Testosterone Therapy: Myths vs. Facts

Evidence-based analysis of common testosterone replacement therapy myths, reviewed by Dr. David Croland.

Myth: Testosterone replacement therapy causes heart attacks and strokes

False. The TRAVERSE trial (2023), published in the New England Journal of Medicine, enrolled 5,246 men with preexisting cardiovascular disease or high CV risk. After 33 months of follow-up, TRT showed no increase in major adverse cardiac events (HR 0.96, 95% CI 0.78–1.17). A 2025 meta-analysis of 23 RCTs (9,280 men) confirmed no increased cardiovascular mortality, stroke, or myocardial infarction. A 25-year systematic review of 51 studies (~3.1 million men) found an 18% reduction in cardiovascular events with TRT.

Myth: Testosterone causes prostate cancer

False, with one important exception. The TRAVERSE Prostate Substudy (2024), published in JAMA Network Open, followed 5,204 men over 14,304 person-years. High-grade prostate cancer, any prostate cancer, urinary retention, and prostate procedures showed no significant difference between TRT and placebo. A 2024 meta-analysis of 28 RCTs found no detrimental effect on PSA, prostate volume, or urinary symptoms. Caution remains appropriate for aggressive, high-grade cancer (Gleason ≥8).

Myth: Testosterone is unsafe even after prostate cancer treatment

Increasingly challenged by evidence. A 2025 scoping review of 12 studies in the International Journal of Impotence Research found TRT was not associated with increased biochemical recurrence. Several studies reported lower recurrence rates in TRT groups (e.g., 7.2% vs. 12.6%). Consistent with the androgen receptor saturation model.

Myth: Testosterone doesn't actually help with erectile dysfunction

False. A 2024 meta-analysis of 28 RCTs (3,461 patients) found TRT significantly improved IIEF erectile function scores (+3.26 points, P<0.0001). Benefits were consistent across all administration methods and durations.

Understanding the Saturation Model

The androgen receptor saturation model, proposed by Dr. Abraham Morgentaler of Harvard Medical School, demonstrates that prostate androgen receptors become fully occupied at approximately 250 ng/dL. Beyond this saturation point, additional testosterone does not stimulate further prostate cell growth. This model explains why restoring testosterone in hypogonadal men does not increase prostate cancer risk.

Frequently Asked Questions

Does testosterone replacement therapy cause heart attacks?

No. The TRAVERSE trial (NEJM, 2023) found no increase in major adverse cardiac events with TRT in 5,246 men.

Does testosterone cause prostate cancer?

Current evidence says no. The TRAVERSE Prostate Substudy (JAMA, 2024) found no significant difference in prostate cancer between TRT and placebo groups. Exception: aggressive, high-grade cancer (Gleason ≥8).

Is testosterone safe after prostate cancer treatment?

Emerging evidence suggests yes in selected men. A 2025 review found no increased biochemical recurrence with TRT after definitive prostate cancer treatment.

Does TRT improve erectile dysfunction?

Yes. A 2024 meta-analysis of 28 RCTs found significant IIEF improvement (P<0.0001).

What is the androgen receptor saturation model?

Prostate androgen receptors become fully occupied at low T levels (~250 ng/dL). Additional testosterone beyond saturation does not increase prostate growth.

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