What to expect
onTestosterone Replacement Therapy

Longstanding low testosterone levels can manifest through a range of symptoms, including:

• Low mood, anxiety, or feelings of depersonalisation
• Brain fog and difficulty concentrating
• Persistent lethargy and reduced energy
• Decreased libido and erectile dysfunction
• Loss of lean muscle mass, increased body fat, and reduced bone mineral density

If you’re concerned you may be experiencing Testosterone Deficiency, the next step is to undergo diagnostic blood testing followed by a thorough consultation with a medical doctor.

Your initial blood test should be a comprehensive panel, as detailed in our article, Testosterone – Which Blood Test Do I Need & Why? Both our TRT COMPLETE  and TRT COMPLETE PLUS blood panels provide extensive screening to identify potential causes, reversible factors, and any contraindications to therapy.

To confirm a diagnosis, two separate blood tests are required to demonstrate chronic low testosterone levels. If the first test reveals areas that can be improved, such as lifestyle or metabolic factors, it’s advisable to address these before repeating the test. If the second test confirms low levels and you are committed to making the necessary lifestyle changes with realistic expectations, Testosterone Replacement Therapy (TRT) can be life-changing.

It’s important to remember that Testosterone Deficiency should be a diagnosis of exclusion. Before considering TRT, focus on optimising stress management, sleep quality, nutrition, and physical activity. Achieving balance in these areas is crucial to experiencing the full benefits of healthy androgen levels.

Ideally, TRT should be a last resort. The therapy requires a commitment of time, effort, and finances, and it’s best approached after exhausting natural options. To support you on this journey, we’ve created helpful resources such as:

1. How to Increase Testosterone Levels Naturally
2. How to Improve Metabolic Health – The Facts

Testosterone Replacement Therapy (TRT) is designed to restore male androgen levels to a healthy, physiological range, supporting both physical and psychological wellbeing. Naturally, many patients begin treatment hoping for quick relief from the symptoms they’ve been struggling with. But low testosterone is often the end result of a more complex chain of events, influenced by lifestyle, stress, and long-term health behaviours. Addressing those underlying factors is just as important as correcting hormone levels. No one lives a perfect life, but progress comes from consistent effort, and effort leads to reward.

One of the common concerns about TRT is its predictability. Unlike the body’s own hormone production, medications have a more fixed effect. Human physiology, however, is dynamic – constantly adapting to internal and external stressors to maintain balance. That’s why our approach goes beyond simply prescribing a set dose. After careful titration based on how you feel and how your body responds, we provide ongoing support with structured follow-up, tracking both symptom improvement and key biomarkers. This ensures your therapy remains not only effective, but safe, sustainable, and tailored to your individual needs.

Traditional testosterone monotherapy suppresses the release of luteinising hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary gland – key signals required for healthy sperm production (spermatogenesis). This suppression can lead to reduced fertility or even infertility, which is often cited as a reason not to offer TRT to younger men.

At The Men’s Health Clinic, we routinely incorporate human chorionic gonadotropin (hCG) into our gold-standard TRT protocol. hCG mimics the action of LH, helping to maintain testicular function and support the brain–testes signalling pathway. In doing so, it not only helps preserve fertility, but also supports a more physiological approach to testosterone replacement. In fact, we’ve lost count of how many of our patients have successfully conceived while on therapy.

The benefits of hCG go well beyond fertility, too — something we explore in more detail in our article, The Benefits of Using HCG with TRT.

Hair loss can be distressing, but it’s important to understand that male pattern baldness is primarily genetic in origin. While medications like Finasteride – a 5-alpha reductase inhibitor – are often promoted as a solution, we advise against their use. Finasteride works by blocking the conversion of testosterone to dihydrotestosterone (DHT), a hormone essential for male health and optimal wellbeing. Suppressing DHT can lead to a range of troubling side effects, including sexual dysfunction, reduced libido, anxiety, and a general sense of emotional blunting, all of which may result from both low DHT and downstream effects on neurotransmitters such as GABA.

As a clinic that specialises in the diagnosis and treatment of testosterone deficiency, we have no bias against prescribing Finasteride – if the benefits truly outweighed the risks, it would be in our interest to recommend it. However, in our clinical experience, the risk of Post-Finasteride Syndrome (PFS) is very real and can be severely life-altering for those affected. We explore this in greater depth in our article, The Devastating Effects of Finasteride: Post-Finasteride Syndrome (PFS).

Those who dismiss PFS often misunderstand human physiology – or may have a financial incentive to downplay the risks.

