Given the choice between making life changes and filling a prescription for testosterone, it’s an easy decision. But is the easy answer an effective one?
The fight to thwart male decline has been going on ever since the first guy with hair growing out of his ears plunked down a check for a four-wheeled mojo enhancer. But in the past seven years (since the start of the Great Recession—go figure), the struggle to stay vital is increasingly being approached as a biochemical problem, one requiring pharmaceutical intervention in the form of testosterone replacement therapy (TRT).
And we’re not just talking about men over 50 or even 40.
Depending on who you ask, the turbocharged rise in the use of TRT shots, gels, patches, and pills is either (1) an inspiring transformation in how doctors treat a vast and despairing brotherhood of men, or (2) expensive quackery that targets male vanity and has nonexistent benefits and deadly risks.
The fact that the symptoms driving men to testosterone therapy are often subjective and can easily resemble those of normal aging, depression, poor sleep, or bad choices at the food trough only complicates the debate. Also not helping: Men’s hormone levels are in a historic, culture-wide decline, under assault from a steady increase of obesity, painkiller abuse, food toxins, and estrogen-mimicking compounds in water and soil.
In March, the FDA announced that it had asked drugmakers to add language to the labels of testosterone replacement products warning of increased heart attack and stroke risk. But in February, a large review of the literature concluded that the research indicting testosterone replacement as a heart risk is vastly outgunned by the research showing that it helps.
Confused? You’re not alone.
“I have been shocked and at times even overwhelmed by the number of guys seeking help from my forum, due to misinformation, lack of information, and some doctors’ cruel dismissal of their concerns about low testosterone,” says Lee Myer, 55, a testosterone user in Tempe, Arizona, who runs an online forum for T-curious men.
“The confusion is only made worse by pharmaceutical and clinic ads that push men toward a single answer,” Myer says. (Yes, some of those ads have run in Men’s Health. It’s a complicated topic, as you’ll see.)
Myer’s site, Peak Testosterone, is just one of several gathering spots where men trade notes about their experiences with vitality in a bottle. An IT professional who’s married with three children, Myer hopes to change perceptions about TRT, starting with the idea that it’s comparable to taking steroids or that the symptoms of low T are overblown.
“Unless you’ve gone through low testosterone, you don’t know what it’s like,” he says. “I’d like to take that doctor who is suspicious of the drug therapy and get his testosterone down to 259—to where he’s got erectile dysfunction, he’s about to lose his marriage, he can’t think very well, and he’s struggling in his practice.”
Myer says TRT shots relieved him of a dysphoric mood—unease, anxiety, misery—that first took up shop in his cranium during his teen years. He says his testosterone turnaround gave him the energy to attack his job and responsibilities with renewed drive. “My cognitive abilities have never been better,” he says.
His focus has improved, too. He is listening to music with attention and joy, he says, for the first time since he was a teenager.
The pharmaceutical companies have not yet produced evidence that testosterone can help a guy dig that funky groove, but the oddness of the observation has an authentic ring. It makes you wonder if some sort of fountain of youth can be tapped in male hormones.
“In my early 50s,” Myer says, “I am finally living the youth I should have had in my 20s.”
It’s praise echoed by a man I’ll call Sam, a 43-year-old scientist in San Francisco who went on testosterone shots three years ago when blood work revealed that he had low levels of something called sex hormone binding globulin, or SHBG. For Sam, it was lifestyle-related—he spread 215 pounds over a 6-foot frame, ate poorly, and found time to stress but not to exercise—and the SHBG deficiency was causing his body to burn through its available testosterone way too quickly.
At the time, all he knew was that he couldn’t get himself out of bed most mornings.
“I had become a father but realized I wasn’t being a good father,” he says. “I would sleep in. I didn’t have the energy to read a story to my children at night, and it caused a lot of tension in my marriage.”
Today Sam rides a bike and has more lean muscle, and his weight is under control. He says testosterone gave him the energy to do all that.
Those are the guys the testosterone industry wants you to hear from. But there are other guys.
“I get a testosterone shot in the ass every week,” says my childhood buddy Andy, 51, a marketing specialist in the Phoenix area. Andy couldn’t tell you the exact blood level that triggered his decision.
A single man, he’s never had libido problems, and as for his physical condition, he trains at a place where NFL guys tune up.
Andy’s choice to go on testosterone was all impulse: Four years ago he saw the ads, heard about a clinic from someone in his gym, and decided it might help him stay on top of his game. He thinks TRT has helped his body composition, but he isn’t sure.
