Low testosterone has become a product. Men’s health clinics, med spas and telehealth services offer to test and treat it, and the symptoms they list, low energy, low drive, belly fat, low mood, are ones most men over forty recognize in themselves. Some of those men have hypogonadism and are undertreated. Many do not, and treating a normal level because of a tired week is medicine done backwards. This page is about telling the two apart and about what a program has to include before it deserves your trust.
It is a number and a symptom, together
The urology and endocrine guidelines agree: low testosterone is diagnosed when a man has symptoms or signs and a total testosterone below 300 ng/dL on two separate early-morning blood tests. Levels peak in the morning, fall through the day, and drop temporarily with illness, which is why one afternoon draw proves nothing. Symptoms without a low level are not the diagnosis, and the guidelines do not recommend questionnaires to decide who gets treated. Routine screening of men without symptoms is recommended against.
The sexual symptoms are the specific ones: low desire, fewer morning erections, trouble keeping an erection. Loss of body hair, shrinking testicles, hot flashes and a low sperm count point strongly to it. Fatigue, low mood, poor concentration, more body fat, breast tissue and less muscle are real but common for many other reasons.
Find the cause before the vial
Testosterone falls about 1% a year from the late thirties, but the men who turn up low in middle age usually have a reason: obesity, poorly controlled type 2 diabetes, untreated sleep apnea, opioids, past anabolic steroid use, heavy drinking, certain medicines, or a pituitary problem. A proper workup measures luteinizing hormone and sometimes prolactin to see whether the fault is in the testicles or the pituitary, and treats what it finds. For a heavy man that means weight: nutrition and activity are the first-line treatment, a supervised weight loss program can raise levels, and it carries none of the risks below.
What therapy is, and who it is for
Testosterone replacement therapy is approved for men with low testosterone caused by a medical condition. The FDA label keeps a limitation of use for age-related decline, and the Endocrine Society suggests against routinely treating all older men, while allowing it case by case for those with symptoms and consistently low levels. It comes as a daily gel, injections every one to two weeks or a long-acting one every ten weeks, pellets every three to six months, a nasal gel, and in specific conditions an oral form. FDA-approved products are the starting point; compounded versions are not FDA-approved, their safety, effectiveness and quality are not verified before sale, and the FDA’s position is that compounding is for patients who cannot use an approved drug.
It is not for everyone with a low number. Men who want to father a child soon are not given testosterone, because it suppresses sperm production; clomiphene is an option for them. It is not started in men with prostate or breast cancer, an untreated prostate lump, a high PSA, a high red cell count, untreated severe sleep apnea, uncontrolled heart failure, or a heart attack or stroke in the last six months.
Heart risk, as of 2025
In February 2025 the FDA removed the boxed warning about cardiovascular risk from all testosterone products after a large trial found no increase in heart events in men treated for hypogonadism, and at the same time added a warning that every testosterone product raises blood pressure. The urology guideline still says it cannot be stated definitively whether therapy raises or lowers cardiovascular risk. That is the honest state of the evidence, and a clinic should tell you both halves.
What a legitimate program looks like
Two morning tests before a prescription. A history that asks about sleep, opioids, steroids, alcohol, medicines and children. Hemoglobin and hematocrit before starting, and PSA if you are over 40. Testosterone levels every six to twelve months on therapy, with hematocrit and PSA rechecked. Follow-up once or twice a year at minimum. And a plan to stop at three to six months if your level has normalized and you feel no different, because then the testosterone was never the problem.
How to choose a provider
Ask who orders and reads the labs and what they do if the second test is normal. Ask whether they prescribe FDA-approved products or compounded ones, and why. Ask how they handle a man who wants children. Ask what they monitor and how often. A clinic that offers a ‘free testosterone check’ and a prescription the same day, sells pellets to a symptom, or promises muscle, energy and youth is selling a product. A clinic that is willing to tell you your level is normal is practicing medicine.
Browse the clinics below. If you already have a testosterone result, bring it with the time of day it was drawn.