About Testosterone Replacement Therapy (TRT)
When it comes to topical therapies, these are the most physiological; they are put on every morning, and they match your body’s natural daily peak and trough of testosterone release. This is great, as patients are less likely to see side effects and the treatment is better tolerated. The downside to topical treatments, however, is that they can wear off more quickly, and some men find they are still tired by the end of the day. Other men may get an irritant skin reaction from the topical gels, and then there is also the fuss of having to put on the treatment every day.
Injectable therapies come in various different preparations and are administered every few days to every 12 weeks depending on the patient. The advantage of the injectable therapies is that testosterone levels stay high for the entire time the injection is in the system, which can give much better symptomatic improvement for some men. The downside of the injections, however is that is much more likely to induce a condition called polycythaemia. Testosterone indirectly stimulates your body to make red blood cells. A small increase can be good, as this means more oxygen to go around. But too much blood makes it thicker and sticky, and sticky blood can block up blood vessels, resulting in an increased risk of stroke and heart attacks. This is polycythaemia, and is something we have to be careful to monitor and manage in all testosterone replacement therapies.
Overall, all forms of testosterone replacement therapy convert to testosterone in the blood, so there is simply no “best” treatment. The best therapy is the one that suits you as a patient, matches your blood work, your lifestyle, and is the most safe for you to use.
What about other therapies?
Because TRT can reduce fertility, some men often express the desire to use an adjunct treatment with their TRT to help promote testicular function and sperm production. This can be either in the form of a tablet called clomiphene, or an additional injectable treatment given a few times a week (HCG). These medications have been studied quite extensively, but there are a few important points to be aware of when considering testicular-stimulating medications. They are largely used to improve fertility and therefore have only every had short term studies used. There is almost no data looking at the long term safety of these medicines.
In general, studies tend to be 3-6m in nature, and we just do not know what they could do if used for many years. Secondly, HCG is very expensive, it is not licensed to be used in conjunction with testosterone replacement therapy and this means we have little evidence in terms of regulation, safety or even where the medicines are produced. This is not to say that in some men these treatments are not helpful, but this should be the minority and only used under senior specialist guidance.
What about oestrogen?
We naturally convert a small amount of the testosterone in our bodies to oestrogen, and just as women need testosterone to function properly, we need oestrogen too; just not very much. Some clinics will advocate the use of anti-oestrogens as a standard adjunct therapy to testosterone, but this is neither medically advisable, nor safe. Men need oestrogen for several things: sex drive, good mental health, making sperm, and keeping our bones dense. Without oestrogen it can cause infertility, mental health problems, erectile dysfunction, and osteoporosis.
That is why we rarely use anti-oestrogens in men who are taking TRT. The most common reason for men on TRT to have high oestrogen levels, (if they were not high before), is simply that they are taking too much testosterone, and therefore too much is being converted. Reduce the TRT and the oestrogen gets better. When using oestrogen blockers, it is very hard to regulate levels and therefore it should not be a matter of routine prescription and one of exceptional use only.