As we mentioned previously, 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 mid thirties, forties, or not until his fifties; eventually, however, it will drop to a lower level than when he was twenty. If it drops below 300 (assuming he is lucky enough to get his doctor to check it), 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 9 ng/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 more than 30 percent, he notices he has been having trouble making progress at the gym, and he notices that it is tougher to keep the weight off of his waist? Herein lies the crux of the controversy.
Two questions immediately come to mind when pondering this controversy. First, Are there benefits to be had from raising a testosterone level from 500 to 800 ng/dl? If there are, Are there any significant risks—both short and long term—to maintaining this level of testosterone with therapy? The first is the “Where’s the beef?” question; the second is the “There’s no free lunch” healthy skepticism question.
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. In case you’re wondering, 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.