Getting testosterone replacement therapy (TRT) starts with bloodwork confirming you have clinically low testosterone, followed by a prescription from a licensed provider. The process typically involves two separate morning blood draws, a medical evaluation, and ongoing monitoring once treatment begins. Most men can get started through their primary care doctor, a specialist, or a telehealth clinic.
Step 1: Get Your Testosterone Levels Tested
The first step is a blood test measuring your total testosterone. The widely used diagnostic threshold is a total testosterone level below 300 ng/dL, based on American Urological Association guidelines. But a single low reading isn’t enough. You need two separate morning blood draws on two different days, both showing low levels, before a diagnosis is made. Morning testing matters because testosterone peaks early in the day and drops as hours pass, so afternoon readings can be misleadingly low.
Free testosterone (the portion not bound to proteins in your blood) is sometimes tested as well, but it’s not the primary diagnostic tool. It can be helpful when your total testosterone falls in a borderline range, roughly between 230 and 317 ng/dL, where the picture is less clear. Outside that gray zone, total testosterone is the number that drives the diagnosis.
Step 2: Choose the Right Provider
You don’t necessarily need a specialist. Primary care doctors, endocrinologists, and urologists all evaluate and prescribe TRT. If your primary care provider is comfortable managing hormone therapy, that’s often the simplest route. If your case is more complex, or if your doctor prefers not to manage TRT, they’ll typically refer you to an endocrinologist or urologist.
Telehealth TRT clinics have become increasingly popular. These are legal in every state, though the specific rules vary. The provider must be licensed in your state and must establish a genuine patient-provider relationship, which includes reviewing your medical history, ordering lab work, making a diagnosis, and providing ongoing monitoring. Some states allow the entire process to happen remotely, while others require at least one in-person visit. Because testosterone is classified as a Schedule III controlled substance under federal law, no provider can legally prescribe it without a proper evaluation, and it cannot be purchased over the counter.
Nurse practitioners and physician assistants can also prescribe TRT in many states, depending on local scope-of-practice rules.
Baseline Testing Before You Start
Beyond the two testosterone draws, your provider will order additional bloodwork before writing a prescription. According to Cleveland Clinic protocols, baseline labs typically include:
- Hemoglobin and hematocrit to check your red blood cell concentration
- PSA (prostate-specific antigen) to screen for prostate concerns
- Liver function tests
- Luteinizing hormone to help determine whether low testosterone originates in the testes or the brain’s signaling system
- Prolactin to rule out a pituitary issue
You’ll also get a physical exam, and your provider will review your full medical history. This baseline picture helps confirm the diagnosis, rules out other causes of your symptoms, and establishes reference points for monitoring once treatment starts.
Who Cannot Use TRT
Certain conditions disqualify you from testosterone therapy. Absolute contraindications include breast cancer, prostate cancer, and a hematocrit above 54% (meaning your blood is already too concentrated with red blood cells). An elevated PSA level or suspicious findings on a prostate exam will also stop the process until further evaluation is done.
Some situations make TRT riskier without ruling it out entirely. If you want to have children, TRT is a serious concern because it suppresses sperm production, sometimes to zero. Uncontrolled heart failure and untreated sleep apnea also need to be addressed before starting. Your provider will weigh these factors with you.
Delivery Methods and What to Expect
TRT comes in several forms, and the method you choose affects how often you use it and how steady your hormone levels stay.
Injections are the most common option. Many providers start with a weekly injection, adjusting the dose based on follow-up labs and how you feel. Some protocols space injections out to every 10 to 14 days, though this can cause more noticeable peaks and valleys in energy and mood. Others use smaller, more frequent doses (sometimes called micro-dosing) to keep levels more stable.
Topical gels are applied daily, usually to the shoulders or upper arms. They provide steady absorption but require care to avoid transferring the gel to other people through skin contact, particularly children and women.
Patches also deliver a daily dose through the skin, though skin irritation at the application site is a common complaint.
Pellets are small implants placed under the skin, typically in the hip area, every three to six months. They offer convenience since you don’t have to think about daily or weekly dosing, but they require a minor in-office procedure for insertion.
Your provider will help you choose based on your preferences, lifestyle, and how your body responds. Most men start with one method and adjust from there.
Insurance and Out-of-Pocket Costs
Insurance plans generally cover TRT when it’s medically necessary, but they require documentation. Aetna’s policy is representative of most major insurers: they require at least two confirmed low morning testosterone results that fall below the normal range before approving coverage. The diagnosis must be established before therapy begins, and documentation needs to be on file for continued approval.
If you go through a telehealth TRT clinic, some accept insurance while others operate on a cash-pay model. Out-of-pocket costs for testosterone itself (especially injectable forms) are relatively modest, but the clinic fees, lab work, and follow-up visits can add up. It’s worth confirming coverage details with your insurer before choosing a provider.
Ongoing Monitoring Once You Start
TRT isn’t a set-it-and-forget-it treatment. After starting, you’ll have follow-up labs at the three-month mark to check your testosterone level (drawn midway between doses), hematocrit, and PSA. This first check confirms the dose is working and that your body is handling the therapy safely.
After that initial visit, expect blood work every six months for as long as you’re on therapy. Providers should not refill testosterone prescriptions without safety labs on file within the past six months. You’ll also need an in-person visit at least once a year. PSA screening continues annually for most men, and every six months if you have a family history of prostate cancer.
The main safety concern during treatment is your hematocrit creeping up. Testosterone stimulates red blood cell production, and if levels get too high, it increases the risk of blood clots. If your hematocrit rises above safe thresholds, your provider may lower your dose or have you donate blood to bring it down. Some men also develop elevated estrogen levels on therapy, which can cause breast tenderness or paradoxically worsen libido. Your provider can check for this if symptoms arise.