What Do I Need to Know About Testosterone Replacement Therapy (TRT) for Men?

The term “andropause” is sometimes used as a male analog to menopause, but the comparison is far from exact. Hormone levels fall relatively abruptly and predictably at menopause. In males, hormone production generally declines more gradually — on average about 1 percent per year in midlife and beyond. Some don’t experience much of a decline at all, with testosterone levels staying in the normal range well into older age.

That means testosterone replacement therapy (TRT) is generally used for a narrower set of problems — most often clinically significant low testosterone, or hypogonadism — rather than as a broad response to one universal life stage.

The American Urological Association considers low blood testosterone to be less than 300 nanograms per deciliter for adult men. An estimated 39 percent of men age 45 and older have low testosterone.

In addition to age, other causes of hypogonadism include obesity, chronic stress, injuries to the brain or testes, sleep apnea, genetic disorders, and medication side effects. Symptoms may include low libido, erectile dysfunction, fatigue, reduced muscle mass, depressed mood, and low bone density. All of these can have other causes, making careful diagnosis crucial.

For men with symptomatic hypogonadism, TRT can help. Clinical trials generally show improvements in sexual desire, mood, and body composition, especially when paired with resistance training.

One of the biggest tradeoffs with TRT is fertility. When men take exogenous testosterone, the brain reduces production of luteinizing hormone and follicle-­stimulating hormone, the signals that tell the testes to make testosterone and sperm. That can sharply ­reduce sperm count and shrink the testes.

For younger men who want to preserve fertility, clinicians may use strategies to stimulate the body’s own production of testosterone, along with recommending weight loss, resistance training, stress reduction, and better sleep. (See “11 Tips to Boost Your Testosterone” for more.)

Other downsides of TRT can include sleep apnea, acne, breast enlargement, and excessive red-blood-cell production; the latter increases the chance of blood clots.

Then there’s the prostate question. For decades, men have been warned that testosterone is fuel for prostate cancer. While it’s true that testosterone can influence prostate growth, that doesn’t automatically translate to cancer risk, says holistic urologist Geo Espinosa, ND, LAc, IFMCP.

According to current evidence, raising testosterone — whether through lifestyle measures or TRT — does not elevate prostate-cancer risk in otherwise appropriate candidates. Espinosa adds that while TRT can modestly increase prostate volume in some men, research suggests it doesn’t typically worsen lower-urinary-tract symptoms.

Like any form of hormone replacement, TRT is best ­undertaken with the guidance of a knowledgeable clinician who can monitor symptoms and lab markers over time to adjust treatment as needed.