How To Discuss Testosterone with Your Physician

What follows is a guide to discussing testosterone with your physician, what labs to monitor, what adjunctive therapies to consider, and what the trade-offs are.

Testosterone & Aging: More Than Just One Hormone

When people talk about testosterone (T) and “anti-aging,” there’s often an oversimplified narrative: “My T is low → I’ll take exogenous testosterone → I’ll feel better, live longer.” The reality is more nuanced. Testosterone is one node in a complex endo­crine network. Long-term or high-dose use can lead to side effects (e.g. estrogen conversion, testicular atrophy, elevated red blood cell counts, hair loss) that must be actively managed or mitigated.

What Is Total Testosterone vs. Free Testosterone (and Why It Matters)

• Total testosterone (TT) measures the sum of all testosterone in the blood — both the portion bound to proteins (mostly sex hormone binding globulin, SHBG, and albumin) plus the small fraction that is unbound (free).  

• Free testosterone (FT) (or “free + bioavailable testosterone”) refers to the fraction that is not bound (or loosely bound) to proteins and is biologically active — able to enter cells and exert androgenic effects.  

• In most men, FT represents ~2–3% of TT.  

• Why does this distinction matter? Because SHBG levels can vary (due to age, liver status, thyroid, medications, obesity), which can “mask” low active testosterone even when TT is “normal.” In cases where symptoms are present but TT is borderline, measuring or calculating FT helps refine the diagnosis.  

• Some labs provide a calculated free testosterone (based on TT, SHBG, albumin) rather than a direct measurement; the “gold standard” direct method is equilibrium dialysis, but it’s expensive and mostly used in reference labs.  

So, in short: don’t rely solely on total testosterone — especially if your symptoms suggest deficiency but your TT is “in the low-normal” range. Understanding free & bioavailable testosterone gives you a clearer picture of what’s actually “working” in the body.

What’s a “Normal” Range — and What Should You Aim For?

Here’s what the literature and labs typically report, acknowledging that ranges vary by lab and assay:

• Many sources list a “normal” TT reference range in men as ~300 to 1,000 ng/dL (or ~10–35 nmol/L), though the lower bound is controversial.  

• Some clinicians and expert groups regard ~350 ng/dL as a more conservative lower cutoff for “functional adequacy,” especially in symptomatic men.  

• One meta-analysis suggested that TT needs to exceed ~ 350–400 ng/dL to reliably predict a normal free testosterone level.  

• For FT, absolute numbers are more lab-dependent; many labs provide reference intervals. But the principle is: if TT is borderline or symptoms persist, FT provides context.

Where should you keep yours?

Ideally, within the mid to upper portion of the normal range (without overshooting into supraphysiologic levels). The goal is symptom relief + physiologic safety, not maximally high testosterone. Many physicians target somewhere between ~ 500–800 ng/dL (or equivalent in nmol/L) in men, but the exact “sweet spot” is individualized.

The key is: your levels should be consistent, symptomatically appropriate, and not driving side effects like high hematocrit, estrogen excess, or suppressed gonadal function.

How Often Should You Monitor Labs?

When on testosterone therapy (or considering it), monitoring is critical:

1. Baseline before initiation — Full labs including TT, FT (or SHBG for calculation), estradiol, LH/FSH, prolactin, liver function, lipid profile, PSA (in men), CBC (to get baseline hematocrit/hemoglobin).

2. Early follow-up (3–6 months) — Check TT (and FT if applicable), estradiol, hematocrit/hemoglobin, PSA / prostate screening, liver enzymes, lipids, possibly DHT (dihydrotestosterone).

3. Ongoing / maintenance (every 6–12 months) — For stable patients, periodic checks of TT/FT, estradiol, hematocrit/hemoglobin, PSA (if applicable) are common.  

4. If any symptoms or side effects emerge (e.g. polycythemia, gynecomastia, erectile issues), additional labs may be needed more frequently.

In short: baseline → early follow-up → regular monitoring annually or semiannually depending on risk and dose.

Should You Take Testosterone? And How (Weekly, Biweekly, etc.)

Deciding whether to start testosterone is a shared decision between you and your physician, after considering:

• Clinical symptoms consistent with testosterone deficiency (fatigue, low libido, muscle loss, mood, etc.)

• Confirmed low or borderline TT/FT on repeat testing

• Discussion of risks, benefits, alternative options (lifestyle, weight loss, sleep, etc.)

• Exclusion of contraindications (e.g. prostate cancer, polycythemia, untreated sleep apnea)  

Dosing intervals & formulations

There are multiple ways to administer testosterone (gels, patches, injections, pellets). If using injections (which are common in hormone optimization protocols), considerations include:

• Shorter-acting esters (e.g. testosterone enanthate, cypionate) are often given once weekly, or sometimes split (e.g. twice weekly) to smooth peaks and troughs.

• Longer-acting esters (e.g. testosterone undecanoate) offer less frequent dosing (e.g. every 10–14 weeks in some formulations) in some settings.  

• In some protocols, “micro-dosing” or more frequent small injections is used to avoid hormonal swings.

There’s no universal “right” interval — it depends on your response, side effects, and how your hormone levels fluctuate. Many anti-aging or hormone-optimization clinicians prefer twice-weekly smaller injections to keep levels more stable and avoid spikes.

Risks, Side Effects & Considerations

When used long-term, testosterone therapy can lead to a set of potential adverse effects. Awareness and proactive mitigation are key.

Estrogen Conversion (Aromatization)

• Testosterone can be converted to estradiol (E2) via the enzyme aromatase (especially in adipose tissue). Too much conversion can lead to side effects like gynecomastia, water retention, mood changes, and sexual dysfunction.  

