Pros and Cons of Testosterone Replacement Therapy (TRT)

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TRT (testosterone replacement therapy) is a medical treatment that helps restore low testosterone levels to a healthy range, typically via weekly testosterone injections. Men with low testosterone symptoms frequently resort to TRT, hoping it will be a quick-fix.

I can assure you that’s not how TRT works.

Taking testosterone replacement therapy to correct low testosterone symptoms is a major commitment – lifelong for most men. We’ve talked about what the side effects of TRT are before on the blog. Once you’ve been on TRT for a significant amount of time, it’s tough to turn back and go the “natural” route. Hence, it’s crucial to weigh the pros and cons of TRT before taking the plunge (no pun intended).

So, what is testosterone replacement therapy (TRT), exactly?

What is TRT?

Some key terms to know before moving on:

  • Exogenous = Originating from outside the body
  • Endogenous = Originating from within the body
  • Primary hypogonadism = Low testosterone caused by testicular dysfunction
  • Secondary hypogonadism = Low testosterone caused by brain dysfunction

TRT works by supplying the body with testosterone through an exogenous source rather than encouraging your body to produce more of its own endogenous (i.e., natural) testosterone. In most cases, this means injecting prescription testosterone, either weekly or bi-weekly. Though there are other forms of prescription testosterone, which we will discuss later.

Does TRT Cause Shutdown?

The conundrum with taking exogenous testosterone is that it shuts down your body’s natural testosterone production due to a negative feedback mechanism in the hypothalamic-pituitary-gonadal (HPG) axis.

The HPG axis senses that it’s already getting enough testosterone from an exogenous source, so it shuts down its own natural (endogenous) production. Over time, this can lead to the body being dependent on exogenous testosterone, making TRT a lifelong commitment.

There are drugs that “kickstart” the body’s natural testosterone production after taking TRT long enough, but they aren’t always reliable.

Therefore, it’s prudent to exhaust all other options before starting TRT.

Benefits of Testosterone Replacement Therapy

TRT’s most apparent benefit is that it gives the body a steady supply of testosterone, which is quite reliable for treating low testosterone symptoms.

After being on TRT for 2-3 months, many men notice an increase in energy, sex drive, confidence, motivation, and ability to build muscle and burn body fat more efficiently.[1] 

However, don’t think that TRT will “do all the work for you” because it’s not magic. If you’re hoping all it takes is a quick jab with a needle full of testosterone to get ripped and buff, you’re in for a major letdown.

Yes, TRT can help men build more muscle and gain strength quicker so long as they are consistent with their diet and exercise routine, but it is not intended to replace a healthy lifestyle. There is no drug, supplement, or medication that can make up for things like poor diet, drinking beer all the time, lack of exercise, and skimping on sleep.

If anything, taking testosterone and not living a healthy lifestyle is going to make things even worse.

→ Check out these simple lifestyle hacks that boost testosterone naturally!

How to Tell if You Have Low Testosterone

The surest way to tell if you have low testosterone is to have blood work done. Most physicians can order lab work that assesses your total and free testosterone levels. This will give you and your doctor an objective measure to guide further diagnostics. You can also order testosterone blood work through an independent lab in your area, but this is usually not covered by health insurance.

Your doctor may also check other pertinent labs, such as hematocrit, prostate-specific antigen (PSA), blood lipids, blood glucose, estrogen, sex-hormone binding globulin, and thyroid hormones.

If you’re not within the normal range for any of these, you’ll need to consult with the doctor about how to proceed.

Moreover, if your testosterone levels come back on the lower end of the spectrum, TRT isn’t necessarily the solution. You should only consider TRT if your testosterone levels are very low (i.e., < 200 ng/dL) and you identify the root cause through medical testing.

If you’re experiencing symptoms of low testosterone, but your blood work comes back in the low-to-mid normal range, chances are TRT isn’t for you. Taking testosterone when you already have adequate endogenous testosterone production can be detrimental down the road.Try changing your lifestyle habits and things you can control first (e.g., diet, exercise, and daily routine).

Even simple adjustments like getting more sunshine and sleeping enough can have profound benefits on testosterone levels.[2],[3] Give it an honest 60 days of diligent effort to naturally raise your testosterone levels; you owe it to yourself. Then, get tested again and see if your levels have increased; if they have, you’re on the right track and should stay the course.

