TRT Pros and Cons: A Longevity Doctor’s Honest Assessment of Testosterone Replacement Therapy

Testosterone replacement therapy (TRT) may be the most debated topic in men’s health. On one side, online communities and direct-to-consumer clinics promote TRT as a near-universal solution to male aging. On the other, risk-averse conventional physicians refuse to discuss it even with clearly symptomatic patients with confirmed low testosterone.

The truth is in the evidence — and the evidence is now more robust than ever. At Grossman Wellness Center in Denver, Dr. Terry Grossman has prescribed and monitored testosterone therapy for over 30 years. This is his honest, evidence-based assessment of TRT: who benefits, what the risks actually are, and when it should and should not be used.

What Is TRT and Who Is It For?

Testosterone replacement therapy involves administering exogenous (externally sourced) testosterone to restore levels that have declined below the range needed for normal physiological function. It is FDA-approved for the treatment of hypogonadism — clinical testosterone deficiency confirmed by lab testing plus symptoms.

Good candidates for TRT have:

• Total testosterone consistently below 300–350 ng/dL on morning measurements (or low free T with elevated SHBG)
• Symptoms clearly attributable to low testosterone (fatigue, reduced libido, mood changes, muscle loss, etc.)
• Ruled out reversible causes (obesity, sleep apnea, hypothyroidism, medication effects)
• No contraindications (untreated prostate or breast cancer, elevated hematocrit, uncontrolled heart failure)

TRT is not appropriate for men with normal testosterone levels seeking performance enhancement, or as a first-line treatment before lifestyle optimization is attempted.

Proven Benefits of TRT

When appropriately indicated, TRT produces well-documented improvements across multiple domains. These are not anecdotal — they are consistently demonstrated in randomized controlled trials including the Testosterone Trials (TTrials), the largest TRT study ever conducted:

Body Composition

TRT consistently increases lean muscle mass and reduces fat mass, particularly visceral (abdominal) fat. The TTrials found significant improvements in body composition even without changes in diet or exercise — effects that are amplified substantially with resistance training. For men with low T and metabolic syndrome, improved body composition also improves insulin sensitivity.

Energy and Vitality

Fatigue and low energy are the most commonly reported symptoms of low testosterone and among the most reliably improved with TRT. Most patients notice meaningful energy improvement within 3–6 weeks of starting treatment, reaching maximum benefit by 3–6 months.

Sexual Function and Libido

Testosterone is the primary driver of libido in both men and women. Low T is associated with significantly reduced sexual desire and contributes to erectile dysfunction (though ED has multiple causes). TRT reliably restores libido when testosterone is the primary driver. Erectile function improvement is more variable and may require additional support.

Mood and Cognitive Function

Testosterone receptors are abundant in the brain — particularly in the amygdala, hippocampus, and prefrontal cortex. Low T is strongly correlated with depression, anxiety, and cognitive decline. The TTrials found significant improvements in mood and depressive symptoms with TRT. Many patients at Grossman Wellness Center report clearer thinking and improved motivation as early benefits of optimized testosterone.

Bone Density

Testosterone is critical for bone mineral density in men. Hypogonadism is associated with significantly elevated fracture risk, and TRT consistently improves bone density — a benefit that may take 1–2 years to fully manifest on DEXA scans but is clinically significant, especially for older men.

Cardiovascular Health

The landmark TRAVERSE trial (2023), which enrolled over 5,200 middle-aged and older men with low testosterone and cardiovascular risk factors, found that TRT did not increase the risk of major cardiovascular events (heart attack, stroke, death). This largely settled the debate that had surrounded TRT’s cardiac safety since a problematic 2010 study. Low testosterone itself is associated with increased cardiovascular risk — correcting it appears neutral to beneficial.

Real Risks and Side Effects of TRT

TRT is not risk-free, and informed decision-making requires understanding what the actual, evidence-based risks are — not the overstated fears or the minimized dismissals you might get from either end of the debate.

Erythrocytosis (Elevated Hematocrit)

Testosterone stimulates red blood cell production. In some men, this causes hematocrit to rise above safe levels (>54%), increasing blood viscosity and theoretically increasing clotting risk. This is the most clinically significant real risk of TRT and is why hematocrit monitoring every 3–6 months is non-negotiable. Management options include dose reduction, changing delivery method, or therapeutic phlebotomy.

Testicular Atrophy and Suppression of Natural Production

Exogenous testosterone suppresses the HPG axis (hypothalamic-pituitary-gonadal axis), causing the testes to reduce or stop their own testosterone production. This leads to testicular shrinkage and reduced sperm production. This is manageable — hCG can be added to TRT protocols to maintain testicular volume and function — but must be understood before starting.

