Low Testosterone in Men: Symptoms, Diagnosis, and Treatment Options

Hormone replacement therapy does not refer to one medication or one standardized treatment.

Depending on which hormone is being replaced, a patient's medical history, symptoms, treatment goals, and individual risk factors, hormone therapy may be delivered as a pill, skin patch, topical gel or cream, injection, implantable pellet, or another specialized formulation.

These delivery methods are not necessarily interchangeable.

For example, estrogen taken by mouth is processed differently by the body than estrogen absorbed through the skin. Testosterone injections have different dosing characteristics than testosterone gels. Pellets remain in the body for an extended period and cannot be adjusted as easily as a medication that can simply be stopped or changed.

The goal is therefore not to determine which form of HRT is universally "best." The goal is to determine which combination of hormone, dose, route of administration, and monitoring strategy makes the most sense for the individual patient.

For a broader introduction to treatment, start with our Hormone Replacement Therapy: A Complete Guide for Patients.

What Does "HRT" Actually Include?

The term hormone replacement therapy, or HRT, is used broadly, but the medications involved can be very different.

For women experiencing perimenopause or menopause, treatment may involve:

• Estrogen

• Progesterone or another progestogen

• A combination of estrogen and a progestogen

• Local vaginal estrogen

• Testosterone in carefully selected circumstances

For men with clinically appropriate testosterone deficiency, hormone replacement generally refers to testosterone replacement therapy, which may be administered through injections, topical medications, implantable pellets, or other formulations.

The FDA recognizes several forms of menopausal hormone therapy, including systemic estrogen, combined estrogen-progestogen therapy, progestogen therapy, and local vaginal estrogen therapy. Systemic estrogen products can be delivered through routes including pills, patches, sprays, and gels.

Testosterone products likewise exist in several formulations. Treatment for male hypogonadism should be based on an appropriate clinical evaluation rather than symptoms or age alone.

If you are unsure whether hormone treatment is appropriate in the first place, read Am I a Candidate for Hormone Replacement Therapy?.

HRT Pills

Oral medication is one of the most familiar ways to administer hormone therapy.

Examples may include oral estrogen, oral progesterone or progestins, and certain oral testosterone preparations.

Oral Estrogen

Estrogen tablets can be effective for systemic menopausal symptoms such as:

• Hot flashes

• Night sweats

• Sleep disruption related to vasomotor symptoms

• Other estrogen-deficiency symptoms

Because an oral medication is absorbed through the gastrointestinal tract and passes through the liver before entering the systemic circulation, oral estrogen has different metabolic effects than transdermal estrogen.

This "first-pass" effect is one reason the route of estrogen administration may matter when evaluating cardiovascular, metabolic, gallbladder, or blood-clotting considerations.

Evidence has suggested that orally administered estrogen has more pronounced effects on hepatic clotting pathways than estrogen delivered through the skin. Route of administration may therefore influence treatment selection in patients with particular risk factors.

That does not mean oral estrogen is inherently inappropriate. Many patients can use oral therapy successfully. The decision depends on the patient's overall clinical picture.

Oral Progesterone

Patients with a uterus who receive systemic estrogen generally require adequate endometrial protection with progesterone or another progestogen unless there is a specific clinical reason otherwise.

Unopposed systemic estrogen can stimulate the lining of the uterus and increase the risk of endometrial hyperplasia and endometrial cancer. The FDA continues to specifically recognize this risk with systemic estrogen-alone treatment in women with a uterus.

Micronized progesterone is available orally and is commonly incorporated into menopausal hormone therapy when appropriate.

Advantages of HRT Pills

Oral medications may be appealing because they:

• Are familiar and easy to administer

• Do not require an injection or procedure

• Can generally be adjusted or discontinued easily

• May be relatively inexpensive depending on the medication and pharmacy

• Are available in multiple FDA-approved formulations

Potential Limitations

Potential disadvantages include:

• Daily medication adherence

• Gastrointestinal absorption

• First-pass liver metabolism

• Different clotting and metabolic effects compared with transdermal estrogen

• Difficulty using oral medications in patients with certain medical conditions

Whether oral HRT makes sense should therefore be determined individually.

