Battling the Testosterone Clinics and Websites

“You paid how much in cash for what?” I gasped after a middle-aged man told me that he had shelled out over $3000 at a “men’s health” clinic. For that cost, he recalled receiving just a supply of sildenafil for a lower libido and erectile dysfunction. I breathed a sigh of relief that he didn’t start testosterone based upon one borderline-normal testosterone level that was not confirmed.

My second patient was an overweight man in his thirties with fatigue, low motivation, and weight gain who came to see me following an interaction with an “online clinic that helps men optimize their hormones.” For the price of only $49, my patient had his testosterone level checked, as well as a virtual consultation with a physician. All he had to do was deposit a drop of blood on a card that he mailed in. During the consultation, my patient was advised to start clomiphene despite a completely robust total testosterone over 450 ng/dL. The company would charge roughly $100/month for this treatment even though clomiphene retails for much less. Upon hearing the quoted price, my patient decided to seek a second opinion. I was tempted to call the physician to ask him why he would prescribe a medication to a healthy young man without any medical illness and a normal testosterone whom he did not even examine. My tendency to avoid conflict got the better of me.

These two men are representative of many of the patients that come to my weekly men’s health clinic at my teaching hospital. I confess that I actually don’t like the name “men’s health clinic” as I don’t want to be erroneously lumped with the myriad of private for-profit “men’s health” clinics or websites that promote and market testosterone-raising products. These clinics (and pharmaceutical companies) know that there is a huge market of millions of men with fatigue and sexual symptoms who are eager and willing to shell out hundreds of dollars to purchase medications that they hope will alleviate their common non-specific symptoms.¹ These clinics purport that androgen deficiency is the root cause of their symptoms and that this deficiency is an inevitable part of aging that can be reversed with testosterone therapy. These clinics often neglect or downplay potential harms of testosterone such as infertility, erythrocytosis, and gynecomastia.

I recognize that I am working in a murky area as there are many unknowns regarding the diagnosis of male hypogonadism. There is no clear consensus as to what level of serum testosterone should define androgen deficiency.² There is disagreement whether total or free testosterone better reflects a man’s androgen status. The reference ranges for testosterone simply use the lower 2.5th percentile to classify a level as “low” rather than clinically relevant signs or symptoms. Furthermore, there are often discrepancies between total and free testosterone measurements due to low levels of sex hormone–binding globulin.³

My approach has been to avoid labeling a patient with a disease unless it has been clearly diagnosed and to treat the underlying conditions that may lower a testosterone rather than simply dispensing testosterone to correct an abnormal lab value. Common causes of functional hypogonadism include obesity, diabetes, chronic illnesses, and opiate use. I often feel like a fish swimming against the current as it is human nature to want a quick fix or cure (e.g., prescription medication or surgery). Many men come to my clinic with expectations that they will leave with a prescription for testosterone or clomiphene. In the USA, testosterone prescriptions increased by 10 fold from 2000 to 2011.⁴ While giving the green light for testosterone would certainly be the easiest and least time-consuming way to handle men with borderline low testosterone levels, I want to do what is in the best of interest of their health. Motivating men to make major lifestyle changes to lose weight is not easy, often not successful, and often not what patients want to hear. In a meta-analysis, diet-associated weight loss (mean 9.8%) increased endogenous testosterone concentrations by an average of 84 ng/dL.⁵

Speaking of underlying conditions, having a men’s health clinic puts me on the challenging interface between medicine and psychiatry. In a study of 200 men seen for borderline total testosterone levels between 200 and 350 ng/dL, 56% had depression and/or depressive symptoms.⁶ These depressive symptoms are often not volunteered when taking a history. While most of my men’s health patients would not be reluctant to take a medication to increase their testosterone, a large number are reluctant to seek professional help for depression, especially from mental health professionals.⁷

My men’s health clinic is an outlier because the goals are often contrary to those of my other clinic sessions. For many of my general endocrine patients, I enthusiastically recommend and prescribe medications to treat their hyperthyroidism, gender dysphoria, or osteoporosis. For patients in my men’s health clinic, however, I frequently find myself doing the opposite. While I certainly have men with bona fide diagnoses of hypogonadism, I have plenty more men without. I often spend a considerable amount of time trying to actively persuade men not to seek out testosterone or clomiphene from a predatory men’s health clinic or the internet.

While I marvel at the countless and impressive advances of modern medicine over the past generation, I also find it ironic that many common beliefs about testosterone have not changed much over the past century. Take the debunked field of organotherapy in which extracts from animal or human tissue were used to treat medical conditions. In the late 1800s, the French physician Charles-Édouard Brown-Séquard injected himself with fluid extracted from the testicles of freshly killed guinea pigs and dogs and claimed dramatic rejuvenation effects following just a few subcutaneous injections. Specifically, he reported regaining all of his muscle strength, a marked improvement in defecation, and a return to baseline of his cognitive abilities.

While it is gratifying and rewarding to treat men with established hypogonadism to improve their quality of life, I often ponder how much of an impact I am making, if any, on men with borderline testosterone levels with common non-specific symptoms. How many of these men successfully get their weight and/or depression under control? I often never know as they typically don’t return to my clinic for follow-up. Perhaps they see no further benefit if they have heard my recommendations. Perhaps they seek out a testosterone-boosting medication from someone else. By dissuading men from what I see as an inappropriate use of testosterone, how much harm is being avoided? Are potential benefits being lost from these missed opportunities? For every patient that sees me, an exponentially greater number are seeking care from the hundreds of men’s health clinics and websites across the country. I wonder if there are steps that we can take to counter the rising trend of men receiving testosterone off-label. Perhaps establishing more evidence-based, academic men’s health programs and/or working with state medical boards to educate them on the growing problem. In the meantime, I wonder if my quest to dissuade men from jumping on the testosterone bangwagon is similar to Don Quixote’s battle with windmills.