Only 12% of TRT Prescriptions Get the Right Workup

A study presented at ENDO 2026, the Endocrine Society's annual meeting in Chicago, put a hard number on a problem clinicians have suspected for years: only 12 percent of men who started testosterone therapy had received the full diagnostic workup that guidelines call for.

Researchers at the University of Michigan reviewed 200 men who received an initial testosterone prescription at Michigan Medicine between 2020 and 2025. The vast majority were missing at least one piece of the standard evaluation before they ever picked up a prescription.

The finding lands in the middle of a testosterone boom. Prescriptions in the US jumped from roughly 7.3 million in 2019 to over 11 million by 2024. As access expands through telehealth and the FDA signals a more permissive stance, the question is no longer whether men can get testosterone. It is whether they are being properly diagnosed first.

Key Takeaways

• University of Michigan study (ENDO 2026) found only 12 percent of 200 men had guideline-concordant testing before an initial testosterone prescription
• Guideline-concordant means two low morning testosterone tests, LH and/or FSH measured, and no contraindications
• 62 percent had a PSA test, 77 percent had a complete blood count, but most were missing confirmatory morning labs or pituitary hormone testing
• Prescriptions came from primary care (45 percent), urologists (35.5 percent), and endocrinologists (18 percent)
• The fix is patient-side too: insist on two morning draws plus LH and FSH before starting, and choose a clinic that requires the full workup

What the Study Looked At

The research was a retrospective chart review led by Sophia Sinha, MD, a clinical assistant professor at the University of Michigan, with Maria Papaleontiou, MD, as senior author. The team pulled a random sample of 200 male patients (mean age 52.5 years) who had a diagnosis of hypogonadism, at least one recent primary care visit at Michigan Medicine, and an initial testosterone prescription written between 2020 and 2025.

They then checked each chart against the Endocrine Society's clinical guidelines for diagnosing testosterone deficiency. The bar for "guideline-concordant" was specific and not unreasonable:

• Two low morning testosterone levels (total testosterone below 300 ng/dL, free testosterone below 70 pg/mL, or low bioavailable testosterone), drawn between roughly 5 and 10 AM
• Measurement of LH and/or FSH
• No contraindications to testosterone therapy

Only 12 percent of the 200 men cleared all three. That is the headline.

Where the Workups Fell Short

Interestingly, the gaps were not uniform. Some safety tests were done fairly often:

• 62 percent had a PSA test before starting
• 77 percent had a complete blood count (which captures hematocrit, the value that drives polycythemia risk)

But the core diagnostic steps were missed far more often. Many men had only a single testosterone measurement, frequently drawn in the afternoon when levels are naturally lower. Many never had LH and FSH measured, which is the test that distinguishes a testicular problem from a pituitary or hypothalamic one. And the comorbidity picture was striking: 55 percent of the men had obstructive sleep apnea, 63 percent were obese, 52 percent had hypertension, and 40 percent had depression.

Those last numbers matter because untreated sleep apnea, visceral obesity, and depression all suppress testosterone and all cause the same symptoms men attribute to "low T." Treating the hormone without addressing the driver is exactly the pattern guidelines are designed to prevent. We cover this fork in detail in TRT versus natural optimization.

The Workup You Should Actually Get

You do not need to memorize a guideline document to advocate for yourself. Before any initial testosterone prescription, three things should happen.

1. Two Morning Testosterone Tests

Testosterone peaks between 7 and 10 AM and drops 20 to 40 percent by afternoon. A single afternoon reading of 280 ng/dL might be 380 ng/dL first thing in the morning. Levels also swing with sleep, illness, and stress, so one low value can be a false alarm. Two confirmed morning lows (drawn before 10 AM, ideally fasting) are the standard. The TRAVERSE trial and the 9,537-man real-world safety cohort both used this threshold. We walk through the timing rules in how to test testosterone and testosterone blood test timing.

When total testosterone lands in the borderline 250 to 350 ng/dL range, free testosterone and SHBG should be measured too. High SHBG can bind enough testosterone that your free level is clinically low even when total looks fine, which is why we treat total versus free testosterone as separate questions.

2. LH and FSH

These two pituitary hormones tell you where the problem lives. High LH and FSH alongside low testosterone points to primary hypogonadism (the testicles). Low or inappropriately normal LH and FSH points to secondary hypogonadism (the pituitary or hypothalamus), which can flag a pituitary tumor, chronic opioid use, or another reversible cause worth chasing before committing to lifelong therapy.

This step also changes treatment. Men with intact pituitary signaling who want to preserve fertility are often better served starting with enclomiphene rather than TRT, which raises the body's own testosterone production instead of shutting it down. You cannot make that call without LH and FSH on the table.