HRT Patches

Transdermal patches deliver medication through the skin and into the circulation.

They are particularly common in estrogen replacement therapy.

An estrogen patch is typically placed on the skin and replaced according to the product's dosing instructions.

Why Transdermal Estrogen Is Different From Oral Estrogen

Because estrogen absorbed through the skin avoids much of the initial passage through the liver associated with oral therapy, transdermal administration produces different physiologic effects.

This distinction can become clinically important.

Research and professional guidance have suggested that oral estrogen can exert a greater prothrombotic effect, while transdermal estrogen appears to have less effect on coagulation pathways.

That does not eliminate the need for a careful medical evaluation. A history of cardiovascular disease, thromboembolism, cancer, unexplained vaginal bleeding, liver disease, migraine characteristics, smoking, age, and other health factors may still influence treatment recommendations.

Advantages of Estrogen Patches

Potential advantages include:

• Consistent systemic estrogen delivery

• Avoidance of first-pass liver metabolism

• Less frequent administration than a daily pill, depending on the product

• Easy discontinuation if treatment needs to be stopped

• Availability of multiple strengths

• Ability to adjust treatment relatively easily

Potential Limitations

Possible disadvantages include:

• Skin irritation

• Difficulty keeping the patch attached

• Visibility of the patch

• Variation in insurance coverage or product availability

• The need to remember scheduled patch changes

For many patients requiring systemic estrogen, however, a patch is an important option to consider.

HRT Gels and Creams

Hormones can also be delivered topically through gels, creams, sprays, or similar preparations.

The terminology can occasionally be confusing because some topical therapies are intended to produce systemic hormone levels, while others are intended primarily for local treatment.

Estrogen Gels

Systemic estradiol gel is applied to the skin and absorbed into the bloodstream.

Like an estrogen patch, it allows estrogen to enter the systemic circulation while largely avoiding first-pass liver metabolism.

Potential advantages include:

• No pill to swallow

• No adhesive patch

• Flexible topical administration

• Transdermal hormone delivery

Patients must follow application instructions carefully and allow the product to dry appropriately.

Testosterone Gels

Topical testosterone is another established method of testosterone replacement in appropriately diagnosed men.

The medication is applied to designated areas of the skin and absorbed over time.

Potential advantages include:

• No needles

• Daily administration that can provide relatively consistent exposure

• Easy discontinuation or dose modification compared with an implanted medication

One important consideration is secondary exposure. Depending on the product, testosterone can potentially be transferred from treated skin to another person through direct contact. Patients using topical testosterone should follow the medication's specific instructions regarding application, drying, clothing, handwashing, and contact with others.

What About Compounded Hormone Creams?

Not every hormone cream is an FDA-approved commercial medication.

Some preparations are made by compounding pharmacies.

Compounded medication can have an appropriate role when a patient has a specific clinical need that cannot be met by an available commercial product. However, compounded hormones have not undergone the same FDA premarket evaluation for safety, effectiveness, dosing consistency, and manufacturing quality as FDA-approved medications.

The FDA states that it does not have evidence that compounded "bioidentical" menopausal hormones are safer or more effective than FDA-approved hormone therapy.

The term bioidentical should also not automatically be confused with compounded. FDA-approved medications containing hormones chemically identical to human hormones are available.

HRT Injections

Injections are most frequently discussed in relation to testosterone replacement therapy.

Common injectable testosterone formulations allow medication to be given intramuscularly or, with some treatment approaches and products, subcutaneously.

Why Testosterone Is Often Given by Injection

Injectable testosterone offers reliable systemic delivery and allows the dose and dosing interval to be modified according to:

• Symptoms

• Serum testosterone measurements

• Treatment response

• Side effects

• Hematocrit

• Other relevant clinical findings

At Ask Dr. Hu's Hormone Replacement Therapy program, injectable testosterone is one of the treatment options that may be considered for appropriately evaluated men.

