An estimated 20 million American men are testosterone deficient. So, it makes sense that testosterone replacement therapy, or TRT, is gaining interest among men of all ages.
Testosterone replacement therapy is the process of replacing the testosterone that the body is missing due to sub-optimal production, according to Anthony A. Mitchell M.D., a urologist who specializes in men’s sexual health and fertility with Central Texas Urology. “Simply put, it replaces the testosterone that your body should be making under ideal conditions,” he says. (Medically speaking, blood levels of testosterone below 300 ng/dL are considered lower for men.)
Estimates suggest that less than three percent of men are on prescribed TRT. One study published in The Journal of Urology suggests that a large percentage of men who could benefit from testosterone replacement therapy are not placed on it because of a combination of factors, including clinician concerns, patient hesitance, and systemic structures that have led to a widespread lack of access to appropriate medical care.
In the name of replacing myth with information so that more men who would benefit from taking testosterone feel comfortable talking to their clinicians about options, we put together this myth-busting guide with the help of men’s health and hormone specialists. Ahead, gain clarity on six common misconceptions about the treatment.
- ABOUT OUR EXPERTS: Anthony A. Mitchell M.D., is a urologist specializing in men’s sexual health and fertility with Central Texas Urology. Lisa Golding-Granado, M.D., is a board-certified internal medicine specialist focusing on hormone health and the medical director of Serotonin Centers of Colts Neck, NJ. Monika Wassermann, M.D., is a medical doctor with London’s It’s Me & You Clinic.
Myth: TRT Is The Same Thing As Doping
Despite some confusion around them, “testosterone replacement therapy and doping are not the same thing,” says Lisa Golding-Granado, M.D., a board-certified internal medicine specialist who focuses on hormone health and medical director of Serotonin Centers of Colts Neck, NJ.
Testosterone replacement therapy is a medical treatment that involves an individual with low levels of testosterone taking prescription synthetic hormones in order to raise their levels to the normal range, she explains. Generally, the goal of TRT is to relieve any symptoms someone experiences as a result of having low testosterone. Just a few of these low-T symptoms include depression, fatigue, loss of muscle mass, low libido, bone loss, reduced muscle strength, and unexplained body composition changes.
Read More: Exactly How Sleep Impacts Testosterone (And Vice Versa)
Doping, on the other hand, refers to the use of banned substances—also known as performance-enhancing drugs, or PEDs—to gain an unfair advantage and illicitly improve athletic performance or competitiveness in a sport. The exact drugs someone takes may vary, but they usually involve testosterone and/or other substances, says Golding-Granado. These other (banned) substances might include human growth hormone, stimulants, anabolic steroids or agents, beta-blockers, or erythropoietin.
Notably, “people who are doping with testosterone often take doses that are much higher than those used in medical treatments,” says Monika Wassermann, M.D., a medical doctor with London’s It’s Me & You Clinic. And in many instances, the testosterone taken isn’t medically prescribed but rather a black-market option purchased from a drug dealer or other illegal method.
While using testosterone as part of hormone replacement therapy is different in many ways from doping—primarily in terms of dose, intent, and source—Wassermann suggests that competitive athletes consult with medical professionals and check the regulations of their respective sports organizations prior to supplementation. “Using TRT may require disclosure and approval to ensure it is not considered doping,” she explains.
Myth: Taking Testosterone Causes Anger and Aggression
When properly monitored and medically supervised, TRT should not significantly increase aggression or anger, says Wasserman. If an individual experiences actual rage or increased incidence of aggression following supplementation, it’s because they are (illicitly) taking extremely high doses of testosterone that far exceed what is prescribed to the general population.
The closest thing to aggression an individual might experience with testosterone replacement therapy is slight mood swings, says Wasserman. “Mood swings when supplementing with doctor-approved doses of testosterone are rare, but possible,” she says. In the event that this happens, most providers will lower the dose or suggest a different application method. Some research suggests that mood swings are a more common side effect with injection-based testosterone than topical or oral application.
Most individuals actually report an improvement in mood after starting testosterone replacement therapy. One published in the European Journal of Endocrinology, for example, found that individuals may experience relief from depression after just three to six weeks of testosterone supplementation. Meanwhile, research published in the Journal of Clinical Endocrinology & Metabolism linked TRT with slightly improved mood and energy levels amongst middle-aged folks with lower testosterone.
Myth: TRT Impacts Penis Size
FYI: “Testosterone replacement therapy does not affect penis size in adulthood,” says Golding-Granado. In fact, research suggests that there are currently no non-surgical ways to change penis size.
That said, extended testosterone replacement therapy can make the testicles shrink, she says. In men, the testicles are the primary producers of testosterone. Taking testosterone via hormone replacement therapy may reduce exactly how much they make—even if they were pumping out lower-than-normal levels prior to the prescription, she says. Why? Well, testosterone supplementation halts the production of gonadotropin-releasing hormone (GnRH). Without GnRH, the pituitary gland doesn’t get the signal to make more luteinizing hormone (LH). The testicles need luteinizing hormone to make testosterone, so in the absence of LH, the body produces less.
