Question 1

What does it mean when I am told my testosterone level is “normal“?

Accepted Answer

Each lab has their “normal” reference range for testosterone, generally about 250–900 ng/dL. These numbers were based on averages from a “normal” group of men, not knowing their specific symptomatology. Instead of asking what your “normal“ level of testosterone is, it would be more appropriate to ask what is your “optimal“ level of testosterone. That differs from one man to another. A “normal” level of, say 300, for any individual man may be entirely sub-optimal in terms of alleviating his symptoms and may need to be in the 500–600 range or higher, for optimal health. We are all different in our production and response to testosterone, so what is optimal for one man may be entirely suboptimal for another. TRT is aimed at symptom improvement/resolution, not aimed to achieve a particular lab number.

Question 2

What is “free testosterone”?

Accepted Answer

Testosterone travels in the blood in one of two forms, bound (to a protein) or unbound (free). The most prevalent protein in the blood that binds testosterone is known as Sex Hormone Binding Globulin (SHBG). The only form of testosterone that is capable of binding to receptors and carrying out an effect in the body is that which is unbound, the “free” testosterone. The higher your SHBG (produced by your liver), the lower your free testosterone. So it is possible to have a high (normal) total testosterone level, as measured in your blood test, but have a diminished and totally inadequate testosterone response in the body, if your SHBG is high and binding most of your testosterone. Thus, it is very helpful to know your free testosterone level, which is either calculated based on your total testosterone and your SHBG levels or measured directly with a lab test.

Question 3

What is the most effective way to raise my free testosterone if I have a high SHBG? (see above question to understand SHBG)

Accepted Answer

Unfortunately, there is no proven effective way to reliably lower your SHBG (and thus raise your free testosterone). Thus, the most effective way to raise your free testosterone is typically to raise your total testosterone dose. So generally, men with higher SHBG levels need higher testosterone doses (and a higher total T) to achieve optimization.
Another consideration would be to opt for testosterone replacement with a transdermal cream for application, which generally results in higher free testosterone levels (for any given total T) than injections.

Question 4

What are some conditions that studies have shown to be highly correlated with low testosterone levels?

Accepted Answer

Cardiovascular disease 
Prostate cancer
Alzheimer’s disease 
Type 2 diabetes 
Depression 
All-cause mortality (death at a younger age from any cause is correlated with chronic low testosterone)

Question 5

What is the primary medical benefit of initiating TRT?

Accepted Answer

A common misconception is that the primary benefit of TRT is to improve libido and to improve one’s energy, motivation, and sense of well-being. Although these are common and very beneficial effects, the most significant medical benefit of TRT is to improve BODY COMPOSITION; that is, to increase muscle mass and to decrease body fat, especially visceral fat (fat around the organs). Both of these effects ultimately lead to an improved metabolic profile, thus decreasing chronic inflammation and your risk for chronic disease, including diabetes, kidney disease, heart disease, and neurologic disease. Testosterone has a direct anabolic effect by stimulating protein synthesis within the muscles, and through its conversion to estradiol, directly decreases body fat, especially visceral fat, which tends to accumulate as we age. This visceral fat surrounding the organs is very unhealthy and inflammatory by nature, steadily releasing inflammatory mediators, which are the root cause of many disease processes within the body. So by directly stimulating protein synthesis within the muscles and by promoting the breakdown of body fat, TRT over time (especially when combined with a healthy diet and exercise) results in a very favorable change in body composition leading to a healthier metabolic profile with improved glucose utilization and less body inflammation. In regard to this benefit to muscle growth, it is important to note that increased muscle mass and strength has been shown to be highly correlated with longevity (longer life); the higher your muscle mass, the longer you are expected to live.
Also worth mentioning as an important medical benefit of testosterone is its effect of increasing bone density, thus decreasing the risk of osteoporosis.

Question 6

Beyond improving body composition, what are other beneficial effects you can expect with TRT?