Advantages of Testosterone Injections

Potential advantages include:

• Reliable absorption

• No risk of transferring topical medication to another person

• Ability to individualize the dose

• Relatively straightforward dose adjustment

• Less frequent administration than daily topical therapy

Potential Limitations

Possible disadvantages include:

• Needles

• Injection-site discomfort or irritation

• Proper injection technique

• Need for medication storage and supplies

• Fluctuations between peak and trough testosterone levels depending on the formulation, dose, and dosing interval

Some patients administer injections at home after appropriate instruction, while others prefer administration in a medical setting.

Monitoring Matters With Injectable Testosterone

Testosterone therapy should not be prescribed solely because a patient reports fatigue, weight gain, low motivation, or reduced libido.

These symptoms can occur for many reasons.

The Endocrine Society recommends diagnosing hypogonadism in men who have compatible symptoms or signs together with consistently low serum testosterone concentrations and an appropriate evaluation of the underlying cause.

Monitoring may include testosterone levels, complete blood count and hematocrit, symptom response, adverse effects, fertility considerations, prostate assessment when appropriate, and other testing determined by the patient's medical history.

You can learn more about the laboratory side of hormone evaluation in Hormone Testing: Blood, Saliva & Urine Tests.

Hormone Pellets

Hormone pellets receive considerable attention because they offer a very different approach to hormone delivery.

Small pellets containing hormone are placed beneath the skin through a minor procedure. They gradually release medication over an extended period.

Testosterone pellets have been used as one form of testosterone replacement in men, and pellet therapy is also marketed extensively to women for menopausal or "hormone optimization" treatment.

However, those situations should not automatically be considered equivalent.

Testosterone Pellets in Men

For appropriately evaluated men with testosterone deficiency, implantable testosterone pellets can provide a longer-acting option.

Potential advantages include:

• No daily medication

• No regular injections

• No risk of topical medication transfer

• Hormone delivery lasting substantially longer than most injections or topical products

For patients who dislike frequent dosing, this can be appealing.

The Tradeoff: Less Immediate Dose Control

The feature that makes pellets convenient also creates one of their main limitations.

Once a pellet has been implanted, the dose cannot be changed as simply as changing a tablet, gel, patch, or future injection.

If hormone levels become higher than intended or side effects occur, the medication cannot simply be stopped that evening.

For this reason, careful patient selection and dosing are particularly important.

Other potential concerns include:

• Bruising

• Bleeding

• Infection

• Pellet extrusion

• Local discomfort

• Scar formation

• Difficulty making rapid dosage adjustments

Follow-up laboratory testing remains important even though treatment does not require daily medication.

What About Estrogen or Testosterone Pellets for Women?

This requires additional nuance.

Many hormone pellets marketed to menopausal women are compounded preparations rather than FDA-approved menopausal hormone products.

The American College of Obstetricians and Gynecologists has stated that compounded bioidentical menopausal hormone therapy should not routinely be prescribed when FDA-approved formulations are available. ACOG specifically highlights concerns surrounding pellet therapy, including limited safety data and reduced ability to adjust or discontinue therapy once a pellet has been inserted.

This does not mean every compounded medication is inappropriate.

It does mean that patients should understand the regulatory and evidence differences between:

• An FDA-approved estradiol patch

• An FDA-approved oral progesterone product

• An FDA-approved testosterone formulation

• A custom-compounded hormone cream

• A compounded hormone pellet

Calling all of these treatments simply "bioidentical HRT" can obscure important differences.

Is One Form of HRT Safer Than the Others?

There is no single answer because safety depends on which hormone is being used, who is receiving it, the dose, and how it is administered.

Route of administration can influence risk.

