Low Testosterone in Canada (2026): Symptoms, Testing, TRT Risks and Benefits, Fertility-Friendly Alternatives, and hCG and Kisspeptin Research

Comparison Guide · 22 min read · Updated October 2026

What testosterone does

Testosterone is the main male sex hormone, made mostly by the testes (and in smaller amounts by the ovaries and adrenal glands in women). It drives:

• Sex drive and sexual function
• Sperm production (together with FSH)
• Muscle mass and strength
• Bone density
• Red blood cell production
• Fat distribution
• Aspects of mood, energy and motivation

Levels peak in early adulthood and drift down slowly, roughly 1% a year from middle age on average. But that average hides a huge range: many healthy older men keep normal levels, and weight gain and chronic illness drive much of the decline people blame on age.

How your body controls testosterone

Testosterone is the end of a chain of signals called the hypothalamic-pituitary-gonadal (HPG) axis:

1. Kisspeptin neurons in the hypothalamus trigger the release of GnRH in pulses.
2. GnRH tells the pituitary gland to release LH and FSH.
3. LH tells the testes to make testosterone. FSH (plus high testosterone inside the testes) drives sperm production.
4. Testosterone and estrogen feed back to the brain to slow the signal when levels are high.

This matters for treatment. Problems can start in the testes (primary hypogonadism, with high LH) or in the brain and pituitary (secondary hypogonadism, with low or normal LH). And because external testosterone triggers that feedback, it shuts down LH and FSH, which is why TRT stops sperm production.

Symptoms that actually point to low T

The sexual symptoms are the most reliable signal. Fatigue and low mood have dozens of other causes, which is why testing matters more than online symptom quizzes.

Causes, including the fixable ones

Common and often reversible

• Obesity: fat tissue converts testosterone to estrogen and suppresses the HPG axis. Weight loss raises testosterone, and more weight lost means a larger rise.
• Type 2 diabetes and metabolic syndrome.
• Sleep apnea and short sleep: much testosterone is released during sleep.
• Opioids: strongly suppress testosterone.
• Heavy alcohol use.
• Acute illness or extreme stress or under-eating.
• Past anabolic steroid use, which can suppress natural production for months or longer.

Structural or permanent

• Klinefelter syndrome and other genetic conditions
• Testicular injury, mumps orchitis, chemotherapy or radiation
• Pituitary tumours or high prolactin
• Haemochromatosis (iron overload)

How to get tested properly

Getting this right avoids both missed diagnoses and unnecessary lifelong treatment:

1. Test in the morning, ideally before 10 a.m., when levels peak, and preferably fasting.
2. Repeat it. A single low result is not enough; levels vary from day to day. Guidelines require two low morning results.
3. Don’t test while acutely ill.
4. If low, add LH and FSH to tell primary from secondary causes, plus prolactin, a blood count and sometimes free testosterone or SHBG (sex hormone–binding globulin).

These tests are covered by provincial health plans when ordered by a physician or nurse practitioner, and Canadian guidance from the Canadian Urological Association and others follows this approach (Morales et al., 2015).

What the numbers mean

Canadian labs report testosterone in nanomoles per litre (nmol/L); American sources use nanograms per decilitre (ng/dL). To convert, divide ng/dL by about 28.8.

• The Endocrine Society uses a lower limit of about 264 ng/dL (roughly 9.2 nmol/L) for total testosterone in healthy young men (Bhasin et al., 2018).
• Results well below that, with consistent symptoms, support a diagnosis.
• Borderline results are where free testosterone and SHBG help, because obesity lowers SHBG (making total testosterone look low) and aging raises it (making total testosterone look normal).

The treatment scorecard

TRT: what it actually does

The best evidence comes from the Testosterone Trials (TTrials), which gave testosterone gel or placebo to men aged 65 and older with low levels for a year. Testosterone improved sexual function and desire and had small benefits for mood and depressive symptoms and walking distance, but did not improve vitality (energy) meaningfully (Snyder et al., 2016). Related trials found improvements in bone density and anaemia.

