TRT For Veterans: How VA Testosterone Prescribing Works

Testosterone replacement therapy (TRT) for veterans follows a structured prescribing pathway that differs from civilian telehealth and private practice. The VA requires a confirmed diagnosis of hypogonadism, backed by at least two low fasting morning testosterone draws and documented clinical symptoms, before any prescription is written (VA PBM, 2025). Veterans exploring hormone health options outside the VA system may find that direct-pay telehealth providers offer a different process, though the diagnostic standard remains the same.

TRT for veterans is a prescribed treatment intended to raise testosterone levels in men diagnosed with hypogonadism, a condition where the body produces insufficient testosterone for normal physiological function. The VA's Pharmacy Benefits Management (PBM) criteria, updated in March 2025, define the eligibility pathway, exclusion criteria, and monitoring requirements that govern every VA testosterone prescription.

A 2018 VA Office of Inspector General (OIG) inspection found that providers did not discuss the risks and benefits of TRT with approximately two out of three patients before starting therapy (VA OIG, 2018). Follow-up evaluation within three to six months also didn't occur for roughly two-thirds of patients. These findings led to seven recommendations, all now closed and implemented.

What Is TRT for Veterans?

TRT supplements the body's testosterone when production falls below clinically meaningful levels. The VA frames TRT as treatment for diagnosed hypogonadism only. The FDA retains a Limitation of Use stating testosterone products are not approved for low testosterone due solely to aging (FDA, 2025). The VA's criteria mirror this restriction.

Available formulations include intramuscular injection (testosterone cypionate or enanthate), transdermal gels or patches, pellet implants, and oral options. The VA formulary governs availability. Veterans comparing injectable options should know that cypionate and enanthate are the most commonly prescribed VA formulations.

How Does the VA Diagnose Low Testosterone?

The VA requires more than a single blood draw. Per the March 2025 Criteria for Use, a veteran must have two unequivocally low baseline fasting total testosterone levels, drawn at least one week apart, between 8 AM and 10 AM (VA PBM, 2025). If SHBG alterations are suspected, free testosterone should be assessed using equilibrium dialysis or calculation from total testosterone, SHBG, and albumin. Direct immunoassay for free testosterone is unreliable and not recommended by current guidelines.

The difference between free and total testosterone matters. Free testosterone, the biologically active fraction, can be low even when total testosterone appears borderline normal, especially in men with elevated SHBG.

The VA also requires baseline hemoglobin, hematocrit, LH, FSH, and prolactin. LH and FSH distinguish primary hypogonadism (testicular failure) from secondary hypogonadism (pituitary or hypothalamic dysfunction). Prostate cancer screening discussion must be documented.

The Endocrine Society's 2018 guideline similarly recommends confirmation on two morning samples (Bhasin et al., 2018). The AUA sets the diagnostic threshold at total testosterone below 300 ng/dL plus symptoms (Mulhall et al., 2018).

What are the VA's Exclusion Criteria for TRT?

Not every veteran with low testosterone qualifies for VA-prescribed TRT. The March 2025 criteria list absolute exclusions: active prostate cancer, active breast cancer, and uncontrolled or untreated erythrocytosis with hematocrit above 48% (VA PBM, 2025).

Additional exclusions apply unless further evaluation is documented. These include severe untreated obstructive sleep apnea, unevaluated PSA above 4 ng/mL (or above 3 ng/mL in men with prostate cancer risk factors), severe lower urinary tract symptoms, inadequately controlled congestive heart failure, acute coronary syndrome or stroke within four months, thrombophilia, severe liver or renal disease, desire for near-term fertility, and active anabolic steroid misuse.

Exogenous testosterone suppresses spermatogenesis, and recovery is variable, not guaranteed. Veterans interested in fertility preservation should discuss this with their provider before starting TRT.

Why Do VA Prescribing Practices Vary?

Despite standardized criteria, VA testosterone prescribing varies by provider, region, and facility type. A study of over 132,000 male veterans found that providers aged 31 to 60, with less VA tenure, and credentialed in endocrinology or urology were more likely to prescribe testosterone than older or primary care providers (Jasuja et al., 2017). Endocrinologists were also more likely to obtain guideline-concordant workup before prescribing.

Veterans at smaller community-based outpatient sites (CBOCs) were more likely to receive testosterone but less likely to have received appropriate testing. The 2018 VA OIG inspection found that providers largely did not document signs and symptoms of androgen deficiency before initiating therapy, suggesting, in the OIG's assessment, that testosterone tests were used to screen for rather than confirm a diagnosis (VA OIG, 2018).

What Are the Risks of TRT?

