Testosterone Therapy in SA: What Men Need to Know

South African men are caught between two distortions. On one side, gym culture treats testosterone as a performance upgrade available to anyone with R800 and a willing pharmacist. On the other, the medical system under-investigates low testosterone — missing it in men whose fatigue and low libido are chalked up to stress, HIV, or “just getting older.” Neither failure serves patients. Here is what the evidence actually says.

The myth you need to know first

In 2010 a widely reported observational study linked testosterone therapy to increased cardiovascular risk, triggering years of clinical hesitancy and media alarm. The US Food and Drug Administration issued label warnings in 2015. Since then, the landmark TRAVERSE trial (2023, New England Journal of Medicine) — the largest randomised cardiovascular safety trial of testosterone therapy ever conducted — found no significant increase in major cardiovascular events in men with hypogonadism and pre-existing cardiovascular risk. That does not mean TRT is without risk, but the cardiovascular scare that shaped a decade of under-treatment was applied far too broadly. No equivalent SA cardiovascular outcomes data exists; the TRAVERSE findings are the current international benchmark.

What low testosterone actually means

Testosterone peaks in men’s early 20s and declines at roughly 1–2% per year from the age of 30. Clinically significant low testosterone — called hypogonadism — is not simply “levels on the lower end.” It requires both a consistently low serum testosterone level (generally below 8–12 nmol/L on two separate morning measurements) and symptoms that cannot be explained by another cause.

Symptoms include reduced libido, erectile dysfunction, fatigue, low mood, loss of muscle mass, increased body fat, and poor concentration. The challenge is that these symptoms overlap with depression, obstructive sleep apnoea, hypothyroidism, and the side-effects of chronic disease management — all of which are common in SA men.

No comprehensive SA prevalence study for hypogonadism has been published. International estimates suggest 2–6% of adult men meet diagnostic criteria, rising to roughly 20–30% in men over 70. Among men living with HIV — about 2.1 million in South Africa, per the NICD — rates of hypogonadism are substantially higher, driven by HIV itself, antiretroviral side-effects, and the chronic inflammation the virus produces. A 75 kg man in this population can experience clinically significant muscle loss and fatigue from low testosterone even at an age where most GPs would not routinely test for it.

Who qualifies for testosterone replacement therapy?

Diagnosis requires a blood test, not a symptom checklist alone. The South African Society of Endocrinology, Metabolism and Diabetes (SEMDSA) and international andrology societies align on this: two morning testosterone measurements on separate days, ideally before 10h00 when levels are highest. If both readings fall below the diagnostic threshold and symptoms are present, a clinical discussion about treatment is appropriate.

Men who should not receive TRT include those with prostate cancer, uncontrolled polycythaemia, untreated severe sleep apnoea, or who are trying to conceive — testosterone suppresses sperm production. It is not a fertility treatment.

Men who are simply tired, gym-fatigued, or chasing a physique are not candidates for medical TRT. Prescribing to men with normal testosterone produces no measurable benefit and carries genuine risk, including testicular atrophy, infertility, and erythrocytosis (dangerously raised red blood cell count). This is where the gym-culture use of testosterone diverges sharply from therapeutic use, and why sourcing injectables without a prescription is both medically dangerous and illegal in South Africa.

How diagnosis works in SA’s public and private systems

Private sector: A GP consultation to initiate a testosterone workup costs roughly R600–R950 depending on the practice and whether your medical aid applies consultation benefits. The hormone blood panel — total testosterone, LH, FSH, prolactin, and SHBG — runs approximately R800–R1,400 at a major private pathology lab (Lancet or Pathcare). Medical aids that offer PMB coverage for endocrine conditions may partially cover this if hypogonadism is confirmed, but most aids classify TRT as a chronic medicine benefit only after formal diagnosis, meaning you typically pay upfront for initial investigations. Ongoing TRT via a private endocrinologist adds a specialist consultation of R1,200–R2,000 per visit.

Public sector: Government clinics can request testosterone bloods, though turnaround times vary — sometimes two to four weeks — and results are reviewed at the next scheduled appointment. If hypogonadism is confirmed, referral to a district hospital endocrine or internal medicine outpatient clinic is the standard route. Load-shedding affects some clinic systems’ electronic records and cold-chain storage of injectable preparations; patients in rural areas should ask explicitly about medication continuity planning if injectable testosterone is prescribed.

Practical barrier: Many South African men delay seeking care because a single morning blood test feels like an ordeal in the public system, or because private costs are prohibitive without medical aid. A workaround: ask your GP to include testosterone on a general metabolic panel if you are already having routine bloods for diabetes, hypertension, or HIV monitoring. This bundles the cost and avoids a separate investigation.

What treatment actually looks like

Testosterone replacement comes in several forms. Injections (testosterone undecanoate or cypionate) are the most cost-effective in SA, with a vial costing roughly R180–R450 at a private pharmacy depending on the preparation. Injections are given every two to 12 weeks depending on the formulation. Topical testosterone gel is available at R600–R1,200 per month and allows finer dose adjustment but requires careful handling to avoid transfer to partners or children.

Oral testosterone undecanoate (Andriol) exists but has variable absorption and is generally considered less effective than injectable or transdermal routes.

Treatment is not indefinite by default. Response is assessed at three, six, and 12 months. If symptoms improve and testosterone normalises, many men continue long-term. If there is no symptomatic benefit after six months of adequate dosing, the diagnosis should be reconsidered. Annual monitoring includes haematocrit (to catch erythrocytosis), PSA (prostate screening), and testosterone levels.

SA-specific risk factors that make diagnosis harder

Three SA-specific realities complicate diagnosis. First, men with HIV have a higher baseline rate of hypogonadism, but fatigue and mood changes in this group are often attributed to HIV or its treatment rather than being investigated further. Second, type 2 diabetes — affecting an estimated 4.2 million South Africans per the Department of Health — independently suppresses testosterone, meaning men with metabolic disease may have secondary hypogonadism that goes untreated. Third, chronic psychological stress, which is endemic in a population carrying high rates of poverty, violence exposure, and unemployment, raises cortisol and can suppress the hypothalamic-pituitary-gonadal axis — the hormonal chain that drives testosterone production. This stress-related suppression often reverses with lifestyle change rather than requiring testosterone therapy.

None of this means every tired South African man has low testosterone. It means the investigation is more warranted here than it is in lower-risk populations.

When to see a doctor

See your GP if you have persistent low libido, erectile dysfunction, unexplained fatigue, or mood changes lasting more than four weeks. Ask specifically for a morning testosterone blood test. Men living with HIV, type 2 diabetes, or obesity should ask their treating doctor whether testosterone screening is appropriate for them. Do not self-medicate with injectable testosterone sourced outside a pharmacy. If low mood is a significant symptom, contact SADAG on 0800 567 567 (toll-free).

Bottom line

• Get tested properly: two morning blood tests on separate days, not one result and a prescription.
• Symptoms alone are not enough — low testosterone must be confirmed biochemically before treatment begins.
• Public-sector patients can request testosterone bloods at a clinic and follow a referral route through internal medicine; bundle the test with existing chronic disease monitoring where possible.
• Private costs run R1,400–R2,400 for initial workup; ongoing treatment with injectables is R180–R450 per vial at a private pharmacy.
• HIV, diabetes, and chronic stress all suppress testosterone — address these first, as correction sometimes resolves symptoms without TRT.