Video summary
Dr. Peter Attia expresses significant concern regarding the rising trend of young men utilizing Testosterone Replacement Therapy (TRT), often driven by a desire to improve mood and overall well-being rather than treating clinical hypogonadism. He argues that many users lack an understanding of the critical distinctions between physiologic replacement doses and super-physiologic dosages, as well as the severe risks associated with obtaining testosterone illegally from unregulated sources which introduces contamination issues. Furthermore, Attia criticizes numerous clinics for capitalizing on this demand without adopting a nuanced medical approach, often prioritizing profit over patient safety by failing to adequately educate users or monitor long-term outcomes in younger populations who may not yet fully grasp the implications of suppressing their own fertility. When examining TRT administered correctly under physician supervision with appropriate physiologic doses, Attia addresses two historically feared risks: prostate cancer and cardiovascular disease (CVD). He presents compelling evidence that TRT does not initiate prostate cancer; indeed, it may slightly decrease risk, citing cases where men who have undergone a prostatectomy for existing cancer safely continue on therapy under strict monitoring protocols. While the data regarding CVD is more complex, he references the recent TRAVERSE trial which showed no increase in adverse cardiovascular events with low-dose replacement. However, Attia cautions against concluding that all risks are settled, noting that the study may not have utilized high enough dosages to reflect real-world scenarios where patients often reach total testosterone levels of 800–900 ng/dL compared to the trial's lower targets. The dangers escalate significantly when TRT is administered at super-physiologic levels or without proper medical oversight, leading to a host of severe complications beyond simple hormone elevation. Attia highlights that excessive dosing can drive red blood cell production to alarming rates, causing increased blood viscosity and potentially triggering Polycythemia Vera, a self-sustaining disease where the bone marrow continues producing cells even after stopping therapy. Additionally, high doses often result in elevated levels of estrogen (leading to gynecomastia) and dihydrotestosterone (DHT), forcing users onto aromatase inhibitors like anastrozole or 5-alpha reductase inhibitors such as finasteride. Attia strongly advises against using these medications for hair loss due to the risk of permanent side effects, including irreversible libido loss associated with "finasteride syndrome," and warns that blocking DHT may not be a viable long-term strategy despite its popularity among men experiencing hair thinning. Fertility represents another critical concern, particularly for young men in their twenties who might consider TRT without realizing it can permanently compromise sperm production within two years of use. Exogenous testosterone shuts down endogenous production via negative feedback loops on the hypothalamus and pituitary gland; while fertility is often retrievable after cessation if started later in life or with good testicular reserve, early initiation can lead to a lifetime dependency on therapy for those wishing to have children in their thirties. To mitigate this, some users turn to Clomid (clomiphene) or hCG injections, which stimulate the body's natural hormone production and preserve fertility by tricking the brain into increasing follicle-stimulating hormone and luteinizing hormone levels. Despite these mechanisms for preserving fertility, Attia remains skeptical of long-term reliance on Clomid due to its potential to increase desogestrel (desol) levels over time. Chronic elevation of this steroid is linked to serious health issues such as an increased risk of atherosclerosis and cataracts, drawing parallels to drugs withdrawn from the market in the 1950s and 60s for similar reasons. Consequently, he advises against using Clomid or hCG indefinitely, emphasizing that while short-term use might be acceptable under specific circumstances intended solely for fertility preservation, long-term application poses unknown risks regarding cardiovascular health and ocular integrity. Ultimately, Attia concludes that the benefits of TRT in the brain—such as improved mood and libido—are best realized when estradiol is allowed to function naturally within a physiologic range, rather than being artificially manipulated through aggressive dosing or inhibitory drugs.
