What is TRT?
TRT stands for Testosterone Replacement Therapy. The replacement of a man’s natural testosterone production when it is lower than it should be. Mainly this occurs through the use of testosterone medication (exogenous testosterone) that is usually provided through injections, patches, or gel. In TRT UK clinics there are usually several different options that you can choose from. Nowadays it is also common to have other medications such as HCG and anastrozole included in TRT to optimise function.
What is testosterone?
Testosterone is the male sex hormone responsible for male characteristics and health. It is important for sexual function, muscle building, cognitive function, fertility and mood enhancement amongst other complex roles within the male body. It occurs naturally to a lesser extent in females.
It is extremely important for good health and general well-being in all men but is often ostracised in the media and by many doctors for its connections to violence, aggression and ‘toxic masculinity’ amongst other things.
For a more in-depth explanation, click here to read our ‘What is Testosterone’ article.
What ways are there to administer TRT?
TRT can be administered in a number of ways:
- Testosterone gels
- Monthly testosterone injections
- Weekly testosterone injections
How can I get TRT in the UK? Should I get it with the NHS or through a TRT UK clinic?
Getting TRT in the UK is often a difficult process. Unfortunately the NHS is not always the best means for getting TRT. For men that are refused TRT through the NHS there are several other TRT UK options.
TRT UK options and costs
NHS / GP
If you are lucky enough to get a good GP who can provide you with effective TRT in the NHS then you will pay for your prescriptions only, around £8.50.
This is great but only if you are receiving the medications and support you need from a doctor who knows what they are doing.
Many men are put on medications such as testogel or nebido and left to get on with it. These men often suffer from oestrogen issues, poor absorption from the testogel and fertility issues which are poorly managed by the NHS. These men often stop TRT thinking that it isn’t working for them when actually the treatment isn’t being provided correctly! Very few NHS providers follow up with adequate blood tests.
Harley street TRT UK clinics
This is the most expensive option. You visit a snazzy clinic on Harley Street in London and pay around £300 for the initial consultation. You then usually have to return and pay another £300 three months later.
The quality of the care and the surroundings is normally very good. However the service is arguably less convenient than a good online provider who can communicate with you and provide a service remotely.
The monthly cost is often very high following the start of treatment and blood tests routinely cost over £250 whereas OptiMale can provide a similar test for £59.99 – £89.99.
(At OptiMale we do provide a face-to-face consultation option which is similar to the Harley Street clinics if you’d prefer this to a remote consultation or require a physical examination)
Online ‘medical facilitators’
These are companies that work in a grey area in the TRT UK market. They avoid being called private medical clinics by claiming that they don’t actually provide treatment, they just facilitate treatment by doctors. This is technically incorrect as they are responsible for ordering and sending medication to patients as well as dealing with patient’s concerns.
Being in this grey area also means that they are not regulated and do not have any medical or indemnity insurance. The big risk with using a company like this is that if something goes wrong you will be out of pocket with no treatment available.
The service provided by these companies is often poor, mainly due to an explosion in the number of patients they try to manage. This means that they struggle to respond to queries and provide proper support nor do they screen adequately for medical issues before starting TRT. Also watch out for hidden charges – doctor’s fees and postage costs!
Online private TRT UK clinic (OptiMale)
OptiMale falls within this category. Our highly experienced doctors provide mostly remote consultations over the phone which allows us to keep costs down and still provide safe, effective treatment. We have extremely quick response times to your issues, usually within a few hours for most calls or emails, to ensure you get quick answers and advice. We can support you throughout your TRT experience without the need for costly follow up consultations. All doctor advice and support after the initial consultation is included in the monthly cost.
The monthly cost is roughly £89.99, this is cheaper for some options and sometimes slightly more if you require extra medications. For less than a pint of beer or a cup of coffee a day you can be back to normal and feeling great again. Contact us for more information.
The Black Market
This is not a valid option. It is dangerous to rely on unscrupulous dealers to provide medications. These products are rarely of pharmaceutical grade and are illegal to purchase or sell in the UK. You don’t know what strength or quality of product you are getting. You run the risk of infection from injecting non-sterile medication or unpleasant side-effects from unknown chemicals.
You will not have proper follow ups in place to ensure you are receiving the proper treatment throughout your life. This leaves you open to medical problems which have not been properly identified and addressed by a registered doctor.