Gynecomastia is the abnormal development of breast tissue in males. In both men and women, hormones like oestradiol, prolactin, progesterone, and IGF-1 play a key role in breast tissue growth. Fortunately, when TRT is properly prescribed and carefully balanced, gynecomastia remains a rare occurrence.

Although gynecomastia is benign, it can be understandably distressing due to its visible nature and psychological impact. In the context of TRT, it is most commonly associated with elevated oestradiol levels, which stimulate breast tissue growth. In contrast, both testosterone and dihydrotestosterone (DHT) act as natural inhibitors of this process. Raised prolactin may also contribute, typically as a result of oestradiol suppressing dopamine – also known as prolactin-inhibitory hormone – within the hypothalamus. Elevated oestradiol can also directly stimulate prolactin release from the pituitary gland.

Some individuals appear more predisposed to developing gynecomastia, particularly those with a history of anabolic steroid use, which can sensitise breast tissue over time. However, it’s important not to panic – the fibrous, more permanent stage of gynecomastia usually takes several months to develop. Early detection and appropriate clinical management are key.

If adjustments are needed to optimise your testosterone-to-oestradiol ratio, we’ll guide you through those changes. In cases where intervention is necessary, medical management typically involves Raloxifene, a selective estrogen receptor modulator (SERM) that has shown greater effectiveness than Tamoxifen for fibrous gynecomastia. In rare, persistent cases, surgical intervention may be the only definitive solution.

While acne has traditionally been linked to elevated levels of dihydrotestosterone (DHT), our clinical experience suggests that excess oestradiol is more often the underlying cause. In many cases, simply optimising the ratio of testosterone to oestradiol leads to significant improvement. Acne may occasionally appear during the early stages of therapy due to hormonal fluctuations, but this typically resolves as hormone levels stabilise.

To help minimise the risk of breakouts, we recommend staying well-hydrated and avoiding common dietary triggers such as chocolate and dairy, which may contribute to inflammation or increased oil production. From a skincare perspective, choose a soap or shower gel that is free from sodium lauryl ether sulfate (SLES), a common ingredient that can clog sebaceous glands and exacerbate acne.

With the right balance and supportive care, skin-related side effects are usually short-lived and manageable, and should not deter you from continuing with treatment that supports your overall health and wellbeing.

The relationship between Testosterone Replacement Therapy (TRT) and cardiovascular health is a complex topic, thoroughly explored in our article, Dispelling The Myths: TRT & Cardiovascular Health. At its core, TRT aims to restore male androgen levels to a normal physiological range, supporting the body’s natural functions and overall wellbeing.

“Although testosterone treatment increases the risk of erythrocytosis, the available randomised controlled trials and observational data have failed to reveal any consistent association (positive or negative) between testosterone treatment and cardiovascular or cerebrovascular events.” – Society for Endocrinology

Erythrocytosis – a rise in red blood cell count – is a known potential side effect of TRT, which is why we take careful precautions. To ensure your safety, we routinely monitor both blood pressure and haematocrit levels in all our patients undergoing testosterone therapy. This vigilant approach allows us to manage any risks early and maintain your cardiovascular health alongside hormone optimisation.

Preventing prostate disease is a priority for all men, not just those undergoing Testosterone Replacement Therapy (TRT). At The Men’s Health Clinic, we routinely monitor prostate health through regular Prostate Specific Antigen (PSA) blood tests. Additionally, for men over 40, we offer an optional annual prostate examination via digital rectal exam to provide comprehensive screening.

It’s important to understand that healthy hormone levels are unlikely to cause prostate cancer. Hormones act as chemical messengers, facilitating the normal function of their target tissues. Conversely, abnormal hormone levels can disrupt this balance and may be detrimental. This nuanced topic is explored in greater detail in our article, Dispelling the Myths: Prostate Cancer & Testosterone Replacement Therapy (TRT).

Our approach ensures you receive thorough, evidence-based care that prioritises your long-term prostate and overall health.

We understand that starting Testosterone Replacement Therapy (TRT) can feel daunting, but many patients are surprised at how straightforward and manageable it really is once they experience it firsthand. Until you’ve had your first injection in clinic, it’s hard to fully appreciate just how simple the process is.

Many men arrive feeling apprehensive, but after that initial injection, there’s often an audible sigh of relief. The treatment involves a tiny microdose of testosterone and hCG delivered subcutaneously with a very small insulin needle – and it’s essentially painless. The entire process usually takes less than two minutes to prepare and administer, about the same time it takes to boil the kettle for your morning coffee.

TRT quickly becomes a seamless part of your daily routine, much like brushing your teeth. There’s no need for added psychological stress or anxiety. In fact, many of our patients report at their annual reviews that they barely think about their injections anymore – instead, they’re focused on living their lives to the fullest.

