Testosterone Replacement Therapy: The Honest Balance of Benefits and Risks

آخر تحديث: أغسطس 29, 2026

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Testosterone deficiency is common in my andrology clinic, and testosterone replacement therapy genuinely changes life for the men who have it. It is also, at the same time, one of the most oversold treatments in men’s health. Both things are true, and a man deciding whether to start deserves to hear them together rather than one at a time. Levels peak in early adulthood and drift down slowly from around age thirty — but a number that falls with age is not by itself a disease, and that distinction is where most of the confusion in this subject begins.

First: Is It Actually Testosterone?

Testosterone therapy is for men who have both a low level, confirmed on two separate early-morning blood tests, و symptoms that fit. Symptoms alone are not enough, because tiredness, low mood, poor concentration and reduced libido are produced far more often by sleep debt, untreated sleep apnoea, depression, alcohol, thyroid disease, medication or simply being overweight. Treating a normal man with testosterone does not fix any of those — it just adds a hormone he did not need. If your level is normal and you still feel drained, the answer is elsewhere; I have written about that in why testosterone is a barometer of overall health.

What It Reliably Improves

In men with a confirmed deficiency:

• Sexual desire — the most consistent benefit, and usually the first to move, within weeks
• Mood, energy and sense of well-being — often within weeks to a few months
• Muscle mass and body fat — real, but measured over many months, and much smaller without exercise
• Bone mineral density — improves over a year or more on a scan. Read the next section before treating that as a benefit: the fracture trial went the other way.

And what it does not reliably do

Erections. Desire and erection are not the same thing. Testosterone raises desire dependably; it corrects erectile dysfunction far less often, because most erectile dysfunction is vascular rather than hormonal. A man whose main complaint is getting or keeping an erection needs the cause of that established rather than assumed to be his testosterone.

Metabolic disease and diabetes. Low testosterone travels with obesity, diabetes and metabolic syndrome, and treatment can improve some measures — but the direction of that relationship runs both ways. The prespecified TRAVERSE diabetes substudy found no significant effect on progression from prediabetes to diabetes, and the American Diabetes Association does not recommend testosterone for that purpose. It is not a treatment for diabetes or a substitute for weight loss.

Bones. This deserves stating plainly rather than leaving as an absence of evidence. Testosterone improves bone mineral density on a scan, and it was long assumed that fewer fractures would follow. The TRAVERSE fracture subtrial found a statistically significant increase of roughly 43% in clinical fractures on testosterone — around 3.5% of men versus 2.5% on placebo, with the curves separating within the first few months. Bone density and broken bones turned out not to be the same endpoint. Testosterone should not be prescribed to protect bone, and a man with osteoporosis needs treatment aimed at bone specifically.

Memory and dementia. An earlier version of this article listed dementia prevention among the benefits, on the basis that men with higher testosterone levels have lower rates of Alzheimer’s disease. That is an association, not a demonstrated effect of treatment, and the cognitive substudy of the large TRAVERSE trial did not show a cognitive benefit. That claim has been removed, and it should not appear on a page like this again.

What It Costs You

Fertility — raise this before the first dose. Testosterone from outside switches off the brain signals driving the testicles, and sperm production commonly falls to zero, usually within a few months of starting. The testicles also shrink. It is usually reversible after stopping, and most men recover over the following months to a couple of years — but recovery is not guaranteed in every man, and it is slower after long-acting preparations. If you may want children now or later, say so before you start: clomiphene citrate, hCG and an aromatase inhibitor raise your own testosterone instead, and a semen analysis beforehand is worth having.

Thickened blood. Testosterone stimulates red cell production, and a rising haematocrit is the single finding that most often forces a dose reduction, a change of route or a pause. This was also the clearest and most statistically robust adverse effect in the TRAVERSE trial — several times more frequent on testosterone than on placebo, a difference of a completely different order from the signals discussed below. You cannot feel it. That is why the blood tests are part of the treatment rather than an optional extra.

Prostate. Testosterone does not cause benign enlargement, but urinary symptoms should be assessed before starting and followed afterwards. PSA and a prostate assessment are checked before starting and monitored during treatment.

Sleep apnoea can worsen — and if you snore heavily or wake unrefreshed, treating the apnoea may improve the very symptoms that sent you looking for testosterone. Other effects: acne and oily skin, breast tenderness or enlargement, fluid retention, mood changes.

And the framing that matters throughout: higher is not better. The aim is a level in the normal range with symptoms improved — not the highest number achievable. Testosterone bought from an unregulated source, where neither the dose nor the contents can be relied upon and nobody is checking your blood, is a different and worse proposition from prescribed treatment.

