HRT for Men (Testosterone Replacement Therapy (TRT))

Male hormone replacement therapy has become one of the fastest-growing areas of men's health. Testosterone prescriptions in the US increased over 300% between 2001 and 2023, driven by greater awareness of hypogonadism symptoms and expanding access through telehealth platforms.

The diagnosis starts with symptoms: fatigue, low libido, erectile dysfunction, depressed mood, difficulty building muscle, and increased body fat. These need to be confirmed with two morning blood tests showing total testosterone below 300 ng/dL (the Endocrine Society threshold). Some practitioners use free testosterone or bioavailable testosterone for a more complete picture, especially in men with elevated SHBG.

Testosterone cypionate is the most commonly prescribed form in the US. The traditional protocol was 200 mg every 2 weeks, but modern practice has moved toward more frequent dosing. Most current protocols use 100-150 mg weekly, or 50-75 mg every 3.5 days. The goal is stable blood levels that avoid the peak-and-trough roller coaster of biweekly dosing.

Subcutaneous injection has largely replaced intramuscular injection in progressive clinics. A 2014 study showed equivalent testosterone levels with smaller needles (27-29 gauge vs 22-25 gauge), less pain, and easier self-administration. Most patients can learn to self-inject comfortably within one or two supervised sessions.

A complete male HRT protocol goes beyond testosterone alone. HCG (human chorionic gonadotropin) at 250-500 IU 2-3 times weekly prevents testicular atrophy and preserves fertility by maintaining intratesticular testosterone. Some clinics use gonadorelin (a GnRH analog) as an alternative to HCG for the same purpose.

Estrogen management is important because testosterone converts to estradiol via the aromatase enzyme. Some estradiol is necessary for bone health, cardiovascular function, and libido. Too much can cause water retention, mood issues, and gynecomastia. Aromatase inhibitors (anastrozole 0.25-0.5 mg 1-2x/week) are used only when estradiol levels are confirmed elevated on blood work. The trend in modern TRT practice is to use aromatase inhibitors less frequently and at lower doses than in the past.

Monitoring is essential. Standard blood panels include total and free testosterone, estradiol, hematocrit/hemoglobin, PSA, complete metabolic panel, and lipid panel. Hematocrit above 54% is the most clinically significant side effect and requires intervention (dose reduction, more frequent dosing, or therapeutic phlebotomy).

The TTrials program (7 coordinated RCTs in men aged 65+ with low testosterone) published between 2016-2020 confirmed that testosterone therapy improved sexual function, physical activity, bone density, and corrected anemia. The 2018 Endocrine Society guidelines provide the most detailed evidence-based framework for prescribing.

Cost varies widely. Generic testosterone cypionate through a compounding pharmacy runs $30-80/month. Brand-name Depo-Testosterone is $60-100/month. Adding HCG costs $40-80/month. Total monthly cost for a complete protocol through a telehealth TRT clinic is typically $150-300/month including medication, consultations, and lab work.