If you are a suitable candidate for Testosterone Replacement Therapy, our gold-standard treatment involves either daily injections of Testosterone Cypionate or weekly injections of Testosterone Undecanoate, combined with daily Human Chorionic Gonadotropin (hCG). In our professional experience, this approach is the most effective way to achieve stable male androgen levels and significantly improve overall wellbeing.

Our prescribing rationale is detailed in the article, Microdosing TRT – The Future of Testosterone Replacement Therapy. hCG plays a vital role in preserving testicular function and fertility, among other benefits, which we discuss further in, The Benefits of Using HCG with TRT.

Day 1:

Your TRT journey begins with a comprehensive 60-minute consultation. During this appointment, we take a detailed medical history, perform a physical examination, discuss the benefits and risks of therapy, and jointly confirm that TRT is in your best interest. After you provide informed consent, you can begin treatment.

Days 2-14:

In the first two weeks, you may notice sudden mood changes, either positive or sometimes heightened anxiety. These effects stem from the initial hormonal fluctuations caused by starting hCG and testosterone. This is entirely normal as your body experiences peaks and troughs in hormone levels while adjusting. If you feel nothing, don’t worry – it does not mean the treatment isn’t working; your body may simply be adapting silently.

Weeks 2-8:

By this stage, your hormone levels should start to stabilise, and you may feel gradually better. Occasionally, some patients experience worsening symptoms, often because testosterone or oestradiol levels are not yet optimised. Elevated oestradiol, in particular, can cause anxiety and other symptoms.

This period is a normal part of your treatment – sometimes you feel worse before you feel better. We adjust your doses carefully based on how you feel and your blood test results, aiming to reach a healthy hormonal balance. Around Week 4, repeat blood tests help us assess your response, followed by a review at Week 5 where your dose may be modified to prevent potential side effects.

Some patients experience temporary water retention or bloating, often due to increased aldosterone activity early in treatment. This usually settles as your body recalibrates. Persistent bloating after Week 4 may indicate rising oestradiol, requiring further dose adjustments at Week 5 or Week 11.

Weeks 8-9:

The peaks and troughs of injections begin to smooth out as your hormone levels stabilise. However, your optimal dose may still require fine-tuning. Your body continuously strives for homeostasis, adapting both to your initial low testosterone state and the introduction of exogenous hormones. Achieving this balance takes time and careful management.

Weeks 10-11:

At around 10 weeks, we repeat blood tests to confirm your hormone levels have stabilised from a pharmacokinetic perspective. By this point, how you feel subjectively should align more closely with your lab results. During your Week 11 review, we assess your overall progress and, if appropriate, advise continuing your current protocol to maintain stable, healthy androgen levels.

Because everyone’s physiology is unique, further dose adjustments may sometimes be necessary to achieve the best possible results. Throughout this phase, it’s important to focus on sustainable lifestyle improvements, including stress management, sleep quality, nutrition, and exercise. Remember, low testosterone is rarely the sole factor in feeling “off” – achieving optimal health requires a holistic approach and ongoing commitment.

Understanding the “Drug Effect”

Pharmacokinetics explains that drug levels typically stabilise after about five half-lives – approximately 11 days for hCG and 4–8 weeks for testosterone. During this time, fluctuations in hormone levels are expected and can affect:

• Cardiovascular Function: Changes in heart rate, blood pressure, or extremity temperature
• Endocrine System: Increased thyroid activity, which may temporarily worsen cardiovascular symptoms or cause anxiety
• Mood: Testosterone, oestradiol, and DHT influence brain chemistry, impacting dopamine, serotonin, and other neurotransmitters

Your body needs time to adjust and restore hormonal balance. These early fluctuations are temporary and do not predict your long-term experience on TRT.

Testosterone Level is Too Low:

If your testosterone level is below the optimal range, your dose will be carefully increased to achieve healthy male androgen levels. Your body generally does not respond well to abrupt, dramatic changes – so after the initial boost, a gradual and steady approach is key. Aggressive dose changes can lower levels of sex hormone-binding globulin (SHBG), a crucial glycoprotein that acts as a buffer to help maintain a balanced ratio of oestradiol, testosterone, and dihydrotestosterone (DHT).

Testosterone Level is Too High:

If your testosterone exceeds the physiological range, your dose will be reduced accordingly. While elevated testosterone can initially make you feel great by increasing dopamine levels, this is often temporary. Prolonged high dopamine leads to receptor downregulation, making the initial “high” unsustainable. Reducing testosterone will lower dopamine levels temporarily, which may cause an initial dip in mood, but this is a necessary step for your dopamine receptors to reset. Ultimately, this leads to a more stable and rewarding sense of well-being.

