The case for Testosterone

Steel-manning the case for becoming a man of steel

Alright, let’s just put it out in the open - Testosterone is THE single biggest performance enhancing drug in athletics for a reason.

Many would argue that testosterone is the biggest LIFE enhancing drug, for many of the same reasons.

I want to talk to you about those benefits, the potential downsides and degrees of risk, and get you informed about all of this so that if you’re thinking about doing TRT or gear, you’re going in with open eyes.

You know how whenever people talk about HIIT (high intensity interval training), there’s this impossibly long list of really great sounding benefits? Here’s mine from an older post:

What benefits does HIIT drive?

1. Improves fat burning efficiency and burns twice as much fat as traditional cardio.

2. Drives significantly higher post-exercise EPOC.

3. Improves VO2max, and drives better blood oxygenation.

4. Drives greater stroke volume, and greater cardiac contractibility, ~10-15% more than regular cardio.

5. It drives vascular adaptation, making your heart chambers larger and more elastic, improves the size and elasticity of your arteries, and increases the number of capillaries.

6. It drives hypertrophy - the relevant muscles get bigger.

7. It allows you to recruit more muscle fibers, and to do so more efficiently, driving greater muscular force and contractibility.

8. It improves insulin uptake, and improves the muscles’ ability to transport glucose overall.

9. It increases mitochondrial production and turnover, leaving you with more and “stronger” mitochondria.

10. Relative to traditional moderate-intensity cardio training, it drove a 41% increase in pain tolerance, and a 110% increase in race-intensity output time before dropout in one study.

Man, sounds pretty great, right? And all in ~1/5 the time regular cardio takes!

So Testosterone is basically that, but for athletic performance, building muscle and strength, and living a life well-lived.

What benefits does Testosterone drive?

1. Significantly greater hypertrophy - your muscles get bigger, faster. In the limits, it’s basically the only thing that allows you to put more muscle on past your maximum muscular genetic potential.¹

2. Greater recovery - the ability to recover after a hard workout is significantly enhanced.

3. It enhances the synthesization of creatine in skeletal muscle, which is one of the key factors in ATP replenishment.

4. It increases your red blood cells and hematocrit, improving your ability to oxygenate under load.

5. Greater work capacity - how hard you can work during an intense effort, and how quickly you recover from it - you can take on, and recover from, significantly greater workloads when on it.

6. Related to the above, greater baseline energy in day to day life.

7. Testosterone is actually a significant (and under-rated) nootropic, and typically drives higher motivation, higher status seeking, and higher risk-taking, while also improving concentration and focus in many users.

8. Testosterone, especially for older men, drives greater joie de vivre and often helps them feel younger, more vital, and more engaged with life.

9. Testosterone increases libido, often significantly.

So it will make you ripped, more energetic, let you train and recover better, give you more focus and motivation, AND make you feel happier, hornier, and more engaged with life? Those are *massive* upsides!

Where’s the downside?? Why aren’t people passing this stuff out like candy to every guy in town?

The possible downsides are many and varied, because testosterone affects nearly every system in your body.

Possible Downsides

1. Higher blood pressure

2. Higher cholesterol

3. Impaired insulin production

4. (For orals) liver stress and potential damage

5. (For orals) kidney stress and potential damage

6. Acne

7. Irritability (For some, with decent evidence this is psychosomatic)

8. Male pattern baldness / hair loss

9. Gynecomastia (aka “bitch tits”)

10. Thickening of ventricular walls

11. Immune suppression and greater susceptibility to infections

12. Over time, it suppresses your HPG axis and you stop producing testosterone endogenously

13. It impacts fertility and sperm quality, with exogenous testosterone being a 60-98% effective male fertility suppressant while you’re on it

If you dig into individual case studies, you’ll even find case studies where people claim to have suffered tumors, liver failure, and cardiomyopathy from steroid use.²

Damn. Well, you know, some of that stuff sounds pretty bad, actually.

But as Paracelsus tells us, the dose makes the poison, and I think you’ll find that at reasonable doses, the side effects are both uncommon and typically minimal.

