Two Morning Blood Draws Before Any Prescription
Most men who ask us about testosterone have already seen a lab result. Some of them are right about what it means. Many are not.
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A single testosterone reading drawn at three in the afternoon after a short night's sleep is not a diagnosis. Around 30% of men with one low result read normal when the test is repeated correctly, which is why the American Urological Association requires two separate early-morning measurements before anyone uses the word hypogonadism, and the Endocrine Society requires those two draws to be fasting as well.
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Testosterone replacement therapy is the male-specific arm of hormone replacement therapy. At Stages of Life Medical Institute, Dr. David S. Klein treats it the way he treats everything else: find what is actually driving the problem, then decide whether replacement is the right answer. TRT is a prescription hormone therapy with a structured monitoring schedule attached, not a supplement and not a subscription.
Symptoms of Low Testosterone in Men
Not every symptom on a low-T checklist carries the same weight. The European Male Ageing Study followed 3,369 men aged 40 to 79 and found only three symptoms that consistently tracked with low testosterone:
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Fewer morning erections
Fewer sexual thoughts
Erectile dysfunction
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Fatigue, low mood, poor concentration, broken sleep, lost muscle and added abdominal fat are real complaints, and men with low testosterone often have them. They are also extremely common in men whose testosterone is entirely normal. On their own they justify a workup, not a prescription.
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The gap between the two is wider than most men expect. In that same study only 2.1% of men met the full criteria for symptomatic low testosterone: under 1% of men below 60, 3.2% of men in their sixties, 5.1% of men in their seventies. Biochemically low testosterone is far more common than that. Deficiency that is both symptomatic and worth treating is not.
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Testosterone also declines slowly. About 1% a year from the late thirties, which is why a 55-year-old's result should not be read against a 25-year-old's expectations.
How Low Testosterone Is Diagnosed
The AUA sets a total testosterone below 300 ng/dL as a reasonable cut-off, measured twice, both times early in the morning. The Endocrine Society works from a harmonized reference range of 264 to 916 ng/dL in healthy, non-obese young men and asks clinicians to use their own laboratory's range rather than a universal number.
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Both agree on the part that gets skipped. The number alone is not the diagnosis. Low testosterone plus consistent symptoms is the diagnosis.
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Assay quality is the other half of the problem. In its July 2026 statement the Endocrine Society noted that non-standardized assays mean the same blood sample can read low at one laboratory and normal at another, and recommended assays certified through the CDC's Hormone Standardization Program. It also came out against population-level screening of men without symptoms.
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We draw and run blood in our own building through our in-office laboratory, which is how we control timing, fasting state and turnaround rather than working from a result somebody else produced under conditions we cannot see.
What Your Testosterone Workup Includes
Total testosterone, twice. Early morning, fasting, on two separate days
Free testosterone. When total testosterone sits near the lower limit of normal, or when something is shifting your binding protein
SHBG. Obesity, diabetes, thyroid disease, liver disease, aging and several common medications all move it, and a normal total testosterone with high SHBG can still leave you short of usable hormone
LH and FSH. These separate a testicular problem from a pituitary one. Different cause, different treatment, different fertility options
Prolactin. When LH comes back low or low-normal
PSA. For men over 40, before any prescription is written
Hematocrit and hemoglobin. The AUA advises holding treatment above 50% until the cause is found. The Endocrine Society sets its cut-off lower, at 48%
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Which of these apply depends on your history. Estradiol is not part of a routine male workup. The AUA reserves it for men who present with breast tenderness or gynecomastia.
We Look for the First Domino
Dr. Klein's phrase for this is treating the first domino, not the last. Testosterone sits downstream of a great deal else, and a low number is often a symptom rather than the disease.
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Weight is the clearest example. The Endocrine Society's July 2026 statement is blunt about it: in men with a BMI over 27 whose testosterone is low because of their weight, weight loss is typically the first-line therapy, not testosterone. Visceral fat converts testosterone to estradiol and suppresses the signal from the pituitary, so the fat and the low reading feed each other.
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Untreated sleep apnea, thyroid disease, uncontrolled diabetes, opioids, glucocorticoids and heavy alcohol use all suppress testosterone, and all of them respond to treatment aimed at the cause. So do several less obvious metabolic and endocrine problems that present as nothing more specific than exhaustion.