Abnormal Testosterone to Oestradiol Ratio:

The enzyme aromatase, found in many tissues but particularly in the liver and fat, converts testosterone into oestradiol. Managing this conversion is essential for hormonal balance. Addressing underlying health issues – such as optimising liver function and reducing excess body fat – is fundamental. Additionally, lowering stress, improving sleep, eating a balanced diet, and appropriate supplementation all contribute to maintaining a healthy hormone ratio. For more detailed guidance, see our article: Controlling Oestrogen Without Pharmaceutical Drugs.

While oestrogen is important for overall health, excess levels can cause unwanted effects such as anxiety, emotional instability, water retention, breast tenderness, acne, and joint pain. In some cases, an aromatase inhibitor may be prescribed to reduce oestradiol production. Though initially developed for female breast cancer patients, these medications work by inhibiting aromatase and are used at doses roughly 75 times lower in men on TRT. All medications are prescribed under close medical supervision, using the minimum effective dose.

Patients often experience improved well-being as anxiety decreases and symptoms like water retention and breast issues resolve. However, reducing oestradiol can also lower serotonin levels, sometimes causing temporary mood dips before receptors adjust. Even if you feel well despite elevated oestrogen, you may find you feel significantly better once balanced.

Raised Haemoglobin & Haematocrit:

An abnormal increase in red blood cell concentration (erythrocytosis) raises the risk of cardiovascular complications by thickening the blood, which can increase blood pressure and promote clotting. This topic is explored in detail in our article: TRT & Erythrocytosis – Facts and Recommendations.

Possible causes for raised haemoglobin and/or haematocrit include:

• Supraphysiological Testosterone Levels: Requiring dose adjustment
• Unmasking or Worsening of Obstructive Sleep Apnoea: If you notice increased snoring or poor sleep despite TRT, a sleep study may be recommended
• Dehydration During Blood Testing: It’s important to be well-hydrated even when fasting, as dehydration can skew results
• Delays in Blood Sample Processing: Which can cause inaccurate readings and necessitate repeat testing

If intervention is required to lower these levels, we will advise you appropriately. Importantly, you should not routinely donate blood while on TRT, as exogenous testosterone affects iron metabolism by suppressing hepcidin to varying degrees.

Rise in SHBG Levels if Low Pre-TRT & Lowering of SHBG if High Pre-TRT:

Sex Hormone Binding Globulin (SHBG) is a key glycoprotein that regulates the balance between oestradiol, testosterone, and DHT, impacting how these hormones affect your body and your sense of well-being. Our article: TRT, SHBG & Health – Facts, Questions and Evolution – provides an in-depth look at its role.

If your SHBG was low before starting TRT and rises during treatment, this often signals an optimised protocol and improved metabolic health — a positive outcome for both patient and clinician. However, if your SHBG remains low despite a well-balanced TRT regimen and lifestyle efforts (stress reduction, sleep, diet, exercise), it is likely a genetic trait. We encourage ongoing focus on improving metabolic health rather than fixating on SHBG levels.

We advise patients not to over-interpret their bloodwork independently — that’s what we’re here for, to provide expert, objective clinical guidance. While the internet may suggest lowering SHBG to “free up” testosterone, SHBG actually assists in delivering testosterone into cells for anabolic effects.

Remember, any dose adjustment causes a temporary “drug effect” — changes in physiology and possibly mood that do not reflect your stable state. Drug levels usually stabilise within 4–6 weeks after a dose change, at which point true effects become clearer. Never adjust your dose yourself. Dose changes are carefully managed based on pharmacology and physiology. Self-adjustment disrupts stable baselines and can cloud your perception of how well the therapy is working.

1. Improved Cognitive Function – No More Brain Fog:

While Testosterone Replacement Therapy (TRT) won’t automatically make you a genius or drastically raise your IQ, it can significantly help clear that frustrating mental “fog.” Many men report improved memory, better focus, and a sharper ability to process new information. Tasks that once felt overwhelming – like remembering names or why you entered a room – become easier. TRT supports cognitive clarity, helping you confidently make everyday decisions without hesitation.

Male androgen levels play a critical role in normal brain function. Testosterone positively influences the amygdala, a brain region associated with reducing risk aversion, which may partly explain why men often take more risks. Both testosterone and oestradiol are active in key brain areas including the frontal cortex, striatum, thalamus, hypothalamus, hippocampus, and cerebellum. In short, hormones are essential for optimal brain health and mental performance.

