Adherence to testosterone therapy in real-world care is low. A claims-based study of commercially insured US men treated for primary or secondary hypogonadism found suboptimal adherence to topical testosterone — and that the men who were adherent had greater increases in total testosterone and lower odds of hypogonadism-associated clinical conditions over 12-month follow-up.[1]
The authors' own conclusion is that adherence is low but associated with positive outcomes, "demonstrating the need for future efforts to focus on improving adherence in this population."[1]
A note on scope before going further: that study examined topical therapy, not injections. This page's slug promises a first-year injection dropout figure, and no such rate is asserted here, because the sources consulted do not establish one. What follows is the documented picture.
Reason one: burden is a clinical variable, not a complaint
The Endocrine Society guideline lists treatment burden explicitly among the things to weigh when choosing a formulation, alongside pharmacokinetics, patient preference, formulation-specific adverse effects and cost.[2]
And compliance is one of the four items clinicians are asked to evaluate in the standardised first-year monitoring plan — sitting beside symptoms, adverse effects, serum testosterone, hematocrit and prostate cancer risk.[2] The guideline anticipated that people stop.
That framing matters. A regimen someone abandons is not a more rigorous regimen; it is an ineffective one.
Reason two: the shape of interval dosing
Injectable esters produce a concentration that peaks after administration and falls before the next dose. The literature is direct that the clinically used esters have unfavourable pharmacokinetics measured against the goal of constant physiological levels.[3]
Whether that shape is what men feel is genuinely unsettled — see the peak and crash problem. But a treatment a man experiences as inconsistent is one he is more likely to stop, independently of whether the mechanism is what he thinks it is.
Reason three: expectations the evidence never supported
This one gets least attention and may matter most. A man who starts treatment expecting things the trials have not found will conclude it failed.
The specifics are documented:
- Erectile function. TRAVERSE's sexual function study found testosterone improved sexual activity, hypogonadal symptoms and sexual desire — but not erectile function.[4]
- Cognition. The T-Trials cognitive study found no improvement in memory or other cognitive measures in older men with low testosterone and age-associated memory impairment.[5]
- Mood. Real, replicated, and explicitly small.[6]
- Body composition timing. Fat mass, lean mass and strength do not begin changing until 12–16 weeks.[7] A man judging results at week four is reading a clock that has not started.
Set against those, a treatment can be working exactly as the evidence predicts and still feel like a disappointment. How long TRT takes to work lays out the timeline that prevents most premature verdicts.
What actually helps
Know which clock you are on. Sexual interest plateaus at six weeks; bone continues changing for years.[7]
Get the target right, not the maximum. Mid-normal is the guideline's aim.[2] Being at target rules out under-dosing as an explanation, which is useful information rather than a dead end.
Treat a schedule you will keep as a clinical requirement. It is on the guideline's list.[2]
Raise it before you stop. Discontinuation without discussion removes the one input a clinician needs to fix the problem.
Frequently asked questions
What proportion of men stop in the first year? No figure is given here because the sources consulted do not establish one for injections. What is documented is that adherence in routine care is suboptimal.[1]
Is it worse for injections than topicals? Not something these sources answer. Both have burdens; they differ in kind.
Does stopping cause harm? Testosterone therapy suppresses the HPG axis, so stopping has its own consequences — particularly for fertility, covered in TRT and fertility. It is a decision to make with a prescriber.
Would a different formulation help me stay on it? Possibly, and it is a legitimate conversation — patient preference and treatment burden are both on the guideline's list.[2]
Where the story goes next
Injections were never the only answer to the liver problem. Skin was the other route — and it arrived with a scrotal patch nobody wanted.
In the meantime: gel transfer risk and the published clinical evidence on spray delivery.
References
7 sources
- 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
- 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
- Partsch CJ, Weinbauer GF, Fang R, et al. Injectable testosterone undecanoate has more favourable pharmacokinetics and pharmacodynamics than testosterone enanthate. Eur J Endocrinol. 1995;132(4):514–519. doi:10.1530/eje.0.1320514 · PMID 7711892
- Pencina KM, Travison TG, Cunningham GR, et al. Effect of Testosterone Replacement Therapy on Sexual Function and Hypogonadal Symptoms in Men with Hypogonadism. J Clin Endocrinol Metab. 2024;109(2):569–580. doi:10.1210/clinem/dgad484 · PMID 37589949
- Resnick SM, Matsumoto AM, Stephens-Shields AJ, et al. Testosterone Treatment and Cognitive Function in Older Men With Low Testosterone and Age-Associated Memory Impairment. JAMA. 2017;317(7):717–727. doi:10.1001/jama.2016.21044 · PMID 28241356
- Bhasin S, Seidman S, Travison TG, et al. Depressive Syndromes in Men With Hypogonadism in the TRAVERSE Trial: Response to Testosterone-Replacement Therapy. J Clin Endocrinol Metab. 2024;109(7):1814–1826. doi:10.1210/clinem/dgae026 · PMID 38205962
- Saad F, Aversa A, Isidori AM, et al. Onset of effects of testosterone treatment and time span until maximum effects are achieved. Eur J Endocrinol. 2011;165(5):675–685. doi:10.1530/EJE-11-0221 · PMID 21753068