Testosterone Replacement: When It Is Actually Indicated
Brazilian endocrine and urology societies set a high bar on purpose. Two morning tests, persistent symptoms, and a conversation about fertility — not a pellet from a compounding pharmacy because you felt tired in March.
Testosterone replacement has a clinic version and a market version, and in Brazil they share a waiting room.
The clinic version is a prescription for a man with confirmed hypogonadism. The market version is a pellet, a cream or a "protocol" sold around the idea that a man in his forties should feel twenty-eight. The 2026 joint position statement from SBEM, SBU and ABEMSS was written, in part, because those two had become hard to tell apart.
General educational information, not medical advice. Testosterone is a controlled medicine in Brazil. Starting it, stopping it, or buying it from a compounding pharmacy without a proper work-up is a clinical decision you should not outsource to a group chat.
What the Brazilian document actually requires
Three things at once, not one of them.
Symptoms that persist. Low energy, reduced libido, fewer morning erections, loss of muscle that diet does not explain. Ageing on its own is listed as not an indication. A 1.6% annual decline is physiology. It is not a prescription.
Biochemistry, twice. Two morning total-testosterone results, different days. Below about 264 ng/dL supports the diagnosis; above 350 ng/dL makes it unlikely; in between, you need calculated free testosterone, SHBG and a bit of thinking. One Friday-afternoon draw after a bad week is how men get treated for a number they did not have.
No contraindication. Prostate cancer under work-up, a haematocrit that is already high, a desire to conceive in the near term — replacement suppresses sperm production, and that is not a footnote. If children are on the horizon, the conversation is fertility and fertility-preserving options (hCG, SERMs), not a pellet.
Functional versus organic, because the treatment is different
If the glands are broken — Klinefelter, pituitary disease, testicular injury — replacement is often the right tool, under a specialist.
If the glands work and the environment does not — obesity, sleep apnoea, heavy alcohol, anabolic-steroid recovery — that is functional hypogonadism. Brazilian guidance puts weight loss and exercise first. Treating the number while leaving the waist and the apnoea in place is how men end up on a medicine they did not need, with a fertility problem they did not have. The waist version is in belly fat and hormones; the sleep version is in snoring, apnoea and erections.
Anabolic-steroid hypogonadism after a cycle is a third picture. It is common in Brazilian gyms and it is not "low T of ageing". See steroids and the natural physique.
What the large trial actually found
The TRAVERSE trial, published in the New England Journal of Medicine, randomised middle-aged and older men with confirmed hypogonadism and cardiovascular risk to transdermal testosterone or placebo. It did not show an increase in major cardiac events against placebo in that population.
That is a real piece of reassurance for men who meet the criteria. It is not a green light for men who do not. The trial enrolled men with low levels and symptoms, not men who wanted a sharper jawline. Safety on the heart is also not the same as safety on fertility, haematocrit, acne, sleep apnoea or the prostate conversation you still have to have.
The compounding-pharmacy problem, named plainly
Brazil has a large compounding sector, and testosterone is one of the products it is asked for — gels, injections, and subcutaneous pellets marketed as convenient. A compounding pharmacy is a legitimate part of the system when it fills a prescription that followed the work-up above.
It becomes a problem when the work-up is a questionnaire and a single blood test, the pellet is sold as anti-ageing, and monitoring of haematocrit, PSA and symptoms is optional. SBEM has had to repeat, in public, that "recalibrating the levels" is not a wellness service.
If a clinic offers same-week implants without two morning tests, a fertility conversation and a plan for follow-up bloods, you are in the market version. The medicine may be real. The indication may not be.
What to ask in the appointment
- Can we see two morning results, not one?
- Is this organic or functional, and if functional, what happens if I lose the weight first?
- What is the plan if I want children in the next two years?
- How will haematocrit, PSA and symptoms be checked, and how often?
- Which formulation, and why that one rather than the pellet brochure?
Those are reasonable questions. A clinic that is irritated by them is telling you something.
How to get a usable baseline in the first place is in what actually raises testosterone. The aisle that tries to skip this appointment is in testosterone boosters.
When this is urgent rather than elective
Breast tissue that is hard rather than soft, testicular pain or a new lump, a haematocrit that is already high, or a partner and a timeline for pregnancy: do not start replacement on a hunch. A urologist or endocrinologist — via plano de saúde or the SUS referral path — is the right next step.
Our disclaimer sets out the limits of what this site does.
Sources
- SBEM: testosterone replacement must follow scientific criteria
- Care of patients with male hypogonadism — SBEM, SBU and ABEMSS (PubMed)
- Joint Brazilian position statement on male hypogonadism (PDF)
- Cardiovascular safety of testosterone-replacement therapy (TRAVERSE) — NEJM
- Endocrine Society clinical practice guideline on testosterone therapy