Prostate Cancer: A Correction to What This Page Used to Say

This article previously stated flatly that testosterone therapy is contraindicated in prostate cancer because it accelerates the disease. That reflected a belief held for sixty years on the strength of very thin evidence, and it is no longer where the field stands.

What is accurate today: testosterone is not started in a man with known untreated prostate cancer, and an undiagnosed prostate cancer is a reason to assess before treating rather than after — which is why the pre-treatment prostate check exists. But for men who have been treated for prostate cancer, a blanket prohibition is no longer supported. It has become a carefully selected, shared decision made with the treating urologist, in full knowledge that the data remain limited. The reasoning behind that shift is set out in the saturation model explained, and I discuss the practical cases in testosterone therapy today.

It is worth being plain about how thin the evidence still is: the two largest testosterone safety trials, TRAVERSE and the T-Trials, both excluded men with a prostate cancer history altogether, which is precisely why the question keeps being answered from opinion rather than data. I was a co-author on a 2026 study in The Journal of Sexual Medicine reporting real-world outcomes in a single-centre cohort of 46 men aged 80 and over on testosterone, 39% of whom had a prostate cancer history, with no biopsy-confirmed recurrence during follow-up (DOI 10.1093/jsxmed/qdag258). The limits matter as much as the finding, and an earlier version of this paragraph overstated one of them: the median follow-up was around 21 months rather than the full three years, only about a third of the men reached 36 months, and there was no untreated comparison group, so the study cannot measure relative risk. It is a contribution to that evidence rather than an answer to it.

And the Heart: What TRAVERSE Actually Found

The other fear that shadowed testosterone therapy for years was cardiovascular. TRAVERSE randomised 5,246 men aged 45 to 80 with confirmed deficiency who already had cardiovascular disease or multiple risk factors, and followed them for a mean of 33 months. It found no increase in heart attack, stroke or cardiovascular death, meeting the criterion for non-inferiority, and no increase in prostate cancer or prostate enlargement.

It also produced findings on the other side, and they need separating by how strong they are — because an earlier version of this page did not separate them.

• Statistically significant: erythrocytosis, described above, and — in the fracture subtrial — a roughly 43% increase in clinical fractures.
• Numerically higher but not statistically significant: atrial fibrillation, pulmonary embolism and acute kidney injury. An earlier version of this page said the trial found more of each without that qualification, which reads as though they were established harms. They are not.

That distinction is not pedantry. Describing a difference the trial could not separate from chance as a demonstrated risk misleads a man into refusing treatment he needs — and it is the same mistake, pointed the other way, as the version of this page that called a significant rise in fractures merely undemonstrated. Neither is dismissal: these are serious events, the numbers moved the same way, and a previous clot, a clotting disorder or a known arrhythmia is still worth mentioning before starting so it can be weighed.

And there is a further point about what a safety trial is: it demonstrated the absence of the harm that was feared, not a cardiovascular benefit. Testosterone remains a treatment for confirmed deficiency, not a tonic for ageing. The full account is in testosterone and the heart.

Get Help the Same Day If Any of These Happen

• Chest pain, or breathlessness on less exertion than usual
• Pain, swelling or warmth in one calf, or sudden breathlessness with chest pain on breathing in
• Sudden severe headache, one-sided weakness or numbness, or difficulty speaking, even if it passes
• عدم القدرة التامة على التبول with a painfully full bladder

Attend an emergency department or call 1669 in Thailand. These are symptoms anyone should act on regardless of what medication they take; listing them here is prudence rather than a claim that testosterone caused them. Do not stop a prescribed medicine on your own because of something you have read here — tell the doctor who prescribed it.

Weighing all of this properly needs confirmed blood results and a monitoring plan rather than a trial-and-error prescription. The testosterone replacement therapy service page covers diagnosis, treatment selection and long-term monitoring.

الأسئلة المتكررة

What does testosterone therapy reliably improve?

In men with a confirmed deficiency: sexual desire most consistently and soonest, then mood, energy and sense of well-being, then muscle mass and body fat over many months. It improves erectile function far less reliably than desire, because most erectile dysfunction is vascular rather than hormonal. It is not a treatment for diabetes, not a substitute for weight loss, there is no demonstrated cognitive or dementia benefit, and although it raises bone density on a scan the fracture trial found more fractures rather than fewer.

What are the risks of testosterone replacement therapy?

Suppression of sperm production, commonly to zero, with testicular shrinkage; a rising haematocrit, which produces no symptoms you could notice and most often forces a change; worsening of sleep apnoea; acne, breast tenderness or enlargement, fluid retention and mood changes. Prostate assessment and PSA are monitored throughout. In the TRAVERSE trial, erythrocytosis and clinical fractures rose significantly, while atrial fibrillation, pulmonary embolism and acute kidney injury were numerically higher but did not reach statistical significance.

