Alex Rodriguez TRT: What Clinicians Should Tell Patients

Why the Rodriguez Case Belongs in the Exam Room

Patients ask about testosterone therapy more often when a high-profile figure makes headlines. Alex Rodriguez is one of the most recognizable names in that category.

In a February 2009 interview with ESPN's Peter Gammons, Rodriguez confirmed he used a "boli" (a street term for an injectable testosterone compound) between 2001 and 2003 while playing for the Texas Rangers. He described it as something "I was young and I was stupid" and acknowledged he did not fully understand the substance. Subsequent reporting tied him to the Biogenesis of America clinic in Coral Gables, Florida, which supplied testosterone, IGF-1, and human growth hormone to a number of professional athletes between approximately 2010 and 2012. MLB's 162-game suspension in 2013 was the longest for a position player in the sport's history.

That public record gives clinicians a ready-made teaching case. Patients who follow sports already know the outline. The job is to redirect the conversation toward clinical evidence.

What Rodriguez Actually Said: Parsing the Public Record

The 2009 ESPN admission is the only first-person, on-record statement Rodriguez has made about using testosterone. He described the substance as purchased in the Dominican Republic and said he did not know its exact composition. He has never publicly stated a diagnosis of hypogonadism.

In later years, Rodriguez discussed general wellness practices on podcasts and in interviews, referencing diet, sleep, and fitness, but has not made further specific claims about testosterone or other hormones. Any inference that he continues or continued TRT after 2003 is not supported by a primary public statement and should be labeled as such in patient conversations.

The Biogenesis Clinic Context

Anthony Bosch operated Biogenesis of America without a medical license. Testosterone compounds and peptides were dispensed without standard diagnostic workups, without baseline labs, and without documented informed consent. This is the clinical opposite of how legitimate TRT is initiated. The Biogenesis case is, in practice, a case study in what happens when testosterone is supplied outside any regulatory or clinical framework.

The Evidence Base for Testosterone Therapy in Men

Testosterone deficiency in men is defined by the Endocrine Society as a total serum testosterone below 300 ng/dL on two morning fasting samples, combined with at least one symptom such as reduced libido, fatigue, decreased muscle mass, or depressed mood [1]. Prevalence estimates range from 2 to 6 million affected men in the United States, though that figure varies substantially depending on the diagnostic threshold used [2].

Diagnosing Hypogonadism Before Prescribing

The 2018 Endocrine Society Clinical Practice Guideline recommends against initiating TRT without confirmed biochemical hypogonadism [1]. Two separate morning total testosterone measurements on different days, drawn before 10 a.m., are required before treatment begins. Free testosterone by equilibrium dialysis should be added when total testosterone falls in the 300 to 400 ng/dL range and sex hormone-binding globulin (SHBG) elevation is suspected.

Secondary causes must be excluded first. Pituitary adenoma, hemochromatosis, Klinefelter syndrome, and opioid-induced hypogonadism each require a different management pathway. A single low testosterone reading after acute illness, caloric restriction, or extreme exercise is insufficient to establish the diagnosis.

Formulations and Dosing Reference Points

The FDA has approved multiple testosterone formulations for hypogonadism in men [3]. These include:

• Testosterone cypionate injection (100 to 200 mg IM every 1 to 2 weeks, or 50 to 100 mg weekly to reduce peak-trough variation)
• Testosterone enanthate injection (similar dosing to cypionate)
• Topical gels (AndroGel 1% and 1.62%, Testim, Vogelxo) delivering 40 to 100 mg/day transdermally
• Testosterone undecanoate (Aveed) given IM at 750 mg, then 750 mg at 4 weeks, then every 10 weeks
• Nasal testosterone gel (Natesto) 11 mg three times daily, with a lesser suppressive effect on spermatogenesis

The clinical goal is a trough total testosterone in the mid-normal range, roughly 400 to 700 ng/dL, not supraphysiologic levels. Biogenesis-style dosing aimed for pharmacologic, not replacement, concentrations, which is why adverse effects in athletic doping contexts differ from those in properly managed clinical TRT.

Cardiovascular Risk: What the Trials Actually Show

No topic in TRT counseling generates more patient anxiety, and more clinician uncertainty, than cardiovascular risk. The data have shifted meaningfully in the past three years.