You’ll notice I’ve been a bit coy about dosage here so far. Am I talking about TRT? Am I talking about supraphysiological doses? Am I talking about “blasting gear, bro” like bodybuilders do?

Anabolics dosing

Yeah, I’m talking about all of these doses. Because like most things, the benefits and the side effects are dose dependent.

TRT

In TRT, for example, which typically tops out at 200mg per week, you’re simply bringing an older man’s testosterone levels back to a more youthful benchmark. The risks are generally minimal to positive in these cases (although you want to use your head, don’t do it if you’re in a high-risk category for any of those side effects), because these levels are found in actual people everywhere.

And just speaking firsthand for myself, and from my dad, and from a few other older gym buddies, TRT is life-changing in terms of quality of life. Especially if you were pretty hard charging when younger - it’s like it de-ages you by 10+ years, it’s amazing.

Athlete dosing

For athletes, it really depends on the sport, but typically they might be doing 200-600mg a week, with the lower end for cardio folk who really need better recovery and work capacity, and the upper end for people in sports where muscles and strength matter more.

This is where your track and field, cycling,³ baseball players, soccer players, swimmers, and tennis players live, generally.

Bodybuilder dosing

These are your big dogs, who do up to 1-2g a week, and generally a mix of different anabolic compounds.⁴ Muscle mass and strength matter uber alles, and the work capacity and recovery benefits are needed to cope with the insane loads they put themselves under.

This is where your bodybuilders, football and rugby players, strength athletes, and strongmen usually end up.

I’m gonna assume people in that last category aren’t reading this, because they already know what they’re doing and have years of experience already.

So I’m gonna focus on TRT and <=600mg weekly doses in this missive.

Tell me about the risks

TRT risks

The risks for TRT levels of testosterone are minimal, and on balance, this is likely positive for your health if you were under the 350 ng / dl threshold that delineates low testosterone. From Llewellyn’s Anabolics, 10th ed:

“Unlike steroid abuse, hormone replacement therapy may have benefits with regard to cardiovascular disease risk. For example, studies tend to show hormone replacement as having a positive effect on serum lipids. This includes a reduction in LDL and total cholesterol levels, combined with no significant change in HDL (good) cholesterol levels.⁵ Testosterone supplementation also reduces midsection obesity, and improves insulin sensitivity and glycemic control.⁶ These are important factors in metabolic syndrome, which may also be involved in the progression of atherosclerosis.”

And of course, we can bracket the risks by looking at the higher-than-TRT doses, and we can rest comfortably knowing that TRT doses should have correspondingly lower risks.

200-600mg / week risks

So given that supraphysiological doses are technically illegal, if quite common,⁷ it’s difficult to find RCT’s comparing steroid users to placebo groups. As always, I’ve tried to find and highlight only the strongest and highest quality studies here.

How about a 25 study Cochran, medline, embase meta analysis studying AAS use in athletes and looking at the side effects:

Andrews, et al. Physical Effects of Anabolic-androgenic Steroids in Healthy Exercising Adults: A Systematic Review and Meta-analysis (2018)

Only 13/25 studies had negative effects at all, and the negative effects were all minor (and occured about as often in the placebo groups) - they encompassed slightly changed LDL / HDL cholesterol levels, acne, and irritability:

This argues as long as you stay away from orals, a dose of 200-600mg is actually quite safe in expectation, especially if you’re young and have no preexisting cholesterol or blood pressure issues.

Another study with basically the same findings side-effect wise,⁸ that I’m not going to deep dive into, is Shalender A, et al. Testosterone dose-response relationships in healthy young men. (2001).

Finally, the fun one - an actual RCT! Bhasin et al. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men (1996):

In this they’re giving 600mg of testosterone enanthate weekly over 10 weeks, splitting a population of 43 men from 19-40 years of age into four groups: placebo with no exercise, testosterone with no exercise, placebo plus exercise, and testosterone plus exercise.

