TRT has previously been surrounded by degree of stigma from the older, medical community, but there is now increasing evidence, breaking down the common myths associated with this treatment, and it is proving to be not only safe, but highly effective in helping men with the symptoms of low testosterone.
Our goal at MANUAL is to improve men’s testosterone levels safely and ethically, backed by evidence and guidance, and by using protocols and medications suited to you as an individual, to improve your quality of life and get you back to your old self.
What is TRT?
Testosterone Replacement Therapy (TRT), is a medical treatment used by doctors to replace a man’s decline in natural testosterone production and help restore levels to where they should be. When used correctly, TRT can radically improve the quality of life for its sufferers.
TRT can be administered in several different ways to suit the individual, including injections, creams, gels and tablets.
Modern and more advanced clinics, with specialist doctors, will also use other medications and adapted protocols to counter some of the side effects that occur when testosterone replacement therapy is taken. This includes HCG to improve fertility, or aromatase inhibitors to reduce oestrogen levels in some men. More frequent injections with lower volumes of testosterone may also be used.
A combination of additional medications and bespoke protocols lead to the best possible results in most men. The key is that every man is different, and it is about finding the right treatment protocol for each individual.
How to get TRT in the UK?
It is possible to get TRT via public health services, however the time to treatment is often slow. Furthermore, the public sector is limited by generic medication options which can reduce treatment choice for patients and often impacts of the success of the medication.
Most men now look to get TRT treatment privately via a clinic such as MANUAL, as we can provide the most up-to-date and efficacious medication options, knowledgeable TRT specialists and support medicines.
Manual offers a combination of the best medications available, but also a wide range of support treatments including injections, HCG, creams, and tablets, to provide a tailored and personal approach to your care.
A personalised, bespoke treatment is key to TRT as no one responds in the same way to the same dosing and frequency. Whilst most patients start on similar protocols, treatment is adapted with follow up blood testing on treatment and most importantly, how the patient feels.
MANUAL can also treat men at higher testosterone levels than the NHS, as the NHS has to rely on local laboratory reference ranges to decide who is eligible for treatment. In contrast to locality differences, Manual is guided by the British Society of Sexual Medicine, (a nationally recognised and accredited body on Testosterone Deficiency), for testosterone reference ranges, which affords a wider potential treatment range for patients wishing to consider testosterone replacement.
The treatment process is simple: you need two low testosterone results to start treatment, alongside some more comprehensive blood test results to ensure you are safe and there are no other causes for you to have a low testosterone.
After these two tests, a consultation is performed by a UK registered, GMC doctor, who specialises in Testosterone Deficiency, and who will offer treatment to you if you are medically appropriate.
TRT at Manual
MANUAL is a convenient and professional option, with remote testing options and top of the line medication. We store our own medications in stock to prevent you running out during your treatment due to shortages.
We have the best portal experience, so you can see your blood test values in detail, and track your results with your doctor, for best results. Our service is unparalleled and we have the best response rates to ensure you get the support you need.
How Much Does TRT Cost with MANUAL?
With MANUAL the initial consultation is only £149.99 and can be done remotely for men under 45 or those who don’t need a prostate exam. If you want to transfer from the NHS or another clinic the consultation is only £99.99.
Face to face consultations are £179.99, these are good for men who need a prostate exam, although we will take results that you have done elsewhere.
TRT subscriptions vary based on the medication used. Ours start at £79.99 per month for medication and support with MANUAL. HCG as an add-on to a TRT plan is £35 per vial which lasts from 4 to 10 weeks depending on your dosage.
Blood tests are an additional cost on TRT treatment but we don’t have any hidden costs for postage, letters, consultation reviews or medication changes, unlike a lot of clinics in the UK.
How Easy is it to get TRT in the UK?
Getting testosterone replacement therapy in the UK is easy with MANUAL, just follow these steps:
1. Use our ADAM questionnaire to see if you are likely to be suffering from low testosterone and associated symptoms.
2. Order a blood test to check your total and free testosterone levels (free testosterone levels can be low despite a normal total testosterone level).
3. If levels are low then you need a second test to ensure you are safe and appropriate for treatment (a regulatory requirement in the UK). After this, you can move to consultation, which can be done remotely for almost all men, (some men may require physical examinations or further testing to make sure they are safe to be treated or to investigate other symptoms or signs).
4. Following the consultation, your doctor will prescribe the appropriate, individual treatment, which is delivered to you directly within a few days. You are then taught how to administer the treatment yourself.
5. Follow-up is easy and important. If you start on TRT, you will receive ongoing support on such issues as injection training, advice and guidance from pharmacists, and you will have regular blood tests and reviews with your named doctor, to make sure your treatment is not only safe, but you are getting the most out of the service.
Why is it Important to Maintain Healthy Testosterone Levels?
