Testosterone Replacement Therapy (TRT)

Testosterone Replacement Therapy (TRT)

Testosterone replacement therapy is probably one of the hottest topics in MMA and BJJ right now. Almost every major fight card has fighters that are either openly on TRT or who have tested positive for anabolic steroids at some point in their career. According to Larry Pepe the Nevada State Athletic Commission has given 6 UFC (current or former) fighters TRT exemptions.

If you think that the use of TRT is limited to MMA then you haven’t been around the competitive BJJ scene for long. Prominent BJJ competitors, such as Caio Terra, have been very vocal on instituting testing of all black belt winners and addressing (in his opinion) the rampant use of PEDs in competition. To date there are no major tournaments that include PED testing for any of their athletes.

This article is meant to educate about TRT. It will not go into any detail on any aspect of using testosterone or other anabolic agents illegally. If you’re not going to your physician to get a prescription and then filling it at your local pharmacy you should stop reading now. A level playing field is fundamental for all sports. Athletes should compete within the rules of the sport that they’ve chosen, whatever those rules happen to be.

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What is testosterone deficiency (aka hypogonadism)?
testosteroneTestosterone deficiency is defined as low levels of serum testosterone (low T) when also in the presence of signs and symptoms associated with low testosterone (T). These signs and symptoms could include any of the following: reduced libido, poor morning erection, erectile dysfunction, reduced muscle strength/size, shrinking testes, and infertility. Other less definitive signs are: decreased energy, depression, poor concentration and memory.

Defining the serum testosterone has its own special challenges. For one thing, T levels fluctuate naturally throughout the day based on your circadian rhythms. Another issue is that the standard for what is considered “low” hasn’t been completely agreed upon either. The Endocrine Society standard is <300ng/dL, while more recent studies have shown that men with a T of <350ng/dL are more likely to exhibit the signs and symptoms associated with hypogonadism such as sexual dysfunction, physical dysfunction and diabetes.

What are some of the potential causes?
Two of the more common risk factors for hypogonadism are type 2 diabetes and obesity. Beyond that there are certain medications that can also affect your body’s testosterone levels. Specifically, long-term treatment with glucorticoids (such as prednisone), ketoconazole (an anti-fungal) and opioids (narcotics for pain) can also cause decreases in testosterone. Additionally, previous (mis)use of testosterone can temporarily, and in some cases, permanently alter your ability to naturally produce adequate testosterone. Social activities such as smoking, drinking and general laziness may also contribute to lower level of testosterone.

The Hypogonadism in Males (HIM) study looked at men at least 45 years old to determine the prevalence of hypogonadism in this population. The results were eye opening, of the men tested over a third of them had a serum T of <300 ng/dL and of those men identified as hypogonadal less than 10% of them were being treated. What this suggests is that many men meet the definition of hypogonadism and that most of them either choose not to be treated or don't have treatment offered to them.

What are some options if you have low T?
prednisoneChances are that if you’re reading this you’re probably already doing everything that you can from a non-medication standpoint to improve your testosterone. Limit your alcohol intake, no smoking, exercise regularly and get plenty of rest. Exercise and diet can go a long way towards addressing the two most common contributors to low T (obesity and diabetes).

The pharmaceutical options available today are much different than those of even just 10 years ago. Oral tablets are no longer manufactured and the use of injectable testosterone has decreased dramatically. Physicians can now choose from several different transdermal (absorbed thru the skin) options, implants below the skin and there are still some who use intramuscular injections. The table below is a very brief overview of some options and details about them.

Pharmacy Options to Treat Low Testosterone

Pharmacy Options to Treat Low Testosterone


Frequency Given



 Transdermal Gel


Readily available, flexible dosing, less likely to irritate the skin (than a patch)

Messy and potential risk of transfer to others thru skin contact; daily administration

Transdermal Spray


less messy (1 spray in each armpit)

daily administration

Transdermal Patch

At Night

Mimics body’s natural daily fluctuations in testosterone

daily administration, skin reactions are relatively common

Buccal Tablet

Twice daily

Oral administration (tablet placed under the tongue to dissolve)

twice daily administration, gum/mouth irritation relatively common

Sub-Q pellets

every 3 to 6 mo

only used a few times a year

invasive placement, infection risk and site of insertion pain possible

IM Injection

every 1 to 2 wks

low cost

testosterone levels are over-corrected initially and then fall to hypogonadal range by the time the next dose is due;  injection required;

Many pharmacies do not carry injectable testosterone in their regular stock because of the perception that it is rarely used legitimately. There is also the concern about getting, using and disposing of needles correctly. To put it simply, getting a script for injectable testosterone filled will probably be difficult under most circumstances and may be impossible in some.

Changes, side effects and risks:
Common wisdom is that the use of TRT will cause positive changes in both muscle mass and body fat. This is one of those rare instances where common wisdom has been substantiated by medical studies. TRT can help you achieve the holy grail of training, namely an increase in lean muscle mass while also having a decrease in overall fat mass.

Just so you don’t think that all TRT does for you is make you bigger, stronger and faster there are other benefits, some of which might be a little less well known. TRT can help your love life but it can also improve your good cholesterol (HDL) and improve blood sugar control in diabetics. These changes may not be as interesting as the others but fat diabetics with bad cholesterol place an enormous burden on the medical community.

You may also think that the use of TRT will increase your risk for developing prostate cancer. Meta-studies have been shown that there is no causative link between testosterone levels and risk of developing prostate cancer. Further studies have also shown that there is no relationship between TRT and other prostatic/urologic outcomes.

Increases in patient red blood cells counts (hemoglobin and hematocrit) is the most common side effect observed with TRT. These changes are managed by reducing the dose of TRT and their clinical significance on patient outcomes is still unclear. Potentially, this would increase patient’s blood pressure, lead to an increased risk of clots and strokes. There is also some data to suggest that men at a high-risk for cardiovascular events may be at an even higher risk if they are placed on TRT. The authors of that study did caution against extrapolating that data to include younger, less at-risk populations.

Wrapping it all up:
estradiolLegitimate use of TRT is likely to increase significantly in the upcoming years. Studies have shown that it is an under diagnosed and undertreated condition affecting over a third of middle aged men and that is can be treated successfully and safely in most circumstances.

The quality of life expectations that most middle aged men have include a level of activity that our parents would have never dreamed of. We hear sayings like “30 is the new 20” or “40 is the new 20”. Medical science is now able to put some of these expectations into the grasp of anyone. Like it or not TRT isn’t going anywhere.

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