Oral Testosterone vs Injection: Choosing the Right Testosterone Therapy

Testosterone therapy offers men with testosterone deficiency or low testosterone a way to restore physical and psychological equilibrium. If you have clinically low testosterone, often referred to as low serum testosterone, you may have experienced side effects like low energy, a decrease in your libido, or an increase in body fat.

Testosterone replacement therapy (TRT) can be administered in several ways, with testosterone injections and topical creams being the most commonly used in clinical practice. Both methods are effective at raising testosterone levels to a normal range, though each comes with its own pros and cons. More recently (since around 2019) oral formulations like testosterone undecanoate have received FDA approval, providing an additional option for patients seeking a non-invasive alternative.

Key Takeaways

• Testosterone replacement can help to restore quality of life in men who don’t produce testosterone levels within the normal range, which is between 300 and 1000 ng/DL.
• Oral testosterone undecanoate and enclomiphene are convenient options, especially if you’re already used to taking oral medication regularly. 
• Liver toxicity was previously a concern with oral testosterone, but newer formulations bypass liver metabolism.
• Injectable testosterone, like testosterone enanthate and cypionate, lasts longer. Most men have one testosterone injection every week or every two weeks.
• Both forms of testosterone replacement require regular monitoring. Blood tests must be done to track red blood cells, PSA, and hormone levels.
• Side effects vary by person. Injectable and oral testosterone can impact cholesterol, blood pressure, and estrogen levels.
• Lifestyle and health history influence the type of testosterone that works most effectively for you.

The Benefits of Oral Testosterone

Some men find that taking a pill is the easiest form of testosterone treatment. The appeal of oral testosterone is its convenience. Men who take oral testosterone to treat testosterone deficiency have shown improvements in bone density (Endocrine Society, 2018).

One of the biggest benefits of testosterone pills is convenience. Oral testosterone is typically taken with food, ideally something with fat, to enhance absorption through the intestinal lymphatic system, while injection site management is critical for injectable options.

Practical Considerations when Using Oral Testosterone

Older oral testosterone products used to have liver toxicity concerns. Testosterone undecanoate is a newer formulation designed to bypass the liver, making it safer for hepatic function (Mayo Clinic, 2022).

When you take oral testosterone, you’ve got to be consistent. If you miss a dose or take it on an empty stomach, your serum testosterone levels could fluctuate, potentially leading to mood swings. While the daily routine may seem simpler than administering a shot, some men find it bothersome.

Like all forms of testosterone replacement therapy, oral treatment requires ongoing monitoring. Your healthcare provider should check your red blood cell count, PSA, and overall testosterone levels regularly.

The Benefits of Testosterone Injections

Testosterone cypionate and testosterone enanthate are common forms of injectable testosterone. Injectable testosterone enanthate and cypionate bypass the digestive system, which makes it highly bioavailable (MedlinePlus, 2023).

You inject the testosterone, usually into a muscle like your thigh or glute, and that dose stays in your system for a while. Depending on how your body metabolizes it, testosterone injections can be administered weekly or biweekly (Cleveland Clinic, 2022).

Some men prefer injectable therapy because it supplies a steady dose of the sex hormone for an extended period. Others say they notice a dip in energy, mood, or motivation right before their next dose and find it less effective.

Of course, there is a tradeoff: you’ve got to be comfortable with needles. You’ll also need to administer the injection yourself unless you want to make a trip to the clinic every week or two.

If you’re new to injectable therapy, you can learn the proper technique in our detailed guide on how to inject testosterone.

Treating Male Hypogonadism with Injectable Testosterone

Be aware of the potential side effects. Injections can increase hematocrit (American Urological Association, 2018), which may raise red blood cell counts. While this theoretically could increase the risk of blood clots, a meta-analysis of randomized controlled trials found no significant increase in the risk of venous thromboembolism (VTE) in men on testosterone therapy compared to those on placebo (DOI: 10.1016/j.thromres.2020.12.029). However, individual factors (such as personal or family history of clotting disorders) still need to be managed. That’s why regular bloodwork and ongoing monitoring by your healthcare provider are essential.

