Latest news with #TRT
Scientific American
a day ago
- Health
- Scientific American
Testosterone Therapy Is Booming. But Is It Actually Safe?
As more men turn to testosterone replacement therapy (TRT) for energy, mood and muscle, experts warn the risks are still not fully understood. By , Stephanie Pappas, Fonda Mwangi & Alex Sugiura This episode was made possible by the support of Yakult and produced independently by Scientific American 's board of editors. Rachel Feltman: For Scientific American 's Science Quickly, I'm Rachel Feltman. Whether it's framed as a cure-all for fatigue and low libido or a shortcut to gaining muscle mass, testosterone replacement therapy, or TRT, is all over the Internet these days. But how much of the hype is actually backed by science? On supporting science journalism If you're enjoying this article, consider supporting our award-winning journalism by subscribing. By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today. Here to help us make sense of the testosterone boom is Stephanie Pappas, a freelance reporter based in Colorado. Stephanie recently covered the growing popularity—and availability—of TRT for Scientific American. Thanks so much for coming on to chat. Stephanie Pappas: Thank you. Feltman: So you recently wrote about testosterone replacement therapy for Scientific American. For folks who are not on the right part of the Internet to have heard all about this—or maybe staying off the wrong parts [laughs] of the Internet, depending on your perspective—what's going on with TRT right now? Pappas: Well, testosterone replacement therapy has become extremely popular. It has been something that's been in the background for many, many years. Synthetic testosterone was first invented in 1935, but for a long, long time people thought that testosterone replacement, if it was used for any kind of symptoms men might be having, that it could cause prostate cancer. And then it was believed, perhaps, it could cause heart disease or cardiovascular events like a stroke or a heart attack. As it turns out the last few years we found that it doesn't really cause these really serious events. However, a lot less is known about the long-term health impacts. People are really flocking to TRT largely as a result of word of mouth. There are a lot of private clinics that offer this out of pocket, so you don't have to have an insurance company agree that you need it. And people on social media are using it for just a litany of different symptoms, and it can be anything from muscle-building to fatigue to mood problems and irritability, and it's kind of being pitched as a cure-all for a lot of different things. Feltman: And what evidence is there for the benefits of testosterone replacement therapy, maybe starting with people who actually have low testosterone? Pappas: Yeah, so there is such a thing as low testosterone. No one exactly agrees on what the cutoff is, and probably that's because there's a lot of variability in our hormones—like, anyone who's ever tried any sort of hormone treatment, including birth control or HRT [hormone replacement therapy], can tell you that people respond really differently. So for men who really do have low testosterone, the evidence suggests that you can see some benefits in mood if you have major depression. You may see some improvements in energy. The most well-established result from the studies of TRT is that you'll probably see a little boost in libido if you have low testosterone and you now start taking TRT, and that's because testosterone works in the brain to increase sexual desire. Feltman: Hmm. Pappas: For men who don't have low testosterone, which are many of the men who are now getting treatment, the evidence for benefits is much, much lower. We don't know if you really see much besides additional muscle-building abilities. Feltman: And what are the potential downsides? You mentioned that one of the reasons there's such a boom right now is that research has showed that the connection to prostate cancer is not concerning the way we once thought it was. But what about other issues that can come up when you don't have low testosterone and you start taking a bunch of testosterone? Pappas: Right, so if you are taking a testosterone supplement, your body actually shuts down its own testosterone production. There's this neat little feedback loop that says, 'Oh, if the testosterone's high in the blood, we're going to just kind of ramp it down.' And a side effect of that is, actually, because testosterone is involved in sperm production, your body will also stop producing sperm. So as more younger men turn to TRT, we are seeing that men who are interested in still having children are finding they're losing their fertility. Oftentimes men are told, 'Oh, you'll recover it once you stop.' But that can actually be slow and complicated, so urologists in the field often see men who aren't understanding why they're not, you know, able to get their partner pregnant, and they may have tried for quite some time. Feltman: Right, and, you know, not that this is the reason that's upsetting, but there is also kind of an irony there because a lot of the marketing is sort of stereotypical masculinity, so it's not surprising that people are caught off guard by that potential downside. Pappas: Yes, absolutely. They are really marketing this—if you go, you can see it on billboards or online—these ads are all about muscles, they're about machoism. And oftentimes the reports from some of these freestanding clinics is that