“It is crazy how many dudes do it,” Andy says. “You’re in there for about two minutes. The nurse checks all your vital signs and then shoots you in the ass.”
Combine the serious users with the guys doing it on a lark, and then throw in all the dudes who quit taking testosterone after a month (19 percent, according to one study), and you’re talking about millions of buyers of male hormones.
Since the launch in 2008 of the “Is It Low T?” ad campaign funded by AndroGel (an MH advertiser), sales of testosterone have climbed 460 percent. Six and a half million prescriptions were written for testosterone in the United States in 2014. Total testosterone sales were a $2.1 billion market that year. And it’s all uncharted waters.
“My concern is this whole campaign is encouraging people to take hormones we don’t know they need for a disease they don’t have,” says Steven Woloshin, M.D., codirector of the Center for Medicine in the Media at Dartmouth Institute for Health Policy and Clinical Practice.
Dr. Woloshin may sound out of touch with the latest therapeutic options, or behind the times with the latest drug therapies, or unsympathetic to men who feel less manly. He may also sound unimpressed with the basic middle-aged wish to reexperience the sort of boner before breakfast that makes it hard to pee in a downward trajectory. (A hallmark of low testosterone is less morning wood.)
But he’s right: The phenomenon may be wishful thinking on a massive and expensive scale.
Testosterone replacement therapy is currently approved only for the treatment of male hypogonadism, or lack of testosterone, caused specifically by a problem with the testicles or with certain parts of the brain—the pituitary gland and hypothalamus—that control the gonads. You might inherit such a state, or it could be caused by injury or such conditions as a brain tumor or an undescended testicle.
Men with these types of hypogonadism have extremely low blood testosterone and symptoms like enlarged breasts, hairlessness, loss of muscle mass, low libido, and bones that break easily. According to a study in JAMA Internal Medicine, however, a quarter of men who supplement with testosterone never even bother having a blood test, and only half have been diagnosed with hypogonadism.
In 2010, in an attempt to differentiate what was becoming known as “late-onset hypogonadism” from normal, age-related T decline, researchers analyzed data from the European Male Aging Study, which followed more than 3,000 men ages 40 to 79 in eight countries.
They found that out of 32 symptoms often mentioned in the same breath as “low T,” only three—a decrease in sexual thoughts, fewer morning erections, and erectile dysfunction—were associated with low levels of the hormone.
“Low” was defined by the researchers as a total testosterone blood level of 320 nanograms per deciliter (ng/dl) or less and a free testosterone of 220 picomoles per liter or less. Anything more nebulous, in other words, and you’re just turning to TRT because life is getting weird on you.
Hell, some experts argue that even having these symptoms and coming in at or under these levels doesn’t justify the drug. That matters, because as a number of recent studies have suggested, taking testosterone may double or even triple your risk of heart disease.
So here’s the bad news: Increasing your testosterone can thicken your blood and lower your good HDL cholesterol, both of which hike your odds of heart disease.
Researchers first began to learn of testosterone’s link to cardiovascular risk between 2005 and 2009, when a team in Boston set out to determine if frail older men became more mobile after having their man juice jacked up. Their study, published in the New England Journal of Medicine, noted that the added testosterone made the men stronger on the leg press and chest press and climbing stairs.
However, the trial was halted because 23 of the 106 men taking it developed cardiovascular problems, versus only five of the 103 men who’d been using a placebo gel.
By April 2013, researchers writing in BMC Medicine had sorted through thousands of results in 27 clinical trials and also determined that the risk of cardiovascular events went up for men on testosterone. (Curiously, this risk became apparent only in trials that were not paid for by the makers of the drugs.)
Then in November 2013, researchers for Colorado’s VA system wrote in JAMA that they’d analyzed the data from 8,000 men with low T who had gotten an angiogram before going on the hormone. Three years after starting, 26 percent of the men on testosterone had either experienced a new cardiovascular event or died, versus only 20 percent of the men who didn’t take testosterone.
Another alarm sounded in 2014, when a study in the journal PLOS Onelooked at the health records of 55,000 men and found that testosterone use had doubled the risk of nonfatal heart attack in men over 65 and tripled the risk in younger men with a history of heart disease. (Younger men with no heart disease fared well on the drug.)
“The PLOS One paper excluded anybody who died of a heart attack,” says John Morley, M.D., a low-testosterone expert at Saint Louis University School of Medicine. “It may well be they found a higher level of heartattacks in men on testosterone because those men lived while the others [who didn’t take it] died.”
