TRT: overprescribed or underused?

Testosterone replacement therapy (TRT) is a treatment for men whose bodies do not make enough testosterone. It is given as gels, injections or other preparations, and a doctor decides whether it is suitable and how it is given. In recent years it has also become a lifestyle talking point, promoted online as a fix for tiredness, low drive and ageing. That has opened up a real argument among doctors.

The case for

This side of the argument says TRT is underused: that men with genuine testosterone deficiency are sometimes missed or dismissed.

Symptoms such as low sex drive, fewer morning erections and erectile problems are easy to put down to age, stress or work. Men may not mention them, and when they do, they may not be offered a blood test. The European Male Ageing Study, published in 2010, found that these three sexual symptoms were the ones most closely linked with low testosterone, which gives doctors a clear starting point for spotting it.

For men whose deficiency is confirmed, treatment can help. The T Trials, published in 2016, studied men aged 65 and over with low testosterone and found modest improvements in sexual function and mood compared with placebo. Supporters also point to the TRAVERSE trial, published in 2023, which found that testosterone gel did not increase major heart events compared with placebo in men aged 45 to 80 with hypogonadism and raised cardiovascular risk. That eased a long-standing worry that had made some doctors reluctant to prescribe.

Against, and the limitations

The other side says TRT is overprescribed: that it is too often started without a proper diagnosis.

True symptomatic deficiency is less common than marketing suggests. In the European Male Ageing Study, late-onset hypogonadism, defined by those sexual symptoms plus low testosterone, affected only about 2% of men aged 40 to 79. Many men who feel tired or flat have other explanations, such as poor sleep, weight gain, depression, alcohol or medicines.

The benefits in trials were modest and specific. The T Trials found no meaningful improvement in vitality or walking. And TRAVERSE, while reassuring on major heart events, recorded higher rates of atrial fibrillation, acute kidney injury and pulmonary embolism in the testosterone group.

There is also fertility. Taking testosterone suppresses the body's own sperm production. For a man who wants children, starting TRT without that conversation is a real problem.

What the evidence says

Both concerns can be true at once: some men are treated who should not be, and some who could benefit are not assessed. The guidelines point to the same solution, which is careful diagnosis.

• Symptoms and blood tests together. The Endocrine Society (2018) and American Urological Association (2018) guidelines recommend diagnosing deficiency only when there are consistent symptoms and repeated low morning testosterone results.
• Look for causes. Doctors should look for underlying reasons for low testosterone, and for other explanations of the symptoms.
• Discuss fertility first. The AUA guideline advises that men who want children should be told that testosterone therapy can impair sperm production.
• Monitor. Men on treatment need regular review, including blood tests, to check benefit and side effects.

The question, in the end, is less "more TRT or less?" and more "the right men, properly assessed". For a closer look at the heart evidence, read our piece on testosterone therapy and the TRAVERSE trial.

Questions men also ask

Can I start testosterone therapy because I feel tired?

Tiredness alone is not enough. Guidelines recommend confirming low testosterone with repeated morning blood tests alongside consistent symptoms, and looking for other causes first.

Is testosterone therapy bad for the heart?

The 2023 TRAVERSE trial found that testosterone gel did not increase major heart events compared with placebo in men at raised cardiovascular risk, but it did find more atrial fibrillation, acute kidney injury and pulmonary embolism.

Sources & further reading

1. New England Journal of Medicine Identification of late-onset hypogonadism in middle-aged and elderly men (opens in a new tab) (2010) Wu FCW, et al.
2. Journal of Clinical Endocrinology & Metabolism Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline (opens in a new tab) (2018) Bhasin S, et al.
3. New England Journal of Medicine Effects of Testosterone Treatment in Older Men (opens in a new tab) (2016) Snyder PJ, et al.
4. New England Journal of Medicine Cardiovascular Safety of Testosterone-Replacement Therapy (opens in a new tab) (2023) Lincoff AM, et al.
5. Journal of Urology Evaluation and Management of Testosterone Deficiency: AUA Guideline (opens in a new tab) (2018) Mulhall JP, et al.

This article is general health information. It does not replace an individual medical consultation, examination or diagnosis. Read our editorial policy and medical review policy.