Testosterone

In this episode, Don and Steve flex their clinical muscles and bust myths about testosterone replacement therapy (TRT) - from supplements to safety risks.

🐶 Can topical testosterone transfer to pets and kids?
💊 Are supplements like ginseng and vitamin D legit testosterone boosters?
❤️ Does testosterone increase cardiovascular risk?

Stick around as our pharmacist duo breaks down the evidence and shares insights on these hot-button hormone claims:

• Testosterone should be considered for ALL men with low testosterone levels, or “low T”
• Topical testosterone can transfer to other people and pets
• Some vitamins and supplements are safe and effective for increasing testosterone levels
• Testosterone products increase cardiovascular risks
• Testosterone can cause prostate cancer

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TRC Healthcare Editor Hosts: 

• Stephen Small, PharmD, BCPS, BCPPS, BCCCP, CNSC 
• Don Weinberger, PharmD, PMSP

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Guest: 

• Caitlin Prather, PharmD, BCACP, AAHIVP, TTS

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The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Article: Put Testosterone Replacement Claims to the Test
• Chart: Comparison of Testosterone Products
• Chart: Hormones for Transgender Patients
• NatMed

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Chapters

• 0:30 Introduction
• 0:51 Welcome
• 2:20 Claim: Testosterone should be considered for ALL men with low testosterone levels, or “low T”
• 5:27 Claim: Topical testosterone can transfer to other people and pets.
• 8:52 Claim: Some vitamins and supplements are safe and effective for increasing testosterone levels.
• 11:41 Claim: Testosterone products increase cardiovascular risks.
• 16:15 Claim: Testosterone can cause prostate cancer.
• 18:00 Summary
• 19:48 Audience Question
• 21:57 A few more things...
• 23:15 Find us on YouTube!

Transcript

This transcript is automatically generated. 

00:00:05 Narrator

Welcome to Rumor vs Truth, your trusted source for facts… where we dissect the evidence behind risky rumors and reveal clinical truths. 

00:00:12 Narrator

Today, we'll put claims about testosterone to the test.

00:00:21 Don Weinberger

Hey, Steve, how's it going?

00:00:22 Steve Small

Howdy, Don, how are you doing?

00:00:24 Don Weinberger

Not too, not too bad. So you know, I was at the store the other day and I saw some of these kind of products that were called testosterone booster supplements.

00:00:35 Don Weinberger

Obviously caught my eye and let's just say #1 looks like you've been taking them based off that beard that you have going on right now. 

00:00:44 Steve Small

This is all natural, Don.

00:00:46 Don Weinberger

Ok, sure. Yeah, and #2, I did look at those products and I would say… a lot of bold promises there.

00:00:53 Steve Small

Yeah. And I'm pretty sure it probably had small print that you need a microscope to read.

00:00:59 Don Weinberger

Definitely didn't have it handy with me though, but today we're going to use normal sized fonts and actual evidence, and with that, I'm Don the pharmacist.

00:01:09 Steve Small

And I'm Steve, the pharmacist. And in this episode, we're going to be looking at claims about testosterone to see if they're really as strong as people think they are.

00:01:18 Don Weinberger

So, we know that testosterone replacement has gained a lot of traction over the years.

00:01:21 Steve Small

Yep.

00:01:22 Don Weinberger

Ads and commercials for clinics and online pharmacies are making testosterone front and center with people.

00:01:27 Don Weinberger

And now there are all sorts of products you know, from injections to topicals then going from your nostrils, your armpit.

00:01:33 Steve Small

Yep, everywhere, and that's totally right. And let's check these claims, man to man, to see if they're really legit and stick around folks because we have a guest expert that's gonna help us flex on a couple of claims. 

00:01:44 Steve Small

And we'll also answer a listener’s question about acne antibiotics from our last episode. 

00:01:49 Steve Small

So, to start off with Don, I feel like a lot of men right now are focusing on their testosterone levels. And guys think that taking testosterone is going to instantly make them into macho men. 

00:01:59 Steve Small

And that leaves us to our first claim here that testosterone should be considered for all men with low testosterone levels or low T, right.

