Who Should Be Managing Your Testosterone Replacement Therapy?

As testosterone replacement therapy (TRT) grows in popularity, so too does the list of providers offering it. With so many options, patients often wonder:

What is the best speciality to manage testosterone replacement therapy?

In nearly all cases, urology and endocrinology are the two specialties with the most relevant expertise. Both are legitimate and qualified pathways, but they bring different strengths to the table depending on the underlying cause, patient goals, and complexity of the case.

Urology: The Specialist for the Male Reproductive System

Urologists are trained in the medical and surgical care of the male genitourinary system, including the testes, penis and prostate.

Most urologists routinely manage both:

• Primary hypogonadism (testicular failure)
• Secondary hypogonadism (issues stemming from the hypothalamus or pituitary)

While certain secondary causes, like pituitary tumors or prolactinomas, often benefit from endocrinology input, the majority of men with low testosterone, regardless of cause, can be appropriately and effectively managed by a urologist.

In fact, because testosterone deficiency often presents as with sexual symptoms or reproductive difficulties, urologists are often the first and most appropriate specialty to evaluate and treat these concerns comprehensively.

Additionally, the side effects and complications of TRT (such as testicular atrophy, elevated PSA, changes in prostate size with associated urinary symptoms, fertility suppression) are all issues that fall directly within the urologist’s domain.

Endocrinology: A Systemic Hormonal Lens

Endocrinologists specialize in hormonal disorders affecting multiple organ systems, such as the thyroid, adrenal glands, pancreas, and pituitary.

In the context of low testosterone, endocrinologists are particularly well suited to manage:

• Complex, multi-hormonal syndromes
• Pituitary or hypothalamic disorders
• Men with broader endocrine conditions (e.g., adrenal insufficiency, thyroid disease, diabetes)

Their strength lies in systemic diagnosis and management of rare or multi-gland dysfunction, but not necessarily in the management of sexual or reproductive complications arising from TRT.

Where Other Providers Fall Short

While primary care physicians or wellness clinics may offer testosterone prescriptions, most lack specialized training in:

• Fertility preservation
• Erectile dysfunction and ejaculatory issues
• Benign prostatic hyperplasia
• Testicular health

Perhaps most importantly they lack high level insights into the effects of TRT on both PSA levels and existing prostate cancer. This is especially critical when managing:

• Older men
• Men with a prior history of prostate cancer
• Men with elevated PSA levels or abnormal prostate exams
• Men carrying a low-risk or treated prostate cancer diagnosis who are considering TRT

These are complex, nuanced cases that often lie outside the comfort zone of non-urologist providers, and, in many cases, even some urologists may refer to colleagues with focused interest in androgen therapy in the setting of prostate disease.

So, Who Should Manage Your Testosterone?

For most men, the answer is clear:

• If you’re dealing with sexual or reproductive symptoms, or if you’re concerned about fertility, prostate health, or erectile function, a urologist is likely the best-suited specialist.
• If your low testosterone is part of a broader endocrine syndrome, or if you’ve been diagnosed with a pituitary or hypothalamic condition, then endocrinology should absolutely be part of your care team.

In many cases, the best approach is collaborative especially when overlapping systems are involved.