This is a risky alternative to receiving proper medical care for your condition through a valid TRT UK clinic and it is highly inadvisable.
When to seek TRT?
There are a few things to look for to see whether you might have low testosterone. You can also take the ADAM questionnaire which is a well researched questionnaire that screens for low testosterone – you can access it here.
Low sex drive/libido and/or erectile dysfunction
Many men (but not all) with low testosterone suffer from erectile dysfunction. Others will notice that their sex drive has dropped. Another common indicator of low testosterone is a reduction in morning erections.
Most men will have spontaneous erections in the morning, if you no longer get these it can be an indicator of reduced testosterone levels or sometimes cardiovascular issues.
Sex drive is an important part of feeling healthy and keeping a healthy relationship. It can also improve your confidence and make you feel more manly and energetic.
Poor cognition/poor arithmetic/brain fog
Often one of the first benefits men who start Testosterone Replacement Therapy realise is improved clarity of thought! TRT has been shown to improve the IQ and cognition of older men and allows many to think straight again.
It provides clarity and makes decision-making more assertive and natural. This can lead to really positive changes in a man’s work environment, where men on TRT often find that they suddenly become more productive and competitive. Many men find that TRT is the catalyst for them to start rising up the ranks at work.
Men with low testosterone often complain of low energy levels and feeling tired all the time. Falling asleep after dinner is another big indicator that you may have testosterone deficiency. TRT can have a rapid impact in improving this situation, giving you the energy of your younger self and allowing you to get more done!
Loss of muscle mass/sports performance
Testosterone is a performance enhancing drug. It is sometimes used illegally by athletes to get a competitive advantage over their peers.
In sport and fitness, testosterone has many useful effects including: muscle mass building, strength improvements, improving joint health and reducing body fat levels! It is truely the magic ingredient for improving your physique and your sports performance.
TRT will also improve your energy levels allowing you to work harder and see more gains. You will be amazed at the effect TRT can have on your performance and physique.
Testosterone is always associated with competition, and for good reason! Men and women with more testosterone are more competitive, and tend to win more as a result. Without testosterone, competing and improving yourself can feel close to impossible. If you have low testosterone, starting TRT will make you better at sports, in competition and at work.
There are many other symptoms that you might have noticed, which may not be directly associated with low testosterone – you may have increased body fat around your waist, excessive sweating particularly at night (often caused by oestrogen levels), reduced or absent body and facial hair, increased breast tissue (gynaecomastia), insulin resistance, and particularly in older men: loss of bone mass (osteoporosis), reduced circulation (cold hands and feet).
Loss of height
This is a rare symptoms that we see but is most common in men over the age of 50. It is caused by a loss in bone density. Low testosterone can cause a reduction in bone density in a similar way to low oestrogen in women.
In younger men this isn’t a common problem. However, posture can be affected particularly in men with low mood, anxiety and reduced activity.
Think you might have low testosterone?
Should I pay for a ‘consultation’ for advice on TRT?
No, this is quite simply a waste of money! If someone with no qualifications is trying to charge you £150 for advice then you might as well contact us for free. We can provide advice not only on how to get NHS treatment but also which blood test is best to order, which medications to choose, pros and cons of each and which service to use.
Beware that these seemingly impartial middle men are usually being paid commission by certain companies to send patients their way…
What causes low testosterone/ testosterone deficiency?
- Environmental factors such as plastics and fertilisers leaching chemicals into the water supply/food
- Hormones from the contraceptive pill disrupting the male hormonal system
- Anabolic steroid use – often a full recovery of the HPTA does not occur after shutdown of natural production
- Soy consumption – phytoestrogens from some foods such as soy can reduce T levels
- Stress – chronically increased cortisol production may reduce T levels
- Congenital disposition
- Age related decline/andropause
- Pesticide exposure
- Obesity – increased body fat can lead to higher conversion of testosterone into oestrogen.
Many of these factors are at play in the men of today. These can lead to suppressed hormone function and symptoms of low testosterone. If you notice these factors in your life then it may be time to get a test, or talk to one of our TRT UK advisors today who can help you to further identify any symptoms of low testosterone.
