Who really needs testosterone?
The military plans to start screening service members for low testosterone, and social media is overflowing with claims about testosterone therapy.
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A few times, Dr. Jamin Brahmbhatt suspected he might have low testosterone.
But when he checked his numbers, he discovered they were entirely within a normal range.
“Turns out it was more so my sleep and stress and everything else,” says Brahmbhatt, a urologist at Orlando Health in Florida.
Brahmbhatt treats men with low testosterone every day — meaning he’s on the front lines of the current cultural fixation with testosterone.
Social media is overflowing with testosterone content, from fears of “low T” to “‘t-maxxing”‘ tutorials. Influential voices, including the podcaster Joe Rogan and Health Secretary Robert F. Kennedy Jr., are openly discussing their own use of testosterone therapy. And there’s a huge industry of online clinics that make it easy for anyone to get a prescription.
Brahmbhatt welcomes the increased attention to men’s health — and hormone replacement therapy specifically –– which he says has been “ignored” for too long.
But he also sees men who’ve spent hours in online forums like Reddit, convinced they need testosterone even before they’ve spoken to a doctor or had their levels tested. “Not every guy needs to be on it,” Brahmbhatt says.
“Testosterone has gotten a bad wrap because … you can walk into these clinics, go online, and get a prescription, they don’t do all the testing, they don’t do the follow up. That is the unsafe territory.”
What are the symptoms of low testosterone?
Testosterone is a sex hormone, but its effects on physiology extends well beyond reproduction. It’s also involved in metabolism, bone health, muscle mass, red blood cell production and cognitive health.
Experts in the field emphasize that it’s a powerful indicator of overall health.
“When levels are low and men are symptomatic, it’s not just a testosterone issue, but a men’s health issue,” says Dr. Helen Bernie, director of Sexual and Reproductive Medicine at Indiana University.
Brahmbhatt says what’s challenging is symptoms of testosterone deficiency, technically known as “hypogonadism,” can easily be attributed to other causes. They include depressed mood, fatigue, reduced libido, weight gain and trouble concentrating.
The underlying causes for low testosterone vary.
It can be due to some rare medical conditions, like certain genetic disorders or disorders of the pituitary gland. Testosterone also gradually declines with age. But Bernie says there are often other contributing factors in younger and middle-aged men beyond aging, like obesity, diabetes, sleep apnea, drug use and smoking.
Calls for increased access to testosterone
Testosterone therapy has long been overshadowed by doping scandals and concerns about anabolic steroids in sports and bodybuilding.
Increasingly, messaging from online clinics and influencers emphasizes wellness, athletic performance, longevity and improved focus.
Bernie says she worries about these claims.
“The goal of testosterone therapy isn’t peak performance,” says Bernie. “It’s not some drug to promise the fountain of youth. It is restoring normal physiology in men who have a true deficiency. I think it’s really important to separate marketing from actual medicine,” she adds.
The growing visibility of testosterone therapy reflects more than just a convergence of cultural forces and a booming market for these products — the Trump administration is making a concerted effort to expand access for men.
Under the Food and Drug Administration’s current criteria, testosterone therapy is only approved for men whose low levels can be traced to an identifiable medical condition. But the administration has signaled it wants to revise that so men with low testosterone — whatever the cause — can qualify for treatment, if they have low libido as a symptom.
The FDA wants to remove language from the drug label that explicitly states the safety and effectiveness for “age-related hypogonadism” had not been established.
Dr. Martin Miner, who co-directs the Men’s Health Center at the Miriam Hospital in Providence, Rhode Island, says the changes are long overdue.
“You wouldn’t treat a person with high blood pressure because it’s due to one cause and it’s not due to another,” he says. “You treat it because a person has symptoms. The same is true for low testosterone,” he says.
Miner is also president of the Androgen Society and has consulted for several companies that make testosterone.
He and other high-profile figures in the field are also calling on the administration to place testosterone in a less restrictive category of controlled substances (it’s currently listed alongside drugs like ketamine).
Others remain concerned about the direction the Trump administration is taking — and opening up even wider access to the drug.
“I think it is too soon,” says Dr. Steven Woloshin, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, who has testified in court against a drug company that makes testosterone.
“I think we really need to have a better handle on the long-term benefits and harms.”
The long-running debate around testosterone – and its safety
During the early 2000s, testosterone was one of the fastest-growing prescription drugs in the United States. Topical gels came onto the market, offering alternatives to injectables. Drug companies pushed disease awareness advertising around low testosterone.
But after data suggested testosterone increased the risk of heart attack and stroke, the FDA placed warnings on the products and requested the drug companies conduct a major safety study.
That trial — known as TRAVERSE — was published in 2023 in the New England Journal of Medicine. It did not find an increased risk of heart attack, stroke and other major cardiovascular events when compared to placebo, though it did raise some other concerns like a higher risk of fractures.
Doctor Steven Nissen, a cardiologist at the Cleveland Clinic who led the study, points out they used the drug in a very specific way: They gave it to middle and older-aged men in the form of a gel and ensured their testosterone levels did not go above normal.
“What we know is what we studied,” he says. “It was important to do that. But did our study answer all questions about the safety of testosterone? No, it did not.”
The findings were the main rationale for the FDA’s recent decision to remove the warning language around these cardiovascular risks from the products.
But Woloshin says doing so was premature because the study had a number of major limitations: The follow-up period was not long enough to understand potential harms — and testosterone levels in the blood were not raised as high as they typically are in clinical practice.
In his view, the benefits of testosterone therapy are often overstated, particularly in the realm of longevity, even though there are no well-controlled studies showing that.
Research does show an association between low levels of testosterone and a greater risk of dying from a variety of causes, but Woloshin says “that doesn’t mean giving someone a bunch of testosterone is going to change that.”
Who stands to benefit?
Some of the strongest data on the benefits come from another trial published in 2016 in the New England Journal of Medicine.
That study of men 65 and older showed testosterone gel “improved libido considerably, sexual function considerably, energy a little bit, red blood count, bone density and strength,” says Dr. Peter Snyder, an endocrinologist at the University of Pennsylvania who led the trial.
“Now these benefits apply only to men who have low testosterone, unequivocally low testosterone,” he says. “The lower, the more likely are the benefits,” he says.
The guidelines from both the American Urological Association and the Endocrine Society say that testosterone therapy should only be recommended after identifying symptoms and consistently low levels based on two separate blood tests.
But research suggests that’s not necessarily happening, at least in the world of direct-to-consumer testosterone clinics. In fact, a study published in JAMA Internal Medicine in 2022 sent a secret shopper to seven of these clinics and found most were ready to prescribe, even though the patient in question had normal levels.
The biggest downside, especially for younger men, are the impacts on fertility. Testosterone therapy suppresses the body’s production of sperm, and can lead to permanent infertility.
Because low testosterone is often linked to other health problems, Bernie says lifestyle changes can be an alternative to treatment, but may not always be realistic.
“Think of the 60-year-old guy who’s got low testosterone, he’s tired, he’s overweight, he feels terrible. Now, I’m telling him, ‘Go to the gym, man, go work out!” she says. “Well, it’s kind of like pushing a huge boulder up and up a hill, right?
George Bove, 60, who lives outside Knoxville, Tenn., says he started testosterone therapy 15 years ago because he was constantly exhausted and couldn’t keep the weight off.
It took some time to figure out the right dose, but once he did, the weekly injections have changed his life.
“You stay awake a little bit longer. You got the energy to do things throughout the day instead of having to constantly retire to the couch to recharge your batteries,” he told NPR.
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