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Testosterone Replacement Therapy at a Glance

Testosterone replacement therapy (TRT), also known as testosterone therapy (TT), is approved by the Food and Drug Administration (FDA) to treat men with low testosterone, medically known as hypogonadism.

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This treatment comes in a variety of forms including patches, gels, injections, and pellets, each carrying its own set of risks and benefits.

Not everyone is a fit for testosterone replacement therapy (TRT) and it is important to have an appointment with a doctor prior to starting this treatment.

What is testosterone?

Testosterone is a hormone important for the development of male sexual characteristics and male reproductive function. Testosterone regulates sperm production, bone mass, sex drive, fat distribution, red blood cell production, and muscle size and strength. Without enough testosterone, a man may have fertility issues.

In men, the testicles primarily make testosterone. The levels are controlled by the pituitary gland in the brain. Once it is produced, testosterone moves through the body to carry out its various important functions. Testosterone production increases during puberty and can start to dip after the age of 30.

Women also make testosterone, but it is in much smaller amounts.

If a man has signs or symptoms of low testosterone, we recommend that his testosterone level be checked. This can be completed through a simple blood test.

What is hypogonadism?

Hypogonadism, the medical term for low testosterone levels (low T), can cause a man to have a reduced sex drive, decreased fertility, sexual dysfunction, undesired changes in body muscle and fat content, and possibly fatigue. Over time a man with hypogonadism may lose strength and his body fat may increase.

What is testosterone replacement therapy?

Testosterone replacement therapy, which is increasingly becoming known simply as testosterone therapy (TT) in the medical field, treats men who have low T with testosterone that has been manufactured by pharmaceutical companies.

Currently, testosterone therapy is the only FDA-approved treatment for men diagnosed with hypogonadism. This treatment is becoming increasingly popular. According to a 2016 study completed at the University of North Carolina, the number of prescriptions for testosterone supplements increased fivefold over a four-year period.

Types of TRT

Gels and creams: Fast-acting testosterone gels or creams are applied once a day, allowing the hormone to be absorbed directly through the skin. Care must be taken to cover the site to avoid transferring the medication to others who may contact the area.

Skin patch: A patch is applied to either the back, stomach, thighs, or upper arms. While convenient in theory, these are not used regularly due to problems with skin irritation and sometimes cost.

Injection: Injection therapy involves injecting testosterone into the muscle. The dose and frequency vary depending on the individual. In general, it is inexpensive compared to other treatments and is often effective. But it may require some adjustments to find the optimal dose.

Implants/pellets: A doctor will insert a rice-sized pellet in the soft tissues under the skin, which needs to be replaced every 4 to 6 months on average depending on the type of pellet. They are easy to maintain and are well tolerated once they are in, but do require a minor office procedure for each dose.

Risks and concerns with TRT

Though testosterone therapy is common, there are some known risks and side effects.

Current studies do not seem to support the idea that this therapy causes prostate cancer. But if a patient already has prostate cancer, there may be some risks of TRT.

Additionally, there is some data to support that men with very low levels of testosterone and very high levels may be at increased risk for cardiovascular disease and that men who maintain testosterone levels in a more normal range may be at decreased risk.

Other possible risks include:

  • Acne and oily skin.
  • Swelling in the feet, ankles (fluid retention).
  • Breast or nipple sensitivity, gynecomastia (enlargement of the breasts).
  • Blood clot formation.
  • Increase in red blood cell count.
  • Difficulty sleeping and increased sleep apnea.

In the case is testosterone therapy is combined with HCG there is no risk of any fertility problems. HCG should always form part of your testosterone replacement therapy (TRT) protocol. It helps to maintain fertility, testicular and penis size, cognitive function, and libido whilst on TRT.

HCG mimics Luteinising Hormone (LH).  It’s a complicated mechanism that involves both gene expression and downstream steroid synthesis. The pituitary gland releases LH which stimulates the Leydig cells of the testes to produce testosterone.

In traditional TRT, the use of exogenous testosterone suppresses the release of LH from the brain which subsequently results in infertility in the vast majority of men. It is due to this action that testosterone monotherapy has been investigated as a potential male contraceptive.

The use of HCG helps to preserve some testicular function and subsequent production of intra-testicular testosterone. It would therefore seem logical to maintain function, rather than rely solely on exogenous testosterone to normalize your male androgen levels.

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Once starting testosterone replacement therapy, a man should have his testosterone levels closely monitored with blood work. Additional blood work is routinely checked while on testosterone therapy as well to help minimize some of the above risks.

Who is not a good fit for testosterone therapy?

At our Anti-Aging Center, we use the American Urological Association guidelines as a reference for diagnosing and treating men with testosterone deficiency. However, each man is assessed individually and treatments are personalized.

Not all men are candidates for testosterone therapy. Men who have prostate or breast cancer, or suspect they might, should not use testosterone before talking with their doctor. It may also not be a good fit for a male who has kidney, heart, or liver problems, as it may increase the chance of complications from these diseases.

Prior to starting testosterone therapy, men should check with a provider to confirm the treatment is the right fit. During this appointment, a patient should notify his doctor about other treatments or substance uses including prescription, nonprescription or over-the-counter medications; recreational or illegal drug use; dietary or nutritional supplements; and herbal remedies. These can sometimes have adverse interactions with TRT.

Men should not have this therapy if they have normal testosterone levels or if their testosterone levels have not been tested.

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