Read the full video transcript
one of the other things that's been
happening a lot recently is the rise in
trt usage among young young men um maybe
in part due to hoping to elevate their
mood to improve the way that they feel
what's your opinion on the what appear
to be increasing numbers of young men
using trt uh I'm I'm greatly concerned
by it truthfully I I think it's um I I
think again a lot of men I think don't
understand the risks of trt and while
testosterone is a very safe therapeutic
I mean uh if if done correctly it's as
safe a hormone as there is uh but you
know if you're talking about a young guy
who doesn't actually understand the
impacts of testosterone on fertility for
example later in life uh doesn't
understand what a physiologic dose is
versus a super physiologic dose and
especially in the cases where guys have
to get this stuff illegally um that then
you introduce a whole new of
contamination and uh all sorts of things
like that so so net net I'm a little
concerned um maybe a lot concerned I
also think you know there are lots of
clinics opening up that are kind of
trying to circumvent some of these
issues and again I I I think
their I think their their motivation is
to capitalize on an obvious interest but
they do so without uh you know
necessarily A nuanced approach to how to
do this take me through through the
risks of trt what are they high level so
it depends on the on if we're going to
talk about trt done correctly do you
mean literally trt testosterone
replacement therapy or that and its more
uh malignant offshoots where people
start to push dosages and stuff but take
us through you know the range well I
would say let's start with what's sort
of known in the medical world right so
we'll start with kind of appropriate
physician administered testosterone
replacement therapy for an appropriately
aged individual for an appropiately aged
individual at an appropriate physiologic
dose cool okay so the two big risks that
people have historically been concerned
with are prostate cancer and heart
disease so an increase in the risk of
prostate cancer and an increase in the
risk of cardiovascular disease both of
these have been studied extensively and
I think we can make a very strong and
compelling case that testosterone
replacement therapy is not increasing
the risk of prostate cancer at all and
it may in fact be decreasing the risk
slightly um I've an entire podcast I
think two podcasts on just that topic
that's how nuanced it is um but again we
to give you just one example when we
have a guy who has undergone a
prostatectomy for prostate cancer he's
had his prostate
removed um we will still use
testosterone replacement therapy in that
guy so think about that you have a guy
who had prostate
cancer you will still give him
testosterone replacement therapy if it's
warranted or indicated post
prostatectomy now do you do it and shut
your eyes and never look again of course
not you're still monitoring his PSA
every 3 months and you're going to look
for any sign of recurrence and if there
is infected recurrence you would
immediately cease it because what we do
know is testosterone would feed prostate
cancer but the point I'm making is
around initiation is there any evidence
that testosterone replacement therapy
initiates prostate cancer the answer is
no there is not and there is some
evidence to the
contrary the cardiovascular disease
question is a little bit more difficult
and the data are a little bit more
muddled but on balance they come out in
the direction of trt does not increase
the risk of cardiovascular disease now
there's a big trial that was completed
last year called the Traverse trial that
gave men uh AndroGel so topical
testosterone and followed them for I
want to say three or four years and
there was no increase in the incidence
of ascvd atherosclerotic cardiovascular
disease but there is so so at face value
that study was taken to mean look we
have one more study the biggest and best
that demonstrated no increase in the
risk of cardiovascular disease with trt
so the debate should be settled once and
for all um I did a podcast on this wrote
a long newsletter on this and the long
and short of it is that's a in my view
that's a slightly premature conclusion
because I don't think the Traverse study
was done
perfectly uh most importantly it um did
not give men a high enough dose in my
view so the men started out very
hypogonadal with a total testosterone of
somewhere between 1 and 300 nanog per
deciliter but they were only replaced to
about 600 nanog per deiler and while
that's a reasonable rate of replacement
I don't think it represents what's
happening in the world I mean we replace
patients to higher than that we replace
patients to 800 or 900 we're technically
tracking free testosterone and not total
testosterone but us to get somebody in
the range of where we think a good free
testosterone is we will see a total
testosterone uh that's easily in the
8900 nanogram per deciliter range so
it's possible the Traverse trial only
answered the question does low dose or
as one of my analysts put it does
testosterone light replacement therapy
increase the risk of cardiovascular
disease and I think there we can say the
answer is probably no okay and what
about testosterone replacement therapy
when it's done badly yeah so I think if
you even think about it in the medical
setting I think testosterone can be
given to very super physiologic levels
and I see patients getting super
physiologic levels all the time they
come into our practice they've been
treated at some tea clinic and they walk
in with a free testosterone of 35
nanograms per deciliter um you know
which is like twice what you would
consider reasonable and you know part of
