1. Androgenic alopecia. Potential exacerbation of pre-existing male pattern hairloss, or potentially earlier onset. Can be managed through topical and oral DHT blockers
  2. Testicular atrophy. This is due to shutdown of Hypothalamic-Pituitary-Testicular Axis. Does not usually affect volume of ejaculate or orgasms.
  3. Gynaecomastia. This is due to aromatization of exogenous bioidentical testosterone in fat tissue, which may be higher in patients who have higher body fat %. Can be managed through reducing body fat, lowering T dose or Aromatase Inhibitors.
  4. Lowering of HDL-cholestrol. This can be addressed by modifying the T regimen, and supplementation of omega-3 to reduce CV risk factors.
  5. Hemoglobin and Hematocrit. There is an increased risk of polycythemia while on testosterone therapy and if hematocrit exceeds 50%, testosterone treatment should be withheld or dose reduced.
  6. Acne. This is due to increase activity of sebaecous glands in the skin due to T administration. However this is generally uncommon and can be managed with conventional anti-acne treatment, and/or optimizing therapeutic T levels.
  1. Cardiovascular (CV) risk factors. Although low T is a risk factor for cardiovascular disease including increased incidence of MI, stroke and possible CV-related mortality, CV risk factors should be assessed [hypertension, Diabetes Mellitus, Dyslipidemia (cholestrol and fat in the blood), smoking, family history, previous history of cardiovascular events]. It is to be noted that there is no definitive evidence that TRT increases or decreases the risk of CV events.
  2. Future fertility. For those who are still planning future reproduction, testosterone cessation should occur. Patient to be informed of the variable time course to recover sperm in the ejaculate. While 2/3 of males recovered sperm in the ejaculation within 6 months of exogenous testosterone cessation, 10% failed to do so until 2nd year after cessation
  3. Prostate cancer. There is absence of evidence linking testosterone therapy to development of prostate cancer, although this is still a potential risk and therefore PSA monitoring is necessary while on testosterone therapy

If you are diagnosed with low testosterone, you may be a candidate for TRT. There are different methods of administration of T such as injections, topicals, or implants under the skin. At Sigma Health, regular injections are preferred over other forms of administration as it is easier to titrate your T level, and minimize fluctuations in T levels.

Injections are administered with an insulin-size needle, usually on a weekly basis. Depending on your response, a frequency of every 5 days or twice a week may be necessary to optimize T levels. Such injections of T can be either be performed at Sigma Health or self-administered at home.

TRT is lifelong, and generally the frequency of administration is at least once a week. The goal of treatment is to improve your symptoms by normalizing T levels.

A trial of 6 months is necessary in order to determine if improving T levels improves symptoms. If there is little to no resolution of symptoms, then should consider stopping.

By protocol, routine bloodwork is performed at week 4 to 6, month 3 and month 6 of TRT initiation. Once labs are stable, then labs are performed at a 6 monthly basis. At the outset, it usually takes 6 months to adjust dose and frequency of T administration in order to optimize well-being and performance.

Testosterone can be administered in different forms. This includes injections, topicals or pellets implants under the skin. Each of these have their advantages and drawbacks and will be discussed openly.

Topical application is the least invasive, however the risk of contamination to other individuals in the home exists, and therefore rather undesirable.

Injections are probably the more common administration route. There are three major considerations with injections.

  1. Frequency of injection: from as infrequent as 3 – 4 monthly, to as frequent as weekly or twice weekly.
  2. Dose of each injection: the dose per injection is highest when injection is infrequent.
  3. Administration in clinic or self-administration at home

Major advances in TRT have enabled men to self-administer at home, with lower doses per injection, at a frequency of usually once a week, with an insulin sized needle. This type of protocol enables finer control of testosterone levels in order to optimize well-being.

Testosterone levels can be increased naturally through three aspects:

  1. Improving sleep: Improving duration and quality of sleep is important for natural testosterone secretion
  2. Resistance training: weight training especially for large muscles like legs and back
  3. Reduce stress: Stress is associated with high cortisol levels which interferes with testosterone. Managing stress can improve testosterone levels

Addressing these three factors can improve testosterone levels modestly. However modern life prevents many of us from optimizing these. Supplements have not been shown to definitively improve testosterone levels.