As for the NEJM study of older men and mobility, “It is good that it was a random controlled trial,” says Martin Miner, M.D., codirector of the Men’s Health Center at Miriam Hospital in Providence, Rhode Island. “But what was poor was that it really wasn’t a safety study. We don’t normally start elderly men with a history of heart failure on such large doses of testosterone.”
In other words, the research wasn’t the best way to find out if testosterone is dangerous.
For some men, there’s no question that TRT is trouble. Back in 2008, Mike (not his real name) had borderline low T, some accumulating weight around his midsection, and amorphous regrets about the condition of his condition.
“I’d just turned 43 and noticed that everything was slowing down,” he says. “My libido was low, and I was losing energy.”
His doctor prescribed AndroGel. Mike’s testosterone levels didn’t climb much, but he says he did notice an increase in energy. “The anger went away, my frustration went down, and I was able to deal with things better,” he recalls.
Four years later, Mike had a heart attack. Two in one day, in fact. One of his arteries was almost fully blocked, and two others were at 40 percent.
Yet Mike stayed on the drug for another two years, going off it only after hearing about the PLOS One study. Today Mike is suing the makers of AndroGel. “Nobody discussed the risks, even after my heart attack.”
Blame the fog of T research. “I’m not saying testosterone is safe or unsafe,” says Dr. Miner. “I’m just saying those studies are so complicated, that for the lay public to interpret from them that a product causes significant risk is inappropriate.”
“There were 14 studies between 2006 and 2013 associating lowtestosterone with increased cardiovascular events,” says Dr. Miner. “Just because heart disease is associated with low testosterone doesn’t mean it was caused by it.”
This confusion is why many of the nation’s hormone experts specifically recommend against screening for low T; they just can’t say whether low T is an important health problem or not.
Hormones are chemical messengers that tell our bodies what to do, but only some of their messages are a matter of life and death.
Metabolic hormones turn energy into fuel. Stress hormones protect you in a crisis. Testosterone builds muscle and bone, but it mostly works with your wants, not your needs.
Of course, low testosterone doesn’t have to be deadly to deserve our attention: Sam and Myer depict life before TRT as sluggish and glum. If you can cure a nagging woe, why not?
The problem is, the evidence isn’t even very good that TRT helps your mood.
“We don’t know that low testosterone is the primary reason people feel rotten or without much drive,” says Victor Montori, M.D., an endocrinologist at the Mayo Clinic. “After age 45, men lose a small amount of testosterone each year. If losing testosterone made you feel bad, then there should be more 70-year-olds feeling robbed of life than 60-year-olds, and more 60-year-olds feeling like a shadow of their old selves than 50-year-olds. I haven’t seen that data.”
Moreover, doctors can’t even agree on what a healthy level of testosterone is. “This is why no one should ever make the diagnosis of low testosterone without seeing some sort of symptoms,” says Dr. Morley.
Dr. Morley designed the low-testosterone symptom questionnaire of the moment, the Androgen Deficiency in the Aging Male (ADAM) test, a 10-item worksheet that asks, “Is It Low T?”
Candid and chatty (in 2013 Dr. Morley famously told the national media he had written the highly promoted test in 20 minutes on a roll of toilet paper in the bathroom), he doesn’t try to argue that the test is perfect. “It’s very good at not missing people,” he says, “but it’s not very good at diagnosing low testosterone. It’s a screening test.”
While it’s better than anything else that’s out there, he says, “it may overinclude people who won’t benefit.”
Yet it’s likely that millions of men have diagnosed themselves as having low T after answering yes to some of Dr. Morley’s broadly drawn questions.
The test asks about a cornucopia of subjective existential midlife issues, such as declining energy, increased sadness, soft erections, less enjoyment, poor work performance, reduced height, problems with strength and endurance, difficulty playing sports, and low libido.
You only need to answer yes to both the low sex drive and soft erection questions, or three of any of the others, to be termed a candidate for a low T diagnosis; on bad days it’s easy for many men to run the table. The “Is It Low T?” website that hosted the quiz was taken down in May.
“It’s been extremely effective,” complains Dr. Woloshin, a critic who believes the questionnaire has triggered the current rush on products.
“The problem is that it overpromises the benefits of testosterone while it underplays the harms, and it makes men think low testosterone is the cause of problems that are unrelated.”
The inflated promises of TRT start with the idea that it can inflate your dick, not to mention the suggestion that erectile problems are even reliably related to testosterone deficiency. A 2011 review from Imperial College London, for instance, found “no relationship between testosterone level and the severity of erectile dysfunction.”
