7 TRT myths debunked

Testosterone replacement therapy has picked up plenty of baggage from its association with anabolic steroids. Some men are frightened of a treatment they may genuinely benefit from, while others expect TRT to transform their physique, sex drive and energy overnight.

Verdict: half truth.

There is an obvious reason this myth exists, testosterone is an anabolic androgenic steroid. But what matters is how it is being used.

TRT is intended to replace testosterone in men who have symptoms of testosterone deficiency alongside consistently low testosterone levels. The aim is to bring testosterone back into an appropriate physiological range and improve symptoms and not to push it far beyond normal levels for muscle growth or performance.

Anabolic steroid use runs at several times that, often stacked with other compounds, usually without blood monitoring and this is usually where the horror stories about testosterone use come from.

Verdict: myth.

This was the biggest fear for decades, and the evidence has not backed it up.

A large randomised trial followed 5,204 men with low testosterone. High-grade prostate cancer occurred in 5 men receiving testosterone and 3 receiving placebo, with no statistically significant difference between the groups. Overall prostate cancer rates were also not significantly different.^[1]

What that does not mean is that prostate checks are pointless. Testosterone can accelerate a cancer that is already there, which is why a PSA and a proper history come before a first prescription and get repeated during treatment.

Verdict: mostly myth now, but not zero.

This was one of the biggest unanswered questions surrounding TRT until the TRAVERSE trial.

Researchers studied 5,246 men aged 45–80 with hypogonadism who either had cardiovascular disease or were already at increased cardiovascular risk.

A major cardiovascular event occurred in:

1. 7.0% of men receiving testosterone
2. 7.3% receiving placebo

Testosterone was therefore not associated with a higher overall rate of cardiovascular death, heart attack or stroke during the study. ^[2]

That does not mean TRT is completely free of cardiovascular risks. Atrial fibrillation, acute kidney injury and pulmonary embolism occurred more frequently in the testosterone group, and TRT can also increase haematocrit.

Verdict: true while you're on it.

Taking testosterone from outside the body suppresses LH and FSH these are the hormones that tell the testicles to produce testosterone and sperm. Sperm production can fall dramatically and can sometimes stop altogether.

For this reason, TRT is generally not appropriate for men actively trying for a baby. ^[3]

What is wrong is assuming that this infertility is always permanent.

An analysis of 1,549 men receiving hormonal treatments that suppressed sperm production found that around 67% recovered to at least 20 million sperm per mL within six months of stopping and 90% within 12 months. Recovery can take considerably longer in some men, particularly after longer-term testosterone use. ^[4]

Verdict: myth.

Replacing low testosterone and taking very high doses of testosterone for performance enhancement are not the same thing.

One often-quoted trial gave healthy men testosterone doses rising to 600mg per week which is far beyond normal replacement levels and they did find increases in measures of mania and aggression. Even then, the response varied considerably between individuals. ^[5]

That tells us something about supraphysiological testosterone use. It does not mean a man receiving appropriately dosed TRT will suddenly become aggressive.

Mood changes should still be discussed with the prescriber, particularly if testosterone levels are being pushed too high.

Verdict: half true.

One low blood result isn't enough. Current guidelines recommend diagnosing hypogonadism when someone has symptoms consistent with testosterone deficiency alongside consistently low testosterone levels, usually confirmed with a repeat morning blood test. ^[6]

There can also be reasons why testosterone is low that should be investigated or addressed first, including obesity, certain medicines and problems affecting the pituitary gland or testicles.

TRT treats testosterone deficiency. It shouldn't be prescribed simply because somebody wants their testosterone number to be higher.

Verdict: Mostly myth.

If the supplement industry were to be believed, a mixture of herbs and minerals can apparently do much the same job as prescription testosterone. Now some supplements may produce a small rise in testosterone, but that does not make them a natural substitute for TRT and you are likely wasting your money on them. A systematic review examined 52 studies covering 27 ingredients marketed as testosterone boosters. Most failed to increase total testosterone. Ashwagandha and tongkat ali were among the more promising ingredients, although the studies were generally small and used different doses and extracts. In two small trials, ashwagandha increased total testosterone by roughly 1.6 to 2.3 nmol/L compared with placebo. A third trial found an increase within the ashwagandha group, but it did not significantly outperform placebo. These trials were very small, so a conclusion cannot be drawn from them to say it does raise testosterone levels. ^[7]

Having low testosterone is a medical problem worth properly investigating rather than spending £30 on supplements a month hoping for the best.