How to start TRT in 2026: 6 steps from first visit to first dose
You start testosterone replacement therapy by proving you need it. Write down your symptoms, then get two early morning fasting total testosterone tests on separate days. If both come back low, a clinician orders labs to find the cause, screens for reasons you should wait, helps you choose a form of testosterone and sets a monitoring plan before your first dose.
That is the sequence laid out in the Endocrine Society's 2018 clinical practice guideline and the American Urological Association's testosterone deficiency guideline. Any program that prescribes on a questionnaire alone is skipping most of it. Here is each step, what happens in it and why it matters to you.
Step 1: Write down the symptoms that actually point to low T
Low testosterone is a clinical diagnosis, which means a number on a lab report is only half of it. The Endocrine Society asks clinicians to diagnose hypogonadism only in men who have consistent symptoms and signs plus unequivocally low levels. So before you book anything, make an honest list.
Some symptoms are much more specific to low testosterone than others.
| More suggestive of low T | Less specific on their own |
|---|---|
| Reduced sex drive | Fatigue or low energy |
| Fewer spontaneous or morning erections | Low or irritable mood |
| Loss of body hair, shaving less often | Poor concentration or memory |
| Breast tenderness or enlargement | Poor sleep |
| Low bone density or a fracture from minor trauma | Loss of muscle and strength, more body fat |
Fatigue or low mood by themselves have dozens of possible causes, including poor sleep, thyroid disease, depression, anemia and heavy drinking. Loss of muscle and low energy carry more weight when they show up alongside sexual symptoms. Bring this list to your first visit. It helps your clinician decide whether testing makes sense and gives you a baseline to judge whether treatment is helping later.
Step 2: Get two early morning fasting testosterone tests
Testosterone peaks in the morning and drops through the day, and it also dips after you eat. That is why both guidelines call for early morning testing, and the Endocrine Society specifies a fasting sample. One low result is not enough. Levels vary from day to day, so you need two separate tests on different days, both low, using an accurate assay.
The two guidelines use slightly different cutoffs:
- AUA: total testosterone below 300 ng/dL is a reasonable cutoff for testosterone deficiency.
- Endocrine Society: use the lower limit of the lab's harmonized normal range, which is about 264 ng/dL for healthy young men.
A few practical rules make the results more trustworthy. Do not test while you are sick or recovering from an illness, because acute illness can temporarily lower testosterone. Tell your clinician about medications such as opioids or steroids, which can suppress levels. And do not start any testosterone, supplement or "booster" before testing, or you will cloud the picture.
The Endocrine Society also recommends against routine screening of men who have no symptoms. Testing is for men with a reason to test.
Step 3: Get labs that explain why your testosterone is low
Confirming low testosterone tells you what is happening. The next round of labs tells you why, and the answer can change the treatment. Our team covers these panels in detail on the diagnostics page.
| Test | Why it matters |
|---|---|
| LH and FSH | Separates testicular causes (primary) from pituitary or brain causes (secondary) |
| Free testosterone and SHBG | Clarifies borderline results, especially with obesity, diabetes or aging, which change SHBG |
| Prolactin | A high level can point to a pituitary problem that needs its own workup |
| Hematocrit | Testosterone can raise red blood cell levels, so you need a baseline |
| PSA (age appropriate) | Baseline prostate screening before starting |
| Lipids and A1c | Baseline cardiometabolic risk to track over time |
If LH and FSH are low or normal while testosterone is low, your clinician may look further, for example with iron studies or pituitary imaging, depending on your results. This matters because some causes of low testosterone are treatable on their own, and a few are serious enough that you would want to know regardless of TRT. If you want help interpreting these numbers, our guide to reading your bloodwork on TRT walks through each marker.
Step 4: Screen for reasons to wait or not start
This is the step most fast online programs rush, and it is where a physician earns their fee. The Endocrine Society recommends against starting testosterone in men with any of the following:
- Plans to have children soon. Testosterone therapy suppresses sperm production. If fertility is a near term goal, there are other approaches to discuss first.
- Elevated hematocrit. Many clinicians treat a high baseline hematocrit as a reason to pause and evaluate further.
- Untreated severe obstructive sleep apnea.
- A heart attack or stroke within the past six months, or uncontrolled heart failure.
- Breast or prostate cancer, a prostate nodule, or a PSA above 4 ng/mL (above 3 ng/mL in men at higher risk) without a urology evaluation first.
- Severe lower urinary tract symptoms or a history of blood clotting disorders.
None of these automatically means never. Sleep apnea can be treated. A raised PSA can be evaluated. But each one needs to be addressed before your first dose, not discovered after it.
