What are the Main Side Effects of Testosterone Replacement Therapy (TRT)?


Like all treatments, testosterone therapy is associated with a number of known risks, and these should be communicated to patients prior to initiation of treatment. A key item is impaired spermatogenesis (sperm production) due to suppression of gonadotropins (LH and FSF). Men considered candidates for TRT should be questioned as to their desire to induce a pregnancy. Since sperm production may be reduced to zero, exogenous T alone should be avoided until fertility is no longer a concern. Treatment with hCG injections or oral clomiphene citrate may be considered in these men, as they do not suppress spermatogenesis. There is some limited data on the use of testosterone plus hCG for improvement of sperm quality and quantity in men.

Acne may occur in younger men.  Edema can be occasionally observed in middle-aged or older men due to fluid retentive properties of testosterone.

Erythroctyosis (increased red blood cell count that causes high hematocrit) is infrequently seen with topical and injectable TRT treatments, but is routinely observed in men treated parenterally with short-acting injections or implanted pellets. Although there is no evidence to date that T-induced erythrocytosis is associated with adverse events, it seems reasonable to prevent the hematocrit from rising excessively. Men whose hematocrit rises above 54% (or hemoglobin greater than 18 g/dL) should be considered for dose reduction, temporary discontinuation of T therapy, blood donation or therapeutic phlebotomy

Read this first since it is the most common testosterone side effect: High hematocrit


Acne/oily skin 

Caused by Dihydrotestosterone (DHT) effect on increased oil production

· Accutane– a powerful prescription item - 40 mg/day for one week sometimes stops acne if started at the first sign or as directed by your doctor. Accutane is potentially highly liver toxic and can lower testosterone. Do not use unless as last resort.
· Sporanox – Effective for some acne-like eruptions that are caused by fungi. Some doctors also prescribe antibiotics, like tetracycline, for acne with good results.
. Minocycline
. Shower with Nizoral shampoo· Anti-bacterial soaps - Use a scrubbing brush and wash twice a day, especially after sweating during a workout.
· UV light or sunlight with moderation.
. Zinc/copper supplements or zinc soaps may help some men with acne.
. Other options: How to treat and prevent acne


Hair loss

Caused by DHT effect on hair follicles

· Nizoral shampoo– Available by prescription and over-the-counter as a lower dose product.
· Rogaine – Available over the counter
· Propecia - Available by prescription. A few males experience decreased erections with finasteride. Do not use.


Increased sex drive


· A problem? Sex drive is part of quality-of-life. This is not necessarily a bad side effect. Enjoy it.


Unresolved erectile dysfunction


· ED Medications-Available by prescription; enables robust erections. If you have sinus congestion or headaches/backaches take non-drowsy allergy medication and ibuprofen. ED drugs can be combined with alpha-blockers and/or nitric oxide precursor amino acids (arginine or citrulline)
· Yohimbine (Yocon) - Available by prescription; increases sex organ sensitivity. Can increase heart rate and blood pressure
· Muse - Available by prescription; pellet inserted into the urethra to produce an erection. Unpopular
· Trimix – Available by prescription from compounding pharmacies. The best and cheapest formula for injection into the penis for lasting erections.
· Caverject - Available by prescription. An injection into the penis that produces an erection that can last 1 to 2 hours. Be careful with injecting too much since it can produce dangerously ling erections that need to be treated in emergency rooms! Follow instructions from your urologist.
· Papaverine – An older injectable medication, less expensive than Caverject.
· Wellbutrin – Prescription at 300 to 450 mg/day; increases dopamine.
· Human chorionic gonadotropin (HCG) – First dose is 2,000 IU, then 250-500 IU twice or three times a week. No protocol has been proven in controlled studies yet. When Testosterone Replacement Doesn’t Lead to Better Erections



Usually, this is caused by dosages that are too high. Find the least amount that gives you a good result.

