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July 31, 2017

What Are the Risks of Male Hormone Therapy?

male hormone therapyMale Hormone Therapy and Its Risks

Male hormone therapy is safe but does carry some risks. Not to scare you, but bigger breasts and smaller testicles are two of the risks or side effects related to male hormone therapy – two things no man who desires to be a man desires.  While these and other side effects can occur, the risks related to male hormone therapy when closely monitored by a physician knowledgable in hormone replacement therapy are quite minimal.

When speaking of risks related to male hormone therapy we generally are talking about the risks of testosterone replacement, but DHEA (dehydroepiandrosterone) is another hormone closely related to testosterone that is also frequently replaced, and growth hormone is also replaced but in a much smaller number of males.  We’ll focus only on testosterone in this article.

Most risks and side effects related to testosterone replacement occur when the testosterone dose is too high, though they can still occur with physiologic levels of testosterone. .

Risks Related to Testosterone Replacement

Breast Enlargement/tenderness:  Breast enlargement or gyneocemastia can occur while receiving testosterone replacement therapy.  This is due to conversion of testosterone into estrogen by the enzyme aromatase, which is primarily found in fatty tissue.  Breast enlargement can be prevented by taking an aromatase inhibitor like anastrozole.  Zinc citrate has been reported to be an aromatase inhibitor as well. Another supplement that is used and big in the body builder arena is Chrysin.

Increased Red Blood Cells:  Testosterone stimulates the bone marrow to produce red blood cells.  An increased in red blood cells is called erythrocytosis.  The term polycythemia is sometimes used inappropriately to describe isolated elevations of red blood cells.  There is a theoretical risk that an increase in red blood cells can make the blood “too thick” and lead to clotting, but there has not been a reported case of a blood clot occurring solely due to testosterone replacement.  An increase in red blood cells can be managed by either reducing the testosterone dose, or by periodically donating blood.

Increased red blood cells is more likely to occur from injectable testosterone than it is from topically applied testosterone creams or gels.

Fluid Retention:  Fluid retention can occur, but is very rare and is usually most noticeable in the ankles or legs.  This could lead to increased blood pressure.  Usually decreasing the dose is enough to minimize or prevent fluid retention.  Individuals with heart, liver, or kidney failure need to be monitored closely for fluid retention. It too tends to occur more from injectable testosterone.

Infertility:  Testosterone can lower sperm counts, but this normally reverses when the testosterone is stopped. There are case reports of men using anabolic steroids who remain infertile after stopping the anabolic steroids. Those anabolic are up to 30 times more potent than testosterone.

If a man desires to have children there are other options to raise testosterone without decreasing sperm counts.  These options include use of Clomid (clomiphene) or HCG (human chorionicgonadotropin). Testosterone along with either Clomid or HCG can also be used to treat testosterone deficient men who wish to maintain fertility.

Testicular Atrophy:  Shrinkage of the testicles occurs in 10% to 12% of men receiving testosterone and reverses once testosterone is stopped.  Adding HCG or Clomid along with testosterone can be used to maintain testicular size. Atrophy is a cosmetic concern more than anything. Some men are bothered by it and some are not.

male hormone therapyAcne/thinning of the hair:  Testosterone increases production of sebum that can lead to acne. Some testosterone gets converted to dihydrotestosterone, which can cause thinning of the hair if levels get too high.  This conversion to dihydrotestosterone is easily blocked by a medication called finasteride (Propecia).

Prostate Abnormalities: There has been concern that testosterone causes prostate cancer or lead to benign prostate hyperplasia.  It is now accepted that testosterone does not cause prostate cancer and multiple studies have shown no significant enlargement of the prostate in men receiving testosterone.  Some feel that testosterone can fuel growth of an existing prostate cancer, but a recent study in the Journal of Urology concluded that testosterone therapy does not lead to progression of prostate cancer.

Sleep Apnea:  There are reports that testosterone therapy can worsen sleep apnea, but one 36 month trial of testosterone therapy found no effect on sleep apnea. Typically because testosterone can help with weight (fat) loss it is not uncommon to see sleep apnea improve. Plus, many men reported getting better sleep once starting testosterone replacement.

Mood Disturbances:  This is a myth attributed to athletes and body builders experiencing “roid rage” from high doses of testosterone or anabolic steroids.  Medical studies have reported no violent or bizarre behavior even at extremely high doses (6 times the usual replacement dose) of testosterone. Having said that we have seen some men report mood disturbances or more aggression who seen those symptoms resolve with lowering of the testosterone dose.

So while there are side effects associated with male hormone therapy, they are relatively uncommon and manageable.  But, this highlights the importance of being monitored closely by a physician aware of these risks and side effects.


Infection can occur when testosterone is used in an injectable or pellet forms, but that risk is very minimal. Anytime the integrity of the skin is broken there is a risk of infection.Testosterone pellets look like smaller Tic Tacs that are inserted in the subcutaneous tissue using in the buttock region and provide a steady release of testosterone typically for 4 to 6 months.

“Anti Aging Hormones”

“Suffering From Low Testosterone Levels?”

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“Hormone Replacement Therapy Alternatives….and Their Side Effects”

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Dr. Joe Jacko

Dr. Joe is board certified in internal medicine and sports medicine with additional training in hormone replacement therapy and regenerative medicine. He has trained or practiced at leading institutions including the Hughston Clinic, Cooper Clinic, Steadman-Hawkins Clinic of the Carolinas, and Cenegenics. He currently practices in Columbus, Ohio at Grandview Primary Care. Read more about Dr. Joe Jacko

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