Testosterone Replacement Therapy (TRT) is a medical treatment for clinically low testosterone levels, a condition known as hypogonadism. Since testosterone is a Schedule III controlled substance, its administration requires a prescription and careful medical oversight. TRT aims to restore hormone levels to a normal range, alleviating symptoms like reduced libido, fatigue, and decreased muscle mass. The type of doctor who prescribes this treatment depends on the patient’s case complexity and the specific practice setting.
Primary Prescribing Specialists
Three main types of traditional medical specialists commonly initiate and manage TRT. The choice often depends on the patient’s overall health and the underlying cause of low testosterone.
Primary Care Physicians (PCPs)
Many patients start by consulting their Primary Care Physician (PCP) or an Internal Medicine doctor. PCPs serve as the initial point of contact and are equipped to diagnose and manage straightforward cases of hypogonadism. They can order diagnostic blood work and prescribe treatment, though they typically refer more complex situations to specialists.
Endocrinologists
Endocrinologists specialize in the endocrine system, which includes all hormones and the glands that produce them. They possess deep expertise in treating hormonal imbalances and are preferred for patients with complex medical histories or secondary causes of low testosterone, such as pituitary issues. Their knowledge of hormone regulation allows them to manage sensitive dosage adjustments and side effects, especially when co-existing conditions like diabetes or thyroid disorders are present.
Urologists
Urologists specialize in the male reproductive system and the urinary tract. They frequently prescribe TRT, particularly when the patient’s primary symptoms involve sexual function, fertility concerns, or issues related to the testes. Urologists are experts in the local effects of testosterone deficiency and are well-versed in various delivery methods, including injections, gels, and pellets. They are often the most appropriate provider for patients diagnosed with primary hypogonadism (testicular dysfunction).
Specialized Clinics and Alternative Providers
Specialized Clinics
Many patients access TRT through specialized Men’s Health or Hormone Optimization Clinics. These facilities focus on treating age-related hormone decline and offer a streamlined process for testing and consultation. Practitioners, including physicians, nurse practitioners, and physician assistants, focus exclusively on hormone therapy. They often employ a multidisciplinary approach, incorporating lifestyle and nutritional guidance alongside prescription medication.
Telemedicine
Telemedicine is a growing avenue for accessing TRT. Virtual care platforms allow patients to consult with licensed providers, complete lab work locally, and receive a prescription remotely. This model offers convenience and accessibility, especially for patients in rural areas. However, prescribing a controlled substance like testosterone via telemedicine is subject to evolving state and federal regulations regarding initial in-person evaluation requirements.
The Diagnostic Pathway to Prescription
Before prescribing TRT, the patient must undergo a structured diagnostic process to confirm medical necessity. This begins with a thorough evaluation of symptoms, such as unexplained fatigue, depressed mood, and decreased libido or muscle strength. A comprehensive physical examination and medical history review are required to rule out other causes, like sleep apnea or thyroid dysfunction.
Laboratory testing is required to confirm hypogonadism. Guidelines recommend at least two separate measurements of total serum testosterone levels taken on different mornings. Since testosterone levels peak early, blood draws are typically scheduled before 10:00 AM. A total testosterone value below 300 ng/dL is generally considered the threshold for diagnosis.
Additional blood tests are necessary to understand the patient’s hormonal status and determine the cause of low testosterone. These include measuring free testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). LH and FSH levels help the doctor distinguish between primary hypogonadism (testes issue) and secondary hypogonadism (pituitary/hypothalamus issue).
Ongoing Monitoring and Management
Once TRT begins, the prescribing physician establishes a schedule for ongoing monitoring to ensure effectiveness and patient safety. Initial follow-up blood work is typically scheduled within three to six months to assess the body’s response and adjust the dosage. Specific laboratory markers are tracked to detect potential side effects associated with testosterone administration.
Key Monitoring Markers
- Hematocrit: This measures red blood cells and is monitored closely because TRT can cause an increase, raising the risk of blood thickening and clotting. Physicians aim to keep levels below 54%.
- Prostate-Specific Antigen (PSA): Checked regularly, especially in older men, to screen for potential prostate issues, as testosterone can affect prostate tissue growth.
- Estradiol (Estrogen): Levels can rise as the body converts excess testosterone through aromatization. Elevated estradiol can cause side effects like breast tenderness and may require dosage modification.
After initial dose stabilization, monitoring usually continues every six to twelve months. This ensures the patient’s testosterone levels remain in the therapeutic range while minimizing adverse health outcomes.