TRT Delivery Options: Intramuscular Injections, Subcutaneous Injections, Pellets and Topical Creams

Testosterone replacement therapy (TRT) can work very well, but the delivery method matters more than most people expect. The same dose can feel very different depending on how steadily it is absorbed, how high the peaks run after dosing, how low levels fall before the next dose, and how consistent day to day exposure is. Major clinical guidelines emphasize choosing a formulation that fits the patient’s goals, monitoring needs, and safety profile.

Why Delivery Method Matters

TRT is not just about "getting the number up." Your delivery method influences symptom stability (energy, mood, libido), side effects (acne, fluid retention, elevated hematocrit), and practicality (needle comfort, travel, daily routines). It also changes how and when labs should be checked, because timing relative to dosing matters.

Intramuscular Injections

Intramuscular (IM) injections are a common starting point because they are predictable, cost effective, and easy to manage. Typical esters like cypionate or enanthate are often dosed weekly. Some patients do best by splitting the weekly dose into smaller, more frequent injections to reduce peaks and troughs. The main tradeoffs are needle phobia for some patients and occasional soreness at the injection site. IM therapy can be an excellent option when you want tight dose control and rapid adjustments.

Subcutaneous Injections

Subcutaneous (SC) injections place testosterone into the fat layer under the skin using a smaller needle. For many patients, this is more comfortable and easier to self-administer than IM. Evidence supports that weekly SC testosterone can reliably restore testosterone into the physiologic range, with acceptable safety and tolerability in studied populations. A practical advantage of SC dosing is consistency. Many patients report steadier symptom control when dosing is frequent and peaks are minimized. SC injections may also result in reduced hematocrit and estrogen conversion. The main disadvantage is that the injection is slow and may be more likely to cause bruising.

Pellets

Testosterone pellets are a long acting TRT option where small pellets are placed under the skin (typically the upper glute or flank) during an in office procedure. The pellets slowly release testosterone over months, which can appeal to patients who want to avoid weekly injections or daily creams and prefer a "set it and forget it" approach. From a pharmacology standpoint, the goal is steady exposure with fewer day to day fluctuations, but there is meaningful variability between patients in how quickly pellets dissolve and how long symptom control lasts.

The tradeoffs are procedure related and titration related. Because pellets are implanted, dose adjustments are slow. If a patient feels over replaced or develops side effects (acne, irritability, elevated hematocrit, higher estradiol symptoms), you cannot rapidly "turn down" the dose the way you can with injections. Likewise, if levels run low early, you may be stuck waiting until the next insertion window. Local complications can occur, including bruising, pain, infection, hematoma, pellet extrusion, and scarring at the insertion site. Pellets can still raise hematocrit and require the same monitoring strategy as other TRT forms. While pellets offer some convenience, their unpredictable time release profile raises significant concerns about safety, consistency, and efficacy.

Topical Creams and Gels

Topical testosterone (gels and compounded creams) avoids needles entirely and can produce stable blood levels when applied correctly and absorbed reliably. The tradeoffs are that absorption varies meaningfully from person to person, and daily application becomes a strict routine. Skin irritation can occur, and sweating, bathing, and application site choice can affect exposure. Many patients report that they do not feel much different with creams and gels because the absorption can be much less than what is experienced through injectable routes. Most patients who have tried injectable versus topical testosterone prefer injections over creams and gels.

The biggest safety issue with topicals is secondary exposure. FDA labeling includes a boxed warning because testosterone can transfer through skin to partners or children if precautions are not followed. Patients must wash hands after application, cover the application site with clothing after drying, and wash the site before skin-to-skin contact.

Conclusion

There is no universally "best" TRT delivery method. IM injections, SC injections, and creams can all work when used correctly. The best choice is the one that achieves stable symptom improvement, fits your routine, and allows safe, high-quality monitoring. Want help choosing your best TRT option and dosing schedule? Contact Us to build a plan tailored to your goals.

References

Figueiredo M, et al (2022). Testosterone Therapy With Subcutaneous Injections: A Safe, Practical, and Reasonable Option. J Clin Endocrinol Metab. 2022 Feb 17;107(3):614-626.

Choi E, et al (2022). Comparison of Outcomes for Hypogonadal Men Treated with Intramuscular Testosterone Cypionate versus Subcutaneous Testosterone Enanthate. J Urol. 2022 Mar;207(3):677-683.

Bhasin S, Brito JP, Cunningham GR, et al (2018). Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. May 1;103(5):1715-1744.