Controversies of Testosterone Replacement Therapy

Controversies of Testosterone Replacement Therapy (TRT)

The biggest controversy surrounding Testosterone Replacement Therapy (TRT) is the exactly the same as all Hormone Replacement Therapy (HRT). Preventive-aging experts world-wide including Dr. Steve Zakany believe that hormones should be corrected to optimal levels for optimal functioning of the mind and body1. This corresponds roughly to the 75th percentile of the hormone levels found in a healthy 25 years old.

Traditional physicians who have not received advanced training in Anti-Aging Medicine typically believe that hormone levels should not be optimized or corrected unless they fall outside the “normal range”. The problem is that the “normal range” is typically not age specific and dependent on the lab. It usually includes the range of what 90% of all tested fall into. This would mean that only 5% of all people tested would be considered either high or low.

Both total and free testosterone studies should be measured to adequately evaluate testosterone levels. Depending on the lab used, approximately 300-900 ng/dL are given as a normal laboratory range, for men ages 20-70. For females, this range is 15-70 ng/dL. Free testosterone levels average approximately 2% of the total, 55-200 pg/ml for men and 1-10 pg/ml for women. Free testosterone is the more valuable of the two, reflecting the amount of hormone available to perform useful work.

Relying on a 50-year age span2 (from ages 20 to 70) for a “normal range” is not useful. A decline of 70% from more youthful3 levels can produce numerous clinical problems, yet is declared “within normal range”4. A more accurate approach is using the upper end5 of normal range,” adjusted for age-then maintain these levels over time, rather than letting them continually decline. This is the healthy or optimal range.

There is extensive evidence that replacing testosterone in ‘hypogonadism’ is warranted and is FDA approved. At sometime during his life a man will begin to experience a decline in testosterone levels, both free and total. It may be in his thirties6, forties, or not until his fifties; however, it will drop eventually to a lower level than when he was twenty. If it drops below 300, then there is no controversy-it should be treated. But what about the 50 year old otherwise healthy male with a total testosterone of 500 ng/dl and a free testosterone level of 100 pg/dl who may have had a level of 800 when he was in his early twenties? Should he wait until he reaches the “magic” number of 300 for his total testosterone level before he starts TRT? Or is it sufficient that his level has already dropped over7 35%, and he notices he has been having trouble building muscles at the gym, and having a tougher8 time keeping the weight off of his waist9? This is the center of the controversy.

Two questions come to mind when considering this controversy. First, are there benefits to raising a testosterone level from 500 to 800 ng/dl? If so, are there any significant risks, both short and long term, in maintaining this level of testosterone with therapy?

A number of studies have been done in healthy young men in which doses of testosterone were given that raised their levels into the high adolescent range, 1000 to 2000 ng/dl. In all of these studies, lean muscle mass has increased and fat mass has decreased. Similar studies with lower doses have been done in moderately obese men; again, lean mass increased and fat decreased even more. Moreover, insulin resistance (a pre-diabetic state) improved, triglycerides decreased, and energy increased. None of these studies noted any increase in aggressive behavior that many people expect might happen with high doses of testosterone.

Many more studies have been published showing similar effects in older men (over 65) with mildly low testosterone levels. The NIA has published the results of studies of TRT on body composition (lean muscle and fat ratios) in 108 men which demonstrated a 6 lb. fat loss and 5 lb. lean muscle gain when the testosterone level was raised from an average of 370 to 640 ng/dl for 36 months. The same men had an increase in bone density if they started out with a low bone density. The accumulating evidence shows that whenever you raise the testosterone level-no matter what the starting level-you get benefits in body composition. We think that the dose of testosterone used in this study was too low and that if higher dose had been used even more impressive results would have been demonstrated, without any significant increase in adverse effects.

Short term risks, what we call side effects, are few. If a man had a propensity to develop acne as a teenager, this may be reactivated when the testosterone levels get raised back to adolescent levels. This can be effectively treated with topical or oral medications. The tendency to lose scalp hair can be exacerbated as well, but this also can be effectively treated with a medication that inhibits the conversion of testosterone to dihydrotestosterone called finasteride or Propecia.

