TRT claims on TikTok: separating real benefits from hype

What did @dr_soko actually say?

The claim here is two-part. First, that "most men do not need an aromatase inhibitor when running testosterone therapy." Second, that any clinic defaulting to anastrozole over exemestane doesn't know what they're doing and should be fired. The second claim is where things get messier than the confident delivery suggests.

To be fair, the first part is broadly defensible. The reflex prescribing of aromatase inhibitors (AIs) alongside testosterone has been criticized in the clinical literature for years. But the dismissal of anastrozole as categorically inferior to exemestane is a much stronger position, and one that isn't as clean-cut as it's being sold here.

Does the science back this up?

On the "most men don't need an AI" point, yes, the evidence leans this way. A 2017 paper by Finkelstein et al. in the New England Journal of Medicine showed that estradiol in men serves real physiological roles, including libido, bone density, and metabolic function. Suppressing it aggressively with AIs causes real harm. Ramasamy et al. (2014, Journal of Urology) also noted that excessive AI use in TRT patients was associated with bone loss and sexual dysfunction.

The blanket claim that anastrozole is inferior to exemestane is where the science gets less supportive. Anastrozole is a non-steroidal AI. Exemestane is steroidal and mildly androgenic. Some clinicians prefer exemestane for its androgenic properties, but no robust head-to-head RCT in TRT-specific male populations has conclusively shown exemestane is categorically superior. The preference is largely clinical opinion, not settled science.

What did they get wrong (or right)?

They got the main point right. Routine AI co-prescription with TRT is a well-documented overreach in hormone clinics. The Endocrine Society's clinical practice guidelines don't recommend prophylactic AI use in most TRT patients. Credit where it's due.

What they got wrong, or at least oversold, is the anastrozole versus exemestane hierarchy. Calling a clinic incompetent for prescribing anastrozole instead of exemestane is not a position the current evidence supports with enough confidence to justify that language. Anastrozole has substantial safety data and is FDA-approved. Exemestane has theoretical androgenic advantages, but "theoretical" is doing heavy lifting in that sentence.

There's also a real risk in this kind of content. Men watching this may pressure their providers to prescribe exemestane when anastrozole is working fine, or worse, conclude they need an AI when they don't, just because they heard "XMS staying" mentioned as the smarter choice.

What should you actually know?

If you're on TRT, your estradiol should be monitored, but estradiol suppression is not a goal. The goal is symptom management with labs as a guide. Many men maintain estradiol in a functional range without any AI at all. If you're symptomatic with confirmed elevated estradiol on labs, an AI may be appropriate, but that decision should be individualized, not reflexive.

On the anastrozole versus exemestane debate: both are used off-label in men on TRT. Neither is FDA-approved for this indication in men. The steroidal nature of exemestane does give it a different pharmacological profile, and some clinicians do prefer it. But "your clinic doesn't know what they're doing" is a claim that requires more evidence than currently exists. A well-run clinic using anastrozole with careful monitoring is not practicing bad medicine.

• Finkelstein et al. (2013, NEJM) established that estrogen plays a key role in male libido and body composition, not just testosterone alone.
• Ramasamy et al. (2014, Journal of Urology) linked excessive AI use to bone and sexual health consequences in men.
• The Endocrine Society guidelines do not endorse routine AI use with TRT.