00:02:08 Steve Small

And, I could see where that comes from, because testosterone naturally declines in men with age, especially after hitting the big three O. Right?

00:02:16 Steve Small

And you really start to see that ramp up by even 1 to 2% per year after age 40. So it could see again why men are worried about this decline because of that natural sort of pattern there.

00:02:28 Steve Small

And they may ask about testosterone replacement because of that… whether or not that they actually have symptoms.

00:02:34 Steve Small

But the reality here is that testosterone replacement, or TRT, is only indicated for men with symptoms so low libido, depression, things like that, plus low testosterone.

00:02:47 Steve Small

And we're talking about levels on 2 separate labs, not just a one time deal. 

00:02:51 Steve Small

So those levels have to be below 300 nanograms per deciliter. And just by having that low amount again doesn't automatically mean that you get treatment. 

00:03:02 Steve Small

You have to have those side effects as well.

00:03:05 Steve Small

And we also have to have side effects of treatment in line with TRT, right testosterone can cause acne from increased even production, gynecomastia, mood changes, fluid retention, you name it.

00:03:17 Don Weinberger

All right, so you'd mentioned you know under 300 nanograms per deciliter is is kind of a.

00:03:24 Don Weinberger

Is one of the basis for getting that TRT right? OK. So let's say a person is actually now on TRT.

00:03:31 Don Weinberger

What is the goal testosterone level to kind of shoot for here?

00:03:36 Steve Small

Yeah. So typically we want it between 300 and 1000 nanograms per deciliter, but we also have to think about when these labs are being taken. 

00:03:44 Steve Small

You can't just take them any time of day. 

00:03:46 Steve Small

Testing timing is very important, because testosterone levels fluctuate throughout the day, so it's really best to have people test early in the morning to get consistent results to compare overtime.

00:03:55 Steve Small

And again you need two of them to qualify on the lab criteria and you may get patients asking to need to fast for this lab and the evidence behind that and the recommendations are mixed.

00:04:06 Steve Small

Some labs require it, some don't… have patients fully clarify with their lab beforehand. For more info, it's probably the best bet so.

00:04:14 Don Weinberger

Good points, yeah.

00:04:15 Steve Small

When it comes to, absolutely, and when it comes to this claim that testosterone should be considered for all men with low testosterone levels are low T the verdict is…

00:04:30 Steve Small

Rumor. So men do need to have testosterone levels that are low with symptoms so not all men.

00:04:38 Don Weinberger

So this advice isn't just for men, right per say…

00:04:43 Don Weinberger

TRT can be indicated for all genders, and we answer all the questions that you probably have with that, with our resource hormones for transgender patients on our website.

00:04:54 Don Weinberger

So, feel free to take a look.

00:04:56 Steve Small

Great resource.

00:04:57 Don Weinberger

All right. So jump to claim 2 here.

00:04:59 Don Weinberger

This next line is a little concerning. I hope it doesn't rub you the wrong way, Steve, but the claim is… Topical testosterone can transfer to other people and pets.

00:05:10 Steve Small

Oh.

00:05:11 Don Weinberger

So, let's dive into that evidence.

00:05:14 Don Weinberger

As you know, topical versions usually are applied to underarm, shoulder, stomach area, thighs, places like that.

00:05:21 Don Weinberger

But there are case reports where partners, kids and even pets developing male sex characteristics like hair growth, deepening voice after being exposed to patient’s testosterone treated skin.

00:05:35 Don Weinberger

You know, diving into this, in fact, you know, over the summer, there was a report of a baby girl who started to form male sex characteristics because she laid on her father's bare chest several times after he applied testosterone gel.

00:05:52 Don Weinberger

You know, you may ask… Is she OK? And seems like she is. So once the father stopped using the gel, the child's body began returning to the typical female anatomy. But this isn't always the case.

00:06:07 Steve Small

Yeah, very recent and topical case Don. But what should we really be telling patients then about this?

00:06:13 Don Weinberger

Yeah, good question. Question so how do you avoid these, these… transference of you know the the testosterone?