The TRAVERSE Trial

The TRAVERSE trial enrolled 5,204 men aged 45 to 80 with hypogonadism and pre-existing cardiovascular disease or high cardiovascular risk [4]. Participants received testosterone gel 1.62% or placebo for a median of 33 months. The primary outcome was a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke (MACE). The trial met its non-inferiority margin: MACE occurred in 7.0% of the testosterone group versus 7.3% in the placebo group (hazard ratio 0.96, 95% CI 0.78 to 1.17) [4].

Secondary findings were notable. Atrial fibrillation occurred more frequently in the testosterone arm (3.5% vs. 2.4%, P<0.001), as did acute kidney injury and pulmonary embolism [4]. The FDA updated labeling for testosterone products in 2023 to reflect the TRAVERSE atrial fibrillation signal [3].

Earlier Observational Data and the 2014 JAMA Controversy

A 2014 retrospective cohort study in JAMA (N=8,709 veterans) reported increased rates of myocardial infarction, stroke, and death in men receiving TRT, which prompted an FDA safety communication [5]. That paper drew methodological criticism for immortal time bias and inconsistent comparison groups. The TRAVERSE randomized controlled trial provides stronger causal evidence and currently represents the best available data on MACE risk.

The practical counseling message: TRT in properly diagnosed hypogonadal men does not appear to increase major adverse cardiovascular events at 33 months, but atrial fibrillation risk warrants discussion, particularly in patients with structural heart disease or a history of arrhythmia.

Hematologic and Other Adverse Effects

Polycythemia

Testosterone stimulates erythropoiesis via EPO-mediated pathways and direct bone marrow effects. Hematocrit rises above 54% in approximately 3 to 18% of men on TRT, with the highest rates seen with injectable formulations [6]. The Endocrine Society recommends checking a CBC at 3 to 6 months after initiation, then annually thereafter. A hematocrit above 54% on two separate readings warrants dose reduction, formulation change to a transdermal product, or therapeutic phlebotomy [1].

In the context of athlete doping, supraphysiologic testosterone doses drive hematocrit considerably higher and are one physiologic mechanism by which testosterone improves aerobic performance. Clinicians should explain this distinction to patients who conflate clinical TRT with what Biogenesis-era athletes were actually doing.

Sleep Apnea

Testosterone can worsen obstructive sleep apnea by increasing upper airway collapsibility. Pre-treatment screening with the STOP-BANG questionnaire is reasonable in men with obesity (BMI above 30), large neck circumference, or reported snoring. The Endocrine Society lists untreated severe sleep apnea as a relative contraindication to TRT [1].

Prostate Safety

The TRAVERSE trial found no significant difference in prostate cancer incidence at 33 months (0.19% testosterone vs. 0.12% placebo, P = 0.21) [4]. A 2024 meta-analysis in JAMA Oncology (N=11,847 pooled patients) confirmed no statistically significant elevation in prostate cancer risk with TRT at durations up to 3 years [7]. Current Endocrine Society guidance recommends a PSA at baseline and at 3 to 6 months, with urology referral for a rise greater than 1.4 ng/mL above baseline within 12 months [1].

Fertility and the HPG Axis

Exogenous testosterone suppresses gonadotropin-releasing hormone (GnRH) pulsatility, which reduces LH and FSH secretion from the pituitary within days of initiation [8]. Spermatogenesis depends on intratesticular testosterone concentrations that are orders of magnitude higher than serum concentrations. Exogenous testosterone does not maintain those intratesticular levels, and azoospermia may develop within 6 to 12 weeks of starting therapy [8].

This is a frequent point of confusion for patients in their 30s and 40s who associate testosterone with virility and assume it supports fertility.

Counseling Patients Who Want Children

Men who have not completed their families should receive three options:

1. Sperm cryopreservation before TRT initiation
2. Clomiphene citrate (25 to 50 mg every other day) as a fertility-preserving alternative that raises endogenous LH and FSH
3. Human chorionic gonadotropin (hCG, 500 to 1,000 IU subcutaneously two to three times per week) co-administered with TRT to maintain intratesticular testosterone and partial spermatogenesis

Recovery of spermatogenesis after TRT cessation occurs in most men but may take 6 to 24 months, and recovery is not guaranteed in every case [8]. The American Urological Association's 2023 Male Infertility Guidelines explicitly recommend counseling on fertility effects before prescribing testosterone to men of reproductive age [9].

