Low testosterone · Telehealth for men · Canada & USA
Should I start TRT or fix the causes of low testosterone first?
Get the low result confirmed first, look for causes second, and decide about TRT third. We walk you through each step. Testosterone replacement therapy (TRT) can help men with confirmed low testosterone and symptoms, but it comes with trade-offs. Some of what pulls testosterone down can sometimes be addressed. It often isn’t either/or.
Part of our low testosterone and andropause guide for men in Canada and the USA.
What TRT does, and what it doesn’t
TRT gives your body testosterone from outside: a gel, an injection, a patch or another form. For men with confirmed low testosterone and symptoms, the aim is to bring levels back into a healthy range and ease those symptoms. It doesn’t change why levels were low in the first place.
There is also a feedback effect. Your brain tells the testes to make testosterone with two signals, LH and FSH. When testosterone arrives from outside, the brain senses it and turns that signal down. That is why TRT can reduce your own testosterone and sperm production while you’re on it.
What it can do
Ease symptoms in men with confirmed low testosterone and symptoms. How much it helps differs from person to person.
What it doesn’t do
It doesn’t explain or remove the cause, such as sleep apnea, a medication or weight. That is where we start: we help you look for those.
Why the signal matters
A quieter LH and FSH signal means less natural testosterone and sperm production. Recovery after stopping varies and isn’t certain.
The trade-offs to weigh
None of these rules TRT out. They are the reasons the order of steps matters, and we go through each one with you.
Fertility
TRT can lower sperm production. If you may want children in the near term, say so first. The Endocrine Society guideline (2018) advises against starting testosterone therapy in men planning fertility in the near term.
Monitoring
Ongoing blood tests and checks, commonly including testosterone levels, hematocrit (red blood cells), PSA where age-appropriate and blood pressure, so problems can be spotted early.
Long-term commitment
For many men, TRT is something that continues for as long as it’s used. Stopping may bring symptoms back, and your own production can take time to recover. Agree on goals and review points up front.
Other effects
Possible effects include acne, fluid retention, breast tenderness, a higher red blood cell count and, in men with untreated severe sleep apnea, worsening of it. We go through these with you.
What the TRAVERSE trial found
The heart is the biggest safety question people ask about. TRAVERSE is a randomised, placebo-controlled trial published in the New England Journal of Medicine in 2023 (Lincoff et al.). It enrolled 5,246 men aged 45 to 80 who had symptoms of low testosterone, two low morning readings, and either existing cardiovascular disease or a high risk of it. They used a testosterone gel or a placebo gel.
The main result
For major adverse cardiovascular events (cardiovascular death, non-fatal heart attack or non-fatal stroke), testosterone gel was non-inferior to placebo in these men.
What was seen more often
A higher incidence of atrial fibrillation, pulmonary embolism and acute kidney injury in the testosterone group. These were small increases, and they are why your own history matters.
FDA label changes, 2025 and 2026
In February 2025 the FDA announced class-wide labeling changes for testosterone products: add the TRAVERSE results, remove boxed-warning language about an increased risk of adverse cardiovascular outcomes, and add a warning about increased blood pressure. In June 2026 it requested further label updates for testosterone products, including removing the limitation of use for age-related hypogonadism and revising safety information on prostate cancer and benign prostatic hyperplasia (BPH). Labels outside the USA can differ.
TRAVERSE studied one gel in men with a particular profile. It doesn’t answer every question for every man, which is one more reason to decide this one-to-one, with your own history in front of you.
What can pull testosterone down, and may be addressable
Several well-known contributors can lower testosterone, and some of them can be changed. Fixing one may not be enough for levels to recover, and some causes, such as pituitary or testicular conditions, aren’t lifestyle problems at all. That is why we start by looking for the cause.
Sleep
Short or broken sleep is associated with lower testosterone.
Weight and waist
Extra weight around the middle is linked to lower testosterone levels.
Alcohol
Heavy drinking can lower testosterone.
Medications
Opioid pain medicines and long-term corticosteroids are examples that can lower it. Anabolic steroids or testosterone from other sources switch off your own production.
Sleep apnea
Untreated sleep apnea goes with low energy and low testosterone. Loud snoring, gasping or heavy daytime sleepiness are worth mentioning on your first call. A sleep study can confirm it.
Stress
Long-running stress and poor recovery affect sleep, mood and hormones.