Fertility Impairment

TRT suppresses spermatogenesis and is essentially a form of male contraception. Men who want to father children during their TRT period should discuss alternatives (clomiphene, hCG, FSH) or understand that fertility may not recover quickly after discontinuation.

Estrogen Elevation (Aromatization)

Testosterone converts to estradiol via the aromatase enzyme. While some estrogen is necessary for men (bone health, cardiovascular function, libido), excessive conversion can cause gynecomastia (breast tissue development), water retention, and mood changes. Estradiol monitoring and aromatase inhibitors (AI) when necessary are part of well-managed TRT protocols.

Sleep Apnea Exacerbation

TRT can worsen existing sleep apnea, though it does not typically cause it in men who did not already have it. Men with risk factors should be screened and treated for sleep apnea before or concurrent with TRT initiation.

Skin Effects

Acne and oily skin can occur, especially at higher doses or with more androgenic delivery methods. This is dose-dependent and manageable.

TRT Myths vs. The Evidence

Common Myth	What the Evidence Actually Shows
“TRT causes prostate cancer”	No causal link established. The original androgen hypothesis has been revised. TRAVERSE found no increased prostate cancer incidence. PSA monitoring remains essential.
“TRT causes heart attacks”	TRAVERSE (2023) found no increased MACE (major adverse cardiovascular events). Low T itself is a cardiovascular risk factor. Properly managed TRT appears neutral to beneficial.
“You’ll be on TRT forever once you start”	Natural production can often be partially or fully restored after discontinuation, especially in younger men and when hCG is used concurrently. It takes time — typically months — for the HPG axis to recover.
“High T is always better”	Supraphysiological testosterone does not produce better outcomes than optimized physiological levels and increases risks. The goal is optimization, not maximization.

TRT Delivery Methods Compared

• Intramuscular injections (testosterone cypionate or enanthate) — Most cost-effective. Given every 1–2 weeks. Produces peaks and troughs in testosterone levels. Can be self-administered at home.
• Subcutaneous injections — Smaller doses injected under the skin more frequently (2–3x/week). Produces more stable levels with fewer peaks and troughs. Increasingly preferred for better symptom consistency.
• Topical gels/creams — Daily application. Convenient but with transfer risk to partners and children, and variable absorption.
• Pellets — Implanted under the skin every 3–6 months. Provides very stable long-term levels but is irreversible until the pellet dissolves. Dose cannot be quickly adjusted.
• Oral testosterone undecanoate — FDA-approved oral option. Requires twice-daily dosing with a fatty meal. Less commonly used.

Alternatives to TRT Worth Considering First

At Grossman Wellness Center, we evaluate whether testosterone can be optimized naturally before committing to exogenous replacement:

• Lifestyle optimization — Weight loss, sleep improvement, resistance training, and stress reduction can raise testosterone by 20–30% in men with modifiable risk factors
• Clomiphene citrate (Clomid) — An estrogen receptor modulator that stimulates the pituitary to produce more LH/FSH, which signals the testes to produce more testosterone. Preserves fertility and natural production. Best for secondary hypogonadism.
• hCG (human chorionic gonadotropin) — Mimics LH and directly stimulates testicular testosterone production. Maintains testicular size and fertility. Can be used alone or alongside TRT.
• Peptide therapy — Agents like sermorelin stimulate growth hormone release, which supports the overall hormonal environment. Our peptide therapy program is often a useful adjunct.
• Nutritional correction — Vitamin D, zinc, magnesium, and omega-3s are all required for testosterone synthesis and are frequently deficient in men with low T

Frequently Asked Questions

Does TRT cause prostate cancer?

Current evidence does not support a causal link between TRT and prostate cancer in men with normal baseline PSA. The TRAVERSE trial (2023) found no increased prostate cancer incidence in TRT vs. placebo. PSA monitoring every 6–12 months during TRT is still essential and required at Grossman Wellness Center.

Is TRT safe long-term?

For appropriately selected patients under medical supervision, long-term TRT appears safe. The TRAVERSE trial followed patients for nearly 3 years with no excess cardiovascular events. Real risks — erythrocytosis, fertility suppression, sleep apnea exacerbation — are manageable with proper monitoring.

Will TRT make me infertile?

TRT suppresses sperm production and should be considered contraceptive-level birth control. For men who want to father children, we discuss alternatives (clomiphene, hCG) or fertility preservation before starting TRT. Recovery of fertility after TRT discontinuation is possible but may take 6–18 months.