Walk-in low-T clinics approve almost every man who clears the door. We don't. Real TRT eligibility requires two morning labs, a baseline PSA, hematocrit context, fertility planning, and a cardiovascular screen most consumer clinics skip. Here's what gets you through provider review, what flags an automatic decline, and the cases where the right next step isn't testosterone.
The diagnostic threshold (and why one draw isn't enough)
Endocrine Society guidance: clinical hypogonadism requires symptoms plus two morning total testosterone draws under 300 ng/dL (or LC-MS-confirmed free T under 6.5 ng/dL), drawn at least one week apart, both before 10 AM and fasted.
A single low draw catches diurnal variation, acute illness, sleep deprivation, recent travel, or a heavy training block - not chronic hypogonadism. Approving TRT off one number is sloppy medicine and the reason men end up dependent on a script they didn't need.
Total under 300 with normal LH/FSH points to secondary hypogonadism - often metabolic, obesity-driven, or stress-driven. That's frequently reversible with sleep, weight loss, sleep apnea treatment, and ferritin work, and skipping that step locks men onto exogenous testosterone for life unnecessarily.
What we screen before approval
Cardiovascular: ApoB, Lp(a), lipid panel, blood pressure, family history of premature heart disease. TRT can raise hematocrit and cardiovascular risk in men with pre-existing disease - we screen baseline.
Prostate: baseline PSA. PSA over 3.0 ng/mL or rapid rise (over 0.75 ng/mL/year) requires urology consult before any TRT. TRT does not cause prostate cancer, but it can grow undiagnosed prostate cancer faster.
Hematology: baseline CBC. Hematocrit over 50% disqualifies until investigated - sleep apnea, smoking, dehydration, or a hematologic condition needs to be ruled out first.
What disqualifies you
Active or recent (under 2 years) prostate or breast cancer: hard contraindication. Severe untreated obstructive sleep apnea: TRT raises hematocrit and worsens apnea - treat OSA first. Untreated severe heart failure or recent MI/stroke: defer until stable.
Active fertility goals inside the next 1-2 years: TRT suppresses LH/FSH and sperm production within weeks. We build a different protocol (hCG monotherapy, enclomiphene) instead.
Polycythemia (hematocrit over 54%) without an explanation: investigate before adding any testosterone. Severe BPH with urinary retention: TRT can worsen symptoms - urology consult first.
What happens if you qualify
Standard protocol: testosterone cypionate or enanthate 80-150 mg/week IM or subQ, split into 2 doses. Some men do better on cream or pellet - we discuss based on lifestyle and labs. Aromatase inhibitor (anastrozole) only if estradiol becomes symptomatic, not preemptively.
Monitoring: total T, free T, SHBG, estradiol, hematocrit, PSA, lipids at 6-8 weeks, 3 months, then every 6 months. Hematocrit over 52% triggers dose reduction or therapeutic phlebotomy. PSA rising over 0.75 ng/mL/year triggers urology referral.
Fertility preservation if planning kids long-term: hCG 500 IU 2-3x/week or enclomiphene 12.5-25 mg every other day alongside TRT to maintain testicular function. Discuss this upfront, not after a year on protocol.
What to do now
Run the Men's Baseline panel with two morning draws at least a week apart. SHBG, free T, LH/FSH, estradiol (sensitive), PSA, CBC, lipids, ApoB, ferritin. Bring symptoms and a sleep history.
If symptoms are real but labs come back equivocal, fix sleep, ferritin, weight, and sleep apnea first - retest at 12 weeks. About 1 in 3 men in the borderline range get into normal-T territory without ever starting exogenous hormones.