How to Get TRT: Symptoms, Two Morning Blood Tests, and a Prescriber's Review

To get TRT, you need symptoms of low testosterone and a total testosterone below 300 ng/dL on two separate early-morning blood tests. A prescriber then checks a few more labs, rules out reasons not to start, and follows your levels once you begin. TRT is a treatment for diagnosed testosterone deficiency. It is not a general option for men who want "better hormonal health" with normal labs, and both major guidelines say so (AUA 2018; Endocrine Society 2018).

This guide covers men. Testosterone for women is a separate question; see testosterone therapy for women.

What counts as low testosterone?

The American Urological Association (AUA) guideline sets three conditions, and all of them have to hold:

• Total testosterone below 300 ng/dL is "a reasonable cut-off" for the diagnosis (statement 1, Moderate Recommendation, Grade B).
• The low result has to show up on two measurements "taken on separate occasions with both conducted in an early morning fashion" (statement 2, Strong Recommendation, Grade A).

• The diagnosis "is only made when patients have low total testosterone levels combined with symptoms and/or signs" (statement 3, Moderate Recommendation, Grade B).

The Endocrine Society guideline says the same thing in its own words: diagnose hypogonadism only in men with symptoms and "unequivocally and consistently low" testosterone, measured fasting in the morning and confirmed with a repeat test. When total testosterone sits near the lower limit of normal, or when a condition changes SHBG (sex hormone-binding globulin, the protein that carries testosterone in the blood), it recommends also measuring free testosterone (Endocrine Society 2018).

Which symptoms start the evaluation?

The AUA lists these symptoms and signs of testosterone deficiency (AUA Table 5):

• Physical: reduced energy and endurance, fatigue, reduced lean muscle mass, obesity, loss of body hair, reduced beard growth.
• Cognitive: depressive symptoms, poor concentration, poor memory, reduced motivation, irritability.
• Sexual: reduced sex drive and reduced erectile function.

Symptoms are the reason to test. The repeat morning labs decide whether TRT is on the table, because the AUA makes the diagnosis only when low levels and symptoms occur together. If your level comes back in the normal range, the next step is a search for other causes. Starting TRT at a level like 450 ng/dL is a different question, covered separately.

The steps to getting a TRT prescription

1. Book an evaluation

You can see a primary care doctor, a urologist, an endocrinologist, or a licensed telehealth provider. Bring a list of your symptoms, your medications, and any past lab results.

2. Get two early-morning testosterone tests

The first test is a fasting morning total testosterone. If it is low, it gets repeated on a separate morning to confirm it (AUA 2018). A telehealth provider can usually order these at a local lab.

3. Complete the rest of the workup

Once low testosterone is confirmed, the guidelines call for more labs before treatment, partly to find the cause (Endocrine Society 2018) and partly to check that starting is safe. From the AUA guideline:

• LH (luteinizing hormone, the pituitary signal that tells the testes to make testosterone) in every man with low testosterone (Strong Recommendation, Grade A).
• Prolactin if LH is low or low-normal (Strong Recommendation, Grade A). A prolactin level that stays high without a known cause calls for evaluation for endocrine disorders.
• Hemoglobin and hematocrit (the share of your blood made of red cells) before starting, because testosterone raises the risk of polycythemia, an excess of red cells (statement 11, Strong Recommendation, Grade A). If baseline hematocrit is above 50%, the AUA says to withhold testosterone until the cause is explained.
• PSA in men over 40, to exclude prostate cancer before starting (statement 12, Clinical Principle).
• Estradiol only if you have breast symptoms or gynecomastia (statement 9, Expert Opinion). It is not a routine test for everyone.

Your prescriber should also talk with you about fertility if you might want children later, because testosterone affects sperm production over the long term (statement 16, Strong Recommendation, Grade A).

4. Decide on treatment together

If you have symptoms, confirmed low testosterone, and no reason to hold off, the Endocrine Society recommends testosterone therapy after a discussion of its benefits and risks and of the monitoring it requires. The AUA also says every man with testosterone deficiency should be counseled on lifestyle changes as part of treatment (Conditional Recommendation, Grade B).

5. Choose a form

Testosterone comes as intramuscular injections (cypionate, enanthate, or undecanoate), gels and a topical solution, a skin patch, a nasal gel, a buccal system that sticks to the gum, and pellets placed under the skin (AUA Table 2). The Endocrine Society says the choice should weigh patient preference, how each form is absorbed, its specific side effects, treatment burden, and cost. The dose is your prescriber's decision, adjusted to your labs and symptoms.

6. Follow-up labs

The AUA calls for a follow-up testosterone level "after an appropriate interval" to confirm you have reached the target, then testosterone checks every 6 to 12 months (statement 30, Expert Opinion). The target is the middle third of the normal range (statement 22, Conditional Recommendation, Grade C). The Endocrine Society recommends a standard first-year plan that checks symptoms, side effects, testosterone, hematocrit, and prostate cancer risk.

