TRT Side Effects: The Honest Guide for Malaysian Men

TRT can be life-changing for men with genuine hypogonadism. But every clinic that pushes testosterone should also be honest about the downsides. Too many men start TRT without understanding what they're signing up for.

This guide covers every significant side effect, how common each one is, and what can be done about it.

Common Side Effects (Experienced by 10–30% of Users)

1. Acne and Oily Skin

Testosterone increases sebum (oil) production. This is one of the first side effects men notice, usually within the first 2–4 weeks.

• Severity: Mild to moderate in most men; severe cystic acne in a minority
• Location: Back, shoulders, face
• Management: Benzoyl peroxide wash, salicylic acid, reduce dose if severe. Accutane (isotretinoin) for persistent cases (requires doctor prescription in Malaysia)
• Usually improves after 3–6 months as the body adjusts

2. Testicular Atrophy (Shrinkage)

When you supply testosterone externally, the brain stops sending LH signals to the testes. Without LH stimulation, the testes shrink — typically by 20–40%.

• Timeline: Noticeable within 4–8 weeks of starting TRT
• Reversibility: Partially reversible if TRT is stopped; fully preventable with HCG co-therapy
• Cosmetic vs functional: Shrinkage is primarily cosmetic; testosterone is being supplied externally
• Prevention: HCG 250–500 IU 2–3x/week maintains testicular size and function

3. Mood Changes

Testosterone affects neurotransmitter systems. Most men report improved mood on TRT, but a subset experiences:

• Irritability — especially if estradiol rises too high (aromatization)
• Anxiety — sometimes in the first weeks as the body adjusts
• Emotional blunting — rare; some men report feeling "flat"
• Aggression — the "roid rage" stereotype is largely mythological at therapeutic TRT doses. True aggression is more associated with supraphysiological (steroid) doses

Management: Check estradiol levels. Most mood issues on TRT trace back to estrogen being too high or too low.

4. Water Retention and Bloating

• Testosterone increases sodium retention, which causes water retention
• Most noticeable in the first month; typically stabilizes
• Worse with higher doses and infrequent injections (peak-and-trough effect)
• Management: More frequent injections (e.g., twice weekly instead of biweekly), reduce sodium intake, manage estradiol

Significant Risks (Requiring Monitoring)

5. Polycythemia (Elevated Red Blood Cells)

This is the most medically significant side effect of TRT. Testosterone stimulates erythropoiesis (red blood cell production). Too many red blood cells thicken the blood, increasing risk of blood clots, stroke, and heart attack.

• Marker: Hematocrit (HCT). Normal is 40–52%. Concern begins at >52%, danger zone is >54%
• Prevalence: 10–20% of men on TRT develop elevated hematocrit
• Management:
  • Regular CBC monitoring (every 3–6 months)
  • Therapeutic phlebotomy (blood donation) if HCT >52% — Malaysian blood banks accept donations
  • Dose reduction
  • Nasal testosterone (Natesto) or cream may cause less polycythemia than injections
  • Stay hydrated — dehydration concentrates blood and artificially raises HCT

6. Fertility Suppression — The Big One

TRT is effectively male contraception. This cannot be overstated.

• Exogenous testosterone suppresses GnRH → LH → FSH, shutting down sperm production
• Sperm count drops to near zero within 2–3 months in most men
• Recovery: After stopping TRT, sperm production typically recovers in 6–12 months, but not always fully. Some men never fully recover
• Critical for younger men: If you plan to have children, do NOT start TRT without understanding this risk
• Prevention: HCG co-therapy maintains some sperm production. Enclomiphene is an alternative that doesn't suppress fertility
• Sperm banking: Available in Malaysia (RM500–1,500) as insurance before starting TRT

7. Estrogen Conversion (Aromatization)

Testosterone converts to estradiol via the aromatase enzyme. Higher testosterone doses = more estrogen. Symptoms of high estrogen in men:

• Gynecomastia (breast tissue development) — the most feared cosmetic side effect
• Water retention and bloating
• Emotional sensitivity and irritability
• Erectile dysfunction (paradoxically)
• Reduced libido

Managing Estrogen

Approach	Method	Notes
Dose adjustment	Lower T dose or more frequent injections	First-line approach; smaller, more frequent doses reduce peak aromatization
Aromatase inhibitors (AI)	Anastrozole 0.25–0.5 mg 1–2x/week	Effective but overused; crashing estrogen causes worse symptoms. Use only with blood work confirmation
Body fat reduction	Lower body fat = less aromatase enzyme activity	Long-term solution; fat tissue contains aromatase
DIM / Calcium D-Glucarate	200–300 mg DIM / 500 mg CDG daily	Mild, natural estrogen metabolism support. Not strong enough for serious issues

Warning: Many men and clinics over-prescribe aromatase inhibitors. Crashing estradiol below 15 pg/mL causes joint pain, depression, zero libido, and is arguably worse than high estrogen. Always test, don't guess.