Types of low testosterone
Primary hypogonadism (hypergonadotropic hygonadism)
In primary hypogonadism the gonads (testicles in men) don’t respond to the hormones released by the pituitary (in the brain) LH and FSH. Basically the testicles can’t produce enough testosterone. Often LH and FSH are raised as the body produces more to try to stimulate the testes to produce testosterone.
This can be caused by:
- testicular damage
- testicular tumours
- radiation to the testes
- anabolic steroid use
- genetic problems
Secondary hypogonadism (hypogonadotropic hypogonadism)
In secondary hypogonadism the gonads (testes) are working but the release of LH and FSH is affected. Basically the brain isn’t telling the testes to produce enough testosterone. This can be caused by:
- drugs/medication (opioids and glucocorticoids)
- brain damage
- pituitary tumours
- anabolic steroid use
- genetic problems
Think you might have low testosterone?
UK guidelines on testosterone deficiency and TRT UK
UK British Society for Sexual Medicine
The UK BSSM guidelines on testosterone deficiency are the gold standard for how to assess and treat testosterone deficiency in the UK. If your endocrinologist or GP don’t know about them and aren’t referring to them then you need to find another TRT UK specialist. They contain some extremely interesting information and research.
You can find the guidelines here:
They provide a framework for how to assess for and treat testosterone deficiency. They key points from the guidelines (they are worth a read in full!) are:
- Testosterone deficiency is more common in older men with comorbidities (other medical problems) who are overweight
- The CAG DNA segment can affect not only how sensitive an individual is to testosterone levels but also how the body reacts to the testosterone in its receptors (e.g. how much muscle growth is stimulated from the amount of testosterone present).
- Testosterone has lots of different physical and psychological effects: increased libido and aggression, it aids cognition and memory, supports collagen and red blood cell production as well as muscle and bone growth, sex organ growth, increases the output of the heart and how it contracts (in a beneficial way), and erection strength and frequency.
- Gonadotropins (LH and FSH) should be tested before starting TRT to find the cause of the low testosterone.
- 80% of men maintain normal testosterone levels into old age (but 20% don’t!)
- Lifestyle changes alone are not supported as a means of treating low testosterone – only when combined with TRT are symptoms reduced.
- The three most common symptoms of low testosterone are erectile dysfunction, low sexual desire and reduced early morning erections.
- A minimum of a 6 month trial of TRT is recommended.
- TRT has many health benefits! (too many to list here supported by evidence).
- Having a testosterone level below 8nmol/l protects against prostate cancer but raising it from above 8nmol/l to a higher level doesn’t increase the risk of prostate cancer!
- There is no compelling evidence that TRT increases the risk of prostate cancer or the progression of prostate cancer.
- Men younger than 40 should have their testosterone tested before 11am as this is when it is mostly released in younger men.
- Total testosterone below 12nmol/l should be trialled on TRT.
- Free testosterone below 0.225nmol/l should be trialled on TRT.
- A raised LH with normal TT may have testosterone deficiency.
TRT UK Medication Options
Sustanon is injected roughly once a week. This is a blend of several different esters (chemical tails attached to the testosterone molecule to change how quickly it is released into the body).
It is designed in a way that means it releases gradually over around 2 to 3 weeks.
After a few weeks of injecting it produces a very smooth level of testosterone due to the combination of release patterns.
For some reason this medication has a bad name with many (usually those who have never tried it for long) preferring the american testosterone enanthate. Whilst enanthate is a very good medication the difference between it and sustanon is negligible.
Sustanon has the best results out of all of the medications widely available in TRT UK.
Read more here.
Nebido is a long acting injection favoured by the NHS. It is administered by a nurse every 10-12 weeks in a large injection.
Unfortunately this makes it a difficult medication to provide for private clinics as it can be costly to pay for nurse visits.
This is a testosterone produce which is designed to be applied to the skin and absorbed throughout the day.
It is a good choice for those who don’t want to inject. Strangely some men don’t seem to absorb this well and continue to have symptoms. The other potential risk with this medication is that of transfer to women and children through of the application area. Many men are afraid of this, it can affect intimacy and certain activities.
Read more here.
Technically this isn’t TRT as it works to stimulate the testes to produce more testosterone. It is a good option for men who want to preserve their fertility.
For some men this is a very effective treatment option. For others oestrogen levels rise alongside testosterone levels and cause problems. Others don’t get a change in symptoms despite increased testosterone levels.