They measured potential side effects exhaustively:

“Blood counts, blood chemistry (including serum aminotransferases), serum concentrations of prostate-specific antigen, and plasma concentrations of total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides were measured at the start of the control period and on day 4; on days 28, 56, and 70 of the treatment period; and four months after the discontinuation of treatment. Periodic evaluations to identify adverse effects were performed by examiners unaware of the study-group assignments on days 1 and 28 of the control period; days 28, 56, and 70 of the treatment period; and four months after the discontinuation of treatment.”

In terms of assessing mood and behavior:

“A standardized Multidimensional Anger Inventory³⁸ that includes 38 questions to measure the frequency, duration, magnitude, and mode of expression of anger, arousal of anger, hostile outlook, and anger-eliciting situations and a Mood Inventory that includes questions pertaining to general mood, emotional stability, and angry behavior were administered before, during (week 6), and after the treatment (unpublished data). For each man a live-in partner, spouse, or parent answered the same questions about the man's mood and behavior.”

What did they find? Most interesting to me was that even without training, the guys on gear gained appreciable muscle and strength (3.2kg of FFM, and ~19% in strength). Steroids plus exercise gained ~6.1kg of FFM on average, and twice the strength (~38%).

Since this is the most directly relevant to our dosage range in terms of side effects, I will directly quote:

“The serum liver-enzyme concentrations, hemoglobin concentrations, hematocrits, and red-cell counts did not change in any study group (Table 2). Serum creatinine concentrations did not change, except in the testosterone-plus-exercise group, in which the mean (±SE) serum creatinine concentration increased from 1.0 mg per deciliter (88 μmol per liter) to 1.1 mg per deciliter (97 μmol per liter) (P=0.02). Plasma concentrations of total and LDL cholesterol and triglycerides did not change in any study group;”

They also noted no changes in anger or irritability in this group from the mood assessments.

Fertility impacts

So, this could be either a downside or an upside depending on where you are in life, but testosterone is actually a fairly effective male birth control (and has been studied as such).

From Patel, et al. Testosterone Is a Contraceptive and Should Not Be Used in Men Who Desire Fertility (2018) - testosterone is a 60-98% effective male fertility suppressant:

“[Two studies by the World Health Organization (WHO) Task Force on Methods for the Regulation of Male Fertility] found an azoospermia rate of 64% to 75% in 6 months with testosterone enanthate. A sperm concentration of 3 million/mL was used as a threshold for effective suppression of spermatogenesis in this study. In a Chinese study of a monthly intramuscular TU injection, an azoospermia rate of 93% to 98% was achieved after 6 months with 1 million/mL as the criteria for effective suppression”

“Testosterone as a contraceptive can suppress spermatogenesis and lead to azoospermia in 65% of normospermic men within 4 months of use. Cessation of exogenous testosterone will lead to the reversal of hormonally-induced azoospermia in 64% to 84% of men with a median time of about 110 days. All men in these studies recovered to baseline levels after cessation of therapy; however, it took up to 2 years for some men to recover.”

“In summary, despite the androgenic effects of testosterone on sexual function, libido and mood; its effect on gonadotropins leads to the inhibition of sperm production”

What is the answer if you’re worried about fertility?

If you’re worried about fertility and want to preserve it, the two ways to do so are by using HCG⁹ whenever you’re on anabolics (which ensures your endogenous production of testosterone never stops), or by cycling on and off for roughly equal 10-12 week time blocks and doing Post Cycle Therapy (PCT), where you take tamoxifen or clomid for several weeks to restart your HPG axis (this is “blasting and cruising.”)

“Dr. Scully’s PCT Protocol: Human chorionic gonadotropin (hCG) is taken at 2000IU every other day for 20 days. Clomiphene citrate 50 mg is taken twice per day for 30 days. Tamoxifen citrate is taken 20 mg twice per day for 45 days.”

If you’re extra paranoid, you could hit the fertility clinic and put some sperm on ice before you try steroids.

Not a bad risk / reward profile after all, would be my own verdict.

Being more muscular, stronger, more energetic, able to train harder and recover better, having more focus and motivation, AND feeling happier, hornier, and more engaged with life? In my own personal philosophy, the “benefits” side of that balance is groaning and basically touching the ground. And as long as you’re sensible, the downsides are fairly benign and amenable to monitoring.