Nutrition
Under-eating or very restrictive dieting can lower testosterone.
Other conditions
Type 2 diabetes, thyroid problems, pituitary conditions, liver or kidney disease and testicular problems can all play a part.
How to decide: six steps
Labs first, then causes, then the TRT conversation. You can pause at any step.
- Step 1
Write down what you notice
Symptoms, sleep, medications, supplements, anything you take for muscle or training, and what you want: for example, whether you may want children soon.
- Step 2
Get morning blood tests
Testosterone varies through the day and from day to day, so guidelines call for early-morning tests, repeated on a second morning. See which labs to ask for besides total testosterone.
- Step 3
Is a low result confirmed?
If the repeat is normal, the symptoms still deserve an explanation, and we look at other causes with you. If it is low, carry on to step 4.
- Step 4
Look for the cause
Review medications, screen for sleep apnea, look at weight, alcohol, sleep and stress, and add the tests that show where the problem sits. Address what can be addressed.
- Step 5
Settle your fertility plans
Say so before any treatment starts, so it is part of the plan. If children are a near-term goal, other options may suit better than TRT.
- Step 6
Decide, then recheck
Options include working on causes and retesting, starting TRT with a monitoring plan, or doing both. Agree on review dates so the decision gets revisited.
Six questions to ask as you decide
A short list makes every conversation count. Bring it to your free call and to any appointment.
Questions worth asking
- What do my morning results show, and should we repeat them?
- Could any medication I take be lowering my testosterone?
- Should I be screened for sleep apnea?
- What are my options if I want children in the next few years?
- If we consider TRT, what monitoring would I need, how often, and what would make us stop?
- Can we set a date to recheck after we’ve worked on sleep, weight or other causes?
Sources
- Lincoff AM, Bhasin S, Flevaris P, et al. Cardiovascular Safety of Testosterone-Replacement Therapy (TRAVERSE). N Engl J Med 2023;389:107-117. doi.org/10.1056/NEJMoa2215025
- Bhasin S, Brito JP, Cunningham GR, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018;103(5):1715-1744. doi.org/10.1210/jc.2018-00229
- US Food and Drug Administration. FDA issues class-wide labeling changes for testosterone products, 28 February 2025. fda.gov
- US Food and Drug Administration. Testosterone Information (label updates requested June 2026). fda.gov
Frequently asked questions
Can I start TRT without fixing the causes first?
That is a decision to make with the full picture in front of you. The Endocrine Society’s 2018 guideline recommends confirming low testosterone with repeated morning tests and then looking for the cause. Some causes change what is safe or sensible, such as untreated severe sleep apnea or plans to have children. Some men work on causes and discuss TRT at the same time, and we help you work out which order suits you.
Will TRT affect my fertility?
It can. TRT lowers the brain’s LH and FSH signals to the testes, which can reduce sperm production while you take it. Recovery after stopping varies and isn’t certain. If you may want children in the near term, say so before anything starts, because the Endocrine Society guideline advises against starting testosterone therapy in that situation.
Is TRT safe for my heart?
In the TRAVERSE trial (NEJM, 2023), testosterone gel was non-inferior to placebo for major cardiovascular events in men with hypogonadism who had existing or a high risk of cardiovascular disease. A higher incidence of atrial fibrillation, pulmonary embolism and acute kidney injury was seen in the testosterone group, and testosterone products can raise blood pressure. Whether it suits you depends on your own history, and we go through it with you.
Can lifestyle changes raise testosterone enough to avoid TRT?
Sometimes they help. It depends on what is behind the low result: sleep, weight, alcohol, a medication or sleep apnea can all play a part, while some causes aren’t lifestyle-related at all. We help you work on the causes that can be changed and recheck your levels afterwards, so you can see where you stand.
How long should I work on the causes before considering TRT?
There isn’t one right answer. It depends on your symptoms, how low your results are and what the cause turns out to be. We help you set a review date and a recheck, so the decision doesn’t drift.
How does Odin Health Labs work with my doctor?
Odin Health Labs is a telehealth service for men in Canada and the USA with low testosterone (andropause) symptoms. A free call helps you work out where to start and what to ask. We review your labs with you, build your plan and track your progress, and we can share your plan and results with your doctor if you choose. See our low testosterone overview and our Privacy Policy.
Not sure which way to go? Start with a conversation.
A free call helps you work out where to start and what to ask next.