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Prescribing testosterone to a man whose real problem is untreated sleep apnea corrects a lab value and leaves the patient where he started.
TRT Delivery Methods Compared
Method
Typical schedule
Key Considerations
Transdermal gel or cream
Daily, each morning
Steady levels that follow the body's own daily rhythm. Transfers by skin contact, so application discipline matters
Transdermal patch
One system nightly
No transfer risk. Skin reactions are common: 28% of men had an application-site reaction of some kind on the 2 mg and 4 mg systems, most often itching (17%)
Intramuscular injection
50 to 400 mg every 2 to 4 weeks
The cheapest option. Produces peaks and troughs, and raises hematocrit more than transdermal patches do
Subcutaneous auto-injector
75 mg weekly
The only FDA-approved subcutaneous testosterone. Its blood pressure boxed warning was downgraded to an ordinary warning in March 2025, and blood pressure still needs watching
Pellets
75 mg pellets implanted every 3 to 6 months
Nothing to remember. Also nothing to adjust, because once implanted the dose cannot be withdrawn
Oral
Twice daily with food
Absorbed through the intestinal lymphatics, so not liver-toxic like older oral androgens. All three US products carried boxed warnings for raised blood pressure until July 2025, when the FDA downgraded them to ordinary warnings
Nasal
Three times daily
Short-acting, and the only route with published evidence of preserved LH and FSH. Long-term fertility data are thin, so it is not a substitute for a fertility plan
One point worth knowing before you compare clinics. Subcutaneous injection of testosterone cypionate is very widely used in US practice, but it is off-label: the Depo-Testosterone label specifies intramuscular administration only.
Why We Use Transdermal Testosterone
We use transdermal hormone therapy almost exclusively, because it most closely reflects normal human physiology. A healthy man's testosterone is not a flat line. It peaks in the early morning and falls through the day, and daily transdermal dosing reproduces that pattern rather than overriding it.
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Dose can be adjusted in small increments instead of by stretching or shortening an injection interval
If a man does not tolerate it, stopping the application stops the exposure within a day or two
Injectable testosterone raises hematocrit more than transdermal patches do
Nothing is implanted, so nothing has to be dug out again
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Dr. Klein does not use pellets, and his objection is the same one. Pellets hold hormone levels constant for months, and constant is not what the body does. He has written at more length about why he often prefers the transdermal approach.
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Transdermal therapy carries one real obligation. Testosterone gel transfers by skin contact, and secondary exposure has caused virilization in children. Wash your hands after applying, let the site dry before dressing, and keep it covered.
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If you have arrived set on weekly injections or on pellets, we would rather tell you now than after your consultation. We will explain the reasoning, and if it is not the approach you want, we will say so early.
When Men Actually Feel a Difference
What changes
First noticeable
Near maximum effect
Sexual interest
3 weeks
6 weeks
Erectile function
3 weeks
3 to 6 months, occasionally up to a year
Mood and quality of life
3 to 4 weeks
18 to 30 weeks
Insulin sensitivity
within days
3 to 12 months
Fat mass
3 months
6 to 12 months
Lean mass and muscle strength
12 to 16 weeks
6 to 12 months
Hemoglobin and hematocrit
3 months
9 to 12 months
Bone mineral density
6 months
continues beyond 3 years
These are typical ranges pooled across studies, not a schedule anyone can promise you.
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One caveat is worth stating plainly. In TRAVERSE, the largest randomized trial of testosterone therapy ever run, sexual desire and activity improved but erectile function did not improve meaningfully. That trial enrolled older men who already had cardiovascular disease or high cardiovascular risk. If erectile dysfunction is your main complaint, testosterone on its own may not resolve it, and we would rather work that out before you start than after.
Safety, and What the FDA Changed in 2025
TRAVERSE randomized more than 5,200 men aged 45 to 80, all of them with cardiovascular disease or high cardiovascular risk, all of them with two fasting morning testosterone results below 300 ng/dL. Over a mean 33 months of follow-up, major adverse cardiac events occurred in 7.0% of men on testosterone and 7.3% on placebo. Testosterone was non-inferior to placebo.
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Three findings ran the other way: atrial fibrillation (3.5% against 2.4%), acute kidney injury (2.3% against 1.5%) and pulmonary embolism (0.9% against 0.5%).
