madman
Super Moderator
* Mills emphasizes that TRT is frequently misunderstood as “supplementation” rather than true hormone replacement
* I actually think that the supra-physiologic dosing is probably where things get a little bit muddy; is that we don't have great longitudinal data. Very few studies, uh, out of Europe of the Netherlands show that it's probably safe, but you know, once you get to a certain level in the bloodstream, you can only metabolize so much testosterone. So, I think, unfortunately, a lot of this high-dose testosterone is associated strongly with a placebo effect. Where they, if they feel they're on high-dose T, and their levels look fantastic, then they're feeling all the symptom improvement, but, honestly, there's no good metric to show they're doing much of anything
So, I do actually believe keeping guys in that upper tercile of that normal range seems to hit all the right points. These guys are firing on all cylinders, and meeting their objectives but they have to put in the work themselves
In this video, Jesse N. Mills, MD, director of the Men's Clinic at UCLA, fellowship director of the UCLA male reproductive medicine and surgery program, and director of UCLA Urology Santa Monica, discusses how social media and direct-to-consumer online clinics have reshaped patient expectations around testosterone replacement therapy (TRT), often creating misconceptions that complicate care when patients transition to a urology practice.
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Mills emphasizes that TRT is frequently misunderstood as “supplementation” rather than true hormone replacement. For men with normal testosterone levels, initiating TRT can actually worsen symptoms by suppressing the body’s natural production. Mills notes that he commonly sees patients whose testosterone levels decline after starting inadequately dosed online therapies—enough to suppress pituitary function but not enough to provide physiologic benefit.
A key challenge, he explains, is distinguishing between men seeking “optimization” or supraphysiologic levels and those who are genuinely hypogonadal. For Mills, the clinical decision to treat hinges on metabolic consequences of low testosterone, such as low bone density, adverse lipid profiles, or broader cardiometabolic risk. Although some patients pursue very high testosterone levels based on anecdotal success stories, Mills cautions that there is limited long-term data supporting the safety or efficacy of supraphysiologic dosing, and perceived benefits may largely reflect placebo effects. He advocates instead for maintaining testosterone in the upper tertile of the normal range, combined with lifestyle changes such as exercise and nutrition, which remain essential regardless of hormone levels.
When managing patients who began TRT online, Mills views them positively: informed, motivated, and open to more comprehensive care. His approach begins with a full clinical “reset,” including baseline labs to assess pituitary suppression, metabolic health, and cardiovascular risk, as well as a physical exam and detailed discussion of expectations. He criticizes online models that prioritize prescription renewals over holistic care. However, Mills strongly supports telehealth when used to augment—not replace—the physician-patient relationship. After an initial in-person evaluation, he leverages telemedicine to provide evidence-based, personalized TRT to patients across California, expanding access while preserving high-quality specialty care.
* I actually think that the supra-physiologic dosing is probably where things get a little bit muddy; is that we don't have great longitudinal data. Very few studies, uh, out of Europe of the Netherlands show that it's probably safe, but you know, once you get to a certain level in the bloodstream, you can only metabolize so much testosterone. So, I think, unfortunately, a lot of this high-dose testosterone is associated strongly with a placebo effect. Where they, if they feel they're on high-dose T, and their levels look fantastic, then they're feeling all the symptom improvement, but, honestly, there's no good metric to show they're doing much of anything
So, I do actually believe keeping guys in that upper tercile of that normal range seems to hit all the right points. These guys are firing on all cylinders, and meeting their objectives but they have to put in the work themselves
In this video, Jesse N. Mills, MD, director of the Men's Clinic at UCLA, fellowship director of the UCLA male reproductive medicine and surgery program, and director of UCLA Urology Santa Monica, discusses how social media and direct-to-consumer online clinics have reshaped patient expectations around testosterone replacement therapy (TRT), often creating misconceptions that complicate care when patients transition to a urology practice.
TRT myths, metabolic risk, and the role of the urologist | Urology Times
Urology Times is the leading resource for urologists & allied health professionals offering clinical analysis, policy perspectives, & practical advice.
Mills emphasizes that TRT is frequently misunderstood as “supplementation” rather than true hormone replacement. For men with normal testosterone levels, initiating TRT can actually worsen symptoms by suppressing the body’s natural production. Mills notes that he commonly sees patients whose testosterone levels decline after starting inadequately dosed online therapies—enough to suppress pituitary function but not enough to provide physiologic benefit.
A key challenge, he explains, is distinguishing between men seeking “optimization” or supraphysiologic levels and those who are genuinely hypogonadal. For Mills, the clinical decision to treat hinges on metabolic consequences of low testosterone, such as low bone density, adverse lipid profiles, or broader cardiometabolic risk. Although some patients pursue very high testosterone levels based on anecdotal success stories, Mills cautions that there is limited long-term data supporting the safety or efficacy of supraphysiologic dosing, and perceived benefits may largely reflect placebo effects. He advocates instead for maintaining testosterone in the upper tertile of the normal range, combined with lifestyle changes such as exercise and nutrition, which remain essential regardless of hormone levels.
When managing patients who began TRT online, Mills views them positively: informed, motivated, and open to more comprehensive care. His approach begins with a full clinical “reset,” including baseline labs to assess pituitary suppression, metabolic health, and cardiovascular risk, as well as a physical exam and detailed discussion of expectations. He criticizes online models that prioritize prescription renewals over holistic care. However, Mills strongly supports telehealth when used to augment—not replace—the physician-patient relationship. After an initial in-person evaluation, he leverages telemedicine to provide evidence-based, personalized TRT to patients across California, expanding access while preserving high-quality specialty care.