3. Contraindication Screening

Before starting, a clinician should rule out or manage: untreated or suspected prostate cancer, hematocrit already running high, severe untreated sleep apnea, and a near-term desire for fertility. PSA and a complete blood count cover most of this, and the Michigan study suggests these tests are done reasonably often. The bigger gap is screening for sleep apnea, which over half the sample had.

Why So Many Workups Are Incomplete

Three forces push against a thorough evaluation.

Time and convenience. A two-visit, two-blood-draw workup is slower than a single test and a questionnaire. In a busy primary care visit, or a fast telehealth intake, the path of least resistance is one test and a prescription.

Symptom-first thinking. When a man reports fatigue, low libido, and brain fog, the symptoms feel like a diagnosis. But those symptoms overlap heavily with sleep apnea, depression, and obesity, the very conditions that were common in the study sample. Labs are what separate hypogonadism from its mimics.

Marketing incentives. Direct-to-consumer telehealth has a financial reason to prescribe. A defensible model still requires confirmatory morning labs, measures LH and FSH, and counsels on lifestyle for borderline cases. An over-prescribing model treats "suboptimal" numbers in the 400 to 600 ng/dL range and skips the steps that would slow a sale. We lay out the difference in TRT clinic red flags and the broader who actually qualifies for TRT debate.

The prescriber breakdown in the study reinforces that this is a system-wide pattern, not a single specialty's failing: primary care physicians wrote 45 percent of the prescriptions, urologists 35.5 percent, endocrinologists 18 percent, and other specialists the rest.

What This Means If You Are Already on TRT

A missing workup does not automatically mean your therapy is wrong or dangerous. Plenty of men with incomplete documentation genuinely have low testosterone and benefit from treatment. But it does raise the odds you were treated for a problem that was not actually hypogonadism, or that a reversible cause was never investigated.

If your initial evaluation was a single test and a quick form, it is reasonable to close the gaps at your next bloodwork:

• Ask for a morning total testosterone, free testosterone, and SHBG
• Ask whether LH and FSH were ever measured (if you are already on testosterone they will be suppressed, but the history still matters)
• Get screened for sleep apnea if you snore, wake unrefreshed, or have a large neck circumference
• Confirm your hematocrit and PSA are being tracked on schedule

Our TRT bloodwork schedule lays out what to monitor and how often once you are on therapy.

What This Means If You Are Considering TRT

Use the study as a checklist. Before you pay for anything, make sure your clinic will:

1. Require two separate morning blood draws before prescribing
2. Measure LH and FSH, not just total testosterone
3. Add free testosterone and SHBG when total is borderline
4. Screen for sleep apnea, prostate concerns, and high hematocrit
5. Discuss fertility and offer enclomiphene or hCG where appropriate
6. Re-test on a defined schedule rather than prescribing and disappearing

A clinic that does none of this is the clinic the Michigan data is warning you about. We score online TRT clinics specifically on diagnostic rigor, monitoring, and physician involvement, so you can find the ones that do the work. The questions to ask a TRT clinic gives you the exact wording to confirm it.

The Bigger Picture

The takeaway is not that testosterone therapy is bad. The TRAVERSE trial settled the cardiovascular question for appropriately selected men, real-world data has confirmed the safety profile, and the FDA has been loosening restrictions accordingly. Testosterone works well for the men who actually need it.

The takeaway is that diagnosis has not kept pace with access. As prescriptions climb past 11 million a year, a 12 percent rate of complete workups is a warning that the front door has gotten easier to walk through than the diagnostic process behind it. The fix is partly clinical and partly patient-side: know what a real workup looks like, and refuse to start without it.

Further Reading

• Testosterone is trending: do you actually need TRT?
• How to test testosterone the right way
• Total versus free testosterone
• TRT versus natural optimization
• Questions to ask a TRT clinic
• Best online TRT clinic 2026

Sources

1. Sinha S, Papaleontiou M, et al. "Guideline-Concordant Diagnostic Evaluation Prior to Testosterone Therapy Initiation." Presented at ENDO 2026, Endocrine Society Annual Meeting, Chicago.
2. Medical Xpress. "Study suggests testosterone therapy in men may be overprescribed, inconsistent with clinical guidelines." June 2026.
3. News-Medical. "Study finds gaps in guideline-based testosterone prescribing practices." June 14, 2026.
4. Bhasin S, et al. "Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline." J Clin Endocrinol Metab.
5. Lincoff AM, et al. TRAVERSE Trial. "Cardiovascular Safety of Testosterone-Replacement Therapy." NEJM. 2023;389:107-117.