You don’t want to depend on injections/medication for the rest of your life unless it’s absolutely necessary. Worst case, if things don’t improve, you can reconvene with your doctor and determine the most appropriate course of action.

Common TRT Medications

Testosterone Injections

The standard TRT protocol is to give deep intramuscular testosterone injections every week, but subcutaneous injections are also viable.

There are several injectable forms of testosterone for treating low testosterone, notably testosterone undecanoate, testosterone propionate, and testosterone enanthate. These all classify as testosterone esters, with testosterone cypionate being most common for testosterone replacement therapy (TRT).

It might help to think of testosterone esters as slightly modified forms of the natural testosterone your body produces. The alteration to the chemical structure of testosterone esters turns them into “prodrugs,” meaning your body converts them into biologically active forms upon absorption.

Despite testosterone esters being synthetic androgenic anabolic steroids, they function identically to the natural testosterone your body produces once metabolized.

The use of testosterone esters like testosterone cypionate is advantageous in clinical applications for a variety of reasons, such as:

  • Allowing for controlled/prolonged release of testosterone into the bloodstream
  • Enhancing the bioavailability of testosterone
  • Reducing the need for multiple injections every week

 

For performance enhancement, testosterone injections are the most common approach. Many professional bodybuilders and athletes use testosterone injections year-round to pack on muscle as fast as possible. They will also mix the testosterone with other anabolic steroids, such as deca-durabolin and boldenone.

However, a “performance-enhancing” weekly dose of testosterone is generally much higher than what you would be given on TRT (i.e., 500 – 1,000 mg per week vs. 100 – 150 mg per week).

Though injections come with disadvantages as well. For one, they can be painful and lead to soreness and swelling at the injection site. They may also be impractical for people who don’t want to give themselves injections every week; in such cases, they have to drive to the doctor’s office weekly so a nurse can give the injection.

Testosterone Gels/Creams

Testosterone gels and creams – such as AndroGel® – provide testosterone transdermally (i.e., through the skin). This is the least invasive form of TRT, and arguably the most convenient as well. Many men on TRT will opt for testosterone gels or creams if they are afraid of needles or are uncomfortable having a testosterone pellet implant.

Testosterone gel/cream is quite simple to use. The most common area to apply testosterone gels/creams is the upper arms and shoulders. Take a shower immediately before applying the cream and wait a few minutes for it to dry thoroughly on your skin. Then, go ahead and get dressed.

The main drawbacks of testosterone gels and creams are that they may give off an odor when rubbed on the body, and you have to be careful about letting the substance actually “sink in” for maximal efficacy. Unbeknown to many TRT patients, testosterone gel/cream can transfer to another person’s body if skin-to-skin contact is made with the application site.

Take extra caution to cover up areas where you apply any testosterone gel or cream. The last thing you want is to accidentally expose the hormone to others (especially children and women).

Testosterone Patches

Testosterone patches, such as the Androderm® patch, work similar to gels and creams, delivering the hormone through the skin (albeit at a slower pace). Doctors recommend applying the patch to the skin once daily, preferably an hour or two before bedtime. By doing so, testosterone levels will be higher after waking up and slowly decline throughout the day (much like our natural circadian testosterone rhythms).

One of the advantages of using a testosterone patch instead of a cream or gel is that you don’t have to cover it. It won’t transfer to others who come in contact with the back of the patch—the medication is in the center of the patch and surrounded by a backing that sticks to your skin.

However, if you sweat heavily, have a lot of body hair, or oily skin, the patch might not adhere properly and may fall off, resulting in poor outcomes.

Testosterone Pellets

Testosterone pellets are the most studied form of prescription testosterone and were the first method of low testosterone treatment approved by the Food and Drug Administration. Testosterone pellets are about the size of a grain of rice. They are inserted subcutaneously into the hip area through a tiny incision (which is done in-office and relatively non-invasive).

After the pellet is inserted, the body slowly absorbs and metabolizes it, providing stable plasma testosterone levels for upwards of six months before another testosterone pellet implant is necessary. The main caveat of testosterone pellets is that most health insurance companies don’t cover this form of TRT. Injections, gels/creams, and patches, on the other hand, are generally covered by health insurance (which can significantly reduce the cost of TRT).

