Who shouldn't take testosterone therapy?

Start with the diagnosis

Before asking who shouldn't take testosterone, it's worth asking who has a clear reason to. The American Urological Association (AUA) defines testosterone deficiency as low total testosterone plus symptoms or signs, and says the diagnosis should be made only after two early-morning measurements on separate days. The Endocrine Society similarly calls for consistently low levels on repeated morning, fasting tests.

A single afternoon result, or symptoms with a normal level, isn't enough. Testosterone naturally dips later in the day and after poor sleep or illness, so a one-off low reading can mislead.

Clear reasons not to start

The Endocrine Society's guideline recommends against testosterone therapy in men with any of the following:

• Plans to father a child in the near term.
• Breast cancer or prostate cancer.
• A palpable prostate nodule or firmness, or a PSA above 4 ng/mL (or above 3 ng/mL in men at high risk), without urological evaluation.
• Elevated hematocrit.
• Untreated severe obstructive sleep apnea.
• Severe lower urinary tract symptoms.
• Uncontrolled heart failure.
• A heart attack or stroke within the last six months.
• Thrombophilia, an inherited or acquired tendency to form blood clots.

The prostate question, accurately

For decades, testosterone was assumed to cause prostate cancer. The AUA guideline now says patients should be told there's no evidence linking testosterone therapy to the development of prostate cancer. That's different from saying it's fine for men who already have prostate cancer; that decision belongs with a urologist.

PSA is still checked before starting in men over 40 and monitored during treatment. The Endocrine Society recommends urology referral if PSA rises by more than 1.4 ng/mL above baseline in the first year or exceeds 4.0 ng/mL.

Hematocrit: the most common practical barrier

Testosterone stimulates red blood cell production. If your hematocrit (the share of blood made up of red cells) is already high, raising it further thickens the blood. The AUA recommends checking hemoglobin and hematocrit before starting and discussing the risk of polycythemia. High levels on treatment often mean adjusting the dose, changing the form, or pausing.

Fertility is a decision, not a side note

Testosterone therapy suppresses the brain signals that drive sperm production and can lower sperm counts dramatically. The AUA advises against prescribing it to men currently trying to conceive and says men interested in future fertility should be counseled about long-term effects on sperm production. If children are on the horizon, options that keep your own system running, such as enclomiphene, may be discussed instead.

Fix-first issues

• Untreated sleep apnea: screen and treat it before or alongside any testosterone decision.
• Uncontrolled blood pressure: in 2025 FDA added a blood pressure warning to all testosterone product labels, so pressure should be under control first.
• Recent heart attack or stroke: the AUA advises waiting three to six months after a cardiovascular event.
• Significant obesity, opioid use or heavy drinking: these can lower testosterone themselves, and addressing them may change the picture.
• A borderline result: repeat morning testing and checks of LH, FSH and, when appropriate, prolactin come before a prescription.

What's checked before a first prescription

A careful pre-treatment workup typically includes two early-morning total testosterone measurements, LH (the AUA recommends this for all men with low testosterone), prolactin when LH is low or low-normal, hematocrit, PSA for men over 40, blood pressure, a sleep apnea screen and a fertility discussion. Estradiol is checked when there are breast symptoms.

The AUA also advises prescribing commercially manufactured testosterone products rather than compounded ones when possible.

Heart health and the 2025 label changes

For years, testosterone labels carried a boxed warning about possible cardiovascular risk. In February 2025, after the large TRAVERSE trial found no increase in major adverse cardiovascular outcomes in men treated for hypogonadism, FDA removed that cardiovascular language from the boxed warning and added the trial results to all testosterone labels. At the same time, FDA required a blood pressure warning on testosterone products that didn't already have one.

So heart disease is no longer treated as a blanket barrier, but it's not ignored either. The AUA still advises telling patients that it can't yet be said whether testosterone raises or lowers cardiovascular risk, and recent heart attacks, strokes or uncontrolled heart failure remain reasons to wait or not to start.

How HealifyMD approaches eligibility

Your online assessment covers these questions, and your clinician reviews your history and labs before deciding. If testosterone therapy isn't appropriate now, they'll explain why and what to address first, whether that's a sleep study, a urology visit or a change in another medication. Testosterone Replacement Therapy at HealifyMD is listed at $249 for the first month, then $149/month. The first month includes the lab panel, pricing is confirmed at your eligibility review, and there's no membership fee.