We all know that testosterone levels drop as we age, and because this is a normal process, there is an assumption (even among many in the medical profession) that declining testosterone levels can be ignored. After all, if it happens to everyone, why is it a problem?
Testosterone is usually only tested for in the NHS when patients have symptoms of erectile dysfunction or a decline in libido. However, there is now a wealth of high-quality evidence suggesting that maintaining healthy testosterone levels throughout life has multiple positive effects on health and well-being. In fact, keeping testosterone levels within the normal range, regardless of age, is associated with a reduction in several significant disease processes, including effects on blood sugar regulation and diabetes, cardiovascular health, bone density, mental health, and even a potential link with dementia (though current studies are still early).
Ignoring a drop in testosterone is something we do at our peril.
What are the Benefits of TRT?
There are plenty of benefits of TRT, which mostly treat symptoms associated with low testosterone levels. However, TRT also improves some areas to levels greater than they were previously:
- Higher drive and motivation
- Harder erections and reduced erectile dysfunction
- Improved libido/sex drive
- More confidence and assertiveness
- Less anxiety
- Improved sleep quality
- Reduced all-cause mortality including better heart health
- Improved mental clarity and focus
- Increased muscle mass
- Reduction in body fat in some men
- Improvement in recovery from exercise and a reduction in general joint aches and pains
- Improved bone density
- Faster and more beard hair growth in some men
There is even a possible link between low testosterone and an increased risk of dementia, but evidence is still developing in this area.
What are the Main Low Testosterone Symptoms?
Low testosterone, or "low T," can impact various aspects of your physical and emotional health. Men experiencing a decline in testosterone may notice changes that affect their daily life, mood, and energy levels. Below are some common symptoms that could indicate low testosterone:
- Low sex drive/libido - some patients just describe this as a dis-interest in sex
- Erectile dysfunction
- Brain fog and poor focus
- Anxiety and depression
- Loss of muscle mass
- Loss of strength
- Low energy
- Reduced drive/competitiveness
- Poor sleep or insomnia
- Reduced fertility/shrunken testicles
- Often just an overwhelming feeling of loss of enjoyment for life
What Causes Low Testosterone in Men?
Low testosterone can be caused by several different factors or causes, and our testosterone production is surprisingly sensitive to external factors ranging from environmental and lifestyle, to illness and medications used to treat other conditions.
Men’s testosterone levels are on average 20% less than they were 20 years ago. In fact your testosterone is likely less than your father’s was at the same age, and his is less than his father’s before him.
In fact, 1 in 4 men over the age of 30 now have low testosterone (this is 1 in 3 men in the US)!
This may be due to any of these factors, some of which have better evidence than others:
- Environmental or chemical exposure – micro-plastics and fertilisers leaking chemicals into the water supply/food (a controversial but possible contributing factor).
- Obesity – body fat levels lead to higher conversion of testosterone into oestrogen which suppresses testosterone production.
- Common medical conditions such as:
- Type 2 diabetes
- Thyroid disease
- Cancer
- Chronic kidney or liver problems
- Medications used to treat other conditions such as:
- High blood pressure
- Asthma
- Depression
- Some common pain killers
- Smoking, alcohol, poor diet, lack of sleep.
- Previous Anabolic steroid use – often a full recovery of natural testosterone levels does not occur after it is suppressed by steroid use.
- Stress – chronically increased cortisol production reduces testosterone levels in men and women.
- Genetic issues – genetic conditions can severely reduce testosterone production.
- Age-related decline/andropause – testosterone levels often decrease with age.
This list is not exhaustive. In fact the best way to think about causes of low testosterone is like the game “Buckaroo”. Your body may be able to compensate for one or triggers such as blood pressure or alcohol, but as you keep piling on the problems, such as age, and stress and other medications, eventually the donkey will buck and you have testosterone deficiency.
What is the Best Type of TRT Treatment in the UK?
The most popular and effective treatment form of TRT in the UK is injections of testosterone. 98% of our patients use this route, and we are experts in providing this treatment effectively and safely. This is because new forms of injections are essentially painless, highly effective, and given in amounts as low as 0.2ml.
However, we do have other options for men who would prefer not to inject, and the key is getting the right treatment option of the patient that works best for them.
The most popular injections are with cypionate due to its ease of injection, high efficacy, and good safety profile.
HCG is also used in most men as it is important to maintain fertility and natural testosterone production. It also helps to regulate other hormonal pathways.
• Testosterone gels or creams – the testosterone cream is generally very effective, but needs daily application, and often produces less stable testosterone levels due to fluctuations in absorption.
• Monthly or Quarterly testosterone injections such as Nebido
• Patches - these are not a popular option yet in the U.K.
• Testosterone tablets - these have recently been released in the U.S., but require high doses to be taken to get testosterone levels up to desired levels, and further evidence is still to be gathered before we consider offering it to our patients.