men are not being told all the information about all the side-effect possibilities. Feltman: When you say that regaining fertility after these treatments can be complex and slow, could you walk us through what you mean by that? Pappas: Sure, because your own testosterone levels and sperm production drop, you're going to have to, usually, get off the testosterone. That can really lead to a hormone crash; since your body is, really, at that point in quite low testosterone, you may feel irritable, you may feel fatigue. So you're gonna have to go through that—a bit of a roller coaster. Doctors will prescribe some medications that can help even out your levels and help encourage your body to start producing its own sperm again. That can take some time; it can be a little expensive. Urologists can help you, though. But they do say that they are concerned that men have a, often, too rosy picture of what that's gonna look like. It can take up to two years to recover full fertility, there's kind of an unknown as to whether sperm quality will be quite as high as it was beforehand. And as anyone who's trying to have kids knows, two years can be quite a while when you're dealing with fertility problems. Feltman: Yeah, so let's talk some more about those freestanding clinics. You know, in addition to TRT, you know, being more in demand and more in the conversation, it also seems like it's more accessible than ever, so what are some of the sort of concerning characteristics of these clinics that are popping up? Pappas: Well, you don't wanna paint all clinics with the same brush ... Feltman: Sure. Pappas: Because there is a wide variety of care out there. So it can be any provider that can prescribe—because testosterone is a controlled substance—but they may not really be running you through a full workup, as a urologist or an endocrinologist affiliated with a practice or a hospital system might do. The recommendations from professional societies suggest you get two testosterone tests on different days because testosterone levels swing wildly. I could not find anyone who'd reported to me that they'd gotten two tests. I can't say that there aren't clinics that do it. Typically you're gonna get one test. Typically they are motivated to prescribe what they can to you. The problem, often, is that because of this long-term fear around testosterone, is that many primary care doctors are nervous about prescribing it or don't feel that they've been trained. I spoke to one man who, actually, his doctor said, 'Yes, your testosterone is undeniably low, but I don't know what to do about it. Maybe just go to one of these clinics, and they can help you.' His experience in that clinic, unfortunately, was that they kind of gave him a generic prescription, did not really test through his levels, didn't really talk through, you know, alternative treatments or other things he might look at doing. So he felt his loss and he ended up looking on Reddit for advice, which, as we all know [laughs], is a real hit-and-miss proposition ... Feltman: Sure. Pappas: So men are often kind of left searching for their own information, and they may not have good sources of information. Feltman: And the experts that you spoke to, what do they wanna see change about the way we're treating TRT? Pappas: The first step is that a lot of physicians who specialize in hormone replacement therapy for men would like to see more awareness among primary care physicians and other doctors that men might go to, because if they could coordinate that care in a really responsible way, there are probably many men who could benefit: they do have low testosterone but haven't ever thought about being tested. And then the other side of this is just patient education. If you're going to consider going to a clinic, don't just go somewhere that will happily hand you a prescription. Really look for someone who is going to sit down with you, who is going to talk through lifestyle changes, who's going to look at alternative problems. So one doctor I spoke to said, 'The first thing we do is we look for sleep apnea in our patients. If we can cure that, oftentimes we don't need to look at their testosterone levels again.' And don't be in a rush to walk out that first day with a prescription that might be too high for you and might lead to side effects like acne, or another side effect you can see is an overgrowth of red blood cells that can lead you to need to have to donate blood every month to keep that in normal range. Look for something that's not going to cause the side effects that can really affect your life in the long term. Feltman: Sure, well, thank you so much for coming on to talk us through your feature. I really appreciate it. Pappas: Thank you so much. Feltman: That's all for today's episode. You can read Stephanie's full story on TRT in the July/August issue of Scientific American. We'll be back next week with something special: a three-part miniseries on bird flu. From avian influenza's wild origins to its spread across U.S. farms to the labs trying to keep it from becoming the next pandemic, this looming public health threat has a lot of moving parts, but we'll get you all caught up. Science Quickly is produced by me, Rachel Feltman, along with Fonda Mwangi, Kelso Harper, Naeem Amarsy and Jeff DelViscio. This episode was edited by Alex Sugiura. Shayna Posses and Aaron Shattuck fact-check our show. Our theme music was composed by Dominic Smith. Subscribe to Scientific American for more up-to-date and in-depth science news.