I think the risk / reward profiles lend themselves to some pretty straightforward recommendations.

As long as you’re otherwise healthy, can commit to monitoring the negative side effects, and have mitigation plans in place, it should be fairly low risk to consider trying TRT.

Who should consider TRT?

1. Men over 40, or men of any age below the ~350 ng / dl threshold, who are otherwise healthy and want those upsides

2. Recreational athletes who are otherwise healthy and interested in the upsides

What about larger doses?

I personally think you’re only going to benefit from larger doses if you’re on top of your tripod - your workouts, eating, and sleeping needs to be dialed in pretty well.

If you go on various steroid forums (Meso, reddit), you’ll see a lot of people who are doing high levels of steroids, and who look…let’s just say “unimpressive.” It’s clear they’re using it as a crutch, because they don’t want to put the work into actually executing a rigorous workout, diet, and sleeping regime. It’s equally clear that they’re exposing themselves to noticeable risk for basically nothing - these are always the guys who galaxy-brain their way to stacking multiple compounds in crazy amounts, and at the end they’re not really strong, and they don’t even look good. Let’s not be like that.

Who should consider “athlete levels?”

1. Competitive athletes under serious training loads

2. People near their maximum genetic potential (see footnote 1) in terms of fat free mass who are interested in adding more

3. People who have their diet and workout routines really dialed in and are looking for an extra edge or boost

Who should NOT consider testosterone?

1. Women - women get strong androgenization and virilization side effects at even very small doses, it’s a bad idea generally

2. People with existing cardiac, blood pressure, cholesterol, or sugar problems (if BP or cholesterol were barely over thresholds and now controlled with medication, it’s probably fine to try, but don’t fly blind, monitor your metrics)

3. People who don’t have their diet and routine dialed in, and think “Vitamin T” is an “easy mode” button to getting ripped and swole (it’s going to be mostly wasted and more downside than upside if you don’t have your diet and workout routine on point)

4. Men who want to get somebody pregnant within the next year - because of the effects on the HPG axis and sperm quality (if you do HCG concurrently, this is probably fine)

Risk awareness and mitigation plans

So it’s important when going into anything with potential risk like this that you go into it with open eyes, and a monitoring and mitigation plan. Especially when it’s your one and only body, you need to take care of it!

What are the risk factors for worse side effects?

1. Older age - you’re more susceptible to all the side effects the older you are, and should dose accordingly

2. Not doing cardio - cardio mitigates both blood pressure and cholesterol increases, especially if you do HIIT

3. Pre-existing cholesterol or blood pressure problems

4. Pre-existing diabetes or blood sugar problems

5. Pre-existing male pattern baldness, or history in male line

6. History of stroke, heart attack, or other cardiac problems - obviously don’t do anything that whacks your BP and cholesterol if you have a cardiac history

7. Other pre-existing cardiac problems, due to ventricular hypertrophy and cardiomyopathy potential with long term use

What to monitor?

Did you know there’s a ton of websites where you can just order labs yourself, without needing a doctor?

1. HDL and LDL (labs, 2x annually)

2. CBC - blood chemistry labs, with hematocrit, RBC, neutrophils, that let’s you keep track of excess red blood cells and a few immune measures. (2x annually)

3. Blood pressure

4. A1C or fasting glucose (labs 2x annually)

5. eGFR kidney function, bilirubin and a few other liver metrics (labs 2x annually)

6. Hair (for balding)

7. Skin (for acne and excess hair)

8. Gynocemastia - nipple tenderness and / or itchiness, growth in pectoral mass that doesn’t appear to be muscular

9. Irritability (for the sake of your friends and partners and family)

What are the safety practices to mitigate side effects?

1. Cardio / HIIT - mitigates cholesterol and blood pressure effects, both of which are trackable with labs or simple devices

2. Liver and kidney toxicity - stay away from orals. If you do use them, only do so for 2-3 weeks at low or moderate doses

3. Acne - if it gets bad in a way daily face washing and lotion don’t help, Accutane is your answer

4. Irritability - Mostly due to cultural expectation / placebo effect, but you can get a little bit of this. Just be mindful and keep an eye on it - if it’s getting to be a problem, dial back your dosage.

