Most men who eventually start testosterone replacement therapy (TRT) didn't wake up one morning convinced they had low testosterone. They slowly noticed a cluster of changes — energy that didn't come back after a night's sleep, libido that quietly slid, a body that wouldn't respond to training the way it used to — and at some point asked the obvious question.
This guide is for that moment. It walks through the specific symptoms that genuinely point to low testosterone (and the ones that don't), how the AMS (Aging Males' Symptoms) questionnaire is used in NZ practice, the BPACNZ diagnostic criteria, and what to do next if a few too many of these sound familiar.
The classic symptom cluster
Low testosterone (clinical hypogonadism) doesn't cause one big dramatic symptom. It causes a scattered group of small, easily-dismissed ones. The pattern that matters is the cluster, not any single item. Common features:
- Persistent fatigue that isn't explained by sleep, training load or work stress
- Low libido — a noticeable drop in sex drive over months, not days
- Erectile dysfunction or weaker erections, particularly fewer morning erections
- Low mood, irritability, flatness — not depression with crying spells, but a grey "nothing-feels-fun" baseline
- Loss of muscle mass and strength despite consistent training
- Increase in body fat — especially around the abdomen — without obvious calorie change
- Brain fog, poor concentration, slower decision-making
- Reduced motivation for things that used to feel rewarding (training, work, hobbies)
- Poor sleep quality, particularly increased night-time waking
- Hot flushes or sweats (less common but specific)
- Reduced body and facial hair growth
Most men with low testosterone have four to six of these together, sustained over three months or more. One symptom alone isn't the picture.
What is NOT a sign of low T
It's worth being honest about this because the men's-health internet is full of overclaims:
- A single bad week of energy is not low testosterone.
- Stress, poor sleep, alcohol, and overtraining all suppress testosterone — but the fix is the upstream issue, not external testosterone.
- Loss of motivation in your job or relationship is rarely fixed by hormones.
- A normal age-related slow-down in performance from your peak twenties is not in itself an indication for TRT.
- Wanting to look better in the gym without symptoms of hypogonadism is not a clinical indication for TRT.
The clinical bar for TRT in New Zealand is real, and there's a reason for it: external testosterone shuts down your own production, and for men who don't actually have hypogonadism it tends to swap one set of issues for another.
The AMS questionnaire — what it is, and what it isn't
The AMS (Aging Males' Symptoms) questionnaire is the most widely used validated screening tool for symptomatic low testosterone. It's a 17-item self-report covering psychological, somatic and sexual symptoms, each scored 1 (none) to 5 (extremely severe). Total scores are interpreted in bands:
- 17–26: No / minimal symptoms
- 27–36: Mild
- 37–49: Moderate
- 50+: Severe
A few important things to know about it:
- A high AMS score is not a diagnosis of hypogonadism. It's a flag that says "there's enough symptom load here to warrant a proper hormone work-up." Many men score high on AMS for non-hormonal reasons — depression, sleep apnoea, chronic illness — and the bloods will sort that out.
- A low AMS score in a man with classic localised symptoms doesn't rule it out. The questionnaire is a starting point, not a gate.
- Trend matters. If you've completed it twice, six months apart, and the score has crept up, that's a meaningful signal independent of the absolute number.
You can take the Enhanced Men AMS questionnaire here — your responses are reviewed by an NZ-registered doctor within 1–2 working days.
The BPACNZ diagnostic criteria
NZ practice follows BPACNZ guidance (most recently updated November 2024). For a clinical diagnosis of male hypogonadism in adult men, the standard requirement is:
- Symptoms consistent with low testosterone (the cluster above)
- At least two early-morning total testosterone measurements below the lab reference range, drawn fasting on separate days, ideally between 8am and 10am
- Appropriate work-up to exclude reversible causes — sleep apnoea, opioid use, severe obesity, thyroid disease, prolactinoma, advanced systemic illness
A single low reading isn't enough. Testosterone fluctuates by 30–40% across a day, and acute illness, recent intense exercise or poor sleep can produce a low reading in a man with otherwise normal levels. Two morning bloods, on separate days, fasting, is the minimum.