Which TRAVERSE findings were statistically significant?

Two. Erythrocytosis, a rise in red cell count, was by far the clearest, which is why haematocrit is monitored throughout treatment. Clinical fractures rose by roughly 43% in the fracture subtrial. Atrial fibrillation, pulmonary embolism and acute kidney injury were each numerically higher on testosterone but did not reach statistical significance, and should not be described as established harms. An earlier version of this page did not make that distinction.

Is testosterone therapy contraindicated if I have had prostate cancer?

Not as an absolute rule any longer, though this page used to say so. Testosterone is not started in a man with known untreated prostate cancer, and prostate assessment before treatment exists precisely to avoid treating an undiagnosed cancer unknowingly. But in men who have been treated for prostate cancer, the old blanket prohibition is no longer supported: it is a carefully selected, shared decision made with the treating urologist, with the limits of the data stated openly.

Will testosterone therapy affect my fertility?

Yes, and this is the most important thing to settle before the first dose. Testosterone suppresses the brain signals driving the testicles, and sperm production commonly falls to zero, usually within a few months. Most men recover after stopping, over months to a couple of years, but recovery is not guaranteed and is slower after long-acting preparations. If you may want children, fertility-sparing options such as clomiphene citrate, hCG or an aromatase inhibitor raise your own testosterone instead, and a semen analysis beforehand is worth having.

Who should not start testosterone therapy?

Men actively trying to conceive, in whom fertility-sparing alternatives are used instead; men with untreated prostate cancer; and men with untreated erythrocytosis or untreated severe sleep apnoea, in whom those are addressed first. Men whose testosterone is normal should also not be treated, however tired they feel — the cause lies elsewhere and testosterone will not find it.

How do I know whether I actually need it?

Both a low level confirmed on two separate early-morning blood tests and symptoms that fit. One without the other is not testosterone deficiency. Self-diagnosis on symptoms alone is unreliable, because fatigue, low mood, poor concentration and reduced libido are produced far more often by sleep debt, sleep apnoea, depression, alcohol, thyroid disease, medication or excess weight.

Book an Appointment

Dr. Soarawee Weerasopone sees men’s health and testosterone patients at مقر مستشفى بانكوك and at Samitivej Sriracha Hospital, Chonburi — Urology department 088-022-1445. Questions about cost are answered by the hospital rather than by Dr. Soarawee — for Bangkok Hospital, by email to bhquro@bdms.co.th.

تتوفر خدمة الرعاية الصحية عن بعد من مستشفى بانكوك للمرضى غير القادرين على الحضور شخصياً، بما في ذلك المرضى الدوليين - يرجى ترتيب ذلك مسبقاً عن طريق البريد الإلكتروني مع قسم المسالك البولية على bhquro@bdms.co.th. Because the diagnosis requires two early-morning blood tests, laboratory testing and examination still need an in-person visit. Samitivej Sriracha is in-person only.

المراجع

• Lincoff AM, Bhasin S, Flevaris P, et al. Cardiovascular safety of testosterone-replacement therapy. N Engl J Med. 2023;389(2):107–117.
• Snyder PJ, Bauer DC, Ellenberg SS, et al. Testosterone treatment and fractures in men with hypogonadism. N Engl J Med. 2024;390(3):203–211.
• Bhasin S, Lincoff AM, Nissen SE, et al. Effect of testosterone on progression from prediabetes to diabetes in men with hypogonadism: a substudy of the TRAVERSE randomized clinical trial. JAMA Intern Med. 2024;184(4):353–362.
• Coady PJ, Walia A, Oppenheimer A, Hernandez BS, Chidananda R, Hinojosa-Gonzalez DE, Weerasopone S, Kohn T, Khera M. Testosterone replacement therapy in male octogenarians: clinical outcomes and adverse event rates. J Sex Med. 2026;23(9):qdag258.

إخلاء مسؤولية: This article is written and reviewed by Dr. Soarawee Weerasopone, a board-certified urologist at Bangkok Hospital Headquarters. It is educational only, is not medical advice, and does not create a doctor–patient relationship. It gives no doses: those are set by the prescribing doctor, and testosterone therapy requires ongoing monitoring. Do not start, stop or change a prescribed treatment on your own. No diagnosis, prescription or individual medical advice is given through personal messaging channels or social media, and Dr. Soarawee operates no public social media account — any account offering private consultation in his name is fraudulent. Always consult a qualified healthcare professional before starting any medical treatment.