My testosterone level is 177 ng/dL. I am intimately familiar with this number, having checked it myself on my own laboratory slip, just as I have reviewed countless lab results for patients throughout my 35-year medical career. But this time, however, the patient’s focus was on me.

One year ago, I underwent a prostatectomy for low-grade, minimally aggressive prostate cancer. The surgery was successful, and the pathology results were reassuring. My prostate-specific antigen (PSA) level remains within the expected range. However, my testosterone, a hormone essential for energy, mood, muscle mass, libido, and sense of self, declined to levels that both the American Urological Association and the Endocrine Society classify as unequivocally low. My physician, exercising appropriate caution, recommended waiting a full year post-surgery before considering hormone replacement treatment. I understand the clinical reasoning, even as I experience the physiological effects.

That personal experience is why a recent JAMA Medical News piece on the HHS and FDA’s proposal to revise testosterone therapy labeling caught my attention differently than it might have been five years ago. The proposal would drop the long-standing warning that testosterone’s safety and effectiveness are unestablished in age-related hypogonadism, narrow the prostate cancer contraindication to metastatic disease only, and soften warnings around benign prostatic hyperplasia. On paper, this is regulatory catch-up with the science. In practice, it lands in a gray zone that the label misses.

Fundamental to this controversy is the TRAVERSE trial, which enrolled over 5,200 men exhibiting symptoms of hypogonadism and cardiovascular risk, and found no increase in major cardiac events associated with testosterone therapy. This finding provides reassurance and underpins the reconsideration of the cardiovascular warning. However, TRAVERSE excluded individuals at elevated risk for prostate cancer, limited follow-up to 33 months, and evaluated only a single transdermal gel formulation. The fracture analysis showed concerning signals, including increased rates of atrial fibrillation, more pulmonary embolism, and a fracture risk that surprised the trial’s biostatisticians. As Shalender Bhasin, coauthor of TRAVERSE and the earlier Testosterone Trials, stated, “Prostate cancer survivors were not adequately studied here,” and “Decisions need to be individualized.”

I keep returning to what “individualized” costs a patient day to day, because a cure was never the finish line I imagined. This is the theme I return to in my work as a physiatrist: We are trained, rightly, to save the patient first. But saving and restoring the patient are not the same task, and medicine too often treats the second as an afterthought. For me, that has meant persistent urinary incontinence outlasting the timeline most patients are told to expect. Here, the evidence, while early, is more encouraging than I anticipated. A 2026 study in The Prostate followed men with persistent incontinence after robot-assisted prostatectomy, confirmed low testosterone, and no cancer recurrence, and found testosterone combined with pelvic floor magnetic stimulation associated with measurable gains in continence and pelvic floor muscle volume on imaging. It is a small study and not placebo-controlled, but a first real signal that hypogonadism, not just deconditioning, may delay recovery, though bigger cohorts have been mixed. It is exactly the question I want my physician to ask, since the incontinence has been as demoralizing as the fatigue, and quality of life after survival deserves the same rigor as survival itself.

I represent precisely the type of individualized case: cured by all available clinical measures yet not included in the TRAVERSE trial population. The proposed regulatory change, which narrows the contraindication to metastatic disease, would permit men such as me to receive therapy despite limited supporting evidence. Steven Nissen, the trial’s senior author, expressed concern that “The genie will be out of the bottle.” I understood his apprehension. As a patient with a testosterone level of 177 ng/dL, I acutely experience the complexities on both sides of this issue. The patient should also have a say in weighing the risks and benefits of treatment after being fully informed of all pertinent data.

This aspect of the debate is not addressed by regulatory labeling, yet it is central to the mission of rehabilitation medicine. Low testosterone is not simply a theoretical concern; it manifests as persistent fatigue, loss of muscle mass despite ongoing training, diminished libido, and the challenge of regaining continence and confidence. The Testosterone Trials demonstrated only modest improvements in mood and walking distance. Both realities can coexist: While the data indicate modest average effects, an individual recovering from cancer treatment with a documented deficiency may experience significant functional and personal restoration with appropriately monitored care.

One detail deserves scrutiny: TRAVERSE tested only one formulation, a gel, and about 61 percent of participants in both arms stopped treatment early. In my own practice and recovery, injectable testosterone and subcutaneous pellets have proven far more effective and tolerable than daily gel, consistent with the pharmacology. An American College of Physicians analysis found intramuscular injections produce higher, more consistent serum levels than transdermal gels, which suffer variable skin absorption. A patient under-absorbing gel may feel no benefit and quietly stop, indistinguishable in a trial from a patient whose testosterone genuinely did not help. I suspect formulation-driven dropout diluted TRAVERSE’s ability to detect real benefit. I would like the trial repeated with injectable or pellet dosing before anyone treats gel results as the final word.

Therefore, I wait, recognizing that my physician’s caution is justified and that individualized care requires balance. This approach entails avoiding withholding treatment based on outdated, generalized fears of recurrence that lack recent evidence. Conversely, it also cautions against hastily initiating therapy solely in response to new regulations. It requires a physician who is prepared to participate in thorough surveillance, candid discussions about uncertainties, and joint decision-making founded on empirical data rather than tradition. Ultimately, it is essential not to allow the achievement of survival to distract from the ongoing process of rehabilitation, as a patient who remains unable to trust his bladder or reclaim his sense of self has not yet attained the quality of life that surgery was intended to preserve.

The regulatory label may change this year. My decision will ultimately depend on a comprehensive discussion with my physician, evaluation of my laboratory values and pathology, my personal patience, and the conviction I bring to my practice as a physiatrist: Success is not determined solely by survival, but by guaranteeing the patient is truly living well.

Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness. 

Dr. Torres was born in Spain and grew up in Puerto Rico. He graduated from the University of Puerto Rico School of Medicine. Dr. Torres performed his physical medicine and rehabilitation residency at the Veterans Administration Hospital in San Juan before completing a musculoskeletal fellowship at Louisiana State University Medical Center in New Orleans. He served three years as a clinical instructor of medicine and assistant professor at LSU before joining Florida Spine Institute in Clearwater, Florida, where he is the medical director of the Wellness Program.

Dr. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine. He is a prolific writer and primarily interested in preventative medicine. He works with all of his patients to promote overall wellness.