Is testosterone therapy safe? Take a breath before you take the plunge

Millions of American men use a prescription testosterone injection or gel as forms of testosterone replacement therapy (often referred to as TRT therapy) to restore normal levels of the manly hormone. The ongoing pharmaceutical marketing blitz promises that low-T treatment can make men feel more alert, energetic, mentally sharp, and sexually functional. However, legitimate safety concerns linger. 

The low-T boom

Marketers urge men to talk to their doctors if they have certain "possible signs" that mean they could need low-T treatment. So many men continue to ask about it after seeing ads that ask "Do you feel tired?"

Just being tired isn't enough to seek testosterone replacement therapy. General fatigue and malaise has so many other causes, and when most men get a blood test, the result is a normal testosterone level. 

If a man's testosterone is below the normal range, it's best to repeat it once more to be sure before starting testosterone therapy — often staying on it indefinitely. There is a bit of a testosterone trap. Men get started on testosterone replacement and they feel better, but then it's hard to come off of it. On treatment, the body stops making testosterone. Men can often feel a big difference when they stop therapy because their body's testosterone production has not yet recovered.

What are the risks of testosterone therapy?

A relatively small number of men experience immediate side effects of testosterone supplementation, such as acne, disturbed breathing while sleeping (worsening sleep apnea), breast swelling or tenderness, or swelling in the ankles. Doctors also watch out for high red blood cell counts, which could increase the risk of clotting.

Older observational studies suggested that long term testosterone use could increase their risk of cardiovascular disease. Also testosterone is known to stimulate growth of prostate cancer in men diagnosed with the condition. Recent clinical trials, which provide more accurate information compared to observational studies, have provided some comfort around both the heart and prostate cancer risks. For men who clearly have testosterone deficiency, there is no apparent increased risk of heart attack or stroke or greater chance of developing a new prostate cancer from testosterone replacement therapy.

Although this new information is somewhat reassuring, men and their doctors should still weigh these issues before committing to long term testosterone therapy.

Take a cautious approach

Here is how to take a cautious approach to testosterone therapy.

Take stock of your health first

• Have you considered other reasons why you may be experiencing fatigue, low sex drive, and other symptoms attributable to low testosterone? For example, do you eat a balanced, nutritious diet? Do you exercise regularly? Do you sleep well? Address these factors before turning to hormone replacement therapy for men.
• If your sex life is not what it used to be, have you ruled out relationship or psychological issues that could be contributing?
• If erectile dysfunction has caused you to suspect "low T" as the culprit, consider that cardiovascular disease can also cause erectile dysfunction.

Get an accurate assessment

• Inaccurate or misinterpreted test results can either falsely diagnose or miss a case of testosterone deficiency. Your testosterone level should be measured between 7 am and 10 am, when it's at its peak. Confirm a low reading with a second test on a different day. It may require multiple measurements and careful interpretation to establish bioavailable testosterone, or the amount of the hormone that is able to have effects on the body. Consider getting a second opinion from an endocrinologist.
• After starting therapy, follow-up with your physician periodically to have testosterone checks and other lab tests to make sure the therapy is not causing any problems with your prostate or blood chemistry.

Be mindful of the still possible risks of testosterone replacement therapy

• Approach testosterone therapy with caution if you are at high risk for prostate cancer; have severe urinary symptoms from prostate enlargement; or have diagnosed heart disease, a previous heart attack, or multiple risk factors for heart problems.
• Ask your doctor to explain the various side effects for the different formulations of testosterone. The different treatments include testosterone injections, gels, and patches. Know what to look for if something goes wrong.

Have realistic expectations

• Testosterone therapy is not a fountain of youth. There is no proof that it will restore you to the level of physical fitness or sexual function of your youth, make you live longer, prevent heart disease or prostate cancer, or improve your memory or mental sharpness.
• If erectile function has been a problem, testosterone therapy might not fix it. In fact, it might increase your sex drive but not allow you to act on it. You may also need medication or other therapy for difficulty getting or maintaining erections.

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