• To manage this, some doctors may co-prescribe aromatase inhibitors (e.g., anastrozole, exemestane) in low doses — but this must be done carefully because overly suppressing estrogen can bring its own risks (e.g. negative effects on bone, lipid metabolism).

• Periodic monitoring of estradiol is often recommended when on testosterone therapy.  

Testicular Atrophy & Fertility Suppression

• Exogenous testosterone suppresses the hypothalamic-pituitary-gonadal (HPG) axis via negative feedback (reduced LH/FSH), which reduces endogenous testosterone production and spermatogenesis. Over time, this can lead to testicular shrinkage / atrophy.  

• For men who care about fertility or testicular size, co-therapies such as human chorionic gonadotropin (hCG) or selective estrogen receptor modulators (SERMs) like clomiphene or tamoxifen might be discussed with a doctor to preserve intratesticular testosterone production.

• Some anti-aging protocols use pulsed hCG or periodic gonadotropin stimulation to mitigate testicular downregulation.

Hematocrit / Red Blood Cell Count (Polycythemia Risk)

• Testosterone stimulates erythropoiesis (red blood cell production). Many men on TRT see rises in hemoglobin and hematocrit. This can be beneficial for those with anemia, but can become risky if it leads to polycythemia / hyperviscosity (increased blood thickness, greater risk of thrombosis).  

• If hematocrit goes too high (often > 52–54%, though lab cutoffs vary), therapy might need adjustment: dose reduction, increased monitoring, switching formulations, or even therapeutic phlebotomy.

• Some users on TRT regularly donate blood to manage hematocrit — this is a practical and commonly recommended approach in optimization protocols.

Hair Loss / Androgenetic Alopecia

• Testosterone (and its downstream metabolite dihydrotestosterone, DHT) can accelerate male-pattern hair loss in those predisposed to androgenetic alopecia.

• Some men co-use 5-alpha-reductase inhibitors (e.g. finasteride, dutasteride) in conjunction with testosterone therapy to reduce DHT conversion in scalp tissue (though this remains a nuanced decision and may have side effects of its own).

• You should discuss with your physician whether adding a DHT blocker is appropriate for your risk profile.

Other Risks

• Prostate health: Although evidence generally does not support a strong link between TRT and prostate cancer in men without preexisting disease, monitoring PSA and prostate exams is standard.  

• Sleep apnea: TRT may worsen obstructive sleep apnea in susceptible individuals.

• Cardiovascular risks: Mixed evidence — some older meta-analyses suggested increased risk of cardiac events, but newer studies are more nuanced. Shared decision-making is crucial.  

• Fluid retention, acne, mood changes, gynecomastia, liver effects (rare with non-oral formulations) are additional considerations.  

How to Talk with Your Doctor: A Checklist

When you approach your physician (especially if they are not a hormone optimization specialist), having a structured discussion can improve clarity and shared understanding. Here’s a checklist:

1. Symptoms + History

   
   

   • Bring a symptom log (energy, libido, mood, sleep, body composition, cognitive clarity)

   • Any prior testosterone or hormone therapy history

   • Fertility plans

   
   

2. Baseline Labs to Request

   
   

   • Total testosterone (morning, fasting)

   • SHBG, albumin (for FT calculation)

   • Estradiol (E2)

   • LH, FSH, prolactin

   • DHT (optional)

   • CBC / hematocrit / Hb

   • PSA / prostate screening

   • Lipid panel, liver enzymes, CMP

   • Thyroid panel, A1c / glucose / insulin

   • Others as clinically indicated

   
   

3. Treatment Strategy Discussion

   
   

   • Whether to start exogenous testosterone, dose, and frequency

   • What target TT / FT ranges you’ll aim for

   • How to monitor and adjust

   • Plan for mitigating side effects (e.g. aromatase inhibitors, hCG, 5-alpha reductase inhibitors)

   • Strategy for hematocrit control (blood donation, phlebotomy)

   • Discussion on fertility preservation

   
   

4. Monitoring Plan

   
   

   • Frequency of labs (3-6 mo, then 6–12 mo)

   • What thresholds will trigger dose adjustments or cessation (e.g. hematocrit > 52–54%, estradiol too high or too low)

   • What symptoms or red flags require immediate evaluation

   
   

5. Risk Discussion & Informed Consent

   
   

   • Known and unknown long-term risks (prostate, cardiovascular, erythrocytosis)

   • Alternatives or adjunctive lifestyle strategies (weight loss, strength training, sleep, diet)

   • Realistic expectations — TRT is not a panacea

   
   

6. Follow-Up & Review

   
   

   • A plan to review efficacy (subjective + objective)

   • A “pause test” or trial off therapy if no clinical benefit is seen

   
   

Summary & Practical Guidance

• Testosterone is an important hormone for male health, especially as men age and levels decline — but it is only one branch of a complex endocrine system.

• Distinguishing total vs free testosterone is critical; free testosterone often correlates better with symptoms when binding proteins vary.

• When considering exogenous testosterone, work with a doctor to define target ranges, monitoring frequency, and mitigation strategies for side effects.

• Long-term risks like erythrocytosis, estrogen overconversion, testicular atrophy, hair loss, and fertility suppression are real but can often be managed with adjunct therapies (e.g. aromatase inhibitors, hCG, 5-alpha reductase inhibitors, periodic phlebotomy).

• Frequent laboratory monitoring, shared decision-making, and a plan for dose adjustment or cessation if adverse effects develop are essential.

The information provided in this post is for educational purposes only and is not intended as medical advice, diagnosis, or treatment. Please consult with your healthcare provider before starting any new supplement regimen, exercise program, or making significant changes to your health routine, especially if you have existing medical conditions or take medications.