What are the benefits of strength and stamina training for a male patient with hypogonadism undergoing Testosterone Replacement Therapy (TRT)?

Benefits of Strength and Stamina on TRT

Yes, testosterone replacement therapy (TRT) provides measurable benefits to strength, particularly in men with mobility limitations, though improvements in stamina and overall physical performance are inconsistent and often minimal. 1

Strength Benefits: What the Evidence Shows

Leg and chest press strength improve significantly with TRT in men with functional limitations. The TOM trial demonstrated substantial gains in hypogonadal men with mobility issues: leg press strength increased by 129.8 N (P=0.003), chest press strength by 34.5 N (P=0.002), and climbing power with load by 30.2 W (P=0.05). 1 However, these men showed no improvements in unloaded climbing or gait speed, highlighting that strength gains don't necessarily translate to functional mobility. 1

Lean body mass increases modestly but consistently across studies. Multiple trials show TRT increases lean body mass by approximately 1.1-1.9 kg compared to placebo (P<0.001 to P=0.027). 1 This represents a real but modest anabolic effect that occurs even in frail elderly populations. 1

Stamina and Physical Performance: Limited Benefits

Stamina improvements are largely absent in most populations studied. The evidence reveals a critical disconnect between muscle mass gains and actual physical performance:

• In frail men over 50: No differences in upper- or lower-extremity strength, physical performance, or frailty assessments despite increased lean body mass 1
• In obese men with sleep apnea: No difference in grip strength or most biometric parameters after 12 weeks 1
• Specific strength measures: Only isometric knee extension showed improvement (8.6 N increase, P=0.02) in one 274-patient study, while knee flexion, grip strength, and physical function failed to reach significance 1

Gastrocnemius muscle thickness increases by 1.4 mm (P=0.015), suggesting structural changes occur even when functional improvements don't. 1

The Exercise Combination: Critical for Optimal Results

Adding structured exercise to TRT produces superior outcomes compared to TRT alone. A randomized trial demonstrated that combining supervised exercise with TRT for 20 weeks resulted in:

• Significantly better improvements in serum testosterone levels and symptom scores compared to TRT alone 2
• Sustained benefits even after TRT cessation: Men who continued exercise maintained improvements 8 weeks after stopping testosterone, while the TRT-only group deteriorated 2
• Higher rates of positive response on global assessment (statistically significant difference between groups) 2

Physiotherapy combined with TRT (1 hour twice weekly for 6 months) accelerates and enhances results. This combination significantly increased maximum and relative jump power, maximum jump height, and lean body mass while decreasing relative fat mass—improvements not seen with TRT alone. 3

Clinical Algorithm for Maximizing Strength and Stamina Benefits

Step 1: Set Realistic Expectations

• Explain that strength gains are modest and primarily affect specific muscle groups (legs, chest) 1
• Clarify that improvements in energy, vitality, and overall physical functioning are minimal (standardized mean difference 0.17 for energy/fatigue) 4
• Note that gait speed and functional mobility typically don't improve despite strength gains 1

Step 2: Mandate Exercise Integration

• Prescribe supervised resistance training 2x weekly minimum based on evidence showing this combination produces superior and more durable results 3, 2
• Focus on compound movements (leg press, chest press) where evidence shows TRT effects are strongest 1
• Continue exercise even if TRT is eventually discontinued, as benefits persist with ongoing training 2

Step 3: Monitor Appropriate Outcomes

• Measure specific strength parameters (leg press, chest press) rather than general physical function scores 1
• Track lean body mass changes (expect 1-2 kg increase) 1
• Don't expect improvements in grip strength, walking speed, or frailty scores in most patients 1

Important Caveats and Pitfalls

The population studied matters enormously. Men with mobility limitations show strength benefits 1, while frail elderly men and obese men with sleep apnea show minimal functional improvements despite body composition changes. 1

Bone density improves more reliably than physical performance. Lumbar spine BMD increases 3.2% and femoral neck BMD by 1.4% (both P<0.05), representing a more consistent benefit than strength or stamina gains. 1

Cardiovascular stamina is not improved by TRT. The evidence focuses on muscular strength, not aerobic capacity or endurance performance. 1

Safety monitoring is mandatory given the potential for erythrocytosis (up to 44% with injectable testosterone), which could paradoxically impair stamina through increased blood viscosity. 4, 5