What about that free lunch question? 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 treated with topical or oral medications quite effectively. The tendency to lose scalp hair can be exacerbated as well, but this too 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 and the newer free PSA ( a more specific test) before starting TRT and we continue to monitor it twice yearly
The concern about a link between testosterone and heart disease comes from the following line of reasoning: men have a higher incidence of heart disease than women; men have higher testosterone levels than women; therefore, higher testosterone levels may cause a greater incidence of heart disease. This is another example of the fallacious reasoning that plagues the field of hormone replacement therapy. Because two conditions are found in the same population, it does not necessarily follow that the one causes the other. For these two conditions—testosterone levels and heart disease—we have, in fact, the results of many studies that show just the opposite. This has been studied extensively and there is a greater incidence of heart disease in men with low testosterone levels than those with high levels. More dramatic evidence comes from the fact that giving testosterone intravenously during angina results in improvement in symptoms. Other studies have looked at the effect of TRT on cholesterol levels and have universally found a decrease in total cholesterol, LDL, and triglycerides, and no change or only a slight decrease in HDL. And, as mentioned above, restoring youthful testosterone levels can reverse the metabolic syndrome that can increase the risk of cardiovascular disease. So much for the prevailing wisdom.
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