Testosterone therapy options: forms, monitoring, and safety checks

Some health topics arrive like a nudge rather than a knock. For me, testosterone therapy started that way—a friend asked what “the safest option” might be, and I realized my mental notes were scattered across articles, clinic visits, and half-remembered guidelines. I wanted to pull those threads together in one place, the way I’d explain it over coffee: what the forms are, how people actually monitor treatment, and the safety checks that help it stay boring (which, in health care, is often a good thing). I’ll share what made the topic click for me, where the evidence feels solid, and where it still asks for nuance.

The moment this finally made sense to me

I used to think testosterone therapy (TRT) was mostly about a single number. But it clicked when I learned that the diagnosis is both symptoms and consistently low morning testosterone levels—confirmed with reliable tests—before anyone starts treatment. And even after diagnosis, the choice of therapy is guided by life logistics and safety basics, not just a lab value. If I had to compress my early takeaway into one line, it would be: start with the “why,” confirm with the “what,” and then pick the “how” you can live with. If you want the primary-source version of that, the Endocrine Society’s guideline and the AUA’s guideline both put structure around the same idea (I’ll link these and other sources below, and a few in-line as we go).

  • Confirm the diagnosis with symptoms plus two consistent morning testosterone levels using reliable assays.
  • Find the cause (primary vs. secondary) because that can change the plan.
  • Talk goals and trade-offs: energy, sexual function, bone health, mood, convenience, cost, and safety monitoring.

Helpful primers I bookmarked while learning the ropes:

Choosing a form that fits your life comes before chasing numbers

Every formulation can raise testosterone, but they feel very different in daily life. My short notes on each:

  • Gels and solutions (shoulders, upper arms, abdomen) — Convenient and steady once you’re used to the routine. The major caveat: skin-to-skin transfer risk to partners or kids if sites aren’t covered/washed. That’s why labels and patient education emphasize drying time, handwashing, and covering the area with clothing after application.
  • Transdermal patches — A “stick it and forget it” vibe, usually at night. Downsides: skin irritation and the daily site rotation dance. Upsides: more stable levels than widely spaced injections.
  • Nasal gel — Small, frequent doses through the day (usually every 8 hours). The headline for some folks is no skin transfer risk. The trade-off is remembering multiple daily applications; some love the flexibility, others don’t.
  • Short-acting injections (cypionate/enanthate) — Often weekly or every 1–2 weeks, delivered intramuscularly or subcutaneously depending on the product and your clinician’s plan. They’re inexpensive and reliable. The pattern to know: peaks and troughs can affect mood, energy, and hematocrit; dose frequency adjustments can smooth this out. Some newer auto-injectors include a blood pressure increase warning on the label, so BP checks belong in your plan.
  • Long-acting intramuscular undecanoate — Dosed at 0, 4, then every 10 weeks in a clinic. It’s steady and infrequent, but it carries a boxed warning for rare POME (pulmonary oil microembolism) and anaphylaxis, plus a REMS program and a post-injection observation period. For some, the convenience outweighs the clinic time; for others, the warning and logistics are dealbreakers.
  • Oral testosterone undecanoate — A capsule taken with food (dietary fat helps absorption). The modern caveat is blood pressure: labels highlight BP increases seen in studies, so a monitoring plan that actually measures BP—not just once—is important.
  • Pellets — Implanted under the skin every 3–4 months. The appeal is “set it and forget it”; the trade-offs are a minor procedure, site discomfort, and less wiggle room to adjust the dose mid-cycle.

For balance, here are a few evidence anchors I revisited while writing this section:

A monitoring plan I can actually stick with

My rule of thumb is to bake the follow-up into the calendar on day one. The plan I keep in mind is adapted from guideline rhythms and then individualized with a clinician:

  • Before starting: symptoms review; two morning total testosterone levels (consider free testosterone if needed); LH/FSH to distinguish primary vs secondary hypogonadism; hematocrit/hemoglobin; PSA and prostate check if appropriate by age/risk and shared decision-making; blood pressure; consider sleep apnea risk; medications review (e.g., anticoagulants).
  • At 3–6 months: check symptoms, adherence, side effects; testosterone level (timed to the formulation—e.g., trough for injections if that’s what your clinician prefers); hematocrit; BP; consider PSA per your initial plan.
  • At 12 months: if stable, stretch to every 6–12 months for testosterone levels; hematocrit at least annually; ongoing BP checks; PSA and prostate monitoring per age/risk and your shared plan.

Two safety bookmarks live at the top of my list: (1) a hematocrit at or above 54% usually means hold therapy and address the cause, then restart at a lower dose once it’s normalized; and (2) any sustained BP rise needs attention because some products carry specific BP warnings. The Endocrine Society and AUA both explicitly call out hematocrit monitoring and practical thresholds, and the FDA’s 2025 label update crystallizes the cardiovascular and BP picture from recent trials.