For menopausal estrogen therapy, for example, oral and transdermal estrogen have different effects on the liver and coagulation system. For testosterone therapy, injections, gels, and pellets have different pharmacokinetic profiles and practical considerations.

The patient's underlying medical history is equally important.

A physician may need to consider factors such as:

• Age

• Menopausal status

• Whether the patient has a uterus

• Personal and family cancer history

• History of blood clots

• Cardiovascular disease

• Liver disease

• Unexplained vaginal bleeding

• Migraine history

• Blood pressure

• Hematocrit

• Prostate health

• Fertility goals

• Medications

• Smoking history

• Individual treatment priorities

Current FDA guidance emphasizes individualized decision-making for menopausal hormone therapy, including consideration of the patient's age, timing relative to menopause, formulation, route, and individual health risks.

How Do Physicians Decide Which HRT Form to Use?

Choosing hormone therapy should involve more than asking which medication is most convenient.

The process generally begins by answering several questions.

1. What problem are we treating?

A woman experiencing hot flashes after menopause has a different clinical situation from a man with repeatedly documented testosterone deficiency.

Even within menopause treatment, systemic hot flashes require a different approach from isolated vaginal dryness or discomfort.

2. Which hormone is actually needed?

Not every patient needs multiple hormones.

Depending on the clinical situation, treatment may involve:

• Estrogen alone

• Estrogen plus progesterone

• Progesterone

• Testosterone

• Local vaginal estrogen

• Another targeted treatment

• No hormone therapy at all

3. Are there risk factors that favor one route over another?

A patient's cardiovascular, thrombotic, liver, gynecologic, cancer, or metabolic history may influence whether oral, transdermal, topical, injectable, or another route makes the most sense.

4. How important is convenience?

Some patients prefer taking a pill each day.

Others prefer changing a patch periodically.

Some men prefer a small testosterone injection over daily gel.

Others prefer a longer-acting option because remembering frequent medications is difficult.

Convenience matters because a treatment only works if the patient can realistically follow it.

5. How easily might the dose need to be adjusted?

When treatment is first being established, a medication that can be changed relatively easily may be attractive.

Long-acting therapies may provide greater convenience but less immediate flexibility.

6. What monitoring will be necessary?

The monitoring strategy depends on the hormone being prescribed.

Patients beginning treatment should understand what follow-up will involve before choosing a therapy.

Our Patient's Guide to Starting Hormone Replacement Therapy explains the evaluation, laboratory testing, follow-up, and monitoring process in greater detail.

Are "Bioidentical" Hormones Better?

The term "bioidentical" is widely used in hormone marketing and can cause unnecessary confusion.

A bioidentical hormone is generally understood as a hormone with a molecular structure identical to a hormone produced by the human body.

Estradiol and micronized progesterone are examples.

Importantly, bioidentical does not mean compounded.

There are FDA-approved estradiol and progesterone products.

Compounding may sometimes be appropriate when a commercially available medication cannot meet a patient's legitimate clinical needs, such as an allergy to a specific ingredient or a required dosage form that is unavailable commercially.

But compounded hormones should not automatically be assumed to be:

• More natural

• Safer

• More effective

• More precise

• More personalized

The FDA and ACOG both distinguish FDA-approved hormone products from compounded menopausal hormone therapy.

The Best Type of HRT Is the One That Fits the Patient

Patients frequently ask whether pills, patches, injections, gels, or pellets are "best."

There is rarely a universal winner.

A transdermal estradiol patch may be an excellent choice for one woman, while another may prefer oral therapy. One man may prefer testosterone injections because they are adjustable and relatively inexpensive, while another may prefer a topical product or longer-acting formulation.

The decision should consider four major factors:

Safety.
Does the patient's medical history make one treatment route more or less appropriate?

Effectiveness.
Can the medication reliably treat the condition or symptoms being addressed?

Adjustability.
How easily can the treatment be modified if symptoms, laboratory results, or side effects change?

Practicality.
Can the patient realistically and consistently use the medication as prescribed?