the problem is we don't really know what
the long everything goes out the window
with what I said earlier now can I say
that that doesn't increase the risk of
prostate cancer initiation I can't say
that because I don't have the data can I
really say that doesn't increase the
risk of cardiovas dises no I can't it's
also by the way creating a lot more
Arroyos so these people are making red
blood cells at an alarming rate and they
need to be monitored very closely for
increase blood viscosity is is that uh I
have a friend of a friend who donates
blood every month is that that's why
because they just making too much and
it's too thick correct wow I mean good
for the blood donation people yeah and
again the question is if you have to
give blood every month if your bone
marrow is so revved on that you have to
give blood every month do we run the
risk that you're going to convert into
poemia Vera at some point which is a
disease now where all of a sudden you
can't shut that process off so oh it
becomes self- sustaining even once
you've come off the trt yeah again I'm
not suggesting that that's happening
what I'm asking is we don't know right
and and there's just a big unknown there
the other thing is once you start to get
into these super physiologic doses you
start to run into other issues around
found a lot of estrogen and a lot of DHT
so you'll see these men who are on these
super physiologic doses of testosterone
also showing up on five Alpha reductase
Inhibitors which we could talk about why
I'm not a huge fan of those and on
aromatase Inhibitors which I'm also not
a is that to stop gyno and Halos yes
right and um obviously I'm not I'm not a
guy who takes hair loss very seriously
but um you know I I think it's a mistake
uh to take a five Alpha reductase
inhibitor for hair loss I think there
are far better strategies if it matters
and um I think you know even though the
risk of uh finasteride syndrome or post
finasteride syndrome is low it's not
zero and it's potentially irreversible
and this is this is I think in a young
man taking
finasteride again if you've been T if
you're listening to this and you you're
on finasteride and you have no issues
you're fine it's something that if you
hasn't kicked in within you know 6
months it's not going to kick in but um
we do we do see men who have like a
permanent loss of libido this is
reported in theid syndrome is yeah so so
basically there's something about
blocking DHT that might not be a great
idea permanent loss of libido would be
bad um what what else haven't we spoken
about when it comes to exogenously
increasing testosterone levels fertility
yeah well there's another thing that I I
think is when you yeah fertility for
sure right so at um once you give
exogenous
testosterone um you you're going to cut
down on endogenous production including
sperm production and therefore you're
going to see a reduction in fertility
and at some point that's retrievable uh
and at some point it becomes more and
more difficult to retrieve so it depends
on the person's age when they start and
what their testicular Reserve is but you
know generally speaking two years of
exogenous testosterone can spell the end
of endogenous production and therefore a
lifetime dependency which which again we
do that all the time like if a guy is
old enough and decides it's time to go
on trt we fully accept that and there's
no risk of being on Lifetime tea for
life within physiologic doses but for a
guy who's young that might be an
enormous risk and and we you know we see
this all the time where guys who are
doing this in their 20s decide they want
to have kids in their 30s and they can't
what else haven't we said about the
risks of trt um I think there's another
method of delivery using uh chopine and
en en chopine and these are drugs that
have the advantage of preserving
fertility uh they work by inhibiting
estrogen receptors in the hypothalamus
that trick the brain into thinking you
need more testosterone so now the brain
uh via the pituitary starts producing
more follicle stimulating hormone and
lutenizing hormone and you end up
increasing endogenous production um and
again I I might be a an unusual skeptic
in this regard but my concern with that
approach typically centers around yes
you raise testosterone but are you
getting the full benefits of
testosterone because I think one of the
benefits of testosterone is the benefit
in the brain and if you're now blocking
estradiol's impact in the brain um
certainly anecdotally there's questions
about whether you're taking away some of
the benefits of testosterone including
mood and libido would you have any
concerns for people being on Clomid for
a long amount of time is that something
that you think shouldn't be used um I
would feel very strongly about people
not being on Chopin or Clomid for a long
period of time for another reason which
is it really increases the production of
a stero called
desol um interest so and the reason for
that there's a lot of problems with that
including potentially an increase in the
risk of atherosclerosis increase in the
risk of cataracts and things of that
nature so I think long-term use of
chopine is probably not a good idea the
drug was never intended to be used
longterm it's a fertility drug so it's
intended to be used shortterm and I
think shortterm uh rises in desol are
not problematic but lifetime increases
or many years of increase I think would
be and there's a drug that was there's a
drug that increased as mol levels in the
50s and 60s that was actually pulled
from the market because of the increase
in cataracts and the increases in
cardiovascular disease in other news
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