Safety checks that keep me honest

Here are the guardrails I now see as non-negotiable. They don’t guarantee a perfect course (medicine rarely offers guarantees), but they keep surprises rare:

  • Cardiovascular risk clarity — The large TRAVERSE trial found testosterone therapy was noninferior to placebo for major adverse cardiac events in men with hypogonadism and elevated CV risk. The FDA’s 2025 decision removed earlier language suggesting increased CV risk from the boxed sections while still emphasizing a balanced, monitored approach. Translation for me: don’t panic, but do track BP and symptoms and keep routine follow-ups.
  • Hematocrit drift — Erythrocytosis (thickened blood) is a known, dose-related effect, more common with injectable regimens and higher peaks. Baseline Hct → 3–6 months → yearly feels like a minimum. If Hct approaches 54%, I’d expect a dose reduction, a formulation change, or a pause with repeat labs.
  • Fertility — Exogenous testosterone suppresses sperm production. If having children is a priority in the near term, the conversation shifts to alternatives (e.g., therapies aimed at preserving spermatogenesis). This is where a reproductive-health evaluation earns its keep before starting testosterone.
  • Prostate considerations — This is nuanced. Guidelines emphasize shared decision-making about PSA and digital rectal exams, plus urology referral if PSA rises meaningfully over baseline in the first year. Long-term, follow the same age/risk screening pattern you’d use off therapy unless your team recommends a closer look.
  • Transference and household safety — With gels, the pattern is simple: apply, let it dry, wash hands, then cover. No cuddles or contact on uncovered sites until that’s done.
  • Product-specific cautions — Oral TU and some injectables carry blood pressure warnings; long-acting IM undecanoate has a REMS program for rare POME/anaphylaxis with a clinic observation period.
  • Compounding caution — When possible, I stick to commercially manufactured products because their quality, dosing, and monitoring guidance are standardized in labels and guidelines.

Small habits I’m testing in daily life

None of this replaces medical advice; these are just the practical things that reduced friction and uncertainty for me while learning:

  • Plan “monitoring days” like a mini-ritual — I schedule labs before breakfast, set a reminder to hydrate, and note how I felt the week prior. A tiny symptom log pays off when discussing dose adjustments.
  • Match the formulation to routines — If mornings are chaotic, a nightly patch might beat a morning gel. If weekly rhythms feel steadier, injections might be better than daily applications.
  • For gels — I choose a consistent room, set a timer for drying, and keep a dedicated T-shirt to cover the site. It’s mundane, which is exactly what I want.
  • For injections — I rotate sites, store supplies in one box, and note the exact time/dose. When in doubt about technique, I ask for a quick refresher from a nurse; fifteen minutes can prevent months of bruises and anxiety.
  • Blood pressure — I keep a home cuff and check at a consistent time (seated, feet flat, back supported). I bring the device to clinic once to validate it against their machine.

Signals that tell me to slow down and double-check

Most follow-ups are boring—in the best way. But here are the flags I personally respect:

  • Sudden symptoms: chest discomfort, new shortness of breath, severe headaches, or visual changes—especially if BP is up. That’s not a “wait and see” situation.
  • Hematocrit at or above 54%: time to pause, adjust, and look for contributing factors (dehydration, sleep apnea, too-large or infrequent doses).
  • PSA jump above your baseline in the first year: this is urology territory per guideline advice.
  • Household exposure risk: if someone in your home is pregnant or there are kids around, gels might be less ideal unless you can reliably follow transfer-prevention steps.
  • Trying to conceive: I’d avoid starting TRT and discuss fertility-preserving options first.

What I’m keeping and what I’m letting go

What I’m keeping: diagnose carefully, monitor predictably, and choose the form that matches real life. I’m also keeping a humble stance about benefits; energy and libido often improve, but timelines vary, and bone health is a longer game. What I’m letting go: the myth that one formulation is “the best” for everyone, or that a single testosterone level tells the whole story.

If you want to read more straight from the source, these are the links I keep pinned. They’re also in the reference list with clean titles:

FAQ

1) Do I really need two low morning testosterone tests?
Answer: Yes—guidelines recommend consistent, unequivocally low morning results plus symptoms before treatment. It reduces misdiagnosis and prevents chasing normal fluctuations. See the Endocrine Society and AUA guidance.

2) I want kids in the next couple of years. Is TRT still an option?
Answer: Usually not as a first-line choice, because exogenous testosterone suppresses sperm production. The AUA recommends a reproductive health evaluation before treatment and discusses alternatives aimed at preserving fertility. Talk with a clinician who manages male fertility.

3) Does TRT raise the risk of heart attack or stroke?
Answer: The large TRAVERSE trial found TRT to be noninferior to placebo for major cardiovascular events in men with hypogonadism and higher baseline risk. In 2025, the FDA updated labels to reflect those findings and emphasized blood pressure monitoring. Practical takeaway: align with your clinician on BP checks and routine follow-up.

4) What’s the safe hematocrit range, and what happens if mine rises?
Answer: Many protocols intervene if hematocrit reaches 54% (hold therapy, adjust dose or formulation, evaluate contributors, sometimes consider phlebotomy). Baseline, 3–6 months, and then at least annually is a common rhythm, with earlier checks if you’re on higher-peak regimens.

5) Which form is “best” and how fast will I feel different?
Answer: “Best” is the one you’ll use consistently with a safety plan you can follow. Daily gels/patches feel steady; injections are cost-effective and flexible; long-acting injections reduce clinic visits; oral TU avoids needles but needs BP monitoring; nasal gel eliminates skin transfer risk. Some benefits (libido, energy) can appear within weeks; others (bone density) take months to years. Your monitoring plan keeps all of this on track.

Sources & References

This blog is a personal journal and for general information only. It is not a substitute for professional medical advice, diagnosis, or treatment, and it does not create a doctor–patient relationship. Always seek the advice of a licensed clinician for questions about your health. If you may be experiencing an emergency, call your local emergency number immediately (e.g., 911 [US], 119).