Under these circumstances, TRT is the only means to improve T levels to therapeutic levels in a meaningful manner for well-being.

You have symptoms that are suggestive of testosterone deficiency and need to undergo a blood test. Since blood drawing is required, at Sigma Health, we require a comprehensive lab panel to provide a clear picture of what is happening.

Screening Basic Comprehensive
Testosterone Testosterone Testosterone
Estradiol (E2) Estradiol (E2) Estradiol (E2)
FSH FSH FSH
LH LH LH
Prolactin Prolactin Prolactin
TSH TSH TSH
fT4 fT4 fT4
SHBG SHBG
Albumin Albumin
Hemoglobin Hemoglobin
Hematocrit Hematocrit
PSA PSA
Free Androgen Index
Cortisol
Progesterone
DHEAS
IGF-1

Testosterone:total and free

Estradiol:Testosterone is aromatised in fat cells to estradiol and is needed for sperm production, libido and sexual function.

FSH and LH: Hormones secreted by the pituitary gland and stimulates testes. In particular LH stimulates testosterone production in the testes.

Prolactin: A hormone secreted by the pituitary which can affect testosterone levels

TSH and fT4: thyroid dysfunction can manifest nonspecific symptoms and mimic low T

SHBG and Albumin: Two proteins in the blood which typically bind testosterone. Needed to ascertain free, unbound testosterone levels

Hb and Hct: Screening for red blood cell abnormalities. Important for baseline measurement prior to starting TRT

Cortisol: A ‘stress’ hormone which interferes with testosterone levels

Progesterone:A hormone produced by adrenals and testes. To check adrenal function

DHEA-S: A hormone produced by adrenals which can be converted into testosterone. To check adrenal function

IGF-1: A hormone secreted by the liver which is related to GH secretion.

This is a common question amongst men. You may be experience some or many symptoms depending on how low T manifests in each individual. More importantly, it is important to understand what is causing these symptoms, and to know that effective treatments are available. Men do not need to suffer from the effects of low T.

  • Reduced libido – sexual desire is not only psychological, but also physiological aka T levels
  • Erectile dysfunction – T supports arousal also plays a impt role in ability to have an erection
  • Fatigue – decreasing energy level, don’t have the energy to follow through with plans.
  • Weight gain – changes in body composition esp fat gain e.g. around abdomen
  • Loss of lean muscle – inability to build lean muscle, despite regular workouts and strict diet
  • Depression and anxiety – when T levels are low, you may start feeling depressed and/or anxiety
  • Difficulty concentrating – if you notice a drop in the ability to focus, low T may be a reason
  • Osteoporosis – T can affect bone density and increased risk of fractures
  • General lack of interest – less interested in things you enjoyed previously

Laboratory defines the normal range of T in men as 8.40 – 28.70 nmol/L [242.27 – 827.77 ng/dL]. In general, the threshold is taken at 300 – 350 ng/dL to be considered testosterone deficient. In other words, it does not mean that an individual only has testosterone deficiency if it their T level is below the lowest limit.

Even in men with T levels within normal range, it does not necessarily mean that the individual does not have low T. This is because it depends on the baseline T of the individual, and each individual will have an optimal range which is unique to them.

Looking only at T levels will overlook patients with normal range, but still have T deficiency, and therefore it is important to take symptoms into consideration.

At Sigma Health, we pride ourselves at properly diagnosing every man who has symptoms suggestive of low T, and customizing a TRT program for optimal results.

Erectile dysfunction: As this is a major symptom of low T, the individual may need additional treatments even after restoration of T levels. This is in the form of PDE5 inhibitors such as Sildenafil and Tadalafil. Besides the use of such medication on demand, daily mini doses of PDE5 inhibitors may have benefits outside the bedroom, due to its vasodilation effects in muscles.

Potential hair-loss due to increased androgens. Some men are prone to male pattern hair loss and therefore it may be necessary to start DHT inhibitors to prevent or slow this process

Acne due to increased androgens. Can be managed with conventional anti-acne treatment, including low dose isotretinoin.

Supplementation with omega-3 is recommended for its protective CV effects.

Gynaecomastia onset. This can be managed by reduction in body fat, changing administration protocol and addition of aromatase inhibitors to reduce conversion of testosterone to estradiol by fat cells.