00:06:20 Don Weinberger

So advise patients to wash their hands after applying, wearing clothes over the application site after drying, and avoid sharing clothing, towels and anything that could have testosterone on it.

00:06:34 Steve Small

Yeah, those are totally reasonable tips and we obviously know this wouldn't be a concern with injectable forms of testosterone. But what about that nasal topical form we're mentioning?

00:06:42 Don Weinberger

Yeah, sure. So nasal is a topical form. So natural question be well you know, what's the deal with that?

00:06:50 Don Weinberger

Didn't seem to be the case with the nasal testosterone products. The reason being is because as long as it stays within a nostril, you don't see that transference.

00:06:58 Don Weinberger

Now, if the patient were to touch their nostril, have testosterone on their fingers, then touch something else. Well, that case goes out the window. Right? So.

00:07:06 Steve Small

Right.

00:07:07 Don Weinberger

OK, so go back to that claim. And it is.

00:07:10 Don Weinberger

Topical testosterone can transfer to other people and pets, and the verdict is…

00:07:22 Don Weinberger

True. Patients need to protect others from exposure after applying TRT.

00:07:29 Steve Small

Yeah, great point. And I guess this is a good way to keep people away from you. I just applied my testosterone, do not touch me and it's also a good chance to point to labels. 

00:07:37 Steve Small

Another illuminating fact that patients should think about is they need to keep these products away from fire and heat sources because some of these topical versions of alcohol that can be flammable.

00:07:48 Steve Small

And you do need to allow them to dry first, so keep that in mind.

00:07:51 Don Weinberger

So don't touch me and get that lighter away from me. Right. Those are two kind of things you can say with with.

00:07:55 Steve Small

Right, both. Yeah.

00:07:57 Don Weinberger

With those topical versions. 

00:07:58 Don Weinberger

OK, so before we get into our next claim, a quick reminder if you’re enjoying this episode and want to access even more clinical insights, check out pharmacist letter, pharmacy technicians letter and prescriber insights. 

00:08:10 Don Weinberger

This episode actually has a companion article on all of those sites and as a listener you can get 10% off a new subscription with the code RVT1025 at check out.

00:08:22 Steve Small

Excellent. And I kind of want to go back to what you were saying before Don about supplements, because this next claim is vitamins and supplements are safe and effective for increasing testosterone levels. 

00:08:32 Steve Small

And we see products like this at gas stations on social media. But what's commonly found in them, you could say, who knows, but really what we found is usually it's something like vitamin D or zinc.

00:08:44 Steve Small

Or maybe some more exotic ones like ginseng or ashwagandha. So I asked our friends over at NatMed to give us a rundown of this and maybe a hand with this claim and they share with us a low vitamin D and zinc levels do have an association with low T levels, but studies are pretty mixed.

00:09:01 Steve Small

Supplementation with these may ultimately increase testosterone levels, but the data with patients who are then deficient with these vitamins is not people of normal levels in their body. 

00:09:11 Steve Small

So, for example, ginseng and ashwagandha can increase T levels, but that evidence is mixed, and it really is based on their improvement of sperm counts and motility.

00:09:22 Steve Small

In addition to the increased testosterone levels and it's not all types of ginseng. For example, with ginseng, the Panax version we've studied, not the American version, so you gotta look out for that on labels.

00:09:36 Steve Small

But ginseng does have better evidence in treatment of other symptoms like erectile dysfunction. 

00:09:42 Steve Small

And we gotta think about side effects, too. Even with natural medicines, ginseng can cause things like insomnia and ashwagandha we know has GI side effects like nausea, vomiting, diarrhea, and plus, to add to the confusion here.

00:09:55 Steve Small

These supplements really haven't been studied for long term use, so keep that in mind.

00:10:01 Steve Small

Of course, if vitamin supplementation is needed, we should be steering patients towards brands that are certified by a reputable third party. 

00:10:08 Steve Small

Folks like USP, because many supplements as you know don't have FDA approval and there could be anything in those packets, who knows?

00:10:16 Don Weinberger

Correct. Yeah, that's that's a very good point.