Can You Take Testosterone Orally?

Oral testosterone preparations remain infeasible for TRT since testosterone is subject to extensive first-pass metabolism through the liver. Hence, very high doses are necessary to achieve a stable blood level.

Methyltestosterone, an oral prohormone, was originally developed to circumvent this issue, but clinical trials showed it had significant liver toxicity and untoward effects on blood lipids. As such, methyltestosterone did not gain approval for TRT use in the United States.[4] 

TRT Side Effects: What to Know

Testosterone, like any drug, can produce a range of adverse effects. The most common side effects of TRT are[5]:

  • acne
  • oily skin
  • nighttime sweating
  • high blood pressure
  • testicular shrinkage
  • excessive body hair growth

While testosterone’s side effects are generally manageable, they can be frustrating and dangerous if you don’t take the necessary precautions.

→ Click to read more about the side effects of TRT.

Key Takeaways: Do the Benefits of TRT outweigh the Risks?

Testosterone replacement therapy is a major life decision for a man. There are plenty of men on TRT that feel the benefits outweigh the risks. While TRT is undoubtedly useful for treating true testosterone deficiency, it’s not a medical miracle.

Committing to TRT is ultimately a decision that must be made mutually with your physician. However, be wary of doctors and “men’s health clinics” that are quick to prescribe you TRT without first confirming the diagnosis and underlying cause. If the only reason they give you is “you’re getting old,” you should be skeptical. Aging is only part of the equation.

TRT has become a cash cow for private-practices across the United States. These “male clinics” will often try to sell you on TRT rather than help figure out what’s going on with your health. Sadly, they just want to capitalize on this low testosterone epidemic.

But carelessly prescribing TRT as an overnight fix can ultimately have long-term risks for patients. Remember, once you take TRT long enough, your body depends on it. It behooves you to do everything possible to naturally get your endogenous testosterone production back on track before you commit to TRT.

Lastly, don’t assume you have low T just because you feel tired, depressed, have a low sex drive, etc. General fatigue and lack of motivation is not an adequate diagnosis for low testosterone, and TRT won’t necessarily be the solution. In many cases, the symptoms of low testosterone are “false positives” that a man has hypogonadism. Consequently, it’s common for aging men to believe they are just victims of getting older and that they need to TRT to feel youthful and vibrant again.

That’s simply not the case for the majority of men. Priority number one should be developing healthy lifestyle habits, eating properly, and hitting the gym regularly. These will help support testosterone levels and overall well being naturally and effectively.

You can also consider supplementing with a well-formulated testosterone booster as part of your daily routine. Testosterone booster supplements have the potential to increase your testosterone levels naturally with evidence-based ingredients. 

Documentation


[1] Lašaitė, L., Čeponis, J., Preikša, R. T., & Žilaitienė, B. (2017). Effects of two‐year testosterone replacement therapy on cognition, emotions and quality of life in young and middle‐aged hypogonadal menAndrologia49(3), e12633.

[2] Chen, C., Zhai, H., Cheng, J., Weng, P., Chen, Y., Li, Q., … & Lu, Y. (2019). Causal link between vitamin D and Total testosterone in men: a Mendelian randomization analysisThe Journal of Clinical Endocrinology & Metabolism104(8), 3148-3156.

[3] Abu-Samak, M. S., Mohammad, B. A., Abu-Taha, M. I., Hasoun, L. Z., & Awwad, S. H. (2018). Associations between sleep deprivation and salivary testosterone levels in male university students: a prospective cohort studyAmerican journal of men’s health12(2), 411-419.

[4] Nieschlag, E., Behre, H. M., Bouchard, P., Corrales, J. J., Jones, T. H., Stalla, G. K., Webb, S. M., & Wu, F. C. (2004). Testosterone replacement therapy: current trends and future directionsHuman reproduction update10(5), 409–419.

[5] Ponce, O. J., Spencer-Bonilla, G., Alvarez-Villalobos, N., Serrano, V., Singh-Ospina, N., Rodriguez-Gutierrez, R., … & Brito, J. P. (2018). The efficacy and adverse events of testosterone replacement therapy in hypogonadal men: a systematic review and meta-analysis of randomized, placebo-controlled trialsThe Journal of Clinical Endocrinology & Metabolism103(5), 1745-1754.

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