New York Post
4 days ago
- Health
- New York Post
Ulo wants to help men get their edge back with TRT
New York Post may receive revenue from affiliate and advertising partnerships for sharing this content and/or when you make a purchase. Thinning hair, plummeting energy, and a dwindling sex drive. It's not exactly the future most men imagine for themselves, but for many, it becomes their reality. Society often submits to the idea that aging robs us of physical strength and mental vitality, but what if some of those effects weren't irreversible? Maybe it's not about turning back the clock, but about optimizing health regardless of age. That's what companies like Ulo are trying to make possible with Testosterone Replacement Therapy. As endocrinologists shine light on age-related testosterone decline, interest in TRT has surged. Clinically known as Andropause and sometimes, on social media as 'Manopause,' the natural decline typically occurs when men reach their late 30s or 40s, causing some to experience symptoms like hair loss, lowered libido, fatigue, and decreased muscle mass. 'Men are tired of feeling off and being told it's just aging or stress. They're realizing it's not normal to feel constantly exhausted, unmotivated, or emotionally flat at 35 or 45,' shared Deep Patel, the co-founder of Ulo, a telehealth startup that recently launched into the TRT space. 'It's like the male version of menopause, except no one acknowledged it until recently.' Doctors typically recommend that men with these symptoms also take a blood test to determine if their levels are abnormally low. Normal testosterone levels range from 300 to 1,000 nanograms per deciliter. But low testosterone — also known as hypogonadism — is far from rare. Nearly 39% of men aged 45 years and older have low testosterone. As with many other experts in the space, Patel believes that 'Low T' is even more widespread than society realizes. 'It's not just guys over 50. More and more men in their 20s, 30s, and 40s are dealing with low T. A lot of it comes from stress, lack of sleep, diet, or genetics.' 5 michaelheim – Prescribing TRT online is still a relatively uncharted territory, but some companies are trying to change that. Ulo is among the first to build a site that offers a TRT program with a personalized approach to treatment. 'When we built Ulo, our aim was to help men take back control of their health, especially in commonly overlooked areas such as hormones and hair loss. And when you look at those areas, TRT is an obvious solution,' explained Patel, who co-founded the company with Rob English. Ulo first launched with a focus on everyday men's health concerns, such as hair loss prevention and regrowth. For Patel and English, stepping into the TRT space was part of a natural evolution, especially after they witnessed the powerful impact this kind of treatment had on the people around them. 'I watched friends lose their hair way too young and struggle in silence,' Patel recounted. 'But, I also noticed a deeper issue. A lot of them also felt drained, mentally foggy, and unmotivated. Turns out, in addition to hair concerns, a lot of them were facing low testosterone.' 5 Garnar – Even after optimizing for sleep, diet, and physical activity, their low testosterone was still impacting their everyday lives. But once they got treated, everything shifted. After Patel began looking into TRT, he came across another alarming statistic. A 2023 study in the Journal of Clinical Endocrinology revealed that testosterone levels in American men have dropped about 1% per year since the 1980s. That's when he realized we were in the midst of what he calls 'a silent epidemic.' Emerging research has shown that TRT could be one of the most effective, clinically backed treatments for men with low testosterone levels. Another survey, published in 2019, found that 52% of men claimed testosterone improved their energy, 42% saw improvements in libido, and 29% reported muscle growth. The benefits of TRT are clear, but many people don't know how to get a testosterone prescription or where to go for safe, high-quality treatment. With Ulo, Patel and his team wanted to make TRT more accessible than ever before. 5 Ulo At Ulo, it costs as low as $159 a month to get started with a prescription — and you could have a customized testosterone treatment within a week, without spending any time in a clinic. The process is simple. First, men take a blood test and schedule a consultation with one of Ulo's Doctors. The physician will then examine lab results, symptoms, and medical history before determining if they should receive a prescription. From there, they'll create a customized treatment plan. According to Patel, injections are the most common and effective type of treatment, but Ulo still offers other forms for anyone with strong preferences, including gels and creams. Once everything is cleared, the treatment is shipped directly to their front door. Patel says that most men start noticing changes after a few weeks have passed. 'Heightened energy, mental clarity, better sleep, and an increase in libido are usually the first things you'll notice. After two to three months have passed, you'll start to notice changes in body composition.' He noted that men have also noticed they can build muscle more easily; similarly, many find they are now able to get rid of fat that seemed immovable. In tandem with these changes, participants often experience an increase in confidence. 'The most common side effects include acne, water retention, or elevated red blood cell counts, which can thicken your blood. Some men experience testicular shrinkage or reduced fertility,' he explained, also noting cardiovascular risks for certain populations. 5 OleCNX – Currently, TRT is only FDA-approved for specific conditions, like hypogonadism or diminished functional activity of the gonads. Earlier this year, the FDA also issued class-wide labeling changes for testosterone products, including warnings on increased blood pressure as a potential side effect. Patel explained that the biggest mistake people make is doing TRT without medical guidance or buying unregulated medication online. His advice is to work with a legitimate provider who looks at bloodwork and adjusts the protocol based on how your body specifically responds. 