00:10:18 Don Weinberger

Especially as much earlier about the gas station, kind of promotion of them, it's like well… you know what do I do here?

00:10:24 Steve Small

So with that, let's go back to our claim that some vitamins and supplements are effective for testosterone, increasing testosterone levels. The verdict is…

00:10:37 Steve Small

True, but with conditions. These increases are really only seen in folks who already have vitamin deficiency, and it may help them, but not other groups.

00:10:46 Don Weinberger

Right. So important you did mention earlier about, you know, the USP and you know FDA you know basically USP approval of some of these vitamins so keep in mind these are, you know, approved drugs that they were approved drugs that we’re seeing…

00:10:56 Don Weinberger

But when you get them online or you get them at a, you know, a store or whatever.

00:11:03 Don Weinberger

Who knows what the heck is actually in these products? As you said.

00:11:06 Steve Small

Yeah, requires some due diligence for sure. 

00:11:08 Don Weinberger

Yes it does.

00:11:10 Don Weinberger

OK. So while we're talking about risks, FDA recently changed some of the warnings for testosterone products. 

00:11:18 Don Weinberger

And I would say… to shortchange, I would say... we've got several, to many questions about the safety claims of, of those… that research.

00:11:28 Don Weinberger

One being actually is testosterone products increase cardiovascular risks.

00:11:35 Steve Small

Yeah, and this is a hefty claim. Don glad you pointed it out.

00:11:38 Steve Small

And to help give us some help to unpack the evidence. We reached out to one of our excellent specialty consultants, Dr. Caitlin Prather, PharmD.

00:11:46 Steve Small

She's a board-certified ambulatory pharmacy specialist at the Inova Health system, and I had a chance to actually ask her about this exact claim last week. Let's hear what she had to say.

00:12:00 Steve Small

Welcome, Doctor Prather. Thank you for joining us and jumping into this question here. This claim testosterone products, increase cardiovascular risk. What's your take on that? What's the evidence behind this?

00:12:12 Caitlin Prather

Yeah. Thanks. So today's best evidence really is that when testosterone is prescribed to truly hypogonadal men and titrate into a normal range.

00:12:22 Caitlin Prather

It really does not increase major adverse cardiovascular events. That's really kind of the key take away from the TRAVERSE trial that came out in 2023 and that's why the FDA recently updated their class labeling to focus on more so with the blood pressure increases rather than a broad CV risk warning.

00:12:42 Caitlin Prather

So, in TRAVERSE, which was published in the New England Journal of Medicine in 2023, we had about 5200 men 45 to 80 years old who had confirmed hypogonadism and had established or high CV risk.

00:12:57 Caitlin Prather

And these men were either given transdermal 1.62% testosterone gel or placebo for a medium median of about two years, and the authors found that the primary major adverse cardiovascular events, or MACE, was similar between the two groups. So in other words, it was non inferior. 

00:13:15 Caitlin Prather

Now there were a few safety signals, so they did see slightly higher rates of Afib and AKI, but not major adverse cardiovascular events.

00:13:25 Caitlin Prather

So you know more recently in February of 2025, the FDA did remove that broad CV risk box warning and replaced it instead with that warning about blood pressure across all testosterone products. And that was really primarily because of the results of that TRAVERSE study.

00:13:41 Steve Small

Sure. And are there any limitations to that study, maybe the patients that were involved, can this apply to younger men? What's your thoughts there?

00:13:50 Caitlin Prather

Sure. So the study was, like I said, you know, 45 to 80 years old in hypogonadism. So if we're applying this to those who are younger or perhaps using testosterone for other indications that may not apply. And in fact, it may even be a lower risk than what we saw there. 

00:14:07 Steve Small

Good point.

00:14:08 Caitlin Prather

So we do still have that concern of of hypertension, but I think it's still important that even though maybe that risk has been removed as a boxed warning, we still want to do what we can to reduce cardiovascular risk in terms of, you know, other risk factors, quitting smoking, maintaining a healthy weight, keeping blood pressure or control things like that.