Read More: 7 Signs You Should Have Your Testosterone Levels Tested
When the testicles don’t produce as much testosterone, the testicles can shrink, says Wasserman. However, the size difference usually isn’t significant. One study published in The Journal of Urology found that four months of weekly testosterone injections led to testicular volume decreases between 2.1 and 3.4 percent.
Notably, one 2022 study published in The Journal of Sexual Medicine found that testicular shrinkage was more likely to occur in patients with larger baseline testicular size as well as those treated with injectable formulations. The researchers concluded that patients with large testicular volume and/or anxiety about testicular atrophy should consider TRT in other forms rather than injectable formulations.
Myth: TRT Is The Same as Erectile Dysfunction Medication
TRT and erectile dysfunction (ED) medications are not the same. While TRT medications are designed to be taken to provide the body with additional hormones (specifically, testosterone), erectile dysfunction medications like sildenafil (Viagra) or tadalafil (Cialis) are hormone-free ingestibles that increase blood flow to the penis for a short period, explains Wasserman.
That said, some individuals who previously used ED meds may be able to cease usage after starting testosterone replacement therapy, Wasserman says. Low levels of testosterone have been shown to interfere with the body’s release of stimulatory chemicals that support erectile function, including nitric oxide, dopamine, and oxytocin, and therefore contribute to erectile dysfunction. Using TRT can address the underlying cause of erectile dysfunction in those whose dysfunction is caused by low testosterone, she explains.
Crucially, some individuals with low testosterone may need to supplement with both. “A lot of erectile dysfunction cases have little or nothing to do with having low testosterone,” says Mitchell. “Instead, the ED is caused by another factor, such as circulation issues, stress, chronic fatigue, depression, alcohol, or a dozen other factors,” he says. For these folks, supplementing with TRT will support overall hormone balance, while an ED prescription will be necessary for erectile support, he says.
Myth: TRT Causes Baldness
Despite the prevalence of bare-headed powerhouses like The Rock in mainstream media, concerns around baldness are about as common as baldness itself. (Did you know that up to 50 percent of men go bald by age 50?) But if you’re considering starting testosterone replacement therapy, fear of male-pattern baldness (or, androgenetic alopecia) shouldn’t stop you.
“TRT is not thought to directly cause baldness,” says Golding-Granado. In fact, researchers from a 2017 study published in JAMA Dermatology reported zero connection between sex hormone levels (including testosterone) and hair loss. That said, TRT may accelerate male-pattern baldness in those genetically predisposed to it, according to Wasserman.
You see, a hormone called dihydrotestosterone (DHT) plays a significant role in hair growth (or the lack of it), she explains. Testosterone—including the testosterone an individual on TRT is prescribed—is not the same as DHT. However, about 10 percent of all the testosterone in the body gets converted to DHT. “DHT can shrink the blood supply reaching your hair follicles, and therefore, can contribute to hair thinning and hair loss,” she says.
The thing is, just how sensitive your hair follicles are to DHT is primarily based on genetics, per research. That means that how much your hair follicles shrink (if at all) in response to the slightly elevated DHT levels that occur from testosterone supplementation, depends on whether or not there is a genetic predisposition to baldness, says Wasserman.
If you’re interested in TRT but concerned about balding, talk to your healthcare provider about it. The right doctor will be able to assess your risk of baldness given family history and suggest possible preventative treatments. “There are also supplements and vitamins individuals can take to minimize the conversion of testosterone to DHT,” says Golding-Granado. Two options: green tea and turmeric.
Myth: Testosterone Injections Are More Effective Than Other Formats
Testosterone replacement therapy may be available in a variety of application methods, but many people mistakenly believe that these methods exist in a hierarchy, with intramuscular injection belonging at the top.
The truth is that all forms of testosterone can effectively raise your testosterone levels, says Golding-Granado. However, the forms all work differently from one another, and thus an individual needs to figure out which method they can use reliably and accurately, says Wasserman.
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- Testosterone injections: Also known as T-shots, injections require an individual to inject their muscle or subcutaneous fat one to two times per week, says Golding-Granado. While injections allow for easy dose adjustments, they also require an individual to self-administer a shot, which may not be ideal for anyone squeamish around needles.
- Testosterone pellet implant: “Pellets get inserted under the skin, where they provide a constant correction of TRT to the user,” says Golding-Granado. The steady stream of the hormone can help mitigate testosterone highs and lows, but the pellet needs to be replaced every three to four months, which means signing up for regular procedures.
- Testosterone gel: Testosterone gel is applied daily to the skin (usually to the upper arm and back), where it absorbs into the skin and then the bloodstream. The draw of gel application is that it doesn’t require injections, needles, or minor surgeries to use. “The downside is that the gel can accidentally be transferred to individuals who come in contact with treated skin,” Golding-Granado explains. This can be harmful to women and children and requires the user to take special care.
- Oral medications like Kyzatrax®: Up to 96 percent effective, Kyzatrex capsules are formulated to be easily absorbed and bypass your liver. That means it works efficiently, without causing liver damage. Just two oral doses a day with food make it a safe and convenient option, especially for those first starting out.
Ultimately, the method you choose should be based on personal preference, lifestyle, and medical advice, says Wasserman.
Interesting in exploring TRT? Take the questionnaire at Whole Health Rx to see if you meet initial qualifications.