What online TRT clinics get wrong about men’s cardiovascular health

In this video, Jesse N. Mills, MD, discusses evolving perspectives on testosterone replacement therapy (TRT), particularly regarding cardiovascular (CV) risk and the growing role of direct-to-consumer platforms.

He emphasizes that current literature, including recent regulatory updates, supports the conclusion that TRT does not significantly increase the risk of major cardiovascular events such as heart failure or coronary disease. As a result, the absolute risk of prescribing testosterone—even with minimal monitoring—is relatively low, which explains why many online TRT companies continue to operate without obvious widespread harm.

However, Mills argues that safety alone is not the benchmark for quality care. Men presenting with symptoms of low testosterone often have multiple comorbidities—poor sleep, sedentary lifestyle, suboptimal diet, or uncontrolled CV risk factors—that should be addressed alongside or even before initiating TRT. In his view, many online platforms miss a critical opportunity by focusing narrowly on prescribing testosterone rather than engaging patients in comprehensive health optimization. He sees TRT as one tool within a broader therapeutic framework aimed at improving long-term cardiovascular and overall health, ideally to the point where some patients may no longer need hormone therapy.

Regarding compounded testosterone products, Mills takes a balanced but cautious stance. He acknowledges that reputable compounding pharmacies can provide high-quality, cost-effective medications and are valuable in sexual medicine. The primary concern is regulatory inconsistency: compounding pharmacies are overseen at the state level rather than by the FDA, leading to variability in standards, potency, and quality. Absorption issues with compounded topical formulations can result in unpredictable testosterone levels, underscoring the need for regular laboratory monitoring.

Injectable compounded testosterone poses greater risks, as sterility is paramount when breaching the skin barrier. Contamination due to inadequate oversight has, in rare but serious cases, resulted in severe infections or death. Mills advises patients to be discerning, questioning whether a company focused primarily on selling testosterone—rather than delivering comprehensive patient care—is the right source for long-term treatment.