The Surprising True Risks and Benefits of Testosterone

How to cite: Kohler TS. “The Surprising True Risks and Benefits of Testosterone.” Grand Rounds in Urology. November 13, 2025. Accessed Apr 2026. https://grandroundsinurology.com/the-surprising-true-risks-and-benefits-of-testosterone/

Summary

Tobias S. Köhler, MD, MPH, FACS, Professor of Urology, Director of the Andrology Fellowship, Head of Men’s Health, Mayo Clinic, Rochester, Minnesota, provides an overview of testosterone therapy, separating long-standing myths from data-supported benefits and risks. Dr. Kohler emphasizes that testosterone deficiency is a clinical syndrome defined by both low serum testosterone levels and consistent symptoms, including decreased libido, erectile dysfunction, fatigue, depressed mood, loss of muscle mass, increased fat mass, and reduced bone density.

Accurate diagnosis requires morning serum testosterone testing, confirmation with repeat measurements, and correlation with clinical symptoms. Total testosterone alone may be misleading, particularly in men with altered sex hormone binding globulin levels. In selected cases, free or bioavailable testosterone measurements may be useful.

The physiologic benefits of testosterone therapy are reviewed across multiple organ systems. Therapy is associated with improvements in sexual desire, erectile function in hypogonadal men, lean muscle mass, strength, bone mineral density, insulin sensitivity, and anemia. Improvements in mood, energy, and quality of life are also reported.

Dr. Köhler addresses historical concerns surrounding testosterone therapy. Testosterone therapy does not appear to increase prostate cancer incidence when appropriately prescribed, though monitoring remains essential. Similarly, benign prostatic hyperplasia progression is not consistently worsened by physiologic testosterone replacement.

Risks of therapy are discussed. Testosterone can suppress spermatogenesis and should be avoided in men desiring fertility. Polycythemia is a well-recognized risk and requires routine hematologic monitoring. Fluid retention, acne, and gynecomastia may occur, depending on formulation and dosing.

Dr. Köhler stresses the importance of avoiding supraphysiologic dosing. Testosterone therapy should aim to restore normal physiologic levels, not exceed them. Careful patient selection, individualized dosing, and ongoing monitoring are essential to maximize benefit and minimize harm.

Dr. Köhler reinforces that testosterone therapy is neither a cure-all nor inherently dangerous. When prescribed appropriately for symptomatic hypogonadism, it offers meaningful benefits, while risks can be mitigated through evidence-based practice and surveillance.

About the 32nd Annual Perspectives in Urology: Point Counterpoint conference: Presented by Program Chair and Grand Rounds in Urology Editor-in-Chief E. David Crawford, MD, this conference brought together leading experts in urology, medical oncology, and radiation oncology to discuss and debate the latest topics in genitourinary cancers, primarily prostate cancer and bladder cancer. This interactive conference offered topical lectures, pro/con debates, interesting-case presentations, interactive panel discussions, and interactive audience and faculty networking.