What are the benefits and risks of TRT?

Richard Wayman

BSc (Hons), RNMH, NMP

Advanced nurse practitioner

It's estimated that between 10-40% of men globally will have low testosterone at some point in their lives [1].

Low testosterone can affect everything from mood to muscle composition and sexual health. Unsurprisingly, many people are curious about testosterone replacement therapy (TRT) and its benefits and risks.

In this blog, we look at who could be suitable for TRT and the benefits and risks to be aware of before beginning treatment.  

Contents

• What are the benefits of TRT?
• What are the risks of TRT?
• Who shouldn't take TRT?
• What happens if you take too much or too little TRT?

What are the benefits of TRT?

TRT is a well-researched and widely used treatment for men with symptoms of testosterone deficiency (sometimes referred to as hypogonadism by healthcare professionals).

Testosterone deficiency can cause symptoms related to sexual desire and function, as well as body and muscle composition. These can all impact relationships, self-esteem, mood, and overall quality of life.  

TRT has many well-documented benefits, such as boosting libido and energy, improving bone density and muscle strength, and protecting the heart. 
 
TRT can improve many symptoms relating to: 

• Erectile function
• Reduce BMI and waist size in obese men
• Sexual desire
• Sexual satisfaction

Beyond six months, there is also evidence that TRT can:

• Benefit body composition and bone mineralisation
• Improve blood sugar control and lipid (fat) levels
• Reduce the risk of developing type 2 diabetes in prediabetic people
• Reduce the risk of cardiovascular events and mortality in people with cardiovascular disease [2].

What are the risks of TRT?

TRT can carry serious adverse effects for some people, though they are rare. To assess your suitability for TRT, you can expect to go through a well-established route of two blood tests and a consultation with a doctor. In the consultation, the doctor will assess your risk factors. You'll also need ongoing monitoring and testing to adjust your TRT dosage as needed.  
 
Risks of TRT include [4]:

• Too much testosterone — this can be managed by adjusting the dosage, stopping treatment, or switching to a different formulation.
• Pain and bruising at the injection site (if injecting into a muscle).
• Skin irritation or variable levels of absorption with transdermal gels.
• Polycythaemia (thicker blood) — an increase in red blood cell count and haemoglobin can happen because testosterone stimulates the body to make red blood cells. Polycythaemia increases your risk of heart attacks or stroke. Your blood count will be monitored before and during treatment. If your concentration of red blood cells becomes too high, your treatment will be stopped.  
• Gynecomastia (man boobs) — excess testosterone can convert to oestrogen and cause swelling or tenderness of the breast tissue. Breast swelling or pain may be seen in up to 10-25% of men taking TRT. 
• Thinning hair — TRT may increase levels of dihydrotestosterone (DHT) which can accelerate balding in men who are predisposed to it. 
  
• Skin conditions  — a rise in testosterone causes an increase in sebum production. This can lead to acne, though this effect is typically minimal. 
• Sleep apnoea — TRT may have a transient harmful effect on sleep apnoea. Therefore, it's generally not recommended for men with severe, untreated sleep apnoea.

Side effects tend to be minimal when the dose is correctly managed by a TRT expert. If you develop any new side effects, let your TRT provider know as soon as you can. 

Who shouldn't take TRT?

You should not take TRT if you have active cancer, high red blood cell levels, or plan to have children in the near future. A doctor will assess risk factors with you in a consultation before considering you for any treatment.  
 
TRT should not be started in people with:

• Active prostate cancer  
  
• High levels of red blood cells (haematocrit >54%)
• Male breast cancer
• Severe chronic heart failure

If you and your partner are trying for a baby within the next six months, it might not be the best time to start TRT. Our doctors will chat with you about your options.

What happens if you have or take too much or too little TRT?

Don't worry about taking too little TRT. Starting with a low dose of testosterone is essential to avoid serious health risks. 
 
Taking too much TRT can put you at risk of some conditions. If you are already at a high risk of these, then it's unlikely that treatment is right for you. 
 
Taking too much TRT can put you at risk of:

• Polycythaemia (very high numbers of red blood cells), which increases the risk of heart attacks, strokes, and blood clots
• Liver damage
• Impaired cholesterol metabolism
• Gynaecomastia
  

How much TRT should I take? 

There are different forms of TRT, the most common being gels and injections. There is no consensus on the best method for administering testosterone therapy — each has its pros and cons. It is crucial to discuss the various options to help weigh the advantages and disadvantages.  
 
Testosterone medications are classed as controlled drugs in the UK and require monitoring. Therefore, TRT should be prescribed and monitored by a doctor. Taking too little can lead to suboptimal symptom control and this is relatively easily rectified upon review of your medication with your TRT specialist. With that in mind, it can take several months from starting for the full benefit of TRT to take effect.

Does everyone with low testosterone need TRT? 

For the average man, low testosterone levels only become problematic if they come with troublesome symptoms and signs. 
 
Circulating testosterone in men declines progressively by 0.4–2% per year from the third decade of life [5]. Rising obesity rates and sedentary lifestyles can lower testosterone levels. So, if you are considering testosterone treatment, consult with a doctor first to weigh up your options.

Lifestyle factors heavily influence testosterone levels, such as:

• Obesity
• Levels of physical activity
• Alcohol intake
• Sleep
• Stress [6] 

Is TRT right for me?

TRT can help if you have severe symptoms of low testosterone that affect your quality of life. If you are struggling with low testosterone symptoms, TRT may be a beneficial option for you. 
 
If you suspect that you have low testosterone, then your first step is to check your levels with a Testosterone Blood Test.

References

1. Anaissie J, DeLay KJ, Wang W, Hatzichristodoulou G, Hellstrom WJ. Testosterone deficiency in adults and corresponding treatment patterns across the globe. Transl Androl Urol. 2017 Apr;6(2):183-191. doi: 10.21037/tau.2016.11.16. PMID: 28540225; PMCID: PMC5422691.
2. Blackwell K, Blackwell M, Blackwell T. Testosterone Replacement Therapy and Cardiovascular Disease: Balancing Safety and Risks in Hypogonadal Men. Curr Cardiol Rep. 2023 Oct;25(10):1157-1163. doi: 10.1007/s11886-023-01935-1. Epub 2023 Sep 21. PMID: 37733143.