8. Hair Loss (Androgenetic Alopecia)

• Testosterone converts to DHT (dihydrotestosterone), which miniaturizes hair follicles in genetically susceptible men
• If you're genetically predisposed to male pattern baldness, TRT will likely accelerate it
• If you're NOT genetically predisposed, TRT won't cause hair loss
• Management: Finasteride (blocks DHT conversion), minoxidil, or acceptance. See our complete hair loss guide
• Trade-off: Some men accept hair loss for the benefits of TRT; others won't. Personal decision

Debated Risks

9. Cardiovascular Risk

The relationship between TRT and cardiovascular risk has been hotly debated for years.

• 2010 TOM trial: Raised alarm — older frail men on testosterone gel had more cardiovascular events. But the study had methodological issues
• 2023 TRAVERSE trial (the largest RCT, 5,246 men): Found no increased cardiovascular risk from TRT in men with hypogonadism and pre-existing cardiovascular risk factors
• Current consensus: At therapeutic doses with proper monitoring, TRT does not appear to increase heart attack or stroke risk in men with genuine hypogonadism
• Caveat: Unmonitored TRT with polycythemia DOES increase clotting risk. Blood work is non-negotiable

10. Prostate Cancer

• Old belief: "Testosterone fuels prostate cancer" — led to decades of fear
• Current evidence: TRT at physiological doses does NOT increase prostate cancer risk in men without pre-existing cancer (Morgentaler's saturation model)
• Contraindicated: Men with active prostate cancer or highly elevated PSA should not start TRT
• Monitoring: PSA should be checked before starting TRT and every 6–12 months thereafter
• In Malaysia: Prostate cancer screening is recommended for all men over 50 regardless of TRT status

11. Sleep Apnea

• TRT may worsen pre-existing obstructive sleep apnea (OSA)
• Mechanism: Testosterone may increase upper airway collapsibility and alter central respiratory drive
• If you snore heavily, wake up gasping, or have daytime sleepiness, get a sleep study before starting TRT
• OSA itself lowers testosterone, so treating sleep apnea may improve T without needing TRT

Blood Work Monitoring Schedule on TRT

Timing	Tests Required
Before starting TRT	Full hormone panel, CBC, PSA, lipids, metabolic panel
6 weeks after starting	Total T, free T, estradiol, CBC (hematocrit), PSA
3 months	Same as 6-week panel + liver function
6 months	Comprehensive panel (all Tier 1 + CBC, lipids, PSA)
Ongoing (every 6 months)	T, free T, E2, CBC, PSA minimum. Full panel annually

If your clinic doesn't require regular blood work, find a different clinic. A good men's health clinic makes monitoring non-negotiable.

When to Adjust or Stop TRT

Reasons to Adjust Dose

• Hematocrit rising above 52%
• Estradiol above 40 pg/mL with symptoms
• Acne or oily skin that's intolerable
• Mood instability
• Supraphysiological T levels (above 1,100 ng/dL)

Reasons to Stop TRT

• Hematocrit above 54% despite phlebotomy and dose reduction
• PSA rising rapidly (velocity >0.75 ng/mL/year)
• Desire for fertility without HCG working
• Severe side effects not manageable with dose adjustment
• Prostate cancer diagnosis

What Happens When You Stop TRT

• Natural testosterone production will be suppressed and takes 1–6 months to recover
• You will likely feel worse before feeling better (the "crash")
• Recovery protocols (HCG, enclomiphene, clomid) can accelerate restart
• Some men — especially those on TRT for years — may not fully recover natural production
• TRT should be considered a long-term commitment, not something to try casually

Side Effects Summary Table

Side Effect	Frequency	Severity	Manageable?
Acne	Common (20–30%)	Mild-Moderate	✅ Yes (topicals, dose adjustment)
Testicular atrophy	Very common (80%+)	Cosmetic	✅ Yes (HCG prevents it)
Fertility suppression	Universal	⚠️ Serious	Partial (HCG helps, not guaranteed)
Polycythemia	Common (10–20%)	⚠️ Serious if unmonitored	✅ Yes (blood donation, dose adjustment)
Hair loss	Genetic (30–50%)	Cosmetic	Partial (finasteride helps)
Gynecomastia	Uncommon (5–10%)	Cosmetic/Moderate	✅ Yes (E2 management)
Cardiovascular	Debated	Serious	✅ Monitor HCT, lipids, BP
Sleep apnea	Uncommon	Moderate	✅ CPAP, weight loss

The Bottom Line

TRT is not risk-free. But with proper blood work monitoring, appropriate dosing, and a knowledgeable clinic, most side effects are manageable. The real danger isn't the side effects themselves — it's unmonitored TRT without blood work.

Before starting, understand the commitment: TRT is typically lifelong, it will suppress your fertility, and it requires regular blood tests. For men with genuine hypogonadism, the benefits usually far outweigh the risks. For men with borderline levels, natural optimization or enclomiphene may be worth trying first.

Know the risks. Monitor your numbers. And work with a doctor who takes side effect management seriously.