00:14:28 Steve Small

Those are excellent points and thank you for breaking, breaking down that study and I'm going to take this info back to Don and see what he thinks. Thank you so much for joining us.

00:14:35 Caitlin Prather

Alright. 

00:14:40 Steve Small

So two things. One, I'm impressed by how fast my beard grew in that week since we recorded that. And two, I really liked her points there Don.

00:14:49 Don Weinberger

Right. I did. Yeah. So especially when coming back to well, it may not be causing cardiovascular, you know, negative outcomes in these in this patient group.

00:14:59 Don Weinberger

The blood pressure risks. You know, the bumps are still there, so it's kind of let the important patients know about that kind of stuff. So yeah, I do that.

00:15:06 Don Weinberger

OK. So let's go back to that claim, right?

00:15:09 Don Weinberger

So the claim is testosterone products increase cardiovascular risks and the verdict is…

00:15:17 Don Weinberger

Rumor with conditions, even though box warnings are removed, blood pressure should still be monitored.

00:15:24 Don Weinberger

Prescribers should be prepared to reassess the benefits versus risks of testosterone if they start to notice an uptick in blood pressure it may be better just to stop testosterone in some cases.

00:15:34 Don Weinberger

Practitioners need to separate rumors and truths, get through patient histories and discuss risks and benefits with the patient first.

00:15:41 Steve Small

And thank you again, Doctor Prather, for helping us sort that out. 

00:15:44 Steve Small

And it kind of goes into our next claim here. I've heard patients voice concerns about other issues out there with testosterone and questions, for example. This next claim is testosterone can cause prostate cancer, which sounds pretty scary, right. But what's the latest evidence regarding this?

00:16:01 Steve Small

It's true that testosterone has a role in prostate functioning, and we do use testosterone blockers in some cases of diagnosed prostate cancers or key they're diagnosed.

00:16:13 Steve Small

But studies show that patients without prostate cancer don't have an increased risk when using testosterone products.

00:16:22 Don Weinberger

Wow. OK so. What about patients who have enlarged prostates, like in cases of BPH? Can giving testosterone make that worse?

00:16:31 Steve Small

Yeah, benign prostatic hyperpathy is definitely a common issue. I can see where there's concerns with that.

00:16:37 Steve Small

Speaking with Doctor Prather about this, it turns out studies don't support this really either as a general problem, you may see this in package warnings or testosterone products, and it is something to monitor for, but it's not actually commonly seen based on her experience. 

00:16:51 Steve Small

But again, it's good to ask patients about symptoms like urinary hesitancy and things like that.

00:16:57 Steve Small

So when it comes back to this claim that testosterone can cause prostate cancer, the verdict is…

00:17:08 Steve Small

Rumor. Studies so far show there isn't a direct link to causing prostate cancer, but it should be avoided in patients with diagnosed prostate cancer.

00:17:18 Don Weinberger

Well, you know, that's a relief, especially since TRT is geared towards older men, right? I could definitely see that being a concern.

00:17:26 Don Weinberger

I’m glad studies show that it really isn't.

00:17:28 Steve Small

Yes, finally. And that brings us to our bottom-line truth folks. 

00:17:32 Steve Small

We should weigh the risks and benefits of testosterone replacement and medication options, because every patient is different and so are obviously testosterone products. 

00:17:43 Steve Small

And I gotta say, Don, for a hormone that focuses on, you know, physical strength. Some of these claims are pretty weak.

00:17:50 Don Weinberger

And some patients have high expectations for this med and hopes could be deflated, right? 

00:17:55 Don Weinberger

So it's important to treat the patient and not just the testosterone level number. TRT should be reserved for patients with symptoms.

00:18:05 Don Weinberger

And address other factors like stress, depression while on TRT.

00:18:10 Steve Small

Right. And also remember that testosterone products are a Schedule 3 controlled substance. And yeah, they have a high likelihood of being misused for other non-medical purposes, things like bodybuilding, right. 

00:18:21 Steve Small

So we have to make sure that our prescriptions are from authorized prescribers.