· Sleeping medications – e.g. Ambien, Sonata, Lunesta, Restoril
· Melatonin- 1 to 3 mg before bedtime. If you wake up groggy after 6 hours your dose should be lower.
· Avoid working out too close to bedtime.
· Limit caffeine, especially after 3 pm.
· You may want to try a sleep formula with tryptophan, melatonin, and magnesium. Nutrients do not work as well as drugs, but they can help some people.
Article: How to protect your circadian rhythm


Sleep Apnea


· Have your doctor prescribe a sleep study if you snore and wake up tired even after 7 hours of sleep. Some people may have to wear a C-PAP machine to breathe at night. Visit Home - SleepApnea.org for more information. There are also oral devices for those people who fail CPAP. Fatigue- When Testosterone Is Not Enough


Testicular atrophy


· Human Chorionic Gonadotropin (hCG)– One 2,000 unit injection per week for 2 weeks, followed by maintenance of 350-500 IU twice a week. Decrease testosterone dosage accordingly after starting hCG to reach levels around 500-1200 ng/dL while keeping all other lab work monitored. Watch this video on hCG and men


Enhanced assertiveness or reactivity


· Make sure you are getting enough sleep.
. Count until 10 and be aware of your interaction with others.
· Decrease caffeine.
· Meditation, mindfulness, yoga, breathe from your belly for a few minutes when overreacting.
· The testosterone dosage may be too high.
· Ask yourself: Do I need to always be right?
. Vent extra energy at the gym, sex, and sharing with your buddies at www.excelmale.com


High blood pressure/water retention


· Caused by sodium retention in the kidneys.  Try to limiti salt consumption.

. Blood pressure medications - Elevated blood pressure may be transient or not. Try ACE or ARBs since they seem to have fewer sexual dysfunction related effects.
· Magnesium (600 mg/day); vitamin B6 (100 to 200 mg/day); may help reduce water retention.
· Water - Drink extra water every day to help flush the kidneys.
. Check your estradiol to make sure it is not over 45 pg/ml. Treat if high with low dose anastrozole.
. Make sure you are doing cardio exercise at least 3 times a week for 30 min. Sweat and lower your salt intake since TRT increases sodium retention in some men.


Gynecomastia (male breast development)

Caused by high estradiol in the presence of low testosterone. This is rare in men on testosterone replacement.

· Arimidex Inhibits estrogen production. Available by prescription. 0.25 mg per week. There is no agreement on what the highest E2 level is for men on TRT with high testosterone. Ensure that your estradiol does not go too low (under 20 pg/ml) if you use anastrozole since it is needed for bone, skin, brain, lipids, libido, good lipids and hair health.
· Nolvadex (tamoxifen)– Competes with estrogen for receptors. Available by prescription, 10 to 20 mg/day. Use of Nolvadex during a steroid cycle may reduce the net anabolic effect, as it decreases the production of GH and IGF-1. High IGF-1 may be implicated in gynecomastia.
. Severe cases may require removal of the breast tissue by surgery.
· DHT cream- Some people have obtained great results by rubbing a 10% DHT cream on their nipples. Not available in the US but some people order it online from Germany
. Read about medications/foods to avoid if you have gynecomastia.
. Those who do know to respond to the above, check other reasons

Watch this video about estradiol in men

Check your estradiol with the right sensitive estradiol test.



Find out how long it takes testosterone replacement to potentially show benefits


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More information on TRT lab tests.




Metzger, DL, et al. Estrogen receptor blockade with tamoxifen diminishes growth hormone secretion in boys: evidence for a stimulatory role of endogenous estrogens during male adolescence. J Clin Endocrinol Metab (1994) 79(2):513-518.


[ii] el-Sheikh, MM, et al. The effect of Permixon (saw palmetto) on androgen receptors. J Acta Obstet Gynecol Scand (1988) 67(5):397-399.


[iii] Suzuki, K, et al. Endocrine environment of benign prostatic hyperplasia: prostate size and volume are correlated with serum estrogen concentration. Scand J Urol Nephrol (1995) 29:65-68.


[iv] Gann, PH, et al. A prospective study of plasma hormone levels, nonhormonal factors, and development of benign prostatic hyperplasia. The Prostate (1995) 26:40-49.



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