TRT after TRAVERSE.

For 15 years the question hanging over TRT was: does it cause heart attacks? The 2010-2014 studies were mixed, the FDA put a black-box warning on testosterone in 2015, and most cardiologists started reflexively warning men away from it.

In June 2023, the TRAVERSE trial finally answered the question. 5,246 men, 45-80, with low testosterone and elevated cardiovascular risk, randomized to TRT gel vs placebo for 22 months. Primary endpoint: major adverse cardiovascular events.

Result: no difference between groups. The hazard ratio was 0.96 (95% CI 0.78-1.17). Non-inferior.

This was the definitive trial. After TRAVERSE, the cardiologist's reflex "TRT causes heart attacks" is no longer evidence-based. The FDA changed its labeling guidance in early 2024.

Three secondary findings worth flagging:

1. Slightly more atrial fibrillation in the TRT group (3.5% vs 2.4%). Statistically real, clinically small. If you have a history of AFib, this is a discussion to have.
2. Slightly more pulmonary embolism (0.9% vs 0.5%). Same caveat.
3. No difference in prostate cancer rates — another old worry, also resolved.

Who actually qualifies for TRT

The "low T" marketing industry has been broad. The clinical bar is narrower. You typically qualify if:

• Total testosterone < 300 ng/dL on two separate morning draws, plus
• Symptoms consistent with hypogonadism (low libido, fatigue, muscle loss, mood, cognitive)

Both, not either. A 52-year-old man with T of 380 and "I don't feel like myself anymore" doesn't clinically qualify for TRT — and shouldn't be on it. The reasonable diagnostic workup includes morning total + free T, SHBG, LH, FSH, prolactin, and a hemoglobin/hematocrit baseline.

The men-being-oversold problem is real. There are TRT clinics prescribing to men with T of 450 ("optimal" range marketing) when the symptoms could come from sleep apnea, depression, or thyroid. Get the boring workup first.

Modality math

Three FDA-approved delivery systems:

Gel (daily application). Steady levels, easiest to start/stop, transfer risk to spouse/children if not careful. Most starting protocols use this.

Injection (weekly or twice-weekly). Higher peak/trough variability, lower cost, fewer transfer concerns. Twice-weekly is closer to physiologic than weekly.

Pellet (3-6 month subcutaneous implant). "Set and forget" but harder to titrate. Some men love it; some find the levels too uniform.

The honest expectation-setting:

• Energy and libido — improve in 4-6 weeks if going to improve at all
• Body composition — 12-16 weeks for visible muscle/fat changes
• Mood and cognition — variable, often the slowest to respond
• Erections — improve in 30-50% of men; not a guaranteed effect

What TRT doesn't fix: bad sleep, untreated depression, terrible diet, sedentary life. If those are present, fix them first. TRT works on top of those — it doesn't replace them.

What to ask your doctor

Not all primary care doctors are current on this. The conversation script:

"I'd like a workup for hypogonadism — morning total and free testosterone on two separate days, plus SHBG, LH, FSH, prolactin, and hematocrit. I've read the 2023 TRAVERSE trial and I want to understand my risk-benefit profile if my T is low and I'm symptomatic."

If the doctor reflexively says "TRT causes heart attacks," they may not have read TRAVERSE. That's a referral question — to a urologist or an endocrinologist current on the literature.

On affiliate disclosure

After Forty Feel does not take affiliate commissions on any TRT product, telehealth clinic, or pharma drug. The category has too much grey-market and questionable-medicine activity for us to make money in it. We may link to legitimate diagnostic services in future, with full disclosure.

Next week: peptides honestly — Semaglutide, Tirzepatide, BPC-157, and what FDA-approved means vs. what telehealth-prescribed means vs. what research-grey means.

Alexander After Forty Feel Reader-funded. Research-led. No supplement-brand sponsorships.