'At Ulo, we take the time to assess whether TRT is the right choice for you,' he said. 'We don't rush people into treatment. We're not a marketing brand in the guise of a clinic. We're a bona fide telehealth platform built from the ground up to give men the long-term support they require.' Patel believes that when administered correctly, TRT can have a profound impact on men's physical, mental, and emotional health. Ulo's mission is simple: To make the process safe, efficient, and transparent from day one through every single dose. 5 Ulo Q&A with Deep Patel at Ulo The New York Post spoke with Deep Patel to clear up some frequently asked questions regarding Testosterone Replacement Therapy offered at Ulo. What does Ulo's TRT program include? At Ulo, we offer a full-service program that includes comprehensive blood work, one-on-one consultations with licensed physicians, prescriptions, custom treatment plans, and regular follow-ups. The process is crafted to be efficient and transparent from start to finish. Best of all, you won't have to spend time in labs and clinics. Who oversees the treatment? A licensed, U.S.-based physician oversees every treatment plan at Ulo. Our doctors are specialists in hormone optimization and men's health. They're not just checking a box. Before making decisions, they examine your lab results, symptoms, and medical history. When you join Ulo, you can rest assured that you're getting genuine individualized medical supervision as opposed to a one-size-fits-all program. How do you personalize dosage or adjust the protocol over time? We rely on data and feedback from the men. Your physician will examine your blood work and any changes in symptoms, and will ask how you're feeling in general. If something seems off or if you're not progressing as expected, the team at Ulo will make adjustments to dosage, frequency, or support meds. Everything can be fine-tuned. The goal is to ensure you feel your best. How is TRT administered? Injections are the most common and reliable method, typically once or twice a week. Some guys use creams or gels, but those can be inconsistent in how they absorb, and there's a risk of transferring to partners or kids. Injections might sound intense, but once you're used to them, it takes less than a minute. Most men do it themselves at home with tiny insulin needles. Will TRT affect fertility? Yeah, it can, especially if you're not using anything to counteract it. TRT significantly suppresses natural testosterone production, which can also reduce sperm production. But if fertility matters to you, there are medications like HCG or enclomiphene that can be taken alongside TRT to preserve it. In a 2021 study, over 90% of men maintained normal sperm counts when using these fertility-preserving medications with TRT. Just make sure your provider knows that's a priority from the beginning. How often is blood work required, and is it included in the program cost? Blood work is included in the program cost. The first lab takes place before your initial consultation with the doctor. A second lab is done 30 days after treatment begins to help prepare for your 45-day follow-up. After that, labs are required every quarter and are paired with a live consultation to make sure your treatment stays safe, effective, and personalized. How is the cost for the TRT plan broken up? We ensure pricing is simple, offering a flat monthly rate that includes physician oversight, medication, lab testing, and access to your care team. No surprise bills or upsells. Our program is significantly more affordable than most in-person clinics. And we never compromise on the quality of care. Is TRT covered by insurance through Ulo? Most insurance plans won't cover TRT unless your levels are extraordinarily clinically deficient. Currently, Ulo operates outside of insurance. That gives us the flexibility to treat based on how someone feels. At Ulo, you're never just a box to tick or a chart to fill in. Our approach is proactive, not reactive. This article was written by Miska Salemann, New York Post Commerce Writer/Reporter. As a health-forward member of Gen Z, Miska seeks out experts to weigh in on the benefits, safety and designs of both trending and tried-and-true fitness equipment, workout clothing, dietary supplements and more. Taking matters into her own hands, Miska intrepidly tests wellness products, ranging from Bryan Johnson's Blueprint Longevity Mix to home gym elliptical machines to Jennifer Aniston's favorite workout platform – often with her adorable one-year old daughter by her side. Before joining The Post, Miska covered lifestyle and consumer topics for the U.S. Sun and The Cannon Beach Gazette. Looking for a headline-worthy haul? Keep shopping Post Wanted.
Scientific American
4 days ago
- Health
- Scientific American
What Most Men Don't Know about the Risks of Testosterone Therapy
Rob, 42, is a fitness guy. He loves working out, spends his spare time in the jujitsu gym and eats a high-protein diet heavy on avocado oil. He cares about his health and wants to optimize it, and a lot of the social media influencers he follows are the same. So a few years back, when Rob started seeing ads for testosterone replacement therapy—TRT—pop up in his feeds, he was intrigued. (Names of patients in this story have been changed to protect their privacy.) Rob was already a man in good shape. But testosterone sounded like a great way to get an extra edge. 'I bought into what I was listening to on social media, which is, 'You're going to feel better, you're going to get stronger, and you're going to look better,'' he says. On supporting science journalism If you're enjoying this article, consider supporting our award-winning journalism by subscribing. By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today. Rob went to a local, privately owned clinic. There he got a blood test, which revealed that his testosterone was well within normal range. 'I certainly didn't need TRT,' he says. The clinic prescribed it anyway. Rahim, 48, tells a similar story. He walked into a men's health clinic a decade ago looking for an energy and fitness boost. He got an injection that very day. On subsequent visits the clinic pushed his dose higher and higher, but he perceived little benefit. 