TRT myths, metabolic risk, and the role of the urologist

In this video, Jesse N. Mills, MD, director of the Men's Clinic at UCLA, fellowship director of the UCLA male reproductive medicine and surgery program, and director of UCLA Urology Santa Monica, discusses how social media and direct-to-consumer online clinics have reshaped patient expectations around testosterone replacement therapy (TRT), often creating misconceptions that complicate care when patients transition to a urology practice.

Mills emphasizes that TRT is frequently misunderstood as “supplementation” rather than true hormone replacement. For men with normal testosterone levels, initiating TRT can actually worsen symptoms by suppressing the body’s natural production. Mills notes that he commonly sees patients whose testosterone levels decline after starting inadequately dosed online therapies—enough to suppress pituitary function but not enough to provide physiologic benefit.

A key challenge, he explains, is distinguishing between men seeking “optimization” or supraphysiologic levels and those who are genuinely hypogonadal. For Mills, the clinical decision to treat hinges on metabolic consequences of low testosterone, such as low bone density, adverse lipid profiles, or broader cardiometabolic risk. Although some patients pursue very high testosterone levels based on anecdotal success stories, Mills cautions that there is limited long-term data supporting the safety or efficacy of supraphysiologic dosing, and perceived benefits may largely reflect placebo effects. He advocates instead for maintaining testosterone in the upper tertile of the normal range, combined with lifestyle changes such as exercise and nutrition, which remain essential regardless of hormone levels.

When managing patients who began TRT online, Mills views them positively: informed, motivated, and open to more comprehensive care. His approach begins with a full clinical “reset,” including baseline labs to assess pituitary suppression, metabolic health, and cardiovascular risk, as well as a physical exam and detailed discussion of expectations. He criticizes online models that prioritize prescription renewals over holistic care. However, Mills strongly supports telehealth when used to augment—not replace—the physician-patient relationship. After an initial in-person evaluation, he leverages telemedicine to provide evidence-based, personalized TRT to patients across California, expanding access while preserving high-quality specialty care.