# Who is a Candidate for TRT?

> Medically reviewed by Dr. Michael Chen, MD — Board-certified Endocrinologist
> Last updated: February 2026

## Age Groups

### Men Under 30
Low testosterone in younger men is less common but does occur. Causes may include genetic conditions (Klinefelter syndrome), pituitary disorders, testicular injury, or chronic illness. Fertility preservation is a critical consideration for this age group.

### Men 30-50
Testosterone naturally declines approximately 1% per year after age 30. Many men in this range begin experiencing noticeable symptoms in their late 30s and 40s. This is the most common age group seeking TRT evaluation.

### Men Over 50
Age-related testosterone decline is most pronounced in this group. Approximately 20-40% of men over 45 have testosterone levels below 300 ng/dL. Cardiovascular health and prostate screening become especially important considerations.

## Symptoms of Low Testosterone

### Physical Symptoms
- Persistent fatigue and low energy
- Loss of muscle mass and strength
- Increased body fat, especially abdominal
- Decreased bone density
- Hot flashes (less common)

### Sexual Symptoms
- Reduced libido (sex drive)
- Erectile dysfunction
- Decreased morning erections
- Reduced ejaculate volume

### Cognitive and Emotional Symptoms
- Brain fog and difficulty concentrating
- Depressed mood or irritability
- Lack of motivation
- Poor sleep quality
- Decreased sense of well-being

## Lab Values Interpretation

| Level (Total Testosterone) | Classification | Action |
|---|---|---|
| Below 200 ng/dL | Severely low | Strong candidate for TRT after workup |
| 200-300 ng/dL | Low | Likely candidate if symptomatic |
| 300-400 ng/dL | Low-normal | May benefit from TRT if significantly symptomatic |
| 400-700 ng/dL | Normal | TRT typically not indicated |
| Above 700 ng/dL | Optimal | No intervention needed |

**Important:** Testosterone should be measured via a morning blood draw (before 10 AM) on at least two separate occasions, as levels fluctuate throughout the day and between days.

### Free Testosterone
Total testosterone alone doesn't tell the complete picture. Free testosterone — the portion not bound to SHBG or albumin — represents what's biologically available. Some men with normal total testosterone may have low free testosterone due to elevated SHBG.

## Contraindications

TRT is **not recommended** for men with:

- **Active or suspected prostate cancer** — testosterone can stimulate prostate tissue growth
- **Active breast cancer** — rare in men but a contraindication
- **Untreated severe obstructive sleep apnea** — TRT may worsen this condition
- **Uncontrolled heart failure** — fluid retention risk
- **Hematocrit above 54%** — increased blood clot risk
- **Desire for near-term fertility** — TRT suppresses sperm production (alternatives like hCG or clomiphene may be appropriate)
- **Untreated polycythemia** — already elevated red blood cells

## Factors That Affect Candidacy

### Medical Conditions
- Obesity — reduces testosterone and increases estrogen conversion
- Type 2 diabetes — strongly associated with low testosterone
- Chronic opioid use — suppresses HPG axis
- Sleep apnea — untreated sleep apnea lowers testosterone
- Pituitary disorders — may require different treatment approach

### Lifestyle Factors
- Chronic stress and elevated cortisol
- Poor sleep quality and quantity
- Sedentary lifestyle
- Excessive alcohol consumption
- Nutritional deficiencies (zinc, vitamin D, magnesium)

### Medications
- Opioids — known to suppress testosterone
- Glucocorticoids — chronic use reduces testosterone
- Some antidepressants and antipsychotics
- 5-alpha reductase inhibitors (finasteride)

## The Evaluation Process

A proper TRT evaluation should include:

1. **Complete symptom assessment** — validated questionnaire (ADAM or AMS)
2. **Medical history review** — including medications, surgeries, and family history
3. **Physical examination** — when done in person
4. **Comprehensive blood work** — at minimum: total testosterone, free testosterone, LH, FSH, estradiol, CBC, metabolic panel, lipid panel, PSA
5. **Ruling out secondary causes** — thyroid function, prolactin, cortisol if indicated
6. **Discussion of treatment goals and risks** — informed consent process

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*This content is for informational purposes only and does not constitute medical advice. Always consult with a licensed healthcare provider before starting any hormone therapy.*