Good hormone therapy is not about selecting a fashionable formulation.

It is about finding the most appropriate therapy for the individual patient and then continuing to reassess whether that treatment remains appropriate.

Hormone Therapy Requires Ongoing Follow-Up

Starting HRT is not the end of the treatment process.

Symptoms, medication tolerance, health history, laboratory findings, and treatment goals can change over time.

Depending on the therapy, follow-up may assess:

• Symptom improvement

• Hormone levels when clinically useful

• Hematocrit and hemoglobin

• Blood pressure

• Metabolic health

• Prostate health when appropriate

• Breast or uterine symptoms

• Menstrual or unexpected bleeding

• Acne or hair changes

• Fluid retention

• Mood and sleep changes

• Sexual health

• Fertility considerations

• Medication adherence and convenience

Treatment can then be continued, adjusted, changed to another formulation, or discontinued when appropriate.

At Ask Dr. Hu Hormone Replacement Therapy, hormone treatment is selected after reviewing symptoms, medical history, relevant laboratory findings, individual risk factors, treatment preferences, and reproductive considerations. Follow-up and laboratory monitoring are incorporated when clinically appropriate.

Key Takeaway

Pills, patches, gels, injections, and pellets are all methods of delivering hormones, but they do not behave identically in the body.

Oral medications are convenient but undergo gastrointestinal absorption and, for many hormones, first-pass liver metabolism.

Transdermal patches and gels deliver hormones through the skin and are commonly used for estrogen therapy, while topical gels are also an established testosterone treatment option.

Injections are particularly common for testosterone replacement and allow relatively precise adjustment of the dose and schedule.

Pellets offer long-acting delivery but provide less flexibility once implanted, and compounded menopausal hormone pellets require additional consideration because they do not have the same regulatory status and evidence base as FDA-approved menopausal hormone products.

The appropriate form of HRT should therefore be determined through an individualized medical evaluation rather than by assuming that one route is superior for everyone.

If you are considering treatment, learn more about our Hormone Replacement Therapy services for women and men throughout Arizona or contact Ask Dr. Hu to discuss your individual situation.

Evidence-Based Medical References

This article is intended to provide evidence-informed patient education. Hormone therapy recommendations should be individualized according to the hormone being considered, the patient's symptoms, medical history, risk factors, laboratory findings when indicated, and treatment goals.

Authoritative sources used in developing and reviewing this article include:

• The U.S. Food and Drug Administration's guidance on menopausal hormone replacement therapy, including current information regarding systemic estrogen, estrogen-progestogen therapy, progestogen therapy, and vaginal estrogen.

• The FDA's current testosterone information for patients and healthcare professionals.

• The Endocrine Society Clinical Practice Guideline on Testosterone Therapy in Men With Hypogonadism, which emphasizes appropriate diagnosis, patient selection, and monitoring.

• The American Urological Association Testosterone Deficiency Guideline, which addresses evaluation and treatment of testosterone deficiency.

• The American College of Obstetricians and Gynecologists' clinical guidance on compounded bioidentical menopausal hormone therapy, including considerations regarding compounded pellets.

Medical guidance and medication labeling can change as new evidence becomes available. Treatment decisions should always be made in consultation with a qualified healthcare professional familiar with the patient's complete medical history.

About the Author

YiQiu Hu, NMD

Dr. YiQiu Hu is an Arizona-licensed naturopathic physician and founder of Ask Dr. Hu. His clinical work focuses on concierge medicine, preventive healthcare, health optimization, laboratory evaluation, medical weight management, hormone care, integrative pain management, and individualized treatment planning.

At Ask Dr. Hu, Dr. Hu provides personalized medical care for patients throughout Arizona with an emphasis on thorough evaluation, clear explanations, evidence-informed treatment options, and ongoing physician-patient relationships.

This article is provided for general educational purposes and does not replace individualized medical evaluation, diagnosis, or treatment.