5. Tumors / immune suppression effects - not a problem at TRT levels, and for higher levels, this is what “cruising” and off-cycles are for. Also, 4-6mg of rapamycin on a second rest day every other week downregulates mTor and kills precancerous cells (it’s how and why it’s used for anti-aging). You can get rapamycin with totally online doctor video visit and refills from agelessrx.com, which website I’m a huge fan of.

6. Gynocomastia - there are “aromatization inhibitors” like anastrazole that you can take that prevent the high estrogen levels that can lead to this

7. Fertility - take HCG while using testosterone, or cycle on and off in 10-12 week cycles while doing “post cycle therapy” (PCT) to restimulate your endogenous production.

8. Hair loss - follistatin prophylactically for hair loss if you’re high risk, minoxidil if you see hair loss empirically.

What happens if you want to stop?

Doing testosterone (TRT or higher) over a long enough period does suppress your endogenous production, but it’s not permanent.

Generally with no further interventions, your body will recover over a couple of months:

Alternatively, you can do Post Cycle Therapy using clomid or nolvadex, and shorten this to 1-1.5 months (you can find a PCT protocol in the fertility section).

Finally, if you’ve been doing HCG (to preserve fertility, for example), your endogenous production should not have stopped to begin with, and you’ll be back at your normal testosterone levels after 16 days or so (testosterone enanthate has a ~8 day half life).

And that’s pretty much it!

If you too are interested in something that will make you ripped, more energetic, let you train and recover better, give you more focus and motivation, AND make you feel happier, hornier, and more engaged with life, you’ve got a nice reference here now.

It’s more than just your own internal joie de vivre and experience, too!

When it comes to dating and attribute attractiveness, THE biggest "revealed preferences vs stated preferences" gaps are around having a nice body, being sexy, smelling good and being a good lover - ALL of which are typically markedly improved by testosterone.

From Eastwick, et al. A Worldwide Test of the Predictive Validity of Ideal Partner Preference-Matching (2024):

On the whole, stated and revealed preferences aligned in terms of ranking, although some intriguing differences did emerge. For example, the attributes “confident,” “a good listener,” “patient,” and “calm, emotionally stable” ranked considerably more highly as stated preferences than as revealed preferences. In contrast, the attributes “attractive,” “a good lover,” “nice body,” “sexy,” and “smells good” ranked considerably more highly as revealed preferences than as stated preferences. In fact, “a good lover” was the #1 largest revealed preference but actually ranked 12th in terms of stated preferences.

And on the subject of motivation and risk taking: I have a post in the works on “who should consider a startup, and what are the important factors for success?” So keep your eyes out for that one if it’s an area of interest to you.

Now you have an idea of the landscape, the risk / benefit profile and likelihood, and a plan for what you should do in terms of monitoring and mitigation. Godspeed, and good luck.

More content:

Fitness posts index.

Book review posts index.

1. FFMI is your FFM in kg divided by your height squared in meters. Natty athletes top out at around 25 - this is your max genetic potential. Values above 26 or so require gear, aka supraphysiological levels of testosterone or other anabolics.

Your particular max genetic potential may top out somewhere a little different depending on whether you’re a mesomorph or an ectomorph. Casy Butt’s model taking wrist and ankle measurements into account can give you that (all in inches, output in lbs):

LBM = H^1.5 × {(√W ÷ 22.667) + (√A ÷ 17.01)} × {(F ÷ 224) + 1}

2. As seen in things like this (relatively scaremongering, IMO) survey of AAS possible side effects:

Modlinski et al. The Effect of Anabolic Steroids on the Gastrointestinal System, Kidneys, and Adrenal Glands (2006)

The kidney and liver problems are always driven by orals. Tumors, mostly benign (likely a result of mTor up regulation, this is why you take breaks and/or use rapamycin every other week). The really bad long tail effects like this are based on 1 or 2 single-person case studies. But the global lifetime gear use worldwide is 6.5%, which argues in the west it’s probably 10-15%. So these side effects are super rare empirically and probably down to particular idiosyncratic things in those individual’s biology.