The full work-up panel — the one a clinic actually committed to TRT will run — includes:
- Total testosterone (×2, morning, fasting)
- Free testosterone or SHBG (so free can be calculated)
- LH and FSH (distinguishes primary from secondary hypogonadism)
- Estradiol (sensitive assay)
- Prolactin
- Full blood count
- HbA1c, fasting glucose
- Lipid panel
- TSH
- PSA (in men over 40 or with risk factors)
- Iron studies, vitamin D
If a clinic offers TRT off a single testosterone level and no LH/FSH/oestradiol, that's a red flag. (See How to Get TRT in New Zealand for the full pathway.)
"Is this me?" — a self-check
Run through these honestly:
- Have at least four of the symptoms above been with you for three months or more?
- Has there been a clear change from your previous baseline — not "I'm not 25 any more," but "something's different in the last 6–18 months"?
- Have you ruled out the obvious other causes — bad sleep, untreated sleep apnoea, alcohol pattern, thyroid issues, depression, high stress load, recent significant illness?
- Are you willing to do the work-up properly — two morning bloods, comprehensive panel, follow-up review — rather than chasing a single test?
If you're answering yes to most of those, it's a reasonable time to get investigated. If you're not, the better next step is usually fixing sleep, alcohol or training before chasing hormones.
What to do next
There are three sensible paths from here:
- Take the AMS questionnaire. Quick, free, reviewed by an NZ-registered doctor. You'll get a steer on whether bloods are warranted.
- See your GP with a written list of your symptoms and ask for the full panel above. Most NZ GPs will do total testosterone, LH, FSH, FBC and TSH on request. A few will go further. If yours is engaged with men's health, this is the cheapest path.
- Book a men's health telehealth consult with Enhanced Men. A structured consult, the full diagnostic panel, and an honest answer about whether TRT is warranted — including the option to be told it isn't. NZ-wide, doctor-led, evening and weekend appointments.
Whatever path you take, the rule is the same: get the proper work-up before starting anything. Diagnosis first, treatment second. The men who do well on TRT are the men who actually have hypogonadism — and the only way to know is to test properly.
FAQ
At what testosterone level is TRT indicated? There is no single number. Diagnosis requires symptoms plus two morning total testosterone levels below the lab reference range plus a work-up that excludes reversible causes. Numerical thresholds vary slightly between guidelines and labs.
Can I have low testosterone with normal levels on a blood test? Symptoms with normal lab levels are not a diagnosis of hypogonadism. Other causes (sleep, mood, thyroid, fitness, alcohol) explain most of these cases. Some men have free-testosterone deficiency despite normal total testosterone — this is why SHBG and free T calculation matter.
How accurate is the AMS questionnaire? The AMS is a validated screening tool — sensitive but not specific. A high score warrants investigation, a low score doesn't rule out a localised hormonal issue. It's a starting point.
Will my GP take this seriously? Most NZ GPs are familiar with the symptom cluster and will order initial bloods on request. Some are very confident with TRT and will manage from start to finish; others prefer to refer. If your GP isn't engaging, a private men's-health consult is a reasonable next step.
How quickly should I expect symptoms to improve if TRT is the right answer? Subjective symptoms (mood, libido, energy) often respond within 2–6 weeks. Body composition takes 3–6 months. Bone density and red cell stability take 6–12 months. If nothing has shifted at three months, the diagnosis or the dose is the question — not whether to push higher.
Is low testosterone reversible without TRT? Yes, in many cases. Treating sleep apnoea, fixing alcohol pattern, losing significant body fat, training appropriately, and managing chronic illness all raise testosterone. For men with reversible drivers, addressing those is first-line. TRT is for men who have a confirmed diagnosis and either no reversible cause or no response to addressing one.
Do I need to commit to TRT for life? Not at the time of diagnosis. Most men who start TRT for confirmed hypogonadism stay on it indefinitely because the underlying physiology doesn't usually self-correct, but stopping is always an option and natural production typically recovers over 6–18 months in men with secondary causes.
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Sources / further reading (verify before publishing)
- BPACNZ — Testosterone deficiency in adult men (November 2024 update): https://bpac.org.nz/2024/testosterone.aspx
- Heinemann LAJ et al. — The Aging Males' Symptoms (AMS) Scale: original development and validation
- Endocrine Society 2018 clinical practice guideline on testosterone therapy in men with hypogonadism
- Medical Council of New Zealand — relevant standards on prescribing and ongoing care