• Clomiphene (clomid) - this is a tablet medication that helps encourage your testicles to produce more testosterone. It has limited use in true testosterone deficiency, but can be used in men wishing to maintain fertility and does have some other benefits in some men.
Which Blood Tests do I Need Before Starting TRT in the UK?
UK guidance states that you need to have a minimum of two results showing low total testosterone and/or free testosterone before starting TRT therapy.
Your doctor will also want to ensure you have these tests before your consultation so that you can start any treatment safely. In addition to testosterone, some of the tests you will need include:
• Sex Hormone Binding Globulin (SHBG) – this is a protein that binds to your testosterone making it less available to the body. It is designed to help regulate how much usable testosterone you have at any one time. If you have a raised SHBG level, you could suffer from the symptoms of low testosterone despite good total testosterone levels.
This value isn’t mandatory but it is useful to indicate certain issues and ensure the treatment is effective. It is particularly useful in those men who have symptoms of low testosterone but their total testosterone seems normal.
• Oestradiol (Oestrogen) – oestradiol is the main type of oestrogen in the body. It is produced in the male body from testosterone when it is converted by aromatase (an enzyme). As a man, you do need oestrogen, just not too much.
If Oestradiol is too high, or too low, it can affect male libido, erection quality, fat levels and growth of breast tissue (which can lead to gynaecomastia) This is extremely important to test when on treatment as well as beforehand.
• Prolactin – this is also known as the breast milk hormone. But, both men and women who are not lactating still produce it at lower levels. If your levels are high it can affect your mood and sexual health. High levels can suppress testosterone production. If your prolactin level is very high, it may be associated with a prolactinoma, a type of non-maligant tumour in the pituitary gland in the brain. Although this is very rare, if your prolactin level is above a certain range then your doctor may recommend that you have an MRI scan before starting treatment.
• Follicle Stimulating Hormone (FSH) – a hormone produced by the pituitary gland that stimulates the testes to produce sperm and testosterone in healthy men.
• Luteinising Hormone (LH) – a hormone produced by the pituitary gland that stimulates the production of testosterone in the testicles.
• Prostate-Specific Antigen (PSA) – PSA is an indicator of prostate health. There is now strong and clear evidence that testosterone, and in particular TRT, does NOT cause and cannot cause prostate cancer. However, if you had a pre-existing prostate cancer already that you did not know about, we would want this treated before considering testosterone replacement. Hence, the importance of checking your PSA level in advance. In asymptomatic men, (men with no lower urinary symptoms), we should not routinely perform rectal examinations to check the prostates anymore.
• Lipids – lipids, (cholesterol levels), can be affected by certain medications.
• Full Blood Count – this test looks at how many blood cells you have per ml of blood as well as the other parts that make up your blood including your immune system and clotting.
If the concentration of your blood (haematocrit) is too high, this can indicate that your blood is thick which may need to be addressed before treatment.
• Thyroid hormones – some thyroid conditions present with similar symptoms to testosterone deficiency.
• Liver function tests – certain medications can make these worse, they can also indicate other health issues.
• Renal (kidney) function – we need to check these levels before starting treatment, if they are abnormal we may avoid certain medications or treatments.
• Iron studies – these can indicate certain issues such as haemochromatosis (too high iron levels), which will need investigation before starting TRT.
• HbA1C – this checks for signs of prediabetes or diabetes.
It is essential that as a minimum, the blood tests discussed above are checked in every man prior to considering starting TRT. Without these TRT cannot be safely initiated.
How Safe is TRT for Men?
TRT is probably one of the safest medications we can prescribe as doctors (provided that treatment protocols and monitoring processes are adhered to). This is because testosterone replacement is literally replacing what was missing and is not trying to alter a person’s natural physiology. In a similar way to HRT for women, or thyroxine for thyroid disease, which replace missing hormones, TRT simply restores you to the levels of testosterone you are supposed to have.
TRT has been around since the 1950s, and we have thousands of papers demonstrating its safety and efficacy when used in appropriate patients. Historical concerns over links between TRT and prostate disease have now been completely quashed, and a large-scale trial (the Traverse study) further demonstrated that TRT is also safe in patients with heart disease. Finally, in a landmark paper published in The Lancet in 2023, the T4DM study even showed that TRT can help improve blood sugar levels in diabetic and prediabetic patients.
Conclusion
Testosterone replacement therapy in the UK is growing in popularity every year. Whilst it is a treatment that requires careful monitoring and specialist support to get the best results, it can also be a life changing medical intervention.
There are some risks and side effects associated with testosterone replacement therapy, but if the treatment is carefully monitored and managed by a specialist clinic such as MANUAL, these issues are generally minimal.
If you think that testosterone deficiency could be causing your symptoms then get in touch for more information, or buy a blood test to check your levels.
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