Testosterone ( TRT ) Side Effect Management Table

By Nelson Vergel

TRT can improve the symptoms of low testosterone (fatigue, lack of sex drive, erectile dysfunction, lack of mental focus, etc.). However, testosterone can have side effects that can be prevented or reversed with proper monitoring and education.

Testosterone replacement therapy is not without side effects, although most are manageable and reversible after it is stopped. I’ve been taking testosterone replacement since 1993 and for the most part, have had no side effects thanks to careful monitoring. It’s critical that you are monitored for side effects in addition to your testosterone level. Some men may experience one or more side effects that sometimes go unnoticed until they become aware of them due to symptoms. In part, it is the underground, unmonitored use of testosterone that creates so much bad publicity for this very helpful hormone.

The first step in the proper monitoring of replacement therapy is providing your doctor with a thorough medical history.  Let your doctor know about all the medications you take so that medication-induced sexual dysfunction can be ruled out before starting testosterone.

I also strongly believe that if a patient goes to the doctor to obtain a Viagra, Cialis or Levitra prescription, the doctor should check the patient’s testosterone and estradiol blood levels to ensure that abnormal levels of these two hormones are not the root cause of their ED. Hypogonadal men may not respond as well to ED drugs if their testosterone is not normalized first. Studies combining testosterone and oral sexual enhancement drugs have shown a synergistic effect on sexual benefits.

The following suggestions for monitoring testosterone replacement are recommended by several physician groups and practices:

1. You should be evaluated after the first month of therapy to measure your testosterone blood levels. If your doctor doesn’t ask, let him/her know about your quality of life. Make sure your doctor is aware of your energy level, mood, and sexual function, as well as any potential side effects (tender breasts, urinary flow decrease, frequent trips to the bathroom to urinate, moodiness, and acne).

2. When using testosterone, your doctor will want to measure total blood testosterone levels right before the next corresponding injection or gel use after the first month (it takes a while for the blood levels to stabilize). If testosterone is >900 ng/ dl or <500 ng/dl, your doctor will adjust the amount or the frequency of your dose. I mentioned this earlier in the book, but it bears repeating here: Some men need to have blood levels above 500 ng/dl to experience sexual function benefits from testosterone. It is important to be honest when your doctor asks you about your sexual performance. Do not let false pride, shame, or machismo get in the way of a satisfying sexual and intimate life.

3. Your doctor should check your hematocrit before starting TRT, after three months and then every year after that. If your hematocrit is above 52%, you should donate some blood in a blood bank or get a doctor’s order for therapeutic phlebotomy if you cannot donate blood due to hepatitis or HIV (read the section “Checking for Increased Blood Thickness (Polycythemia)” or for more details. Usually, four units of blood can decrease hematocrit from 54 to 48 percent, but only one unit can be withdrawn at a time.

4. Be ready to have a digital rectal examination done and a prostatic specific antigen (PSA) blood test before starting testosterone, and after three months. Retesting every six months after that may not be unreasonable, especially in older men. A PSA above four ng/ml can be the reason for concern and referral to a urologist. Testosterone replacement needs to be stopped if increases in PSA above normal are observed. Note: at the start of testosterone replacement in older men, when testosterone blood levels are rapidly rising, PSA may also increase. This is especially true when testosterone gels are employed because they elevate DHT more relative to other options. Once testosterone levels have stabilized PSA drops back down to baseline. It is important to allow “steady state” for testosterone fluctuations to stabilize before measuring PSA; a month or so should be sufficient. Also, keep in mind that prostatic infections can also raise PSA, so it is important to see a urologist to rule this out before deciding to stop testosterone replacement due to high PSA.

TRT: What Lab Tests Targets Should be Monitored to Prevent or Reverse Side Effects

I would like to stress that there is no agreement between several medical guideline groups about the proper monitoring of TRT. And none of them include estradiol measurement. You can see how each guideline group recommends different schedules for monitoring testosterone, digital rectal exam, prostatic specific antigen, and hematocrit. It is no wonder that physicians in clinical practice are so confused about what is standard in testosterone replacement therapy monitoring.

For details click: Testosterone TRT Side Effects Table

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