In terms of potential risks, pain and injection site infections can be managed by following good hygiene and injection technique.

Oral Testosterone vs. Testosterone Injections: Which Is Right for You?

If you already take medication every morning and prefer routine, oral testosterone might fit right in with your schedule. A busy person who doesn't want to take medication every day may find injectable testosterone could be a better fit. Some men don’t want to inject themselves. Others get tired of taking pills every day. Ask yourself what you'd prefer, and this will make the decision easier.

Your medical history makes a difference. For example, if you’ve been diagnosed with sleep apnea, this could influence the type of testosterone therapy your provider recommends. Testosterone therapy can affect breathing during sleep (Endocrine Society, 2018), so ongoing monitoring is essential to ensure your treatment remains safe and effective.

How Testosterone Replacement Therapy Can Improve Quality of Life

When it works, testosterone replacement therapy can be life-changing, contributing to a healthier total testosterone level. Men on supervised testosterone therapy report improvements in mood, libido, focus, body composition, and even motivation.

Injectable testosterone tends to deliver quicker and more consistent results. But the newer oral testosterone undecanoate formulations have caught up in many ways, and for men who are consistent with their dosing and meals, it works well.

Testosterone Therapy Options

If you do not produce enough testosterone and experience symptoms of low T, you could benefit from:

Testosterone gel – You apply this daily to the skin, typically on the shoulders or upper arms, and it provides steady absorption. However, topical gel can cause skin irritation and must be kept out of reach of others to prevent accidental transfer.

Transdermal testosterone patches – These deliver a consistent dose through the skin but may cause irritation or fall off during physical activity or sweating. You usually apply transdermal patches at night. Make sure to change them regularly.

Nasal testosterone gel – This is administered through the nose several times a day, offering quick absorption without skin-related concerns; however, you may find the frequent dosing inconvenient.

Testosterone pellets – This type of treatment is implanted under the skin (American Urological Association, 2018) by a healthcare provider every 3 to 6 months, providing a long-term, low-maintenance solution. However, they require a minor surgical procedure.

Buccal testosterone tablets – You place these against the gum or inner cheek twice daily, allowing absorption through the oral mucosa, but they can cause local discomfort.

Compounded testosterone creams – This TRT type is custom-formulated by pharmacies and applied topically, offering personalized dosing but requiring careful application and consistent monitoring.

For the most part, the effectiveness of testosterone replacement therapy is highly dependent on which type integrates into your lifestyle the best and causes the fewest side effects.

Testosterone Replacement Therapy and Risk Management

Testosterone therapy is medicine. And, like all medicines, there are certain risks that you should be aware of. Nothing can replace professional medical advice, so it is worth repeating that all forms of testosterone replacement should be medically supervised.

Testosterone replacement therapy may affect your cholesterol and blood pressure and could aggravate pre-existing conditions. That’s why blood tests before and during treatment are non-negotiable.

There’s been plenty of debate about testosterone treatment and major adverse cardiovascular events. Some studies say there’s a risk; others say it’s overblown. The current thinking is that if you’re otherwise healthy and a healthcare professional is monitoring you, the risk is relatively low. 

Also: don’t expect it to fix everything. If your erectile dysfunction is caused by circulation problems or anxiety and not hypogonadism, testosterone may not make the improvements you need. The same can be said about energy levels. If you're sleep-deprived or stressed, testosterone therapy won’t override all that. That is why it’s important to stick to a healthy lifestyle when you’re undergoing TRT, whether it’s injection-based or oral.

References

Mayo Clinic Staff. (2022). Testosterone therapy: Potential benefits and risks as you age. Mayo Clinic.

U.S. Food and Drug Administration (FDA). (2021). FDA Drug Safety Communication: FDA cautions about using testosterone products for low testosterone due to aging; requires labeling change to inform of possible increased risk of heart attack and stroke.

American Urological Association. (2018). Testosterone deficiency guideline.

MedlinePlus. (2023). Testosterone injection.

Endocrine Society. (2018). Testosterone therapy in men with hypogonadism: An Endocrine Society clinical practice guideline.

Cleveland Clinic. (2022). Testosterone replacement therapy.