Step 5: Choose a form of testosterone with your clinician
Once you qualify and the risk screen is clear, you and your clinician pick a delivery method. No form is best for everyone. The right choice depends on your schedule, budget, comfort with needles and who you live with.
| Form | How often | Practical notes |
|---|---|---|
| Injections (cypionate, enanthate) | Usually weekly to every two weeks | Typically the lowest cost; levels rise and fall between doses |
| Gels and solutions | Daily | Steady levels; boxed warning for transfer to children and partners through skin contact |
| Patches | Daily | Steady levels; skin irritation is common |
| Oral testosterone undecanoate | Daily, with food | No needles or transfer risk; brand products tend to cost more |
| Pellets | Implanted every few months | Fewer appointments, but a minor procedure each time and the dose cannot be adjusted quickly |
The gel transfer risk deserves a real conversation if you have young children or a partner who could be pregnant. FDA labeling for topical testosterone carries a boxed warning after children developed signs of early puberty from secondhand exposure. Washing hands and covering the application site lowers the risk, but injections or oral forms remove it. For a deeper comparison, read our post on whether gels or injections are better.
Cost varies widely by form, brand versus generic and insurance. Ask for a total monthly cost, including labs and supplies, before you decide.
Step 6: Agree on a monitoring plan before the first dose
TRT is not a prescription you fill and forget. The Endocrine Society recommends a structured follow up schedule, and you should agree on it before you start so nothing slips.
| When | What gets checked |
|---|---|
| Baseline | Testosterone, hematocrit, PSA (age appropriate), blood pressure, symptoms |
| 3 to 6 months | Testosterone level, hematocrit, symptom response, side effects, blood pressure |
| PSA follow up | Within 3 to 12 months of starting, then per standard screening |
| Every year after | Testosterone, hematocrit, PSA, blood pressure, whether treatment is still helping |
The guideline advises pausing therapy if hematocrit rises above 54% and referring to urology if PSA climbs sharply or a prostate abnormality appears. Blood pressure now gets more attention too. In 2025 the FDA issued class wide labeling changes for testosterone products that added results from the TRAVERSE trial, which did not find a higher rate of major adverse cardiovascular events with testosterone in men at elevated heart risk, along with a warning about increased blood pressure across all testosterone products. In practice, that means blood pressure checks belong in every TRT follow up.
A good plan also defines what success looks like. If your symptoms have not improved after a fair trial, the guideline supports reassessing rather than simply raising the dose.
Where BioCure fits
BioCure Health covers these steps through telehealth, from online intake and a physician consult to lab testing and a custom protocol, so convenience does not mean skipping steps.
- Five minute online intake. You share symptoms, history and goals.
- Video consult with a board certified physician. The initial consultation is $199 and can be credited back if you start a membership.
- At home or in lab testing. Results typically return in 7 to 14 days, and your physician reviews the full panel, not just a single testosterone number.
- Risk screen and plan. If you qualify, you choose a form together and agree on your monitoring schedule.
- Treatment ships to your door in 5 to 7 days.
BioCure is licensed in 47 states, and patients in South Florida can also visit our Fort Lauderdale clinic in person. If you would rather start with your primary care doctor, urologist or endocrinologist, that is a perfectly sound path; the steps should look the same wherever you go. You can learn more on our testosterone therapy page or meet the physicians on our team.
Frequently asked questions
Can I start TRT without blood work?
No, and you should be wary of anyone who offers it. Both the Endocrine Society and AUA require two separate low morning testosterone results plus consistent symptoms before diagnosing testosterone deficiency. Labs also establish your baseline hematocrit and PSA, which you need for safe monitoring.
What testosterone level do you need to qualify for TRT?
The AUA uses a total testosterone below 300 ng/dL on two early morning tests. The Endocrine Society uses the lower limit of the lab's harmonized range, about 264 ng/dL. A low number alone is not enough; you also need symptoms that fit.
Will testosterone therapy make me infertile?
TRT suppresses the signals that drive sperm production, so it can sharply reduce sperm count while you take it. Recovery after stopping is common but not guaranteed and can take months. If you want children in the near term, tell your clinician before starting so you can discuss other options.
Is TRT bad for your heart?
The FDA's 2025 labeling update added TRAVERSE trial results, which did not show a higher rate of major cardiovascular events in men with low testosterone and elevated heart risk. The same update added a class wide warning about increased blood pressure. Regular blood pressure and hematocrit checks are part of safe treatment.
Can I start TRT through telehealth?
Yes, as long as the telehealth program follows the same steps as an in person clinic: real lab confirmation, a cause workup, a risk screen and scheduled monitoring. BioCure Health offers video consults with board certified physicians and at home or in lab testing in 47 states.
Longevity is not accidental, it is intentional. Starting TRT by design means two good lab tests, an honest risk screen and a monitoring plan you agree on before the first dose, not after.
Let BioCure Health lead you in the right direction. Call or text us to schedule an introductory call at 754-206-0838, your future self will thank you.