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On 28 February 2025 the FDA made class-wide labeling changes to every testosterone product sold in the US. It removed the boxed-warning language about increased cardiovascular risk. It added or strengthened warnings about increased blood pressure, after ambulatory monitoring studies confirmed the effect across the whole class. And it kept the limitation of use stating that safety and efficacy in men with age-related hypogonadism have not been established.
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That third point gets lost in the marketing. The FDA did not declare testosterone heart-safe, and it did not endorse testosterone for age-related decline. It removed one warning and added another. Dr. Klein has covered the same ground for bioidentical hormone therapy and what the FDA says now.
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Prostate. The TRAVERSE prostate substudy found high-grade prostate cancer in 5 of 2,596 men on testosterone and 3 of 2,602 on placebo, a difference well inside the range of chance. PSA rose more on testosterone during the first year and then tracked with placebo. The AUA's position is that there is no evidence linking testosterone therapy to the development of prostate cancer. The Endocrine Society's position, as of July 2026, is that long-term prostate safety remains unestablished. Both are true: the trials are reassuring out to about three years and silent beyond that.
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Fractures. A TRAVERSE substudy published in 2024 found more clinical fractures on testosterone than on placebo, 3.50% against 2.46%. Testosterone raises bone mineral density, and it still did not reduce fractures in that trial.
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Hematocrit. Therapy raises the risk of erythrocytosis roughly fourfold. Above 54% we hold treatment, look for a contributing cause such as sleep apnea, smoking or dehydration, and restart at a lower dose once it is sorted.
Monitoring Is Part of the Prescription
Dr. Klein's rule is that the prescription and the lab schedule are a package deal. You do not get one without the other.
At 3 to 6 months
Testosterone, hematocrit, PSA and examination for men being monitored, blood pressure, and a symptom review.
At 12 months, and annually after that
The same panel.
While a dose is being adjusted
Blood work at 90-day intervals.
Target
The middle of the normal range, not the top of it.
Three findings in the first year send you to a urologist rather than to a dose increase: a confirmed PSA rise of more than 1.4 ng/mL above baseline, a confirmed PSA above 4.0 ng/mL, or a prostate abnormality on examination.
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This is not busywork. It is the difference between a monitored medical therapy and a subscription.
TRT and Fertility
Testosterone taken from outside suppresses the signal from the pituitary. Intratesticular testosterone collapses, and sperm production falls with it. The AUA is unambiguous here: testosterone should not be prescribed to men who are currently trying to conceive.
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Recovery is usual but slow. In male contraceptive studies, two-thirds of men recovered sperm in the ejaculate within six months of stopping and around 10% took until the second year. Older age and longer treatment both predict slower recovery.
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If fertility matters to you now or might in future, say so at the first visit. hCG is FDA-approved in men for other indications and is used off-label alongside testosterone to hold intratesticular levels up: in a three-week study of 29 healthy men, 250 IU every other day held the drop to 7%, against 94% on testosterone alone. Clomiphene is used off-label for the same purpose, and enclomiphene has no approved US product.
Who Should Not Start TRT
Known or suspected breast or prostate cancer
A palpable prostate nodule, or PSA above 4 ng/mL (above 3 ng/mL in higher-risk men) without urological evaluation
Hematocrit above 48%, or above 50% at altitude (Endocrine Society). The AUA's threshold for investigating first is 50%
Untreated severe obstructive sleep apnea
Severe lower urinary tract symptoms
Uncontrolled heart failure
Heart attack or stroke within the last six months
Thrombophilia
Men currently trying to conceive
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Insurance is the other practical filter, and it is worth knowing before you start. Most payers cover testosterone for documented primary or hypogonadotropic hypogonadism and classify age-related low testosterone as unproven. Aetna's policy, last reviewed in July 2026, is representative. The commonest reason men seek TRT is precisely the indication insurers decline and the FDA still flags as unestablished.
TRT Costs at Stages of Life
Initial hormone consultation: $495
Laboratory testing: $200 to $495
Follow-up visits: $160
Confidential reporting outside insurance: additional $150
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Fees are effective 1 December 2025 and are subject to change. Therapy typically begins two to four weeks after the initial consultation, once your second blood draw is back and a plan is set.
