FAA CACI Approval For Pilots On Testosterone Therapy

Pilots diagnosed with hypogonadism can continue flying while on testosterone replacement therapy, but TRT for pilots requires meeting specific FAA criteria before an Aviation Medical Examiner will issue a certificate. The FAA updated its CACI (Conditions AMEs Can Issue) worksheet for low testosterone on April 29, 2026, and the process varies based on the type of treatment for diagnosed deficiency a pilot uses. When the condition is stable, medications fall within the approved list, a clinical progress note addresses all required items, and a CBC shows hematocrit at or below 54%, pilots can move through the CACI pathway without deferral.

Why does the FAA monitor testosterone therapy?

Low testosterone can mask or coincide with conditions that compromise flight safety, including sleep apnea, depression, pituitary tumors, chronic opioid use, and diabetes (FAA, 2026). Testosterone therapy can also be associated with side effects that may warrant monitoring, such as elevated hematocrit, blood pressure changes, and estradiol imbalances, which carry considerations in a cockpit environment.

How the FAA classifies TRT for pilots under CACI

The FAA categorizes pilots on testosterone therapy into three tiers (FAA CACI Worksheet, 2026):

Tier A (topical testosterone only). If the AME can determine the condition is under control, the AME may issue the certificate. A clinical progress note is not strictly required but may help support a smoother process.

Tier B (standard CACI pathway). Pilots using injectable or oral testosterone, Testopel, HCG, anastrozole, clomiphene citrate, or tamoxifen must provide a clinical progress note and a CBC. If all criteria are met, the AME can issue the certificate at the appointment.

Tier C (deferral required). Pilots who need phlebotomy, use enclomiphene citrate, or have a history of venous thromboembolic events are deferred for Special Issuance review at FAA headquarters.

What does the CACI worksheet require?

The AME reviews a clinical progress note from a visit with the treating provider (such as a urologist, endocrinologist, or other qualified clinician), dated no more than 90 days before the FAA exam. The note must confirm:

1. The condition is stable on the current regimen, with no changes recommended

2. No side effects that interfere with flight duties (mild skin irritation and acne are acceptable)

3. No history of venous thromboembolic events

4. No current treatment with phlebotomy

5. Current medications, dosage, and any history of cardiovascular disease or prostate cancer

A CBC within 90 days must show hematocrit at or below 54%. The Endocrine Society clinical practice guideline recommends withholding testosterone therapy when hematocrit exceeds this level until it normalizes, then resuming at a lower dose (Bhasin et al., 2018).

First- and second-class applicants must provide this documentation annually. Third-class applicants provide it with each required exam (every 60 months under 40, every 24 months at 40 and older).

Accepted medications and ground trial rules

The FAA's April 2026 update lists these approved medications:

1. Testosterone (oral or injectable)

2. Testopel (implanted pellets)

3. HCG, requires a 7-day initial ground trial

4. Clomiphene citrate, requires a 14-day initial ground trial with confirmation of no visual side effects

5. Anastrozole

6. Tamoxifen

Enclomiphene citrate is not acceptable. The FAA has explicitly excluded it from the CACI pathway, and pilots using enclomiphene will be deferred regardless of how stable their condition appears.

When pilots don't meet CACI criteria

Common deferral triggers include hematocrit above 54%, a history of venous thromboembolism, concurrent phlebotomy, use of enclomiphene citrate, and conditions the AME can't confirm are stable. Pilots who are deferred remain grounded while FAA headquarters reviews for a possible Special Issuance, which can take months (FAA, 2026).

What role does hematocrit play in flight certification?

Testosterone therapy can stimulate red blood cell production (erythropoiesis), and elevated hematocrit may increase blood viscosity and thromboembolic risk in some individuals. A 2025 retrospective study of 247 testosterone-treated men found that 23% reached a hematocrit above 50%, and 5% exceeded 54% (Neidhart et al., 2025). For pilots, crossing that threshold blocks CACI certification entirely.

The TRAVERSE trial enrolled 5,246 men and met its primary non-inferiority endpoint for MACE (7.0% testosterone vs. 7.3% placebo), though it did report numerically higher rates of atrial fibrillation, acute kidney injury, and pulmonary embolism in the testosterone group (Lincoff et al., 2023). The FDA subsequently removed the boxed cardiovascular warning and added a blood pressure warning (FDA, 2025).

Periodic lab work, guided by the treating provider and supplemented by resources like a structured lab panel, can help identify hematocrit changes before they trigger deferral.

Preparing for the FAA medical exam on TRT

A common reason pilots on TRT face delays isn't medical disqualification. It's arriving with incomplete documentation.

The treating provider visit should happen within 90 days of the planned AME appointment, and the progress note must address every item on the CACI worksheet. Pilots should not provide a MedXPress confirmation number to an AME until all documentation is ready, since the AME has only 14 days to submit the exam once that number is received.

TRT for pilots doesn't have to mean certification delays, but it does require preparation.

Disclaimer: This blog post is intended for informational purposes only and should not be considered medical advice. Always consult a healthcare professional before making changes to your health routine.

FAQs

Can pilots on TRT still get an FAA medical certificate?

Yes. The FAA designated hypogonadism treated with testosterone as a CACI condition, meaning AMEs can issue medical certificates directly if all worksheet criteria are met. The condition must be stable, the medication must be on the approved list, and a CBC must show hematocrit at or below 54%.

What is the FAA's hematocrit limit for pilots on testosterone?

The FAA requires hematocrit at or below 54% for CACI eligibility. A CBC must be performed within 90 days of the AME exam. Pilots with hematocrit above 54% are deferred for FAA review regardless of how stable the condition is.

Does the FAA require a ground trial for testosterone injections?

No. Injectable testosterone does not require a ground trial under current CACI rules. Clomiphene citrate requires a 14-day ground trial with confirmation of no visual side effects. HCG requires a 7-day ground trial.

Why is enclomiphene not accepted by the FAA for pilots?

The FAA's April 2026 CACI update explicitly states that enclomiphene citrate is not acceptable. Pilots using enclomiphene are deferred for Special Issuance review. The FAA has not published a detailed rationale, but the medication's regulatory status differs from clomiphene citrate.

How often must pilots on TRT provide documentation to the FAA?

First- and second-class medical applicants must provide a clinical progress note and CBC annually. Third-class applicants provide documentation with each required exam, every 60 months for pilots under 40 and every 24 months for pilots 40 and older.

What happens if a pilot is deferred from CACI?

The AME submits supporting documents to FAA headquarters for a possible Special Issuance. This review requires a more detailed clinical progress note covering the full medical history, current treatment plan, and prognosis. Pilots remain grounded during the review period, which can take several months.

Does the TRAVERSE trial affect FAA certification for TRT for pilots?

The TRAVERSE trial met its primary non-inferiority endpoint, showing no statistically significant increase in major adverse cardiac events with testosterone therapy, and the FDA removed the boxed cardiovascular warning in February 2025. The FAA's CACI worksheet does not directly reference the trial, but it does require disclosure of cardiovascular history, consistent with the FDA's continued attention to cardiovascular risk factors in testosterone-treated patients.

References

• J Clin Endocrinol Metab. 2018;103(5):1715–1744

• FAA CACI, Low Testosterone (Low T) Hypogonadism Worksheet. Updated April 29, 2026

• FAA Low Testosterone (Low T) Hypogonadism Disposition Table. Updated April 29, 2026

• FDA Class-Wide Labeling Changes for Testosterone Products. February 28, 2025

• N Engl J Med. 2023;389:107–117

• Front Endocrinol. 2025;15:1496906