Andrology and endocrinology · London
Testosterone replacement therapy (TRT) - private in London.
TRT for men with biochemically confirmed hypogonadism, worked up and monitored to BSSM 2022 standards. Not a wellness product, not a lifestyle add-on. A prescribed medicine with a workup, a monitoring schedule and a set of contraindications that matter.
What TRT is
Testosterone replacement for confirmed hypogonadism.
Diagnosis rests on two morning samples plus consistent symptoms, per the British Society for Sexual Medicine (BSSM) 2022 guidelines.
Testosterone replacement therapy replaces the androgen that a man's own testes or pituitary can no longer produce in adequate amounts. It is a prescribed medicine, not a supplement. The diagnostic threshold in the UK is a total testosterone repeatedly below 8 nmol/L in the presence of consistent symptoms, or between 8 and 12 nmol/L when a low calculated free testosterone and symptoms both point to hypogonadism.
The BSSM 2022 guideline is the reference standard in UK private practice. It requires two early-morning fasted samples on separate days, an assessment of pituitary function, and a search for reversible causes before starting therapy. TRT that skips these steps is not clinical care.
Symptoms of low testosterone
When symptoms and biochemistry line up.
Symptoms alone do not diagnose hypogonadism. They point to where to look and give the biochemistry its meaning.
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Persistent fatigue
Not one bad week, but months of low energy that sleep does not repair.
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Low libido
A sustained drop in sexual interest rather than a transient dip.
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Erectile difficulty
Difficulty achieving or maintaining erections, often alongside reduced morning erections.
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Low mood
Flat affect, loss of drive, sometimes misread as primary depression.
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Loss of muscle mass
Reduced strength and lean mass despite unchanged training and diet.
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Reduced body hair
Thinning of beard and body hair over months to years.
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Decreased bone density
Fragility fractures or a low T-score on DEXA in men under 70.
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Cognitive slowing
Word-finding difficulty, slower processing, poor concentration.
Proper workup before TRT
The tests that must precede a prescription.
A workup that omits pituitary hormones, prostate assessment or haematocrit is not a workup.
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Two morning total testosterone
Between 07:00 and 11:00, fasted, on two separate days. Diagnosis requires a repeatably low value, not a single reading.
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LH and FSH
Distinguishes primary (testicular) from secondary (hypothalamic or pituitary) hypogonadism.
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SHBG and calculated free T
SHBG shifts with age, obesity and thyroid status. Free or bioavailable testosterone clarifies borderline totals.
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Prolactin
Raised prolactin points to a pituitary cause and warrants pituitary MRI.
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HbA1c and lipid profile
Metabolic screen. Type 2 diabetes and obesity commonly coexist with low testosterone.
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PSA if over 40
Baseline prostate-specific antigen and a digital rectal examination before starting.
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Haematocrit and full blood count
Baseline before therapy. TRT raises haematocrit and can cause polycythaemia.
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DEXA scan where indicated
If osteoporosis is suspected or fragility fracture history is present.
Causes to identify
Primary, secondary and reversible causes.
The cause changes the treatment. Reversible causes should be corrected before committing to lifelong TRT.
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Primary hypogonadism
Testicular failure: Klinefelter syndrome, orchitis, trauma, chemotherapy or radiotherapy. LH and FSH are elevated.
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Secondary hypogonadism
Hypothalamic or pituitary cause. LH and FSH are inappropriately low or normal alongside low testosterone.
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Pituitary tumour
Prolactinoma or non-functioning adenoma. Raised prolactin, visual field defects or headache should prompt MRI.
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Obstructive sleep apnoea
Suppresses testosterone and often reverses with CPAP. Screen with STOP-BANG and refer where positive.
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Obesity and metabolic syndrome
Weight loss of 10 percent frequently restores testosterone into the normal range without TRT.
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Medication effects
Long-term opioids, glucocorticoids, anabolic steroid use and some antidepressants suppress the HPG axis.
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Chronic disease
Chronic kidney disease, liver disease, HIV and haemochromatosis all cause functional hypogonadism.
Formulations available in the UK
Gels, injections and buccal preparations.
Choice of formulation is a clinical decision shaped by pharmacokinetics, lifestyle and monitoring practicality.
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Testogel 50 mg gel
Daily transdermal gel to shoulders or upper arms. Steady levels, easy to titrate, but risk of transfer to partners or children if skin contact occurs before drying.
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Tostran 2 percent gel
Alternative daily gel with a metered pump. Similar profile to Testogel with different vehicle and absorption.
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Nebido (testosterone undecanoate)
1000 mg intramuscular injection every 10 to 14 weeks after loading. Stable levels, low peak-to-trough variation, requires clinic visit.
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Sustanon 250 mg
Mixed testosterone esters, intramuscular every 2 to 3 weeks. Cheaper but produces peaks and troughs in mood and energy.
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Buccal Striant
Rarely used in the UK. Buccal mucoadhesive tablet applied twice daily. Gum irritation limits uptake.
Monitoring schedule
Ongoing checks that make TRT safe.
A TRT prescription without a monitoring plan is a red flag.
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At 3 months
Total testosterone (timed to the formulation), haematocrit, PSA if over 40, symptom review and side-effect check.
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At 6 and 12 months
Repeat bloods and clinical review. Adjust dose or formulation to keep testosterone in the mid-normal range.