TRT is not a fountain of youth. Men with normal testosterone do not benefit from extra testosterone for these outcomes, and the risks remain.

Gels, injections and pills in Canada

• Gels applied daily to the skin give steady levels. Risk of transferring testosterone to partners or children through skin contact; wash hands and cover the area.
• Injections (testosterone cypionate or enanthate) are inexpensive. Levels peak and trough between injections; shorter intervals smooth this out.
• Oral testosterone undecanoate capsules are taken with food.
• Long-acting injections and other formulations exist in some markets.

In Canada, testosterone is a controlled substance under the Controlled Drugs and Substances Act (as an anabolic steroid) and requires a prescription. Monitoring typically includes testosterone levels, haematocrit (red blood cell concentration), PSA in men over a certain age, and a symptom review a few months after starting, then yearly.

TRT risks, including the heart question

The heart question

Around 2014, observational studies raised fears that TRT caused heart attacks, and Health Canada and the FDA reviewed the issue and updated warnings. The definitive answer came from TRAVERSE, a trial of more than 5,000 men with low testosterone and existing heart disease or high cardiovascular risk. Testosterone gel was non-inferior to placebo for major cardiovascular events (heart attack, stroke, cardiovascular death). However, the testosterone group had a higher incidence of atrial fibrillation, pulmonary embolism and acute kidney injury (Lincoff et al., 2023).

Other risks

• Erythrocytosis: too many red blood cells, raising clot risk; more common with injections. Monitored by blood tests.
• Infertility (see next section).
• Testicular shrinkage.
• Acne and oily skin.
• Worsened sleep apnea in some men.
• Breast tenderness from conversion to estrogen.
• Prostate: TRT doesn’t appear to cause prostate cancer, but it is not given to men with untreated prostate cancer, and PSA is monitored.

The fertility problem

Fertility-friendly alternatives: clomiphene and hCG

For men with secondary hypogonadism (a brain/pituitary signal problem) who want to preserve fertility, urologists and endocrinologists use off-label options that work with the HPG axis instead of replacing it:

• Clomiphene citrate is a selective estrogen receptor modulator. By blocking estrogen feedback in the brain, it increases LH and FSH, so the testes make more testosterone and sperm. It is approved for female infertility and used off-label in men.
• hCG (human chorionic gonadotropin) mimics LH and stimulates the testes directly to make testosterone and support sperm production. It is used off-label for male hypogonadism, and sometimes alongside TRT to maintain testicular function.
• Aromatase inhibitors (such as anastrozole) block conversion of testosterone to estrogen. Used selectively; long-term use can harm bone.

These need specialist supervision. Enclomiphene, a purified form of clomiphene, has been studied but is not an approved drug in Canada.

Raising testosterone naturally

For men with borderline levels, these steps often move numbers meaningfully, and they help health regardless:

1. Lose excess weight. Meta-analyses show weight loss raises testosterone, with larger losses (including after bariatric surgery) producing larger increases. GLP-1 weight loss drugs are now part of this conversation; see weight loss injections in Canada.
2. Sleep 7 to 9 hours, and get tested for sleep apnea if you snore or wake unrefreshed.
3. Resistance training: builds muscle and improves insulin sensitivity.
4. Limit alcohol.
5. Review medications, especially opioids.
6. Eat enough: chronic under-eating and very low fat intake suppress testosterone.
7. Correct deficiencies (vitamin D, zinc) if tested low; supplementing when not deficient does little.

“Testosterone boosters” and online clinics

Most over-the-counter “T boosters” (tribulus, fenugreek, D-aspartic acid, tongkat ali blends) have weak or inconsistent evidence. A few show small changes in small studies; none rivals treating the underlying cause. Some products sold online have been found to contain undeclared drugs.

Online men’s health and TRT clinics have grown quickly. Some are excellent; others start testosterone after a single test, skip the fertility conversation, or push add-ons. A good clinic confirms low levels twice, checks LH and FSH, asks about fertility plans and monitors haematocrit.

