and the need for repeated implantation. Side effects include pellet expulsion, infection, and fibrosis of the surrounding skin. Surgery is needed to insert them, and there’s limited data on the serum testosterone concentrations during treatment. Most physicians do not routinely recommend testosterone in pellet preparation

Oral testosterone 

The oral agent Jatenzo (testosterone undecanoate) received FDA approval in 2019. It is a good option for treating low testosterone levels due to specific medical conditions like damage to the pituitary gland and Klinefelter syndrome. The recommended starting dose is 237 mg twice per day. Kyzatrex, which received approval in 2022, is formulated to bypass the liver, as the older oral agent methyltestosterone presents a significant liver toxicity risk. Available in 100, 150, and 100 mg doses, Kyzatrex is taken twice a day.

Nasal testosterone gel

Natesto is a nasal testosterone gel formulation designed to be dispensed into the nose with a recommended dose of two pumps (5.5 mg per pump and one actuation per nostril) three times a day. This formulation allows patients to self-administer testosterone, is non-invasive, and has a low total daily dose. However, frequent dosing may be inconvenient for some people, and some may experience side effects like headaches, nose bleeding, and nasal discomfort.

Gum and cheek (buccal) testosterone

Buccal testosterone medications are administered in the space to the left or right of the upper gums and cheek, called the buccal cavity. While the medicine looks like a tablet, it works like a patch, sticking to the gum for 12 hours. The dosage for adults is typically 30 mg, applied twice daily.

How much does TRT cost?

“Depending on which type of testosterone is considered (injection, cream, patch, or pill), insurance may or may not cover it,” says Dr. Tandon. She says that sometimes insurance companies will only cover it if the baseline testosterone levels are below a certain threshold —and even then, insurance coverage is variable. Without insurance, TRT can cost anywhere from several hundred dollars to over $1,000 monthly.

Risks of TRT

Dr. Schweig emphasizes that TRT is not suitable for everyone, including:

• Patients with untreated prostate or breast cancer
• Men with elevated prostate-specific antigen (PSA) levels
• People with an enlarged prostate that causes difficulty urinating
• Individuals with severe untreated sleep apnea
• People with uncontrolled heart failure or heart disease
• ​​Those with untreated sleep apnea
• Men who are planning to have children (as TRT can reduce sperm production)
• Individuals with elevated red blood cell counts
• Patients who have had a heart attack or stroke in the last six months
• People with severe lower urinary tract symptoms

Potential side effects and risks include:

• Acne and oily skin
• Worsening sleep apnea
• Prostate enlargement
• Benign prostatic hyperplasia (growth of the prostate)
• Excess body hair
• Breast enlargement
• Decreased sperm production
• Testicular shrinkage
• Increased risk of blood clots
• Cardiovascular risks
• Liver problems
• Anger issues

Testosterone is in the same class of organic molecules as cholesterol and is a steroid. However, “testosterone replacement therapy (TRT) should not be considered the same as an anabolic steroid,” says Ramkishen Narayanan, MD, a board-certified urologist at Providence Saint John’s Medical Center in California. “TRT is a regulated administration of external sources of testosterone, under the care of a medical professional, to treat male hypogonadism.”

Anabolic steroid use, on the other hand, is geared toward athletic enhancement and muscle-building. It typically involves the use of unregulated synthetic steroids or unsupervised self-administration of testosterone.

Alternatives to TRT

Dr. Schweig recommends the following lifestyle changes to improve testosterone levels naturally:

• Regular exercise, particularly weight and resistance training, can significantly boost testosterone levels.
• A balanced diet rich in lean proteins, healthy fats, and vegetables supports healthy hormone production.
• Adequate sleep, aiming for 7-9 hours per night, is crucial as poor sleep can lower testosterone levels.
• Managing stress through practices like mindfulness, meditation, and yoga is also essential, as chronic stress elevates cortisol levels, negatively impacting testosterone.
• Maintaining a healthy weight through diet and exercise can improve testosterone levels
• Limiting alcohol intake and avoiding tobacco and street drugs is essential, as their use can lower testosterone levels.

Bottom line

Low testosterone levels can lead to various symptoms, such as low energy, mood swings, and decreased muscle mass. For those experiencing significant symptoms of hypogonadism, testosterone replacement therapy (TRT) helps restore hormone levels. TRT is medically supervised and comes in various forms, including injections, patches, gels, and pellets. While it offers benefits like increased energy and improved mood, TRT also carries risks, and not all with low testosterone levels are suitable candidates. Lifestyle changes can also significantly increase testosterone levels naturally.