'I just felt like I was taken advantage of,' he says now. 'I felt like somebody was using my body to make money.' Testosterone therapy—prescription supplements in the form of pills, patches, injections or implantable pellets—has probably never been more publicized or popular. Podcaster Joe Rogan is on it. On Reddit and on TikTok, on highway billboards and in TV commercials, you'll see testimonials in praise of TRT promising mood boosts, better sex, extra energy and quite possibly an abdominal six-pack. The global market has been estimated at $1.9 billion. For the right men, usually those with seriously low levels of the hormone, TRT can improve mood, energy levels and sex drive. It can increase muscle, decrease fat and lower levels of biomarkers for heart disease. Rigorous studies have dispelled once common medical concerns that the supplements increase the chance of prostate cancer; they don't. And many responsible clinics that prescribe TRT inform their clients of the potential risks and benefits and monitor them closely. But many men getting supplements may not have low testosterone to begin with, and for them, boosting levels of the hormone even higher could cause harm. There is a lot of medical disagreement about what constitutes 'low,' driven by several studies with different populations and different cutoffs. Because of this uncertainty, some clinics will legally prescribe TRT for men whose hormone levels are, according to many measures, just fine. 'It will not make you live longer. It will not make you otherwise healthier,' says Channa Jayasena, who is a reproductive endocrinologist at Imperial College London. And TRT carries risks. Supplemental testosterone can increase the chances of infertility and shrink testicles. It can lead to an abnormal blood condition called erythrocytosis. It is also associated with heightened rates of acne and painful swelling of male breast tissue. So urologists and endocrinologists who study the hormone caution men thinking about TRT to proceed very carefully. Thanks to its inexorable cultural ties to masculinity, testosterone is perhaps more prone than other 'wellness' treatments to emotional appeal. The TRT ads that show up on social media promise a lot but rarely mention side effects or proper testing. 'The majority of the testosterone information on TikTok and Instagram is horrible, horrendous,' says Justin Dubin, a urologist at Memorial Healthcare System in southern Florida. 'It's not accurate.' The normal range for testosterone level is broad, spanning from around 300 to 1,000 nanograms per deciliter of blood (ng/dl). After about age 40, a person's amount of circulating testosterone starts to decline by approximately 1 percent a year, and with the U.S. population getting older, it's no surprise that interest in TRT is rising. There is also some evidence that average levels of testosterone are dropping in young men. Diseases that have become more common, such as obesity and diabetes, affect hormone production and likely explain some of that decline. But interest in boosting testosterone goes way back—back to before anyone knew what testosterone was. In 1849 German scientist Arnold Adolph Berthold observed that castrated roosters showed little interest in fighting over females. When rooster testes were transplanted into these peaceniks, they suddenly developed an interest in sex and barnyard brawling. Doctors soon sought to harness the testes' miraculous masculinizing power. In 1889, 72-year-old Mauritian neurologist Charles-Édouard Brown-Séquard injected himself with a slurry of crushed-up dog and guinea pig testicles, seeking rejuvenation. He reported that after a few injections he could sprint down stairs like a young man and stand at his laboratory table for hours. Russian-born physician Serge Voronoff tried transplanting testicles from monkeys into people and gushed about his results in his 1925 book, Rejuvenation by Grafting. He wrote of one 74-year-old patient that after surgery, 'his superfluous fat had disappeared, his muscles had become firm, he held himself erect and conveyed the impression of a man in perfect health ... The grafting had transformed a senile, impotent, pitiful old being into a vigorous man, in full possession of all his faculties.' Today doctors say any positive effects from these treatments were pure placebo. In 2002 Australian researchers tried making Brown-Séquard's testicle extracts and found that the amount of testosterone in the preparations was a quarter of what would be needed to produce a biological response. And in the days when Voronoff worked—before modern tissue-preservation advances or any understanding of antirejection drugs—testicle transplants (especially cross-species transplants) would have been incredibly unlikely to survive. A synthetic form of testosterone was developed in 1935, making a drug form of TRT possible. But its advent did not lead to a prescribing boom right away. (It did catch the notice of bodybuilding communities, who began asking for it.) In part, the medical reluctance was because of a small 1941 study showing that adding testosterone made prostate cancer grow faster and that the tumors shrank when levels of the hormone were low. The connection made doctors extremely wary of treating men with testosterone—even men with undeniable hypogonadism, meaning their testes could not make sufficient amounts of the hormone. 