Kisspeptin and hCG research

Because kisspeptin sits at the very top of the HPG axis, it is one of the most studied peptides in reproductive endocrinology:

• In healthy men, infused kisspeptin raised LH and testosterone (Dhillo et al., 2005).
• It has been studied as a diagnostic tool to distinguish causes of delayed puberty and hypogonadism, and as a way to trigger egg maturation in IVF.
• In brain imaging studies, kisspeptin enhanced activity in sexual and emotional processing regions in men (Comninos et al., 2017).
• A challenge for any treatment use: continuous kisspeptin exposure can desensitize the system, so the natural pulsatile pattern matters.

hCG, by contrast, is an established medicine with decades of clinical use in fertility, and is a reference compound in reproductive research.

These are sold for laboratory research use only, with lab reports in our COA library. They are not a substitute for medical diagnosis and treatment. Background: kisspeptin vs hCG vs PT-141, hCG side effects and kisspeptin side effects.

Costs and access in Canada

Low T and weight: the vicious cycle

Obesity and low testosterone feed each other, and understanding the loop explains why weight loss is often the most powerful “testosterone treatment” for men with excess weight:

1. Fat tissue contains aromatase, the enzyme that converts testosterone into estrogen. More fat means more conversion.
2. Higher estrogen and insulin resistance suppress the brain signals (kisspeptin, GnRH, LH) that tell the testes to make testosterone.
3. Lower testosterone favours fat gain and muscle loss, and reduces energy and motivation to exercise.
4. More fat restarts the cycle. Sleep apnea, common with obesity, lowers testosterone further.

Breaking any link helps. Weight loss raises testosterone, and the effect grows with the amount lost. In men with obesity-related low testosterone and no structural problem, levels often normalize after substantial weight loss, without TRT. Treating sleep apnea and improving sleep add to the effect.

Low T in younger men and after steroid use

Low testosterone in a man in his twenties or thirties deserves a careful look for a cause, because it is less likely to be age-related:

• Previous anabolic steroid or SARM use is now one of the most common causes in young men. External androgens shut down the HPG axis, and when they stop, natural production can take months to recover, occasionally longer. This is sometimes called anabolic steroid-induced hypogonadism.
• Pituitary problems, including prolactin-secreting tumours, which cause low LH and low testosterone.
• Genetic conditions such as Klinefelter syndrome, often first noticed during fertility testing.
• Opioid use, including prescribed pain medication.
• Over-training and under-eating, sometimes called relative energy deficiency in sport.

For young men who want children, starting TRT can make fertility worse. Specialists often prefer to restart the natural axis, sometimes with clomiphene or hCG, and allow time for recovery. Being honest with your clinician about past steroid use is important: it changes the diagnosis and the plan.

Monitoring on TRT: what the blood tests mean

The timing of the testosterone test matters. With injections, levels vary widely over the injection cycle, so clinicians usually test at a consistent point (often midway between injections). With gels, testing a few hours after application is common.

What happens if you stop TRT

TRT is usually a long-term treatment. If it’s stopped:

• Symptoms of low testosterone return over weeks as levels fall.
• Natural production restarts in most men, but can take months, and may not fully return in men who were on TRT for a long time or had a structural cause.
• A temporary dip below the original baseline is common while the axis wakes up.
• Fertility recovery also takes months; some men need medical help to restart sperm production.

A planned exit, sometimes using clomiphene or hCG to restart the axis, is better than stopping suddenly. That should be managed by a clinician.

Testosterone in women

Women make testosterone too, in the ovaries and adrenal glands, at roughly a tenth to a twentieth of male levels. It contributes to libido, energy and bone health. Levels decline gradually with age and drop sharply after removal of the ovaries.