Accepted Answer

If you are truly sub-optimal in your level of testosterone, there are numerous benefits that you can expect to obtain by getting your level up to the optimal range. These benefits include:
Greater energy
Greater motivation and desire to get moving
Less tendency to depression
Greater mental clarity (decreased brain fog)
Improved libido
Stronger, more frequent erections
Increased insulin sensitivity (decreased risk of diabetes)
Greater strength and motivation in the gym

Question 7

How long does it take to notice the benefits of testosterone replacement therapy?

Accepted Answer

If your levels were truly suboptimal, you can generally expect to notice some differences in the way you feel within 2 to 3 weeks. Some may take longer, maybe months. When you combine a healthy lifestyle, including proper exercise, a healthy diet and adequate sleep, with your TRT you will notice more substantial and most likely quicker results. If you are converting from an unhealthy lifestyle, noticeable improvements in the way you look and feel may come within weeks to months, but it could possibly take a year or longer to reach your peak. Discipline and consistency with a healthy lifestyle are the key! Testosterone serves as a catalyst, but the speed and degree of improvement in your health and body are directly proportionate to the sweat equity that you put in! Such is life!

Question 8

What are lifestyle changes that could increase the chances of obtaining the maximum health benefits of testosterone therapy?

Accepted Answer

1. Eat a healthy diet. What are the basics of a healthy diet?
High protein: a goal of 1 g of protein per pound of body weight if trying to gain muscle 
High Fiber Intake: you should intake a goal of 50g but you AT LEAST need 25g
Grass fed meats
Healthy fats:  fatty fish (such as salmon and sardines), free-range eggs, nuts, avocados, healthy oils such as extra-virgin olive oil and coconut oil
Fruits and vegetables, preferably organic 
Minimize sugar, especially unnatural sources 
Minimize (preferably eliminate) processed food 
Minimize alcohol intake 
 2. Do regular resistance training (does not have to be extremely heavy). Increasing lean body mass is extremely important to optimal health. Testosterone potentiates muscle growth, but some degree of resistance training is mandatory for optimal results.
3. Get adequate sleep. Aim for 8 hours per night 
4. Control your stress level (I know, way easier said than done!)

Question 9

Does TRT increase the risk of blood clots, stroke or heart attack?

Accepted Answer

There have been no consistent studies that show a definitive link between TRT and blood clots, stroke or heart attack. Conclusion from the Traverse trial looking at TRT and cardiovascular risk (among other possible risks), released in 2023 stated, “This study shows that for men with androgen deficiency in whom testosterone is clinically indicated, testosterone appears to be safe from a cardiovascular perspective”. TRT resulted in no evidence of higher risk than placebo with respect to the occurrence of major adverse cardiac events and the overall incidence of adverse events was low. On the contrary, numerous studies have shown that a chronic LOW testosterone level in men is associated with increased cardiovascular events and all-cause mortality and the association gets stronger as men age.

Question 10

Does TRT increase the risk of prostate cancer?

Accepted Answer

This has been proven to be an emphatic NO. As a matter of fact, it has been shown that maintaining optimal levels of testosterone has been shown to protect against the development of prostate cancer. And clinical evidence supports this, as middle-age or elderly men with declining testosterone levels are much more likely to get prostate cancer as opposed to young men who are at their peak in testosterone. It is true that if a patient on TRT is diagnosed with prostate cancer, the TRT will be discontinued during treatment of the prostate cancer. Even in these patients, once the cancer is successfully treated, and the PSA has returned to baseline and is stable or in some cases undetectable, testosterone therapy is generally safely resumed. In these post-cancer patients who resume TRT, there is no evidence of increased risk in recurrence, according to studies. Studies have also shown that normal/optimal levels of testosterone tends to be protective against acquiring high grade/aggressive prostate cancer.

Question 11

Will TRT cause me to lose my hair?

