Most of what a careful clinician does about testosterone traces back to one document: the Endocrine Society's clinical practice guideline on testosterone therapy in men with hypogonadism.[1] It is not a marketing-friendly text. Its most consequential recommendations are about restraint — who should not be treated, and what has to be established before anyone is.
The gate before the prescription
The guideline's central move is to make diagnosis a precondition rather than a formality. Testosterone therapy is for men with hypogonadism — a clinical syndrome together with unequivocally low testosterone concentrations — not for men with symptoms alone, and not for men with a single low reading.[1]
That has three practical consequences.
- One low result is not a diagnosis. Testosterone varies through the day and between draws. The reasoning is set out in why one low result doesn't mean you have low testosterone.
- Symptoms alone are not a diagnosis. Fatigue, low mood and low libido are common and mostly caused by something else. Each has its own entry under low testosterone symptoms.
- The historical failure mode is exactly this gate being skipped. In US claims data covering 2001–2011, only about three-quarters of men starting androgen therapy had a testosterone level measured in the prior twelve months.[2]
Choosing a formulation
The guideline does not name a best delivery method. It lists what to weigh:
Pharmacokinetics · patient preference · formulation-specific adverse effects · treatment burden · cost[1]
Two of those five are about the man rather than the molecule, which is why "which formulation is best" has no general answer. A curve that looks better on paper is worth nothing if the regimen is not followed — and adherence to topical therapy is measurably imperfect.[3] The trade-offs across methods are laid out in ninety years of delivery methods.
Monitoring is part of the recommendation, not an optional extra
Treatment is not a one-time decision. The guideline frames testosterone therapy as something that is started, checked, and adjusted — which is why the follow-up panel exists and why hematocrit is on it. The most common adverse effect of therapy is a rise in red cell mass, covered in polycythemia and hematocrit, and what the follow-up bloods are actually for is in the 3-month panel.
Where the guideline sits against the trial evidence
The guideline predates TRAVERSE. That matters for the cardiovascular question specifically, and not much for anything else.
- On benefit, the guideline is consistent with the T Trials: real improvement in sexual function, less elsewhere. The T Trials found no benefit for vitality or walking distance.[4]
- On cardiovascular safety, the evidence moved after publication. TRAVERSE reported in 2023, and the FDA issued class-wide labeling changes in February 2025.
- On fertility, the guideline's position is unchanged by any of it — testosterone therapy suppresses spermatogenesis, which is covered in testosterone and sperm production.
A guideline is a snapshot of evidence at a date. Reading it as permanent is a mistake; so is discarding it because one endpoint was later clarified.
The nearest thing to an updated snapshot is the 2026 JAMA review, which restates the diagnostic threshold and is more explicit than the guideline about obesity as a cause — and about treating the weight before the testosterone.
What it does not do
The guideline does not recommend testosterone as a treatment for ageing, for non-specific fatigue, or for men with normal concentrations. It does not endorse treating a number without a syndrome. And it does not support the practice — visible in the prescribing data of the 2000s — of starting therapy without measuring first.[2]
Anyone using the guideline to justify broad prescribing is using a document that says the opposite.
Bottom line
The Endocrine Society guideline is best understood as a set of brakes. Confirm the diagnosis before treating. Choose the formulation with the patient rather than for him. Monitor, and be prepared to change course.
None of that is exciting, and all of it is what separates testosterone therapy from the supplement market that competes with it on promises it is not required to keep.
References
4 sources
- 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:10.1210/jc.2018-00229 · PMID 29562364
- Baillargeon J, Urban RJ, Ottenbacher KJ, Pierson KS, Goodwin JS. Trends in androgen prescribing in the United States, 2001 to 2011. JAMA Intern Med. 2013;173(15):1465–1466. doi:10.1001/jamainternmed.2013.6895 · PMID 23939517
- Grabner M, Hepp Z, Raval A, et al. Topical Testosterone Therapy Adherence and Outcomes Among Men With Primary or Secondary Hypogonadism. J Sex Med. 2018;15(2):148–158. doi:10.1016/j.jsxm.2017.11.225 · PMID 29425664
- Snyder PJ, Bhasin S, Cunningham GR, et al. Effects of Testosterone Treatment in Older Men. N Engl J Med. 2016;374(7):611–624. doi:10.1056/NEJMoa1506119 · PMID 26886521
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