For postmenopausal women with distressing low sexual desire, an international consensus supports testosterone at doses that keep levels in the normal female range (Davis et al., 2019). No testosterone product is approved for women in Canada, so it is prescribed off-label, usually by menopause specialists. Higher doses cause acne, unwanted hair growth and voice changes. More in our menopause treatment guide.

Testosterone myths

• “Every man over 40 needs TRT.” Most men maintain adequate levels; treatment is for confirmed deficiency with symptoms.
• “TRT causes prostate cancer.” Evidence does not show it causes prostate cancer, but it isn’t used in men with untreated prostate cancer and PSA is monitored.
• “TRT is a performance enhancer.” Replacement aims for normal levels; supraphysiological use is a different, riskier practice.
• “Natural boosters work as well as TRT.” Most supplements have weak evidence; weight loss and sleep do far more.
• “Low T always causes ED.” Low testosterone mostly reduces desire; most ED is vascular.
• “TRT will improve fertility.” It does the opposite, suppressing sperm production.

TRT forms compared

There is no single best form. Many men start with a gel to test whether symptoms improve, then switch for cost or convenience. Whatever the form, the target is normal mid-range levels, not the highest possible.

Low T, mood and depression

Low testosterone and depression share symptoms: low energy, low motivation, poor concentration and low libido. That overlap causes confusion in both directions:

• Men with depression are sometimes assumed to have low T, and vice versa.
• In men with confirmed low testosterone, TRT has produced small improvements in mood and depressive symptoms in trials, but it is not a treatment for depression in men with normal levels.
• Depression, poor sleep and chronic stress can themselves lower testosterone modestly.

If mood symptoms are prominent, it’s worth screening for depression and treating it directly, alongside testing testosterone properly. See our guide to anxiety treatment in Canada for related mental health options.

Questions to ask before starting TRT

1. Have my low levels been confirmed on two morning tests?
2. What are my LH and FSH, and do we know the cause?
3. Could weight, sleep, medications or alcohol explain this, and should we address those first?
4. Do I want children in the future, and how does TRT affect that?
5. Which form suits me, and what will it cost?
6. What blood tests will we monitor, and how often?
7. What symptoms should improve, by when, and what happens if they don’t?
8. What is the plan if I want to stop?

A good clinician will welcome these questions. A clinic that starts testosterone after one test without discussing fertility or monitoring is a red flag.

FAQ

Related reading

• Erectile dysfunction treatment in Canada
• Kisspeptin vs hCG vs PT-141
• Muscle loss on GLP-1 drugs
• Insomnia treatment in Canada

References

1. Bhasin S, Brito JP, Cunningham GR, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018;103(5):1715–1744. PubMed
2. Morales A, Bebb RA, Manjoo P, et al. Diagnosis and management of testosterone deficiency syndrome in men: clinical practice guideline. CMAJ. 2015;187(18):1369–1377. PubMed
3. Snyder PJ, Bhasin S, Cunningham GR, et al. Effects of testosterone treatment in older men (TTrials). N Engl J Med. 2016;374:611–624. PubMed
4. Lincoff AM, Bhasin S, Flevaris P, et al. Cardiovascular safety of testosterone-replacement therapy (TRAVERSE). N Engl J Med. 2023;389:107–117. PubMed
5. Dhillo WS, Chaudhri OB, Patterson M, et al. Kisspeptin-54 stimulates the hypothalamic-pituitary gonadal axis in human males. J Clin Endocrinol Metab. 2005;90(12):6609–6615. PubMed
6. Comninos AN, Wall MB, Demetriou L, et al. Kisspeptin modulates sexual and emotional brain processing in humans. J Clin Invest. 2017;127(2):709–719. PubMed
7. Davis SR, Baber R, Panay N, et al. Global consensus position statement on the use of testosterone therapy for women. J Clin Endocrinol Metab. 2019;104(10):4660–4666. PubMed

This article is general information, not medical advice. Testosterone treatment requires diagnosis and monitoring by a clinician. TrueLabs research compounds are sold for in vitro and laboratory research use only and are not intended for human or veterinary use.