Testosterone therapy dangers — a published case and what it teaches
Most discussions of TRT risk are abstract: percentages, study results, hazard ratios. This one is about a real patient whose case my colleague and I wrote up for Mayo Clinic Proceedings. He was prescribed testosterone at a men's-health clinic. He nearly didn't survive the complication. The lesson isn't that TRT is dangerous — it's that TRT prescribed without proper monitoring is.
The case
A man in his early sixties came to the emergency department with abdominal pain. He had been started on testosterone replacement therapy at a men's-health clinic some months earlier. His symptoms before TRT had been relatively typical — fatigue, low drive, the kind of complaints that overlap with a dozen other diagnoses. The clinic checked a testosterone level, told him it was low, and started injections.
What they did not consistently do was monitor what testosterone does to the blood. Testosterone stimulates the bone marrow to make more red blood cells. In some men — particularly older men, men on injectable formulations, men with sleep apnea, and men on supraphysiologic doses — the rise is dramatic. Hematocrit climbs into ranges where blood viscosity itself becomes a clinical problem. Thrombosis becomes a real possibility.
By the time he arrived in the ED, the picture was thromboembolic. The diagnostic workup — imaging, labs, the response of the clinical team — is the substance of the case report my colleague and I published in Mayo Clinic Proceedings in 2023 (Dunn R, Sahni N. "62-Year-Old Man With Abdominal Pain." Mayo Clin Proc. 2023;98(2):337-341). It is the kind of complication that should not happen, and routinely does, because the gap between starting TRT and properly monitoring it is the gap most clinics never close.
Why this happens — the pathophysiology
The mechanism is well-established and was understood long before TRT became a direct-to-consumer product:
- Testosterone stimulates erythropoiesis. It suppresses hepcidin (freeing iron for red cell production) and directly increases erythropoietin sensitivity. Red cell mass rises.
- Hematocrit increases. In a meaningful subset of men on TRT, hematocrit rises above the upper limit of normal — sometimes well above 54%, which is the threshold most guidelines flag for intervention.
- Blood viscosity rises with hematocrit, nonlinearly. Above the high-50s, the relationship gets steep. Sluggish flow in low-pressure venous beds becomes much more likely.
- Thrombosis becomes the failure mode. The clots can land anywhere veins drain: splanchnic veins (mesenteric, splenic, portal, hepatic), the cerebral sinuses, the lungs, the deep veins of the legs. Arterial events — stroke, myocardial infarction — are also reported.
This is not exotic medicine. It is the most predictable serious complication of testosterone therapy. Every legitimate guideline — Endocrine Society, AUA — specifies hematocrit monitoring as mandatory before, during, and throughout the course of therapy. The reason it keeps happening in practice is that monitoring takes time, takes attention, and isn't built into the rapid-prescription model.
Who is at higher risk
TRT-induced polycythemia and its thrombotic complications are not random. The risk concentrates in identifiable populations:
Already on TRT and never been monitored? That's a problem.
- Older men. Baseline hematocrit tends to be higher, and the erythropoietic response to testosterone is more pronounced.
- Men on injectable testosterone — particularly weekly or biweekly cypionate — rather than transdermal gel. Peak-and-trough pharmacokinetics seem to drive more erythrocytosis than steady transdermal levels.
- Men with untreated obstructive sleep apnea. Chronic nocturnal hypoxia is itself an independent driver of erythrocytosis. Add TRT and the effects compound.
- Smokers and men with chronic lung disease, for similar hypoxia-related reasons.
- Men on supraphysiologic doses. The dose-response is real. Some clinics push testosterone levels well above the upper limit of normal in the name of "optimization" — an approach for which the long-term safety data is essentially nonexistent.
- Men with pre-existing prothrombotic conditions — prior VTE, known thrombophilia, active malignancy — for whom TRT raises baseline risk further.
None of these risk factors are exotic. They are the kinds of details that a five-minute symptom questionnaire, however well-designed, doesn't reliably surface.
What proper monitoring looks like
The standard of care for men on TRT is not complicated. The hard part is doing it consistently.
- Baseline hematocrit before the first dose, with TRT deferred or alternative therapy considered if hematocrit is already elevated.
- Repeat hematocrit at 3 months, 6 months, and every 6 to 12 months thereafter. Some patients warrant more frequent checks.
- Action thresholds. Hematocrit climbing into the low-50s warrants attention. Above 54% generally triggers dose reduction, switch from injectable to transdermal, or therapeutic phlebotomy. "We'll watch it" is not a response when the curve is rising.
- Sleep apnea screening in any man being evaluated for TRT, with a low threshold for formal sleep study.
- A physician who actually sees the lab. An NP or PA who briefly reviews a result is not the same as a physician who knows the patient and can integrate the trend with everything else — sleep, weight, blood pressure, medications, family history.
- A way for the patient to reach the prescriber if symptoms develop — new headache, leg swelling, unexplained abdominal pain, chest pain, neurologic symptoms — without going through a generic intake queue.
Why this fails at chain men's-health clinics
The specific failures are predictable from the model:
- The intake is built for throughput. Sleep apnea risk, smoking, prior VTE, family history — these often get a yes/no checkbox and move on. The patient who would benefit most from a careful conversation gets the same flow as everyone else.
