Worsening of sleep apnea: some men who snore have been reported, in the literature, to require CPAP for sleep apnea after receiving T replacement. I have had no patients, thus far, who progressed from snoring to receiving CPAP.
Elevated blood density, as measured by the hematocrit (Hct): T stimulates the bone marrow to make more red cells. Sometimes this creates an iatrogenic polycythemia, where the red cell volume is too high. If the Hct reaches 55, I usually recommend "donating" a unit of blood or withholding the T therapy.
Possible increased cardiovascular risk: a recent article in JAMA studying veterans who had a significant number of comorbidities and underwent coronary angiograms showed a possible increased chance of death, stroke and heart attack. Further investigations are ongoing, similar to further studies on cardiovascular risk from taking NSAID's (Celebrex, Motrin, Aleve, etc). I recommend each patient take an enteric-coated 325 mg ASA each day.
Possible stimulation of occult prostate cancer: There is a current controversy over when and for whom PSA testing should be done. We require and annual test, along with a digital rectal exam by a qualified medical practitioner to help identify those men at risk. If a concern is raised, we refer or return you to a knowledgeable urologist to recommend appropriate treatment.
Injection site sequelae: Like any minor surgical procedure, the placement of pellets may result in a hematoma, infection, and in very few, extrusion of the pellets. We do our best to prevent/treat these sequelae so that most men can continue with the pellet therapy, if they so desire.