'There was a near-complete prohibition,' says Abraham Morgentaler, a urologist and testosterone researcher at Harvard Medical School. In the 1980s Morgentaler, who had investigated the effect of testosterone on the reproductive behavior of lizards as a student, was a young urologist specializing in male infertility, treating patients with low testosterone, erectile dysfunction and a lack of libido. They were desperate. Morgentaler thought back on his lizards, which had failed to woo females when deprived of testosterone. Cautiously, he began to dose a few of his patients with the hormone. Not only did they report improved sex lives, he says, but 'they described to me how they felt better outside of their sexual symptoms—things like 'I've never had so much patience for my small children,' 'I wake up in the morning, I swing my legs over my bed, I'm optimistic about my day.'' As Morgentaler continued his hormone-treatment research, he failed to see any increase in prostate cancer growth in patients. Over time the evidence that testosterone does not necessarily supercharge prostate tumors has piled up. By the early 2000s fears of prostate cancer with testosterone treatment were easing, if not altogether disappearing. As a result, TRT began to rise in popularity, and its use increased more than threefold between 2001 and 2011, according to research published in 2013. Still there was hesitation. The U.S. Food and Drug Administration issued a warning in 2014 that TRT might raise the risk of heart attacks and strokes. Testosterone influences muscle growth and activity; muscle fibers are dotted with many androgen receptors. The heart, of course, is a muscle. In men who take anabolic steroids for bodybuilding—natural testosterone is a form of this type of hormone—heart problems are a known consequence. To tackle these two safety issues, a consortium of researchers put together the TRAVERSE trial, the largest-ever randomized, controlled trial on TRT for men with low testosterone. They screened more than 5,000 men, aged 45 through 80 years, to ensure participants had low levels of prostate-specific antigen (or PSA, a marker of prostate cancer) at the onset of the study, and they followed the men for an average of three years. In 2023 the researchers reported the results. There was no increase in prostate cancer with testosterone treatment. Nor was there an increase in strokes, heart attacks or cardiovascular deaths. That's the good news for men interested in TRT: for those with low testosterone and normal PSA levels who get boosted into the average range for testosterone, the risk of cancer or heart problems is low. But TRT remains controversial, largely because there is no consensus on how to define 'low testosterone.' The American Urological Association guidelines suggest that as a rule of thumb, 'low' means a total testosterone level under 300 ng/dl, as measured twice on different mornings (because testosterone levels fluctuate). But an international group, the Endocrine Society, has a 'normal' range—between 264 and 916 ng/dl—that partly overlaps with that category. The European Academy of Andrology guidelines put the 'lower limit of normality' between 231 and 350 ng/dl. One reason for these disparities is that testosterone levels can swing by 100 ng/dl or more in a single day, so symptoms (fatigue, for instance) can correlate with very different numbers. The TRAVERSE trial used a cutoff of 300 ng/dl for 'low.' When men who had lower levels received supplements, there were clear benefits for mood and energy. In 2024 researchers reported a 50 percent increase in sexual activity among men with low testosterone from TRAVERSE who were treated with hormone supplements. That translated to an increase of almost one additional sexual 'event' per day—a category that included partnered sex, masturbation, daydreams, flirting and spontaneous erections. A comparison group that got a placebo had only a 25 percent increase. Less clear are the effects of TRT on the fuzzier symptoms sometimes ascribed to low testosterone, such as fatigue, brain fog, depression and irritability. Joe, 38, says he was in a pretty low place when he learned, in his early 30s, that his level was only 95 ng/dl. He started TRT that keeps him above 600, and he says it works. 'It just helps me feel incredibly normal,' he says. The TRAVERSE trial found no benefit of TRT over a placebo for addressing low-grade depressive symptoms. But it did find improvements in both mood and energy in men with significant depression, according to another 2024 study. There was no benefit for cognition or sleep. Men in the borderline-low range, with levels around 300 ng/dl, haven't been studied systematically, says Frederick Wu, an emeritus professor of medicine and endocrinology at England's University of Manchester who led the European Male Aging Study (EMAS), a very large study of aging men. And for men with normal-range testosterone, the results of TRT might not be as dramatic as they are for men with uncontested low levels. Symptoms such as low energy are particularly difficult to tie to testosterone. Any of the minor insults of midlife can cause fatigue and irritability: young kids who don't sleep, a sedentary computer job, stress, a poor diet. One of the first things urologists or endocrinologists do when a patient comes in with these symptoms is check for sleep apnea, which can cause brain fog and fatigue while also reducing testosterone. 'Testosterone is a very robust indicator of general health status,' Wu says. 'If you find low T in a patient, then it is imperative to investigate their general health status rather than having a knee-jerk reaction of starting testosterone treatment.' There are also almost certainly symptom differences in the way individual men respond to particular hormone levels. 'It's possible that a man with a total testosterone of 350 ng/dl might be deficient in certain ways,' says Joshua Halpern, chief scientific officer at fertility clinic Posterity Health and an adjunct professor of urology at Northwestern University Feinberg School of Medicine. 'Different tissues and organ systems in the body require different levels of testosterone to function optimally.' Herein lies another area of disagreement. Some doctors argue for trying testosterone only after other health interventions because changes in exercise and diet can boost testosterone and improve general health. Others, such as Morgentaler, argue that TRT can be offered first to men with low levels because supplements could give a man with low energy the boost he needs to start working out and eating better. This argument may now be complicated by the arrival of GLP-1 drugs, such as Ozempic, which make losing weight a lot easier. Should a man with obesity and low testosterone be offered TRT or Ozempic? It's a question that hasn't been studied. A final uncertainty is what type of testosterone measurement to use. Most studies have looked at total testosterone, a measure that captures all of the hormone circulating in the blood. But a lot of that testosterone is bound to other proteins, such as albumin and sex-hormone-binding globulin (SHBG). The hormone sticks tightly to SHBG, and in that state it can't be used by body tissues. 