Different Types of Testosterone Replacement Therapy for Men

There are multiple different types of testosterone replacement therapy. Once diagnosed with testosterone deficiency (low testosterone), it can be a bit overwhelming to work out which form of testosterone to start on. Here I outline the different forms of testosterone, and some of the benefits and negatives of each. This decision should always be made in collaboration with a physician & tailored to you.

If you are struggling with symptoms of low testosterone, or you’ve been on TRT but have stopped seeing benefits, do book an appointment with me to discuss further. I help many men work out whether testosterone is really the issue, and what the right treatment is for them. You can find out more about me here.

Gels or Injections?

The first decision is topical testosterone (a cream or gel you apply to the skin), versus injectable testosterone. Many men have negative views about gels, but for many men they work well, have fewer side effects and mean they don’t have to deal with needles.

Topical Testosterone - Creams and Gels

Advantages

• Topical testosterone is easy to use.

• It doesn’t involve any injections or needles.

• Lower risk of side effects: hardly ever causes raised oestrogen, haematocrit or acne vs injectables

• We have really good long term data on the cardiovascular safety of topical testosterone (TRAVERSE study)

Disadvantages:

• Daily application

• Need to wait for it to dry for a few minutes

• Some men don’t absorb it so well

• Risk of transfer to another person

Cost:

• Depends on dose.

• For a standard dose: Approx £45/month

Injectable Forms of Testosterone

There are several different forms of injectable testosterone, the most common are:

• Testosterone Cypionate

• Testosterone Enanthate

• Sustanon

• Testosterone Undecanoate (Nebido)

For Cypionate, Enanthate and Sustanon, injectable equipment is needed, which costs approximately £40-50 for 3 months’ supply

Testosterone Cypionate

Advantages

• Single testosterone ester, not a mix of testosterones, means it has a predictable effect over time with a stable level of testosterone achieved easily

• Can be used to inject into fat rather than muscle

• Can be used for more frequent injection (three times a week), which has some advantages

• Olive oil carrier oil, which causes less reaction than other oil bases

Disadvantages

• Imported from the USA and so more costly.

• For some, frequent injection is a pain

• Not licensed in the UK, but used off license

Cost:

• Approximately £215 for 4 months’ supply, plus cost of injecting equipment

Testosterone Enanthate

Advantages

• Single ester which might enable more predictable stable levels

• Can be used for microdosing (e.g. twice weekly injections)

Disadvantages

• Only suitable for intramuscular injection, not so suitable for injection into the fat

• Carrier oil is castor oil, which can cause some men more reactions / pain

Cost

• Cost very variable up to £60/month plus costs of injecting equipment

Sustanon

Sustanon is a mix of four different types of testosterone. Each has a different half life. This was designed to reduce the ups and downs of testosterone levels, which works for some men.

Its licensed for injection every three weeks, but many men find that they feel pretty awful in the third week when their levels drop. Instead it can be microdosed, injecting a small amount once or twice a week.

Advantages:

• Cheap - £10/month

• Can be used for microdosing

• Licensed in the UK & readily available

Disadvantages

• Some men don’t do well with the multiple esters, although this is rare

• It can’t be used subcutaneously

• Often not available outside Europe & the UK

Nebido

Advantages:

• Licensed in the UK

• Slow release testosterone. Only one injection needed every 3 months after first 3 months - therefore fewer injections

Disadvantages:

• Levels change over the course of the three months, which some find unsatisfactory

• Large volume of injection

• More difficult to adjust levels. Once the medication is in, it is there for three months

Cost:

• Cost is approximately £100/3 months

There are multiple different options for testosterone replacement and discussing each with your doctor is important to work out what is right for you. The above is no substitute for advice from a suitably qualified doctor.

It can take time to work out the right solution for you. Some men start on one form and then switch to another form after some time, if this isn’t working for them. There is no once size fits all.

I specialise in men who have been on TRT but still have symptoms, or where there is a question around whether testosterone deficiency is the right diagnosis. Many men struggle with sexual symptoms which end up being treated with testosterone, even when testosterone deficiency isn’t really the issue. As a clinical sexologist I look at the whole picture - medical and psychosexual - to find a way forward for men with symptoms of low sexual desire, erectile difficulties and low mood - whether the issue is medical or more psychological.