2. Change in Libido:

Low libido and erectile dysfunction are common symptoms of Testosterone Deficiency, but it’s important to understand that reduced sexual desire isn’t always caused by low testosterone alone. From our clinical experience, TRT typically does not harm an already healthy libido—in fact, we often see libido improve before erectile function does.

The mechanisms behind libido and erection are complex and involve both physical and psychological factors. Usually, the psychological benefits of TRT—like increased confidence and mood improvements—precede physical improvements. Many men experience a rekindling of their former sexual vitality, though it’s natural that life’s stressors and increased responsibilities as we age will continue to influence libido.

Sexual desire and erections are largely driven by the parasympathetic nervous system (the “rest and digest” mode), rather than the sympathetic system (the “fight or flight” response). This makes sense evolutionarily: when there’s perceived danger, survival takes priority over sex, so libido naturally decreases in risky situations.

3. Improved Mood:

Contrary to common myths, testosterone is a calming hormone when balanced – it does not cause aggression. Most men on TRT report feeling calmer, more thoughtful, and emotionally balanced.

Imagine a seesaw balancing excitatory neurotransmitters and catabolic hormones on one side (linked to stress and stimulation) against inhibitory neurotransmitters and anabolic hormones on the other (linked to relaxation and repair). Testosterone primarily acts as a dopaminergic (stimulating) hormone, while oestradiol has serotonergic (calming) effects. Achieving the right balance between these hormones is key to emotional wellbeing – think of it as yin and yang working together.

4. Improved Energy & Motivation:

Men’s motivation and reward systems are deeply connected to testosterone’s relationship with dopamine – the brain’s “feel good” neurotransmitter. Unfortunately, modern life often disrupts our natural physiological patterns. Historically, dopamine rewards were earned through physical activity and survival behaviors: wake up, hunt, catch food, then return to safety.

Today, many people seek quick, artificial dopamine hits through less healthy behaviors that do not require effort, choosing the “take” instead of the “earn” path. This often leads to reduced testosterone and diminished long-term wellbeing because your body isn’t “earning” its reward.

As physical beings, we need regular exercise to stimulate dopamine naturally, this is non-negotiable. Testosterone peaks in the morning, making this the ideal time for physical activity. Exercise then lowers testosterone slightly, which encourages behaviors to regain dopamine, often through food intake. Understanding this cycle can help you maintain balanced energy, motivation, and overall health.

As your doctor, one of the most challenging parts of my job is managing expectations. On paper, our role is straightforward: carefully adjust your TRT dosage to achieve healthy, stable male androgen levels based on how you respond. We provide expert advice on every aspect of TRT, but ultimately, we cannot do the work for you. The responsibility to improve your health lies with you – through better diet, managing stress, improving sleep, and committing to regular exercise.

Don’t let negative thoughts or doubts dictate your reality. Take control by understanding what you need to do rather than what you want to do in the moment. Growth and change often require stepping outside your comfort zone. The true reward comes from effort, not from passive or easy gains. If it were easy, it wouldn’t be nearly as meaningful.

While testosterone is a foundational hormone vital for both physical and psychological health, TRT is not a magic cure-all. Instead, it can be a powerful catalyst for positive change, but only if you put in the effort. Remember: effort equals reward.

Testosterone itself is not a simple “feel-good” hormone. Your body doesn’t respond to your current emotional state – it simply follows physiological processes. You must actively combat negativity, nurture positivity, and continually strive to “Earn Your Reward.”

Your prescribing clinician is your objective partner in this journey, equipped with the knowledge and clinical tools to make decisions in your best interests. Avoid comparing your personal experience with anecdotal stories on the internet. Trust the process and the expertise guiding your care.

Low testosterone is just one potential cause of symptoms like low mood, anxiety, brain fog, lethargy, and low libido. The list of possible causes is long. That’s why a holistic approach to your health is essential. Remember, there are no “days off” when it comes to improving your wellbeing.

Focus continuously on:

• Lifestyle: Managing stress and prioritising restorative sleep
• Nutrition: Making mindful, healthy food choices
• Physical Exercise: Which not only improves fitness but also enhances sleep quality and mental health
• Mindset: Cultivate resilience, patience, and a positive attitude towards challenges

Supporting your parasympathetic nervous system through practices like breathwork, mindfulness, yoga, ice baths, and grounding techniques can also help maintain balance and resilience.

Many patients who initially doubted the process later tell me – often between six months and eighteen months in – “You’ve changed my life, Doc!”

This journey requires patience, commitment, and a partnership built on trust and effort. Together, we can help you reach your healthiest self.

Dr Robert Stevens
MBChB MRCGP Dip.FIPT