Accepted Answer

The propensity for male pattern baldness is determined genetically. Testosterone therapy results in increased levels of DHT, which can hasten the rate of hair loss in these men with genetic predisposition. This is known as androgenic alopecia. However, men without genetic predisposition to hair loss will have little to know effect caused by the TRT.
Finasteride (Propecia) and Minoxidil (Rogaine) are drugs that can potentially minimize the hair loss effect caused by testosterone.

Question 12

Can TRT affect my fertility?

Accepted Answer

Yes. Any man who may desire children in the future should be aware that TRT can affect sperm production and therefore fertility. Taking exogenous testosterone causes the testicles to decrease and possibly stop their production of testosterone which is necessary within the testicles for sperm production. At what point this effect reaches a point of permanent testicular shutdown and infertility is unknown and will vary from one man to another. There are other medications that can be taken along with the TRT to maintain testicular activity and sperm production and therefore decrease the chances of infertility, but there are no guarantees. If maintaining fertility is a definite concern, the best option would be to postpone TRT until infertility is not a concern or to bank some sperm for future use (sperm cryopreservation).

Question 13

What are my options for how I can take the testosterone?

Accepted Answer

The two preferred routes of administration are by injections or transdermal application of testosterone cream. Both are highly effective and are typically determined simply by patient preference. Cream is usually applied to the scrotum once or twice daily; typically in the morning after your shower, and then 12 hours later, if doing twice a day. Injections are typically intramuscular with a small needle that can either be done by the doctor or nurse in office or easily self administered at home. Injections are recommended to be done at a minimum of two times per week. More frequent and smaller dosing is recommended over larger and less frequent dosing, as it better mimics the body's natural daily release and minimizes significant peaks in blood levels. Adequate blood levels of testosterone can easily be obtained with either route of administration.

Question 14

Does TRT worsen benign prostatic hypertrophy (BPH) and does it make lower urinary tract symptoms worse?

Accepted Answer

The prostate is a hormone sensitive organ with androgen receptors. Does this mean that the more testosterone that is in circulation, the more the prostate grows? In fact, this is NOT the case. It has been shown that there is a threshold level of testosterone, above which there is no further growth in prostate tissue; and this threshold level for “total testosterone“ is relatively low, around 250 to 300 ng/dL which is on the low end of the “normal” range. So if you raise the level of testosterone in a man from 100 ng/dL to 300 ng/dL with TRT, you will likely see some enlargement in the prostate. However, if you raise the level from 300 ng/dL up to 700 ng/dL there will likely be minimal or NO increase in size of the prostate because it has already reached its androgen sensitivity plateau prior to TRT. So, in most cases, raising a man’s testosterone to optimal levels can be expected to have a minimal and self limiting effect on any possible pre-existing BPH (prostate enlargement). So TRT in the vast majority of cases does not exacerbate any lower urinary tract symptoms associated with BPH and urination. In fact, on the contrary, data shows that it is not uncommon for men who undergo TRT, over time, to experience some improvement in their lower urinary tract symptoms. This is likely because of the effect that testosterone has within the prostate/body of decreasing inflammation.

Question 15

Will TRT cause my PSA level to rise?

Accepted Answer

With the initiation of TRT, it is not uncommon to see a slight rise in PSA. This is a self limiting effect that plateaus usually within weeks and that will generally return to baseline. This is in no way affiliated with any increase in risk of prostate cancer (as noted in a previous question above).

Question 16

Will TRT affect the size of my testicles?

Accepted Answer

Not in all men, but it definitely can. A man’s “sperm factory“ within the body is his testicles. Giving exogenous testosterone (TRT) results in an inhibition of the hypothalamic/pituitary/testicular axis that is responsible for stimulating sperm production in the testicles. In other words, higher circulating levels of testosterone results in a decrease in sperm production by diminishing the signal from the brain. As this decrease in testicular activity becomes more prolonged the testicles sometimes decrease in size. This effect on testicular size and function can possibly be attenuated by the concomitant use of hCG which stimulates the testicles to produce intra-testicular testosterone, and thus sperm, keeping them active even in the presence of higher serum testosterone levels.

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