While impaired sexual function is required for the diagnosis of late-onset hypogonadism, most men with erectile dysfunction have normal T levels.
What can testosterone do? “When you look at clinical trials of people with moderate or mild low testosterone receiving physiologic testosterone replacement,” says Dr. Montori, “the impact on quality of life and sexual function is either minimal or nonexistent.”
Dr. Morley disagrees: “Poor libido and a poor quality of erection are the symptoms most related to poor testosterone,” he says. “There is also a subset of people with low testosterone who have fatigue, who are unhappy, and who don’t have strength. They look like they’re depressed, but they actually have low testosterone.”
Except here, too, the science isn’t on his side: The European Male Aging Study results also show that psychological symptoms had little or no association with testosterone levels.
John La Puma, M.D., is a critic of using TRT without a diagnosis of hypogonadism. The California-based internist and author of Refuel: A 24-Day Eating Plan to Shed Fat, Boost Testosterone and Pump Up Strength and Stamina wrote a widely shared op-ed arguing that low T was a pharmaceutical-industry-generated sickness.
But he’ll readily acknowledge that the decline in testosterone is real. He says it’s the causes of low T we should be talking about and correcting.
“Men’s testosterone levels are dropping,” says Dr. La Puma, who cites a 2007 study in the Journal of Clinical Endocrinology and Metabolism, which found that average T levels in men over age 45 were 501 ng/dl in the late 1980s, 435 ng/dl in the mid-1990s, and 391 mg/dl in the early 2000s.
“That’s down 20 percent in a few decades’ time,” he says. “I think what’s not recognized is how lifestyle affects testosterone levels.”
Alcohol lowers testosterone. So do steroids, stress, and opioid painkillers (enough opioid prescriptions are written these days for every adult to have his or her own bottle).
There are also testosterone-diminishing forces in the environment to be considered. A study in the journal Fertility and Sterility found a specific association between exposure to phthalates (a group of chemical compounds widely used in soft plastics) and male infertility. These so-called endocrine disruptors can invade your system every time you heat up foods in plastic containers, plates, or wraps.
“They transfer into hot, oily foods,” says Dr. La Puma, “and change the way hormones work in the body.”
Still, the smart money says the primary cause is in front of our eyes, and down about 18 inches.
“I think it’s pretty clear that men gain weight in the belly,” says Dr. La Puma. “We tend to overeat starchy, sugary foods because they’re handy, quick, cheap, and available. Those foods are incredibly efficient at making men obese.”
Men’s belly fat cells convert their testosterone into estrogen, he says, and can make testosterone plummet.
Results from the European Male Aging Study also found that low T was often paired with excess body weight. Three out of four men with low T were overweight, and that included every one of the 40-somethings in the group. And the fatter the man, the greater the risk, the study noted.
These are mostly the men Andy shares the waiting room with, before the needle in the ass. “The guys I see skew between 40 and 60,” he says, “and most don’t look like they work out regularly.”
“If you have an epidemic of obesity, an aging of the population, and increased stress and stress hormones,” says Dr. Montori, “all those things should go hand in hand with loss of testosterone on average in the population.”
That’s why even supporters think testosterone therapy is only meaningful if it triggers men to do what’s right for their health.
“I am not in any way advocating the use of testosterone for treating obesity,” Dr. Morley says. “The risks don’t seem reasonable to me.”
Dr. Miner agrees: “Testosterone without exercise and diet or lifestyle change is of very little value.” Treating obesity could entail showing men the biology behind their bellies and how it influences their T. The rest might just come down to needing an expert ear.
“Many of my patients finish our conversations crying,” says Dr. Montori. “Maybe it’s a college professor making mistakes while teaching and wondering if he is getting Alzheimer’s. That’s life, not low testosterone. It’s the fear of death. The fix to that, for a doctor, is to listen. Can you prescribe someone a hug? We can’t expect doctors to fix all these existential problems, and the costs for health care are going to keep going up.”
“Small changes can make a big difference when guys learn how their bodies work,” adds Dr. La Puma. “If you tell guys the reason their testosterone is dropping is because of their belly fat cells, they go, ‘Really?’ Then if you tell them that their belly is not just a spare tire but an active endocrine organ, men like to know that. We like to know how stuff works. It helps to know that their belly fat is breaking them, that it’s a fixable problem.”
Specifically: It’s fixable without turning to a shot of testosterone.
Source: Men’s Health