00:18:25 Steve Small

Based on a legitimate patient provider relationship and we should continue checking state’s, you know, prescription drug monitoring programs when dispensing folks may forget that those products will be listed there too.

00:18:37 Don Weinberger

Yeah, that's a good point. And even if that prescription is legitimate, right, what are some other things that patients should should be concerned about, with TRT?

00:18:46 Steve Small

Yeah. Yeah. Like also have folks monitor for those side effects we mentioned with you since again, it may outweigh testosterone benefits. It may not be worth all the emotional changes, acne.

00:18:55 Steve Small

My goodness, adolescence was hard enough, and now you’re doing it again. 

00:18:59 Steve Small

And patients may have injection related adverse effects too. If you're using those versions, things like pain or infection even and pharmacists can be a great resource to teach patients the safest injection technique. If that's the case.

00:19:14 Don Weinberger

Yeah, that's a good point, Steve. I like that.

00:19:17 Don Weinberger

And speaking of that, it's now time for our audience question from the last episode on managing acne. We can't really get away from those, they pop up all the time, right?

00:19:27 Don Weinberger

So, this audience member asked. You talked about oral tetracycline antibiotics for acne being equally effective. But are the topical versions equally effective as the oral ones?

00:19:43 Don Weinberger

And you know, I, you know, I love, give cut and dry answers when we can, but this one is not really a cut and dry answer because there's a lot of factors that come into play. 

00:19:51 Don Weinberger

It can come down to like how severe the acne is. 

00:19:55 Don Weinberger

Where the acne is. What other option the patient can afford that kind of goes into payer coverage gauging to take consistently. 

00:20:03 Don Weinberger

Are they going to apply something full body every single day, twice a day, where may be right, and tolerating medications. 

00:20:11 Don Weinberger

So going to the dosage forms orals are usually safe for moderate to severe acne where topicals don't work or for the more widespread acne like on the trunk of the body or like the back, right?

00:20:24 Don Weinberger

Or the top of the, of the back where, you know, maybe hard to apply topicals.

00:20:28 Don Weinberger

Topical Minocycline which you mentioned, it's available on a foam… but it's tends to be pretty pricey and not covered by payers at first.

00:20:40 Don Weinberger

Where usually you try other topical antibiotics like Clindamycin with benzoyl peroxide first.

00:20:46 Don Weinberger

And the use of both topicals and orals is used fairly commonly as a as a 1-2 punch against acne on the face and body.

00:20:53 Steve Small

Yeah. Good answer, Don. And I'm loving these questions from the audience. If you'd like to have your question about this episode answered next month, send us a message. We're looking forward to it.

00:21:02 Don Weinberger

Yeah, it's, it's all we live for people, so please send them.

00:21:07 Don Weinberger

So we also use your suggestions to plan our episodes. So send us your ideas for rumors and truths to analyze.

00:21:13 Don Weinberger

Using the contact US link at the bottom of your TRC healthcare homepage or the send us a text link right from the podcast show notes.

00:21:23 Steve Small

Yeah, we'd love to know what you've got in terms of ideas for us to demystify and a couple more things here if you like what you heard on this episode, be our friend. Tell a friend about our show.

00:21:35 Don Weinberger

Be a friend, friend, so and also a quick reminder for our special 10% discount we mentioned earlier. Just use the code RVT1025 when you check out.

00:21:47 Don Weinberger

And if you’re a student, even better, students can access a free version of pharmacist letter and you know, Steve, we were students at one point, anything is free, it's me, right?

00:21:56 Steve Small

Yeah. I'll even take free stuff now, I think that's great. We've got links in the show notes that take you directly to the right places to take advantage of these awesome deals. So go check them out. 

00:22:05 Steve Small

And if you aren't already subscriber, don't miss on these resources, Sign up today to stay ahead with trusted insights and tools.

00:22:13 Don Weinberger

And join us next time where we'll take a bite out of the claims about medications and dental health. 

00:22:19 Steve Small

I’ll try to put a smile on for it, Don, and thanks for joining us on rumor versus truth. Your trusted resource for facts where we dissect the evidence behind risky rumors and reveal clinical truths. See you next time.