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Annually thereafter
Bloods, PSA, haematocrit, LFTs and clinical review. Repeat DEXA at 1 to 2 years if the baseline was abnormal.
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Prostate surveillance
Any PSA rise above 1.4 ng/mL in a year, or an absolute value above 4, warrants urological review before continuing.
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Haematocrit threshold
If haematocrit exceeds 0.54, hold TRT, investigate, and consider venesection or a lower dose on restart.
Risks and side effects
What to weigh before starting.
The evidence base is strongest for polycythaemia, PSA changes and fertility suppression. Discuss all three before prescribing.
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Polycythaemia
The most common adverse effect. Injectables carry a higher risk than gels. Managed by dose reduction, formulation switch or venesection.
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PSA rise and prostate risk
TRT does not cause prostate cancer but can unmask existing disease. Baseline PSA and DRE before starting; do not treat men with active prostate cancer.
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Worsening sleep apnoea
TRT can worsen untreated OSA. Screen and treat sleep apnoea before or alongside therapy.
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Subfertility
Exogenous testosterone suppresses the hypothalamic-pituitary-gonadal axis, reduces LH and FSH, and suppresses spermatogenesis. Recovery after stopping is variable.
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Sperm cryopreservation
Men who may want biological children should be offered sperm banking before starting, or use hCG or clomiphene as alternatives that preserve fertility.
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Fluid retention and skin changes
Mild peripheral oedema, acne and oily skin. Usually settles with dose adjustment.
Cost of private TRT in London
Indicative ranges for the first year.
Firm figures depend on formulation, monitoring frequency and whether workup investigations are already available.
| Item | Indicative range | Time | Frequency |
|---|---|---|---|
| Initial consultation and workup | £250–£450 | 45–60 min plus bloods | 1–2 weeks |
| TRT medication | £45–£120 per month | Ongoing | Monthly supply |
| Monitoring review | £150–£300 per review | 20–30 min plus bloods | 3–6 monthly |
| First-year total | £750–£2,400 | — | — |
Where to be seen in London
Providers with a proper workup and monitoring pathway.
A shortlist of UK providers that follow BSSM-compliant protocols.
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Optimale
National telehealth-led TRT service with UK-based clinicians and monitoring bundles.
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Balance My Hormones
UK online and in-person hormone clinic offering full workup and monitoring.
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The Men’s Health Clinic
London andrology-led clinic covering TRT, ED and fertility together.
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London Andrology
Consultant urology and andrology clinic with hospital-grade diagnostics.
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Nuffield Health
National hospital group offering endocrinology-led hormone review in most cities.
When TRT is not appropriate
Situations where the answer is no, or not yet.
Absolute contraindications and situations where reversible factors must be addressed first.
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Single low reading
One low testosterone is not a diagnosis. Repeat morning bloods and consider free testosterone before treating.
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Active prostate or breast cancer
Absolute contraindications. TRT is androgen-dependent tissue fuel.
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Untreated severe sleep apnoea
Treat the OSA first, or use CPAP concurrently.
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Planning fatherhood
Not without sperm banking, or discussion of hCG or clomiphene as fertility-sparing alternatives.
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Unexplained polycythaemia
Investigate the polycythaemia first. Do not add an androgen to an unexplained high haematocrit.
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Severe untreated heart failure
Fluid retention risk. Optimise cardiac status before considering TRT.
Frequently asked
Common questions about TRT.
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Why does the NHS often refuse to start TRT?
NHS thresholds for treatment are conservative and services are stretched. Many GPs and endocrinology clinics will only start TRT when total testosterone is repeatedly well below 8 nmol/L with clear symptoms and a specialist opinion. Borderline cases between 8 and 12 nmol/L are frequently declined or referred back for lifestyle measures first.
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Gel or injection: which is better?
Neither is universally better. Gels give stable daily levels and are easy to stop, but carry a small transfer risk to partners or children. Nebido offers steady levels with an injection every 10 to 14 weeks. Sustanon is cheaper but produces peaks and troughs. The right choice depends on lifestyle, family circumstances and how your body responds.
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Will TRT affect my fertility?
Yes. Exogenous testosterone suppresses LH and FSH and reduces sperm production. Recovery after stopping is variable and can take months to years, and is not guaranteed. If future fatherhood is a consideration, discuss sperm cryopreservation before starting, or ask about hCG or clomiphene as fertility-sparing alternatives.
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Does TRT increase prostate cancer risk?
Current evidence does not show that TRT causes prostate cancer. It can, however, accelerate the growth of an existing prostate cancer. A baseline PSA, digital rectal examination and periodic monitoring are essential, and TRT is contraindicated in men with active prostate cancer.
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Is TRT covered by private medical insurance?
Diagnostic workup and consultant fees are often covered with a specialist referral and a clear indication. Ongoing medication and long-term monitoring are frequently excluded and paid privately. Check with your insurer in writing before starting.
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Is TRT for life?
Usually yes when the cause is permanent, such as primary testicular failure. In functional cases driven by obesity, sleep apnoea, opioids or reversible pituitary suppression, treating the underlying cause can restore normal testosterone and allow TRT to be stopped.
Speak to a consultant
A workup, a diagnosis and, where appropriate, a prescription.
Send your history and any recent bloods. We match you to a UK andrology or endocrinology consultant who follows BSSM 2022, and set out costs before you commit.