The TRAVERSE trial enrolled 5,246 men aged 45-80 with hypogonadism and cardiovascular risk factors. The primary cardiac endpoint was noninferior to placebo (7.0% vs. 7.3%; hazard ratio 0.96, 95% CI 0.78-1.17), but secondary safety analyses showed numerically higher rates of atrial fibrillation (3.5% vs. 2.4%), pulmonary embolism (0.9% vs. 0.5%), and acute kidney injury (2.3% vs. 1.5%) (Lincoff et al., 2023).

In February 2025, the FDA issued class-wide labeling changes for testosterone products: the previous boxed cardiovascular warning was removed based on TRAVERSE data, but a new blood pressure warning was added. The Limitation of Use for age-related low testosterone was retained (FDA, 2025).

Clinical guidelines flag hematocrit above 54% as requiring dose reduction or phlebotomy (Bhasin et al., 2018; Mulhall et al., 2018). The VA is more conservative, flagging untreated erythrocytosis at hematocrit above 48%. Understanding hematocrit management is part of responsible TRT use.

Other side effects include acne, fluid retention, mood instability, breast tissue growth, and elevated estradiol from aromatization. Monitoring with a sensitive E2 assay gives providers data to guide dosing decisions.

How Does Telehealth TRT Compare to VA Access?

Temporary DEA flexibilities, extended through December 31, 2026, allow prescribing of Schedule III controlled substances via telemedicine without a prior in-person visit, subject to state law and legitimate medical purpose. Permanent rules remain pending.

Both pathways require a legitimate medical evaluation and confirmed diagnosis. The difference is in speed of access, choice of formulation, and the model of care delivery.

Marek Health operates as a direct-pay telehealth provider that requires lab confirmation and clinical evaluation before prescribing. Veterans exploring options outside the VA can review how lab-guided protocols differ from standard VA workflows. TRT for veterans, whether through the VA or a telehealth provider, requires evaluation by a licensed clinician and is prescribed only when medically appropriate, where permitted by law. The decision to start TRT should involve a conversation between the patient and provider, weighing potential benefits against risks based on individual health factors.

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

What testosterone level qualifies a veteran for VA-prescribed TRT?

The VA requires two unequivocally low fasting total testosterone levels drawn between 8 AM and 10 AM, at least one week apart. The VA criteria reference clinical trial enrollment thresholds around 275 ng/dL, while the AUA uses 300 ng/dL as its cut-off. Low levels alone don't qualify; documented symptoms of androgen deficiency must also be present.

Does the VA cover all forms of testosterone therapy?

The VA National Formulary determines which formulations are available. Coverage can vary by facility and may require prior authorization for certain products. Veterans should check with their local VA pharmacy about specific formulation availability. Compounded testosterone is not FDA-approved and may not be available through the VA formulary.

Can veterans get TRT through telehealth instead of the VA?

Yes. Temporary DEA telemedicine flexibilities allow prescribing of testosterone without a prior in-person visit through December 31, 2026, subject to state law. Direct-pay telehealth providers offer an alternative for veterans who prefer faster scheduling or broader formulation access. A valid prescription still requires confirmed low testosterone plus symptoms and evaluation by a licensed clinician.

What monitoring is required during TRT?

Guidelines from the Endocrine Society and AUA recommend symptom review, serum testosterone levels, hematocrit, and prostate risk assessment within three to six months of starting therapy. The VA OIG found that approximately two-thirds of patients did not receive this follow-up in a timely manner, which led to system-wide corrective actions.

Does TRT affect fertility in veterans?

Exogenous testosterone suppresses sperm production and is not appropriate for men planning near-term fertility. Suppression is variable across patients and should not be assumed to be fully reversible. Veterans concerned about fertility should discuss preservation options, including off-label adjunct therapies such as hCG, with their provider before initiating TRT.

How long does it take to see results from TRT?

Response timelines vary by individual and symptom. Some men report changes in energy and mood within several weeks, while measurable body composition changes, when they occur, may take three to six months. Ongoing lab monitoring helps providers adjust dosing based on measured levels and clinical response rather than a fixed timeline.

Is TRT through the VA the same as what telehealth providers offer?

The diagnostic standard is the same: confirmed low testosterone plus symptoms. The differences are in access speed, formulation availability, cost structure, and the care delivery model. VA TRT is covered for eligible veterans but subject to formulary and facility constraints. Telehealth providers typically offer faster scheduling and broader product access on a direct-pay basis.

References

• FDA class-wide labeling changes for testosterone products. February 2025

• J Clin Endocrinol Metab. 2017;102(9):3226-3233

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

• J Urol. 2018;200(2):423-432

• N Engl J Med. 2023;389(2):107-117

• VA OIG Healthcare Inspection: TRT Initiation and Follow-Up. Report No. 15-03215-154. April 2018

• VA PBM Testosterone Replacement Criteria for Use. March 2025