Why Central Florida Men Choose Stages of Life
Patients travel to our Longwood practice from across Seminole County, Orlando and Central Florida.
On-Site Laboratory
Blood drawn and run in our own building, which is how we control the timing, the fasting state and the turnaround
Physiologic Delivery
Transdermal therapy that follows the body's own daily rhythm
Physician-Led Care
Every plan is set by Dr. David S. Klein, board certified, in practice since 1983
Ongoing Monitoring
A fixed lab schedule, not a repeating prescription
Objective Data First
Treatment decisions come from lab findings, not from a symptom quiz
Secure Privacy
Confidential reporting outside insurance is available on request
TRT FAQs
What is TRT?
TRT stands for testosterone replacement therapy: prescription testosterone given to men with a confirmed deficiency, to bring levels back into the normal range. It is the male-specific arm of hormone replacement therapy. It is not a performance drug and it is not appropriate for men whose levels are normal.
How do I know if I need TRT?
You need two things: consistent symptoms, and two separate early-morning fasting blood draws showing low testosterone. One low result is not enough, because roughly 30% of men with a single low reading test normal on the repeat.
What is the difference between TRT and HRT?
HRT is the umbrella term for replacing any hormone the body has stopped making in sufficient quantity. TRT is the subset of HRT that replaces testosterone in men. We treat both, and the diagnostic approach is the same.
Can women receive testosterone therapy?
This page covers testosterone replacement for men. Testosterone is measured in women too, and in some cases treated, but the dosing, the diagnostic thresholds and the monitoring are all different, so it is not covered here. Women should start with our hormone replacement therapy page, and Dr. Klein will confirm at the consultation whether testosterone belongs in the plan.
Do I have to fast for a testosterone test?
Yes, and it needs to be early in the morning. Testosterone follows a daily rhythm and peaks in the early hours, so an afternoon draw or a non-fasting draw can produce a low reading in a man whose levels are fine.
How long does TRT take to work?
Sexual interest usually shifts around three weeks. Mood and quality of life around three to four weeks. Changes in fat mass and muscle take three months to begin and six to twelve months to reach their full effect. Bone density keeps improving past three years.
Does Stages of Life use testosterone injections?
Generally no. Dr. Klein uses transdermal delivery almost exclusively, because it reproduces the body's own daily rise and fall rather than creating peaks and troughs. Injectable testosterone also raises hematocrit more than transdermal patches do.
Do you use testosterone pellets?
No. Pellets hold hormone levels flat for three to six months, which is not how the body works, and once a pellet is implanted the dose cannot be withdrawn.
Is TRT safe for the heart?
The TRAVERSE trial randomized more than 5,200 men with existing cardiovascular disease or high risk, and found testosterone non-inferior to placebo for major cardiac events over about three years. Atrial fibrillation, acute kidney injury and pulmonary embolism were all more frequent on testosterone. In February 2025 the FDA removed the cardiovascular language from the boxed warning and added a warning about increased blood pressure.
Will TRT make me infertile?
It suppresses sperm production while you are on it. In contraceptive studies, two-thirds of men recovered within six months of stopping and around 10% took until the second year. If you are trying to conceive now, the AUA advises against starting testosterone, and there are alternatives that raise your own production instead.
Does TRT cause hair loss?
Testosterone converts to dihydrotestosterone, the hormone involved in male pattern baldness. Men who are genetically predisposed may notice thinning sooner than they otherwise would. It is not a universal effect, and it is worth raising at your consultation if male pattern baldness runs in your family.
Can I stop TRT once I start?
Yes, and one of the reasons we favor transdermal delivery is that stopping it stops the exposure within a day or two. Your own production takes time to recover, and symptoms generally return, so it is a decision to make with us rather than on your own.
Does insurance cover TRT?
It depends on the diagnosis. Most plans cover testosterone for documented primary or hypogonadotropic hypogonadism. Most classify age-related low testosterone as unproven and decline it. Our fees are published above so you know where you stand either way.
How much does TRT cost in Orlando?
Our initial hormone consultation is $495, laboratory testing runs $200 to $495 depending on the panel, and follow-up visits are $160. Medication is billed separately by your pharmacy.
Do you treat men outside Longwood?
Yes. Patients come to us from Orlando, Winter Park, Sanford, Altamonte Springs, Lake Mary and across Central Florida.