On treatment, a hematocrit of 54% or higher "warrants intervention", and adjusting the dose comes first (AUA 2018).

Who should not start TRT?

The Endocrine Society recommends against starting testosterone in men who are planning fertility in the near term or who have any of these (Endocrine Society 2018):

• Breast or prostate cancer.
• A palpable prostate nodule or induration, a PSA above 4 ng/mL, or a PSA above 3 ng/mL in men at higher risk of prostate cancer (such as African American men or men with a first-degree relative with prostate cancer), until a urologist has evaluated it.
• Elevated hematocrit.
• Untreated severe obstructive sleep apnea.
• Severe lower urinary tract symptoms.
• Uncontrolled heart failure.
• A heart attack or stroke within the last 6 months.
• Thrombophilia (an inherited or acquired tendency to form blood clots).

The AUA is direct about fertility: "Exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive" (statement 23, Strong Recommendation, Grade A). It also advises waiting three to six months after a cardiovascular event before starting (statement 24, Expert Opinion).

Age alone is not a diagnosis. The FDA's 2025 labeling update kept the "Limitation of Use" language for age-related hypogonadism on testosterone products (FDA 2025).

What can TRT do, and what is unproven?

The AUA guideline says men should be told that testosterone therapy may improve erectile function, low sex drive, anemia, bone mineral density, lean body mass, and depressive symptoms (Moderate Recommendation, Grade B). It also says the evidence is inconclusive on whether it improves cognitive function, energy, fatigue, diabetes measures, lipids, or quality of life (AUA 2018).

The Testosterone Trials give a sense of size. In 790 men aged 65 or older with testosterone below 275 ng/dL and symptoms, a year of testosterone gel brought a moderate benefit to sexual function and some benefit to mood and depressive symptoms, with no benefit to vitality or walking distance (Snyder et al., NEJM 2016). These were older men, so the results may not carry over to younger men.

What are the risks?

The prescribing label for testosterone cypionate lists acne, seborrhea, and male pattern baldness among skin effects, and warns that edema (fluid retention) can be a serious problem in men with existing heart, kidney, or liver disease. It also lists gynecomastia, which "occasionally persists", and says hemoglobin and hematocrit should be checked periodically on long-term treatment (DEPO-Testosterone label). The label gives no rates for these effects.

Testosterone can suppress sperm production. The same label notes that spermatogenesis can be suppressed at large doses and that oligospermia (low sperm count) can follow prolonged or excessive dosing.

Testosterone can raise blood pressure. In 2025 the FDA added a blood pressure warning to every testosterone product after monitoring studies "confirmed an increase in blood pressure with use of all testosterone products, class-wide" (FDA 2025). More detail is in does TRT raise blood pressure.

TRAVERSE is the largest trial of testosterone and heart attacks and strokes. It randomized 5,246 men aged 45 to 80 with, or at high risk of, cardiovascular disease, symptoms, and two fasting testosterone levels under 300 ng/dL. Over a mean follow-up of about 33 months, major cardiac events occurred in 7.0% of men on testosterone gel and 7.3% on placebo, which met the trial's test for noninferiority (no worse than placebo). Atrial fibrillation, acute kidney injury, and pulmonary embolism were more common with testosterone (TRAVERSE, NEJM 2023).

Common questions

Can I get TRT through telehealth?

Yes, if the same steps happen: symptoms, two morning tests, the baseline labs above, and follow-up labs on treatment. The provider orders bloodwork at a lab near you and reviews it before prescribing. A service that offers testosterone without repeat morning labs is skipping what both guidelines require.

What if only one of my tests was low?

The AUA requires two low early-morning results on separate occasions before diagnosing low testosterone (Strong Recommendation, Grade A). One low result is a reason to repeat the test.

Can I start TRT while my partner and I are trying to conceive?

The AUA says no: testosterone "should not be prescribed to men who are currently trying to conceive" (statement 23, Strong Recommendation, Grade A). If you have low testosterone and want children, discuss fertility-preserving options with your prescriber before any testosterone is started.

Do I need labs after I start?

Yes. Expect a follow-up testosterone level after starting, then testosterone every 6 to 12 months (AUA statement 30), along with hematocrit and prostate checks during the first year (Endocrine Society).

Bottom line

You get TRT by showing two things: symptoms of low testosterone and total testosterone under 300 ng/dL on two separate early-morning tests. A prescriber then checks LH, hematocrit, PSA if you are over 40, and other labs, rules out reasons not to start (including trying to conceive), and follows your levels and hematocrit once you begin. If your labs are normal, the next step is looking for another cause of your symptoms.

AlphaMD's licensed providers review these labs before prescribing; see testosterone replacement therapy at AlphaMD.