The main concern that men have with regard to long term TRT is whether it will increase the risk of prostate cancer, BPH, and cardiovascular disease. At physiologic replacement levels-the range we keep our patients within-there is no evidence of any increase risk of prostate cancer or enlargement of the prostate to the point of symptoms. It is true that the longest prospective study is the three year NIA study-which didn’t show any prostate problems-but the overwhelming majority of case-controlled, retrospective, epidemiological studies following men for many years show no increased risk in men whose testosterone levels are higher than average. The concern about TRT increasing the risk of prostate cancer stems from the well documented fact that prostate cancers shrink if you deprive them of testosterone; however, as with breast cancer, this does not prove a causal or initiating role. If one does have an occult (as yet undetected ) cancer, then it may cause it to grow, but we screen all our patients with a total PSA before starting TRT and we continue to monitor it twice yearly.

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Key Terms…
  • available ↔ disponível
  • more youthful ↔ mais jovem
  • upper end ↔ extremidade superior
  • his thirties ↔ seus trinta anos
  • dropped over ↔ caiu mais
  • tougher ↔ mais difícil
  • waist ↔ cintura
  • come to mind ↔ vêm à mente
  • raising ↔ levantando
  • lean muscle mass ↔ massa magra
  • mildly low ↔ levemente baixo
  • fat ratios ↔ gordura corporal
  • whenever ↔ sempre que
  • adverse effects ↔ efeitos adversos
  • side effects ↔ efeitos colaterais
  • scalp hair ↔ cabelo do couro cabeludo
  • enlargement ↔ alargamento
  • overwhelming majority ↔ maioria esmagadora
  • stems ↔ deriva
  • twice yearly ↔ duas vezes ao ano


1 optimal ideal
Eles descobriram que cerca de 20 por cento dos testados ficaram abaixo dos níveis ideais. ↔They found that roughly 20 percent those tested fell below optimal levels.
Estas bandas devem ser integradas e equilibradas para o ideal funcionamento. ↔These sides must be integrated and balanced for optimal functioning.
2 relying on the age span baseando-se na faixa etária
Eu era muito jovem quando cheguei ao topo, então eu estava contando com pessoas mais velhas do que eu. ↔ I was very young when I got to the top so I was relying on people older than me.
Na faixa etária compreendida entre o nascimento e a metade da adolescência, as alterações são mais rápidas em todos os domínios. ↔ In the age span from birth to middle adolescence, the changes are faster in all of the domains.
3 more youthful mais jovem
Proporciona um aspecto mais jovem, firme e suave. ↔ Promotes a firmer, smoother and more youthful complexion.
Na vida real, nem precisaria dizer, ela parece muito mais jovem do que eu. ↔ In real-life, needless to say, she looks a great deal more youthful than I do.
4 normal range normalidade
Este intervalo está acima da normalidade, mas abaixo da faixa que indica a diabetes. ↔ This range is above the normal range but below the range that indicates diabetes.
5 upper end extremidade superior
Por US $ 99, a LifeCam está claramente na extremidade superior do intervalo de preços para webcams. ↔ At $99, the LifeCam is clearly in the upper end of the price range for webcams.
6 his thirties seus trinta anos
Adam Brody está bem agora em seus trinta anos e ainda está atuando nos mesmos papéis. ↔ Adam Brody is now well into his thirties, and is still playing the same roles.
7 dropped over caiu mais de
As primeiras bombas incendiárias foram lançadas ao longo dos subúrbios de Norton Lees e Gleadless. ↔ The first incendiaries were dropped over the suburbs of Norton Lees and Gleadless.
Ambas as filiações a democratas e republicanos caíram no mesmo período. ↔ Democratic and Republican affiliation both have dropped over the same period.
Alguns relatórios indicam que as importações em alguns meses caíram mais de 60 por cento. ↔ Some reports indicate that imports in some months have dropped over 60 percent.
8 tougher mais difícil
A vitória de George Washington em Charlotte torna os colonos um pouco mais difíceis de pegar. ↔ George Washington’s win at Charlotte makes the Colonials a bit tougher to catch.
9 waist cintura
Apenas golpes desferidos no corpo do oponente acima da cintura, no braço e na cabeça são válidos. ↔ Only hits scored on the opponent’s body above the waist, arm and head are valid.


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