The testosterone trap

Why are so many men seeking hormonal supplements they don’t need?

A few years ago I asked our fertility director, Dr. Wael Salem, what he thought Maven could do to help men with low sperm counts. Without hesitation, he looked me in the eye and said, “Take them off testosterone.” 

For most men, the benefits of testosterone replacement are limited at best and not worth the risks. But a quick scroll through my social media feed would have you believing otherwise. As a man in my forties, ads for testosterone supplements have become unavoidable, touted as a panacea for all things–for libido, for strength, for the ideal of modern masculinity. According to a 2017 JAMA study, this type of direct to consumer advertising really works at converting the uninitiated to treatment. For decades, unbranded awareness campaigns for a condition labeled “low T” effectively bypassed standard medical care, supplanting recommended blood testing with dubious self-reported quizzes that drive quick sales.

Dr. Salem’s fertility practice is well-grounded in clinical evidence. But his challenge is that for some, stopping testosterone may seem counterintuitive. Testosterone is a crucial component of sperm production. Yet, the correction for low sperm is usually not more testosterone. 

Our brains and gonads work together like a thermostat. Replacement therapy increases blood-levels of testosterone, which then informs the brain of an excess, which then shuts off production in the testes—the place where you actually need T to produce sperm. If this mechanism sounds familiar, that’s because female birth control works in a similar way. In fact, testosterone pills are a well-understood contraceptive that was first tested as a hormonal birth control for men in 1978. (As you might’ve guessed, it didn’t catch on. We’ll save that for another time.) The process to regain normal sperm counts can take many months, and in some cases, the sperm counts don't ever recover.

However, with aggressive industry marketing, testosterone did catch on in other ways. Over the decade spanning 2001 to 2011, testosterone supplement use among middle-aged men tripled. Then, a groundswell of studies found that indiscriminate testosterone replacement therapy was dangerous, linked with higher rates of cardiovascular problems and prostate cancer. The FDA doubled down on warnings, and health plans accordingly declined to cover many of the treatments. For a time, T prescriptions slumped. 

The sudden boost in boosters

The market responded with a quick pivot to over-the-counter testosterone “boosters.” Unregulated by the FDA, and lacking a standard ingredient composition, a quick Google search for testosterone today will reveal a candy store of options—patches, pills, chewables, mints, all in sharp contrast to the testosterone injections provided at a doctor’s office. The supplement industry has created an even scarier landscape for vulnerable boys and men. 

T boosters have become the perfect tinder for the raging fire of predatory pill ads that define our age. Just in the last quarter, some supplement providers have celebrated record growth while many traditional health care providers have seen their stock wane. Meanwhile, some studies estimate that one in four men who receive testosterone therapy do not have their testosterone tested prior to treatment; one in two do not have their testosterone levels checked after treatment; and one in three would never have met the diagnostic criteria to begin with. 

It is true that male testosterone levels decline with age—by about 1% a year after 40. Most men don’t report noticing it. In practice, most older men generally fall within normal ranges, and among those who are symptomatic and receive medically indicated tests, only 10-25% have genuinely low levels. 

So, why are so many men seeking treatment for a condition they are unlikely to have?

The answer, I think, begins somewhere on Reddit. Consider any of the millions of members in r/Testosterone or r/AskMen. Countless posts begin with “Help!” and end with tips on carnivorous diets, workout plans, or, often, marriage. Many of the symptoms of low testosterone in men—reduced sexual activity, loss of body hair, depressed mood, increased body fat, decreased muscle mass, reduced endurance—are indistinguishable from the symptoms of aging generally, and of course are the exact kinds of concerns that often get passed over or even dismissed by the medical establishment. 

Men are not larger women

The popularity of these forums has also been fueled by a sudden and odd male “andropause” movement. Marketers, capitalizing on the gold rush in menopause care, seized the opportunity to invent a male equivalent. 

Today, the global menopause market is expected to reach $24.4 billion by 2030, a watershed moment for a crucial health disparity that has long been underserved. Under the guise of gender parity, some vendors have started inundating employers and health plans with solutions for “andropause”–a condition that does not technically exist. With the best of intentions, companies rightfully want to know if their midlife benefits should be supporting men too. And of course they should–but the solution for men and women is necessarily different. 

For all females, estrogen production comes to a complete standstill in menopause, with diverse, pervasive, and life-altering symptoms. For the overwhelming majority of males, testosterone production does not “pause” and the decline in production does not cause hot flashes, night sweats, irregular bleeding, or the panoply of other challenges experienced by women. By suggesting a false equivalence, the term “andropause” is misleading. It does a disservice to men and women alike.

Most men don’t need a pill, they need trustworthy primary health care—something far too many men lack. Men do not benefit from regular preventive visits with a urologist. However most women do benefit from regular preventive visits with a gynecologist–for contraception, for cervical and uterine cancer screening, for conditions like endometriosis and PCOS that are linked to a monthly cyclical event. The care model is necessarily different because people who menstruate uniquely benefit from co-locating primary and reproductive health care.

For much of the past century, medicine has treated women as smaller men, leading to massive disparities in women’s health research, care delivery, and outcomes. Treating men as larger women is a different version of the same error. It is possible to affirm men’s needs and address sex-based biological differences at the same time. In fact, it’s the only way to ensure care is truly equitable.

What my team is reading, considering, and building against.

• This week, researchers at the University of British Columbia published a paper suggesting that the CDC surveillance systems may have overestimated the U.S. maternal mortality rate. The technical issue here is the introduction of a check box onto death certificates to record whether a death of a pregnant person is actually pregnancy-related. In many cases, it appears to have been checked in error. In truth, maternal mortality is hard to estimate with precision. Nonetheless, the media headlines belie a basic truth: every preventable death is an unacceptable tragedy and Black women in our country are bearing the brunt. The investments that many are making in solutions, including here at Maven Clinic, remain as critical as ever.

• In an update to my last Preprint, at Maven we were glad to see Alabama pass legislation that reopened IVF access in the state. Some clinics resumed embryo transfers within 24 hours. Still, legal experts are clear: this is a band-aid solution, which only addresses the liability of fertility clinics, and not the legality of IVF entirely. It certainly doesn’t address the maternal outcomes in Alabama writ large. If you’d like to support those on the ground, we’ll be continuing to donate all Preprint subscriptions to West Alabama Women’s Center. :)

• If you’re sick of hearing about GLP-1s, you better buckle up, because we’ve only hit the tip of the iceberg. A piece for the New York Times interrogates a question that we’ve been thinking a lot about at Maven…how does this new crop of weight loss drugs affect pregnant people, and aspiring pregnant people? The short answer is: we don’t really know yet, and with a lack of clinical data at their disposal, patients are seeking answers online.

• Did someone say doula? A new report from Elevance Health examines their medicaid-managed doula care pilot program. Findings, consistent with Maven’s own doula research, included decreased rates of c-section; higher prevalence of postpartum care; and lower prevalence of postpartum depression. 

• The latest issue of the Lancet is an excellent special edition examination of menopause. In particular, we appreciated the framing editorial arguing to rethink menopause from a medicalized disease to a normal phase of life (very parallel to similar arguments in pregnancy), as well as the Hickey et al article that makes the case for managing menopause with an empowerment (vs. “treatment”) based approach.