How to safely discontinue Testosterone Replacement Therapy (TRT)?

How to Safely Discontinue Testosterone Replacement Therapy

Discontinue TRT by simply stopping the medication abruptly—no tapering is required—and reassess symptoms within 12 months, as testosterone levels and hormonal function return to baseline after cessation. 1, 2

When to Discontinue TRT

Stop TRT if there is no improvement in sexual function after 12 months of treatment, as this is the primary evidence-based indication for therapy in men with age-related low testosterone. 1

Additional reasons to discontinue include:

• Development of erythrocytosis with hematocrit >54% 3, 4
• Significant PSA elevation requiring further evaluation 3, 4
• Active or treated male breast cancer 3
• Patient actively seeking fertility (TRT suppresses spermatogenesis) 3, 5
• Lack of symptomatic improvement in the primary complaint 1

The Discontinuation Process

Abrupt Cessation is Safe

• No tapering protocol is necessary—testosterone can be stopped immediately without gradual dose reduction 2
• Hormonal levels return to pre-treatment baseline after discontinuation 2
• Maintenance of symptom improvement has been observed even after stopping TRT in some patients 2

Expected Timeline After Stopping

• For injectable testosterone (cypionate/enanthate): levels return to baseline within 10-14 days after the last injection 3
• For transdermal preparations: testosterone levels decline more rapidly, typically within days of stopping 3
• Symptom recurrence varies by individual but may take weeks to months 2

Post-Discontinuation Monitoring

Reassessment Schedule

• Reevaluate symptoms within 12 months after discontinuation to determine if symptoms return or if improvement persists 1
• Monitor testosterone levels 2-3 months after stopping to confirm return to baseline 3
• Check LH and FSH levels to assess recovery of the hypothalamic-pituitary-gonadal axis 3

What to Monitor For

• Return of hypogonadal symptoms (decreased libido, fatigue, erectile dysfunction) 1, 3
• Resolution of treatment-related side effects (erythrocytosis typically resolves within months) 3
• Recovery of spermatogenesis if fertility is desired (may take 3-12 months) 5

Clinical Considerations

High Discontinuation Rates Are Common

• Discontinuation rates of 30-62% have been reported in clinical practice 1, 4
• Many patients discontinue within the first 3 months: only 52% of topical TRT users and 31% of injection users remain on therapy after 3 months 6
• This suggests that discontinuation is a common and acceptable clinical outcome 6

Not a Lifetime Commitment

Contrary to common belief, starting TRT does not condemn patients to lifelong therapy—preliminary evidence shows men can successfully discontinue treatment without permanent hormonal dependence. 2

Alternative Approaches After Discontinuation

If symptoms return after stopping TRT and fertility is desired:

• Consider human chorionic gonadotropin (hCG) plus FSH for secondary hypogonadism 3
• Selective estrogen receptor modulators or aromatase inhibitors may stimulate endogenous testosterone production 5
• Address reversible causes: weight loss through low-calorie diets can improve testosterone levels in obesity-associated hypogonadism 3

Common Pitfalls to Avoid

• Do not continue TRT indefinitely without reassessing benefit—the American College of Physicians specifically recommends discontinuation if sexual function does not improve within 12 months 1
• Do not assume patients need lifelong therapy—evidence shows hormonal baseline can be restored after stopping 2
• Do not taper the dose—there is no evidence supporting gradual dose reduction, and abrupt cessation is safe 2
• Do not forget to monitor hematocrit after stopping—erythrocytosis should resolve, but confirmation is prudent 3