TRT Downsides and Consequences
TRT is relatively safe and inexpensive, and when you need it, it is a lifesafer. Most men feel great on TRT but like everything this comes at a serious price. There are serious consequences that need to be considered.
Lifelong Commitment
When you introduce external testosterone (TRT), your brain senses sufficient levels and signals your testicles to cease production. Over time, this shutdown can become permanent—especially for older men. While medication can often restart the natural production, the precautionary principle dictates you to consider you will be on TRT for life.
Testicular Atrophy
When you take testosterone injection or gels (TRT), your brain tells your testicles to stop making testosterone, so they shrink to about half their normal size. You can take a medicine called HCG to keep them from shrinking, but like all medicines, it has its own side effects like higher estrogen levels that could provoke the need for even more medications like AI´s (Aromotase Inhibitors), which also have their own side-effects.
Infertility
TRT usually makes men unable to have children because it tells the brain to shut down sperm production in the testicles. Most men (about 65-90%) lose all their sperm within a few months of starting TRT, and some may never get their fertility back even after stopping. The precautionary principle dictates you to consider that medication can not reliably restore your fertililty again.
Major Risks of Testosterone Replacement Therapy (TRT)
| Risk | Cause | Estimated Chance | Mitigation Strategy | Supporting Evidence |
|---|---|---|---|---|
|
Erythrocytosis (Elevated Red Blood Cells) |
TRT-stimulated erythropoiesis leading to elevated hematocrit (Ht). | 7–66% (Ht > 46%) 23% (Ht > 50%) 5% (Ht > 54%) |
Check Ht at baseline, 3–6 months, then annually; hold or reduce dose if Ht > 54%; consider phlebotomy. |
Prevalence and predictive factors Meta-Analysis Data |
| Infertility & Testicular Atrophy | Suppression of the hypothalamic-pituitary-gonadal (HPG) axis, halting natural sperm and testosterone production. | Nearly universal HPG suppression; azoospermia (zero sperm count) in 40–75%. | Discuss reproductive goals pre-TRT; use hCG or SERMs to maintain intratesticular testosterone; consider semen cryopreservation. | TRT and Spermatogenic Dysfunction |
| Cardiovascular Events | Potential prothrombotic effects and hematocrit increase, though data is conflicting. | No significant increase in major adverse cardiovascular events (MACE) in most meta-analyses. One large trial showed a slight increase. | Assess CV risk factors; use the lowest effective TRT dose; monitor lipids, BP, and hematocrit; manage risk factors aggressively. | Updated Systematic Review & Meta-Analysis |
| Prostate Growth & Cancer | TRT-driven prostate tissue proliferation via androgen receptor stimulation. | No definitive evidence of increased prostate cancer incidence or significant BPH progression in clinical trials. | Baseline PSA and DRE; repeat at 3-6 months and then annually. Refer to urology if PSA rises > 1.4 ng/mL in a year. | Systematic Review on Prostate Outcomes |
| Obstructive Sleep Apnea (OSA) | TRT can induce fluid retention and reduce pharyngeal muscle tone, potentially worsening existing OSA. | Up to ~10% may experience an exacerbation of OSA symptoms. | Screen for OSA symptoms (snoring, daytime somnolence); perform a sleep study if indicated; treat OSA before or during TRT. | Adverse Effects Review |
|
Gynecomastia (Male Breast Tissue Development) |
Aromatization of excess testosterone into estradiol, an estrogen. | Approximately 1–5%. | Monitor for breast tenderness or tissue growth; consider adding an aromatase inhibitor (e.g., anastrozole) if symptoms arise. | General clinical observation, not linked to a specific paper in the initial search. |
| Lipid Alterations | TRT can cause a mild decrease in HDL ("good") cholesterol. | Mean HDL decrease of approximately 0.5 mg/dL. | Monitor lipid panel at baseline and annually; emphasize lifestyle interventions (diet, exercise); consider statin therapy if clinically indicated. |
Meta-Analysis on Lipid Effects Systematic Review Data |
| Acne & Skin Oiliness | Androgen-mediated stimulation of sebaceous glands in the skin. | Approximately 5–15%. | Topical treatments like retinoids or benzoyl peroxide; oral antibiotics for severe cases; dose adjustment if persistent. | General clinical observation, not linked to a specific paper in the initial search. |
|
Allergic Reactions (SC Injections) (Injection Site Hypersensitivity) |
Immune response to testosterone formulation excipients (e.g., benzyl alcohol, polysorbate). | Approximately 1–3% of patients receiving SC injections. | Perform test dose; monitor injection site for erythema, swelling, itching; switch formulation or route if allergy confirmed; treat with antihistamines or corticosteroids as needed. | General clinical observation, specific incidence data limited in literature. |