Psychological and Behavioral Dimensions

Mood, Libido, and Cognition

Hypogonadal men show higher rates of depressed mood, irritability, and reduced cognitive performance on standardized tests [10]. A systematic review and meta-analysis in the Journal of Clinical Endocrinology and Metabolism (2020, 49 trials, N=5,765) found that TRT produced significant improvements in sexual function, mood, and energy in men with confirmed hypogonadism, with standardized mean differences of 0.33 to 0.56 across domains [10].

The same review found negligible effects on cognition in men without baseline cognitive deficit, and no significant antidepressant effect in men with testosterone levels in the normal range. Prescribing testosterone to a eugonadal man for mood or cognitive complaints is not supported by this evidence.

The "Optimization" Request

Many patients arrive asking about testosterone not because of documented deficiency but because they have read about "optimization" protocols online or heard about them from a podcaster or public figure. Rodriguez's public profile intersects with this phenomenon: he is a wellness-oriented public figure in his post-baseball career, and his name surfaces frequently in conversations about men's health optimization.

The correct clinical response is not to dismiss the symptom burden but to measure it. Two morning testosterone levels, an LH, FSH, prolactin, TSH, CBC, and metabolic panel will either confirm a treatable diagnosis or redirect the workup. Prescribing testosterone to a man with a total testosterone of 450 ng/dL because he feels tired is not supported by the evidence, and it initiates HPG axis suppression that may take years to reverse.

How to Use the Rodriguez Case in Patient Counseling

Clinicians do not need to bring up Rodriguez. But when patients do, the case offers four specific teaching points that map directly onto clinical concerns:

Point 1: Source matters. Biogenesis operated without a medical license and without diagnostic labs. Patients purchasing testosterone from online pharmacies, compounders without legitimate prescriptions, or gym contacts are in a pharmacologically and legally similar situation. The substance may be mis-dosed, contaminated, or mislabeled.

Point 2: Dose and intent matter. Athletic performance doping uses supraphysiologic doses to increase muscle mass and red cell mass beyond normal physiology. Clinical TRT targets restoration of normal physiology. These are not the same treatment, even if the molecule is identical.

Point 3: "It worked for him" is not a clinical endpoint. Rodriguez's career statistics during his admitted testosterone use period (2001 to 2003 with Texas) were exceptional, but survivorship bias applies: elite athletes who use PEDs without incident are visible; those who experienced adverse effects, career disruption, or health consequences are less so.

Point 4: Regulatory and occupational consequences are real. MLB's 162-game suspension cost Rodriguez approximately $25 million in salary. For a patient who holds a commercial driver's license, a Department of Transportation medical certificate, or military service position, an undisclosed or non-physician-supervised testosterone prescription may carry its own occupational consequences.

Monitoring Protocol for Patients on TRT

The Endocrine Society 2018 guideline [1] and the American Association of Clinical Endocrinology (AACE) 2022 framework [11] align on the following monitoring schedule:

• Baseline: Total testosterone (two morning samples), free testosterone, LH, FSH, prolactin, PSA, CBC, lipid panel, liver function tests, BMI
• 3 to 6 months post-initiation: Total testosterone (trough for injectables, 2 to 4 hours post-application for gels), hematocrit, PSA
• 12 months: Full repeat panel, bone mineral density in men with osteoporosis or prolonged prior hypogonadism
• Annually thereafter: Testosterone level, hematocrit, PSA, symptoms review

Dose adjustments should target trough testosterone in the 400 to 700 ng/dL range. Dose escalation beyond 700 ng/dL trough to improve symptoms in a eugonadal-range patient is outside guideline recommendations and increases adverse effect risk without demonstrated benefit.

The AACE 2022 position statement states: "Testosterone therapy should not be initiated in patients with normal testosterone levels solely for anti-aging or performance-enhancement purposes, as the risk-benefit profile does not support such use" [11].

Special Populations and Absolute Contraindications

The FDA label and the Endocrine Society both list the following as absolute contraindications to TRT [1, 3]:

• Metastatic or locally advanced prostate cancer
• Male breast cancer
• Desire for fertility in the near term (relative; discuss alternatives first)
• Hematocrit above 54% at baseline
• Severe untreated obstructive sleep apnea
• Uncontrolled heart failure (NYHA Class IV)

Men with a history of thromboembolic disease require individual risk stratification before initiation. TRAVERSE data showed a pulmonary embolism rate of 0.9% in the testosterone arm versus 0.5% in placebo (P = 0.03) [4], making prior DVT or PE a significant discussion point in informed consent.