'Free' testosterone, which isn't bound, can. Ultimately, the amount of free T might be a lot more important than total testosterone when it comes to how men feel. 'Symptoms follow free T,' Morgentaler says. In a 2018 study using EMAS data, researchers found that in obese men who developed hypogonadism, only those whose free testosterone dropped alongside their total testosterone actually experienced symptoms. Still, medical societies have no specific free-T cutoffs for treatment, so a doctor's judgment plays a large role in determining how to use the numbers. None of these medical debates is likely to come up, however, when people walk into one of the many men's health clinics. Like Rob or Rahim, they'll probably be offered a prescription. In 2022 Dubin, Halpern and some of their colleagues published a study in JAMA Internal Medicine for which they went undercover, sending Dubin's own testosterone measurements to seven men's health clinics. Dubin's level happened to be 675 ng/dl, above what most urologists aim for when treating low-T men. In addition, he told the clinics that he hoped to have children in the future. This statement should have stopped them cold. Testosterone is part of the feedback loop that regulates sperm production; if levels of the hormone stay high in the bloodstream, the testes stop making their own testosterone and sperm. 'There was really no situation in which I was a good candidate for TRT,' Dubin says. Six of the seven clinics offered him TRT anyway. This outcome isn't unusual. 'Looking back, it was so ridiculous,' Rahim recalls of his own same-day testosterone initiation. Although professional guidelines universally agree that men should be tested at least twice before starting TRT, a single test seems common for online and private clinics. Rahim's numbers were in the high 300s, he recalls, but he was soon put on a dose of testosterone so high that it caused side effects, for which the clinic offered to prescribe more medications. 'It was in their best interests to inject me with more T because it was better for their revenue, even though it wasn't necessarily better for my health,' he says. Other men report similar experiences. John, 42, was in his mid-30s when he sought out TRT, motivated to keep up in the military special-operations job he had at the time. He was prescribed implantable testosterone pellets, which made his total testosterone level shoot up to more than 1,800 ng/dl. He then dealt with a mandibular disorder from clenching his jaw, as well as benign prostate enlargement that required a cascading series of prescriptions. Morgentaler says that these cases are cautionary tales that men should take seriously. Avoid clinics that offer TRT without first taking a baseline test, he says, or those without a clear follow-up plan for monitoring bloodwork. One 2015 study found that less than half of men on TRT in a large metropolitan health center ever got a follow-up blood test. And that could be a problem because one common side effect of TRT is erythrocytosis, which results in the overproduction of red blood cells. An ethical clinic should also be honest about TRT's effect on fertility. Dubin and Halpern say that every month they treat multiple men who haven't been warned that their testosterone regimen will crater their sperm count. Online influencers often shrug off fertility side effects as short-term, but doctors say they can persist. It can take up to two years after cessation of TRT for men to recover a regular sperm count, according to a 2006 study in the Lancet. As any couple going through infertility struggles can attest, two years is a long time. Two medications that doctors prescribe to hasten sperm-count recovery, human chorionic gonadotropin and clomiphene citrate, often aren't covered by insurance and can have their own side effects. Sperm quality may not be as high in men who have recovered post-TRT compared with men who never took testosterone replacement, Halpern says. Finally, although the TRAVERSE trial suggests that men trying TRT aren't putting themselves at undue risk of prostate cancer or heart problems, there was a small but unexplained rise in bone fractures in men on the treatment. In addition, there are no studies looking at the impacts of TRT over several decades—and a man starting TRT in his 30s may well be committing to 40 or 50 years of treatment if he doesn't want to go through the hormonal crash of quitting. One concern from studies of heavy users of anabolic steroids is that natural testosterone production might not fully recover after long-term use, says Harrison Pope, a Harvard Medical School psychiatrist who has studied anabolic steroid use. A 2023 study in the Journal of Clinical Endocrinology and Metabolism looked at men who had used anabolic steroids illicitly. These people reported a lesser quality of life two years after quitting compared with men who had never used them. In the body, these steroid drugs have effects that are similar to testosterone supplements, so the study results raise worries about TRT. 'If you had interviewed me 20 years ago, I would have assured you that if you'd been taking testosterone for a long time, if you stop, the system will rebound and you will go back to normal,' Pope says. 'In some cases, I would have been dead wrong.' For some men it will be worth the risk. Rob, John and Rahim are all on lower doses of testosterone now and being treated by practitioners they trust. They all see benefits in mood, muscle building and energy. But all three feel some ambivalence about the experience. It's a hesitation about TRT shared by a lot of medical professionals. 'There are still many unknowns when it comes to testosterone deficiency,' Halpern says, 'including even the basics.'
Sydney Morning Herald
5 days ago
- Health
- Sydney Morning Herald
Is there really such a thing as the Manopause?