3. From Tyler Hamilton’s The Secret Race, about the pre-and-post gear use performance from a specific athlete, Bjarne Riis:

“But the strangest thing about Riis, by far, was the arc of his career.

For most of his career, Riis was a decent racer: solid, but rarely a contender in the big races. Then, in 1993, at twenty-seven, he went from average to incredible. He finished fifth in the 1993 Tour, with a stage win; in 1995, he finished third. By 1996, some observers believed he might even be able to defeat the sport’s reigning king, five-time defending champion Miguel Indurain.

I remember one of the first times I saw him up close, in the spring of 1997. We were going hard up some brutally steep climb, and Riis was working his way through the group, except he was pushing a gigantic gear. The rest of us were spinning along at the usual rhythm of around 90 rpms, and here comes Bjarne, blank-faced, churning away at 40 rpms, pushing a gear that I couldn’t imagine pushing. Then I realized: he’s training. The rest of us are going full bore, either trying to win or trying to hang on, and he’s training. As Riis went by, I couldn’t resist. I said, “Hey, how’s it going?” to see if he’d react. He gave me a glare and just kept riding.”

And this gives me the opportunity to put my favorite TdF graph into a post - where you can clearly see the first “doping crackdown” in the late 60’s which completely tanks times (prior to this, throughout the 50’s-60’s, many TdF athletes openly used speed and opiates to post better times), then you see the athletes adapt to the new testing regime and find out what they can get away with (EPO and gear), at which point times steadily improve for several decades, then we hit Lance Armstrong’s doping scandal (but literally everyone was doing it at this point, it was one of those dynamics where you needed to dope to even compete), at which point times tank, until athletes start adapting again to the new testing regime post 2017.

Broadly, sports associations and testing bodies don’t WANT to accurately police doping, because performance keeps going up and this makes the races more exciting and more popular, so it’s a bit of a kabuki theater dynamic of “we’ll pretend to monitor you, and you pretend you’re not doping,” up to and including announcing most tests far in advance.

4. There are more than 30 anabolic steroid compounds, and each has slightly different physical effects, mental effects, and side effect profiles. Higher volume users generally “stack” compounds, because you can reduce estrogen levels, complement various gaps in single-compound effects, target putting on “dry” vs “wet” weight, and more. Masteron, for example, is often found to be more nootropic and “focus and motivation” driving than testosterone, while maintaining lower estrogen levels to avoid side effects like gynocomastia that tend to happen at higher doses.

5. “Effect of testosterone replacement therapy on lipids and lipoproteins in hypogonadal and elderly men. Zgliczynski S, Ossowski M et al. Atherosclerosis. 1996 Mar;121(1):35-43.53.

Testosterone and other anabolic steroids as cardiovascular drugs. Shaprio J, Christiana J et al. Am J Ther 1999 May;6(3):167-74”

6. “Androgen deficiency as a predictor of metabolic syndrome in aging men: an opportunity for intervention? Kapoor D, Jones TH. Drugs Aging. 2008;25(5):357-69.”

7. The global lifetime gear use worldwide is 6.5% in surveys, which argues in the West it’s probably 10-15% overall.

Even high schoolers hit about 1% steroid usage incidence (I’m assuming the highest incidence is in football players).

8. In this study they gave men a range of doses, from 25-600mg a week, for 20 weeks. There’s a strong dose-response in terms of strength and FFM.

In terms of sides:

“Total cholesterol, plasma low-density lipoprotein cholesterol, and triglyceride levels did not change significantly at any dose. Serum PSA, creatinine, bilirubin, alanine aminotransferase, and alkaline phosphatase did not change significantly in any group, but aspartate aminotransferase decreased significantly in the 25-mg group. Two men in the 25-mg group, five in the 50-mg group, three in the 125-mg group, seven in the 300-mg group, and two in the 600-mg group developed acne. One man receiving the 50-mg dose reported decreased ability to achieve erections.”

9. HCG is human chorionic gonadotropin.

Meliegy et al. Systematic review of hormone replacement therapy in the infertile man (2017)

Ohlander et al. Testosterone and Male Infertility (2016)