- The prescriber is often not the person who sees you. Many telehealth and franchise models use a medical director model: a physician licensed in multiple states signs prescriptions issued through the platform, while NPs or PAs handle the actual visits. The physician of record may never speak to the patient.
- The follow-up is a refill cadence, not monitoring. "Ship the next vial every 90 days" is not the same as "review the trend in hematocrit and act on it." If labs are drawn, results often arrive into a queue. If hematocrit rises, the response is sometimes nothing.
- There's no continuity for related conditions. Sleep apnea, hypertension, lipid disorders, and depression — all of which interact with TRT — aren't in the clinic's scope. The patient is left to coordinate care across multiple silos.
- The financial model rewards retention on treatment, not outcomes. A clinic that recommends stopping TRT because the patient is doing fine without it is leaving money on the table. The incentive is to keep prescribing.
None of this is unique to any single brand. It is structural to the rapid-prescription model. Some operators do it more carefully than others; none of them, in our experience, do it as carefully as a primary care physician who has been seeing the patient for years.
How to know if your TRT prescriber is set up to keep you safe
A short checklist a patient can apply to their current clinic, or to one they are considering:
- Did the workup include two morning testosterone levels on separate days, plus LH, FSH, SHBG, prolactin, estradiol, and CBC — not a single blood draw and a prescription?
- Was sleep apnea screening part of the intake?
- Will you see the same physician at every visit, or a rotating cast of providers?
- Are follow-up labs scheduled at 3 and 6 months, with a stated plan for what happens if hematocrit rises?
- If you have a concerning symptom — sudden leg swelling, new abdominal pain, headache — can you reach the prescriber directly, the same day?
- Does the prescriber also manage your blood pressure, lipids, diabetes risk, and mental health, or are they only treating one number on one lab?
- Does the prescription come from a standard FDA-approved manufacturer, dispensed by a regulated pharmacy — not a compounded preparation from a pharmacy you have never heard of?
If most of the answers are no, the model is built for refills, not for safety.
What we do differently
TRT evaluation and management at Private MD is integrated into Foundation (direct primary care) and Signature (concierge) memberships, when clinically indicated. Diagnostic and monitoring labs run through our wholesale Quest contract. FDA-approved testosterone cypionate is dispensed through standard cash-pay pharmacies (Cost Plus Drugs and similar) at typical out-of-pocket cost of $30 to $80 per month. No compounded testosterone, no pellets.
If you are already on TRT through a chain or telehealth platform and want a second-opinion review, that is a common reason patients reach out. We can re-run the monitoring labs you may not have had recently, look at the trend, and either continue your current dose or recommend a change based on what the data shows. If hematocrit is climbing, we will tell you. If your symptoms aren't actually testosterone-related, we will tell you that too.
For deeper background on the diagnostic criteria, the TRAVERSE cardiovascular safety trial, and the difference between proper oversight and a refill mill, see our data-driven guide to TRT.
Ready to talk?
Request an introduction. We will walk through your current situation — whether you are considering TRT, already on it and unsure about your monitoring, or recovering from a chain-clinic experience that did not go well — and figure out together whether this practice fits what you need.
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Or email drsahni@privatemd.clinic · (916) 512-1912
About the author
Nishant Sahni, MD is board-certified in Internal Medicine and the founder of Private MD, a small-panel direct primary care and concierge longevity practice serving Granite Bay, Folsom, El Dorado Hills, and the greater Sacramento area. Former faculty at Mayo Clinic and the University of Minnesota.
Cited case: Dunn R, Sahni N. "62-Year-Old Man With Abdominal Pain." Mayo Clinic Proceedings. 2023;98(2):337-341. doi:10.1016/j.mayocp.2022.06.033. Additional sources: Endocrine Society Clinical Practice Guideline on Testosterone Therapy in Men With Hypogonadism (2018, updated 2023); American Urological Association guideline on Evaluation and Management of Testosterone Deficiency (2018, updated 2023). This article is for educational purposes and is not a substitute for individualized medical advice or evaluation.
Legal & Editorial Notes
Educational content only. This article is for educational and informational purposes. It does not constitute medical advice, diagnosis, or treatment recommendations for any specific individual. Reading this article does not establish a physician-patient relationship with Dr. Sahni or Private MD.
Patient case. The cited case report is published in the peer-reviewed literature; the discussion in this article reflects the published case and general clinical principles. Identifying details have been minimized to focus on the teaching point. The complication described is well-recognized but not universal — not every man on TRT will experience it.
Not a substitute for individual evaluation. Medical decisions should be made in consultation with your own physician based on your specific clinical situation, history, exam findings, and goals. If you have specific symptoms or health concerns — particularly new abdominal, chest, or neurologic symptoms while on TRT — seek medical evaluation promptly.
No financial relationships, no endorsement. Mention of specific products, companies, services, or commercial entities is for illustrative comparison only and does not constitute endorsement. Private MD receives no compensation, commission, kickback, or referral fee from any vendor, manufacturer, laboratory, or commercial entity mentioned in this article.
Controlled substance notice. Testosterone is a Schedule III controlled substance under the federal Controlled Substances Act. Prescribing requires individualized clinical evaluation, ongoing monitoring, and proper documentation. Self-treatment without a proper diagnostic workup carries clinical risk. This article does not constitute a recommendation to start, continue, or discontinue testosterone therapy for any individual.