Hot flushes; insomnia; joint pains; loss of libido: for many women, the menopause is no fun. Why exactly women become infertile decades before they die is a much-debated mystery in evolutionary biology. Besides humans, the only other mammals whose females experience so early a menopause in the wild seem to be some species of whale. But equal opportunity is the spirit of the age. These days health influencers, supplement companies and even some doctors talk about a male version of the menopause—variously called the 'manopause', 'andropause', or, for jargon-lovers, 'ADAM,' which stands for 'androgen deficiency in the ageing male'. Symptoms include a flagging libido, tiredness, shrinking muscles and growing body fat. Do men really suffer from menopause, or something like it? On one level, obviously not. Menopause is defined by the end of a woman's menstrual periods, and therefore the loss of her ability to reproduce, usually by her early 50s. Men, by contrast, can stay fertile well into old age. (For instance, Al Pacino, an American actor, fathered a child at 83.) In menopause, a woman's levels of the sex hormones oestrogen and progesterone fall sharply and suddenly. In most men levels of testosterone (the main male sex hormone) likewise start falling during middle age. But unlike in women there is no sudden drop. Levels decline gently, at a rate of around 1 per cent a year, and often stay within the normal range for a man's entire life. Sometimes symptoms that might be ascribed to a 'manopause' may arise from the realities of middle-aged life. Tiredness is a common result of juggling work with family responsibilities. Flabbiness and atrophying muscles are the wages of years of sedentary office work and too little exercise. On the other hand, some proportion of men do suffer from male hypogonadism, a medical condition in which the testicles do not produce as much testosterone as they should. Estimates of its prevalence vary widely: one review paper, published in 2020, cited one American study of ageing men that estimated 20 per cent of those in their 60s might be sufferers. But a separate European study put the figure for the same age group at just 3.2 per cent. The causes of hypogonadism are not always clear. But unlike the female menopause, it is not an inevitable consequence of ageing. Menopausal women can be treated with hormone-replacement therapy (HRT). This aims to replace the missing sex hormones, and thus relieve unpleasant symptoms, using tablets or gels. Similarly, a growing number of men take testosterone-replacement therapy (TRT) to the same ends. Prescriptions have boomed in the past 20 years, though there is not yet a firm consensus on when men actually need it. Still, testosterone—the original anabolic steroid—really is, in some ways, a fountain of youth. Men taking it will put on muscle, lose fat and recover faster from exercise (hence why taking testosterone is considered doping in most sports). The pros and cons of TRT are a subject for another article. But take care: side-effects can include baldness and, ironically, infertility. Add external testosterone and the body will compensate by making less. Reduced production in the testes can slow or even stop sperm production. By trying to relieve the symptoms of the supposed male menopause, men who take TRT risk replicating the defining feature of the female original.
The Age
5 days ago
- Health
- The Age
Is there really such a thing as the Manopause?
Hot flushes; insomnia; joint pains; loss of libido: for many women, the menopause is no fun. Why exactly women become infertile decades before they die is a much-debated mystery in evolutionary biology. Besides humans, the only other mammals whose females experience so early a menopause in the wild seem to be some species of whale. But equal opportunity is the spirit of the age. These days health influencers, supplement companies and even some doctors talk about a male version of the menopause—variously called the 'manopause', 'andropause', or, for jargon-lovers, 'ADAM,' which stands for 'androgen deficiency in the ageing male'. Symptoms include a flagging libido, tiredness, shrinking muscles and growing body fat. Do men really suffer from menopause, or something like it? On one level, obviously not. Menopause is defined by the end of a woman's menstrual periods, and therefore the loss of her ability to reproduce, usually by her early 50s. Men, by contrast, can stay fertile well into old age. (For instance, Al Pacino, an American actor, fathered a child at 83.) In menopause, a woman's levels of the sex hormones oestrogen and progesterone fall sharply and suddenly. In most men levels of testosterone (the main male sex hormone) likewise start falling during middle age. But unlike in women there is no sudden drop. Levels decline gently, at a rate of around 1 per cent a year, and often stay within the normal range for a man's entire life. Sometimes symptoms that might be ascribed to a 'manopause' may arise from the realities of middle-aged life. Tiredness is a common result of juggling work with family responsibilities. Flabbiness and atrophying muscles are the wages of years of sedentary office work and too little exercise. On the other hand, some proportion of men do suffer from male hypogonadism, a medical condition in which the testicles do not produce as much testosterone as they should. Estimates of its prevalence vary widely: one review paper, published in 2020, cited one American study of ageing men that estimated 20 per cent of those in their 60s might be sufferers. But a separate European study put the figure for the same age group at just 3.2 per cent. The causes of hypogonadism are not always clear. But unlike the female menopause, it is not an inevitable consequence of ageing. Menopausal women can be treated with hormone-replacement therapy (HRT). This aims to replace the missing sex hormones, and thus relieve unpleasant symptoms, using tablets or gels. Similarly, a growing number of men take testosterone-replacement therapy (TRT) to the same ends. Prescriptions have boomed in the past 20 years, though there is not yet a firm consensus on when men actually need it. Still, testosterone—the original anabolic steroid—really is, in some ways, a fountain of youth. Men taking it will put on muscle, lose fat and recover faster from exercise (hence why taking testosterone is considered doping in most sports). The pros and cons of TRT are a subject for another article. But take care: side-effects can include baldness and, ironically, infertility. Add external testosterone and the body will compensate by making less. Reduced production in the testes can slow or even stop sperm production. By trying to relieve the symptoms of the supposed male menopause, men who take TRT risk replicating the defining feature of the female original.
