Testosterone Clinics: What to Check Before You Sign Up

Let us be clear at the outset, because this subject attracts a lot of unhelpful sneering: testosterone deficiency is real, it is under-diagnosed, and treating it properly changes people's lives. Men with genuine hypogonadism often describe treatment as getting themselves back.

The difficulty is that the same treatment is also sold, energetically, to men who do not have it — and starting it is much easier than stopping. What follows is what to check before you commit.

How the diagnosis is properly made

Low testosterone is diagnosed on symptoms plus biochemistry, and both halves matter.

The blood test has strict conditions

• Fasting, and taken in the morning — before 11am, ideally before 10am. Testosterone follows a daily rhythm and falls substantially through the day. An afternoon sample can look deficient in a man whose morning level is entirely normal
• Two separate samples, on two different mornings. A single low result should never be treated. Levels vary day to day, and acute illness, poor sleep or a hard training week can all depress a one-off reading
• Not during an acute illness, which suppresses it temporarily

A testosterone level alone is not enough

A proper workup also measures LH and FSH — which distinguish a problem in the testicles from one in the pituitary, and that distinction changes the diagnosis entirely — plus SHBG, prolactin, a full blood count and PSA where age-appropriate.

SHBG deserves a mention because it is where a lot of confusion comes from. It binds testosterone and makes it unavailable. A man with high SHBG can have a normal-looking total testosterone and genuinely low free testosterone; a man with low SHBG — common with obesity and insulin resistance — can have a low total level while his free testosterone is fine. Interpreting a total testosterone without SHBG is guesswork.

The question that matters most: why is it low?

This is the step most often skipped, and it is the one that changes the outcome.

In a large proportion of men with a low reading, the testicles are working perfectly well. Something else is suppressing them — and that something is frequently reversible:

• Excess weight, particularly around the abdomen. Fat tissue converts testosterone to oestrogen and suppresses the signal from the brain. Losing weight raises testosterone measurably, and this is one of the most reliable findings in the field
• Obstructive sleep apnoea. Strongly associated with low testosterone, hugely under-diagnosed, and treating it raises levels. It also matters in the other direction: testosterone can worsen sleep apnoea, so treating one while missing the other is a poor trade
• Opioid painkillers, which suppress testosterone substantially and are rarely considered
• Alcohol, and chronic short sleep
• Anabolic steroid use, past or present — which produces exactly this picture and needs disclosing
• Thyroid disease, raised prolactin, and chronic illness

A clinic that measures your testosterone, finds it low, and offers you testosterone — without asking why it is low — has skipped the medicine.

What TRT actually commits you to

Taking testosterone switches off your own production. That has consequences worth knowing before the first injection, not after.

• It is usually for life. Stopping after a prolonged course means a period of feeling considerably worse than before you started, while your own production recovers — which can take months and is not always complete
• It suppresses fertility, often profoundly. Sperm production can stop. Recovery after stopping is usual but slow and not guaranteed. If you might want children, this must be discussed before starting, and there are alternative approaches that preserve fertility. Too many men find this out afterwards
• The testicles shrink
• It thickens the blood. A rising haematocrit is the commonest reason treatment has to be reduced or paused, and it needs monitoring — unmanaged, it raises clot risk
• It requires ongoing monitoring of blood count, PSA and levels — indefinitely
• Acne, fluid retention, mood changes and breast tenderness are common early on

Warning signs in a clinic

Any of these is worth pausing over:

• Testing in the afternoon, or accepting a sample taken at any time of day
• Treating on a single blood test
• Not measuring LH, FSH, SHBG and prolactin — without these, nobody knows what they are treating
• Treating a low-normal result on the basis of symptoms that overlap with a dozen other conditions
• No screening for sleep apnoea, and no discussion of weight
• No question about fertility plans
• An online questionnaire as the whole assessment. Symptom scores for low testosterone are notoriously non-specific — fatigue, low mood, poor concentration and reduced libido are produced by depression, sleep apnoea, thyroid disease, anaemia and simply not sleeping
• A subscription that starts before any blood test, or monitoring that is optional and charged separately

What good care looks like

Two morning fasting samples. A full hormone panel, not one number. A serious search for a reversible cause, and a genuine attempt at treating it first where one exists. An explicit conversation about fertility. A clear plan for monitoring haematocrit and PSA. And a named clinician who will still be involved in a year.

If after all that your testosterone is genuinely low and symptoms fit, treatment is often excellent — and you should not be talked out of it by anyone, including by people who think the whole subject is a fad.

The honest summary

The men who do best on testosterone are the ones who were properly diagnosed. The men who do worst are the ones who were sold it.

The distinction is not the drug. It is whether anyone asked why the number was low before writing the prescription.