Dose adjustment and monitoring on TRT

TRT is not set-and-forget. The first six to twelve months involve regular dose-and-monitor adjustment until we find the stable regimen that produces good symptomatic outcomes, mid-normal testosterone, and no concerning biomarker shifts. After that, monitoring is quarterly for the first year and biannual thereafter. This article describes what we actually change, when, and why.

Targets we are aiming for

We aim for mid-normal range total testosterone (usually 15 to 25 nmol/L on trough testing for injections, or consistent mid-range across the day for gels). Free testosterone in the upper-normal range. Haematocrit below 0.52. Stable PSA. Oestradiol in physiological range.

Subjective outcomes matter as much as numbers. We are aiming for: consistent libido, reliable morning erections (with or without PDE5 support), stable mood, no injection-site or gel-application issues, and a general sense of wellbeing.

Indicators we check at each review

Quarterly in year 1, biannually from year 2:

- Total and free testosterone - SHBG - Oestradiol - Haematocrit, haemoglobin, mean cell volume - PSA (annually unless rising) - Lipids (annually unless rising concern) - LFTs (annually) - Renal function (annually) - Blood pressure (every visit) - Symptom diary or structured screen

The common adjustments we make

Testosterone too low (total T under 12 nmol/L at trough) - increase dose. Gels: step up from 50mg to 60 or 80mg daily. Nebido: shorten interval from 12 to 10 weeks. Enanthate: increase weekly dose by 25 to 50mg.

Testosterone too high (over 30 nmol/L) - reduce dose. Symptoms matter: if you are feeling fine on a supraphysiological level, the bloods drive the decision anyway. Haematocrit will be rising if T is too high.

Haematocrit rising toward 0.52 - three options. Hydrate aggressively (some of the rise is dehydration-driven). Check for and treat undiagnosed sleep apnoea (untreated apnoea amplifies TRT-induced erythrocytosis). Lower the testosterone dose slightly.

Haematocrit over 0.52 - reduce dose or spread injections more evenly (shorter interval, smaller doses). If over 0.54, consider therapeutic venesection every 3 to 6 months (you can also give blood voluntarily where eligible).

Oestradiol rising disproportionately - sometimes appropriate to introduce low-dose anastrozole (0.25 to 0.5mg once or twice a week) if there is symptomatic gynaecomastia or significant water retention. Be cautious: crushing E2 too low causes joint pain, mood symptoms, and impaired libido. We target E2 in physiological range, not zero.

PSA rising faster than expected (more than 0.4 ng/mL per year) - urology referral. This does not mean stopping TRT immediately, but it means proper investigation before continuing.

Symptoms returning after stable months - check adherence first (gels missed, injections late), then check bloods. Sometimes the dose has drifted out of range through weight loss, age, or other medication changes.

The specific patterns we watch for

Peak-trough variation on injectable regimens - some men feel great at day 3 post-injection and flat by day 12. Solutions: shorter interval (Nebido every 10 weeks instead of 12; enanthate twice weekly instead of once), or switch to gel for smoother kinetics.

Gel non-response - about 10 to 15 percent of gel users do not absorb adequately. If total T remains below target after dose escalation to 80 to 100mg daily, switch to injectable.

Supraphysiological response at standard dose - a few men absorb gel very well and hit high-normal at 50mg daily. Drop to 40 or 25mg rather than pushing through to see higher.

Mood destabilisation - some men feel mood changes on injectables that they do not on gels. The cause is usually hormonal peak-trough volatility. Switching form often helps.

Annual comprehensive review

Once a year we do a longer consultation (60 minutes) covering: full metabolic and cardiovascular review, body composition, sleep assessment, mental health screen, sexual health, medication adherence, lifestyle factors, and plans for the coming year. This is included in all our ongoing-care plans.

When we step back from monitoring intensity

After 12 to 24 months of stable regimen with no concerning changes, monitoring usually settles into six-monthly bloods with annual review. Patients on stable Nebido every 12 weeks with clean bloods can move to an even lighter schedule.

When we step up monitoring

Rising PSA, rising haematocrit, unexplained symptom changes, dose changes, new medications that interact, intercurrent illness, or life circumstances that might affect adherence all trigger tighter monitoring until things are stable again.

Self-monitoring tools

A simple weekly 1-to-10 rating of energy, mood, libido, and sleep is the most useful self-monitoring tool. Wearable data (sleep, HRV, resting heart rate) adds context. Home blood pressure monitoring once weekly is useful in men with any tendency to hypertension.

We do not recommend home testosterone testing or finger-prick TRT panels. The accuracy of these is not clinical-grade and inconsistent results drive unnecessary anxiety.

Adjustments during intercurrent illness

During acute illness (flu, significant infection, hospitalisation) testosterone levels are often suppressed transiently. We do not recommend adjusting TRT during acute illness; wait until the illness has resolved and re-test if symptoms change.

Stopping, pausing, and restarting

If you need to stop TRT for any reason (planning pregnancy, side effect, personal choice, surgery), we manage the wind-down to minimise the dip. The approach differs by delivery form. Gels can be stopped immediately; injections usually taper over one or two cycles. Restarting is straightforward if you have been off for less than six months; longer gaps benefit from re-assessment bloods before restart.

The honest bottom line

Good TRT practice is iterative adjustment based on bloods and symptoms. The goal is stability at a dose that produces good outcomes without concerning biomarker changes. Most patients find this within the first six to nine months and stay stable on it for years. The monitoring cost is what keeps TRT safe long-term.

Ready to start?

If this article has made you think an assessment might help, the next step is a short consultation with one of our men's health doctors.

Begin your consultation at this link. Online or in person at Westfield London.