I am always surprised by the huge increases in testosterone levels from this drug!
This is a good option for men who want to preserve their fertility. It can be used alongside TRT or on its own to try to increase natural production in a similar way to Clomifene (Clomid).
Read more here.
What tests should I get before starting with a TRT UK clinic?
You need to have two results showing low total and/or free testosterone before starting Testosterone Replacement Therapy.
Alongside this, your doctor should make sure that you have the following values tested to ensure your safe treatment:
• Sex Hormone Binding Globulin (SHBG) – This protein binds to your total testosterone making it useless to the body.
If you have a raised SHBG level, you could suffer from the symptoms of low testosterone despite ‘normal’ total testosterone levels.
NHS GPs rarely test for this and therefore cannot accurately tell if testosterone is causing your symptoms. This value is also used to calculate your free testosterone level.
• Oestradiol (Oestrogen) – Oestradiol is the main active part of oestrogen. It is produced in the male body from testosterone when it is converted by aromatase (an enzyme).
If Oestradiol is too high, or too low, it can affect male libido, erection quality, emotions, fat accumulation and growth of breast tissue (which can lead to gynecomastia, also known as ‘man boobs’)
• Follicle Stimulating Hormone (FSH) – A hormone produced by the pituitary gland that stimulates the testes to produce sperm and testosterone.
• Lutenising Hormone (LH) – A hormone produced by the pituitary gland that stimulates production of testosterone in the testicles.
This and FSH are important for understanding why you have low testosterone, as explained above in ‘types of low testosterone’.
• Prolactin – If your levels are low it can affect your mood and sexual health.
High levels can reduce testosterone production. If very high it may be associated with a prolactinoma, a tumour in the pituitary gland that can lower your testosterone levels.
• Prostate Specific Antigen (PSA) – This can indicate prostate health. Testosterone Replacement Therapy has been shown not to increase the risk of Prostate Cancer, but it can increase Lower Urinary Tract Symptoms and potentially make prostate cancer worse if you already have an advanced form of it.
If this value comes back high, you may need further tests before starting TRT, including a physical examination by a nurse or doctor.
• Full Blood Count – TRT increases the production of red blood cells. This can increase the thickness of the blood and the chances of clotting. If this is high or increases during TRT you may need to have some blood let to reduce your levels.
Things also worth looking at:
Thyroid hormones – some thyroid problems present with the same symptoms as testosterone deficiency. Your doctor should check these to ensure you are not suffering from thyroid issues before starting TRT.
If your clinic has not looked at these tests before starting your treatment then they may be trying to rush you into treatment.
What side effects, if any, should I worry about?
Cardiovascular (heart and blood vessel) issues.
Men who were at risk of CV events when starting TRT, had less heart attacks than men at similar risk who weren’t on TRT.
Additionally, men with low testosterone appear to be at higher risk of cardiovascular issues.
Low endogenous (naturally produced) testosterone levels have been shown to be associated with higher rates of all-cause and cardiovascular-related deaths in men.
Read more here.
Raised oestrogen levels
In men testosterone is converted by aromatase into oestrogen. Most men do not require medication to control oestrogen as there levels remain normal as conversion remains at the same rate.
In some men the conversion is higher than others and the higher testosterone can lead to increased oestrogen. In these men an aromatase inhibitor is often prescribed to reduce this conversion and control levels back to normal. This is rare in TRT but happens more frequently in men treated with Clomifene.
These symptoms can indicate high oestrogen:
- gynecomastia (breast tissue growth)
- itchy nipples
- reduced libido
- hot flushes
Testosterone increases sebum (skin oil) production. This can lead to increased spots particularly on the back and shoulders. This is a common side effect of TRT but can indicate that your testosterone levels are too high.
Testosterone also increases hair growth (also called hirsutism). Most men will notice a slight increase in body hair growth once starting TRT, for many with low testosterone this is a positive side effect.
We can provide advice and guidance on how to get NHS treatment, the best tests for you as well as options for TRT UK treatment.
Our highly experienced medical team will be happy to work with you if you are just starting your TRT journey, if you already have blood test results or even if you are unhappy with your current TRT UK provider and want to transfer to a more professional service.
Think you might have low testosterone?