Testosterone has been a hot topic in cycling for years, with former Team Sky doctor Richard Freeman banned for four years for taking possession of an order of 30 sachets of Testogel (testosterone gel) at the National Cycling Centre in Manchester in 2011.
The naturally occurring hormone preserves and increases lean muscle mass, improves cognitive function, increases bone density and improves your ability to recover from exercise.
But, like many things, testosterone declines with age, dropping by around one per cent per year from the age of 40.
Here are 10 things medical professionals believe all men need to know about testosterone.
Most modern cases of low testosterone are down to obesity or ill health
Expansive studies have shown that anywhere from 2% to 20–30% of men today have low levels of testosterone, with shocking reports blaming everything from pesticides and plastic use to the decline of manual labour. So what is the real number?
“The reason for the 2% is that that comes from the endocrinology (hormone) world, where they talk about classical hypogonadism, which is testicular failure which leads to low testosterone,” explains Dr Geoffrey Hackett, a consultant in urology at Spire Little Aston Hospital.
“And they view every form of low testosterone that's secondary, or compensated – those relating to the obese, diabetes, or drug–related and lifestyle–related – as being optimally treated with lifestyle change (not testosterone therapy).”
So, only about 2–3% of men will lose endogenous testosterone production, as a result of a specific physical, medical or hormonal problem in their body.
The majority of men will maintain acceptable testosterone levels as they age. But those studies that suggest 20–30% of men have an issue are specifically including men who are experiencing sub–optimal testosterone levels as a result of poor health, such as obesity, diabetes, alcohol consumption or sedentary lifestyles.
“We know that the overwhelming decline in testosterone with age, aside from that 2–3%, relates to just the accumulation of illnesses and medication and obesity as men get older,” explains Dr Richard Quinton, consultant endocrinologist at Newcastle Hospitals Trust.
“Even in those men who do have falls in testosterone levels, due to ill health or obesity, what puts everything right is if you address the underlying problem.”
Weight loss is the simple solution for most men
For any men experiencing a drop in testosterone levels as a result of ill health, lifestyle change is the best solution. Body fat contains an enzyme that converts testosterone into the female sex hormone, oestrogen.
One research paper found that every one–point increase in a man’s Body Mass Index (BMI) is associated with a 2% decrease in testosterone. Gynecomastia – the medical term for ‘man boobs’ – is one sign of this hormonal imbalance.
But losing weight can reverse this problem. In one study, 30% of overweight men suffered from low testosterone, compared to only 6.4% of men of healthy weight.
And a study by the Endocrine Society found that when 900 overweight men shed weight they slashed their chances of low testosterone by 50%. Exercise and a healthier diet are the simple, effective strategies that can help fire up your testosterone once more.
Testosterone therapy can help men with genuine medical needs
For anyone with a medical diagnosis of low testosterone, which is not related to poor health, testosterone therapy is a legal and effective medical treatment.
And it is an important one, too: low testosterone is linked to worrying health issues, from erectile dysfunction and infertility to high cholesterol, diabetes, anaemia, osteoporosis and heart disease.
Studies confirm testosterone therapy can improve the symptoms of men with low testosterone relating to sexual drive, erectile function, cholesterol, muscle mass and bone density, hugely changing a man’s quality of life.
In fact, the results are remarkable. “We know that it (testosterone therapy) can reverse diabetes,” says Dr Hackett.
“And even if it doesn't reverse it, it increases insulin sensitivity, so you'll need less treatment. We know it reduces mortality. In the studies of patients who've had a previous heart attack, and in diabetes, it reduces mortality considerably. And also in patients with chronic kidney disease, anaemia and osteoporosis.”
Your type of testosterone treatment is usually a personal choice
For men diagnosed with low testosterone, treatments range from injections to gels. But which is recommended by doctors?
“It is largely down to personal choice,” says Dr Hackett. “Generally, if someone is concerned about side effects, they might think: I will start with the gel, because I can stop it and it will be out of my system.
"But the trouble is, if it is going to take a few weeks to work, we always expect a quick fix. So they will probably give up after a week or two.
"Whereas if you use an injection, that lasts 12 weeks. So even if you think a week later that it hasn’t done anything, suddenly a month later the man’s wife will say: I think you are better.”
Illegal use of testosterone is catastrophic for your health
Many men choose to self–diagnose low testosterone or utilise private clinics to purchase testosterone therapy they don’t need.
This is a disaster. Due to cynical marketing and internet misinformation, there has been an “epidemic” of testosterone prescriptions for men with normal testosterone levels who are striving for a more chiselled, muscular physique or more midlife mojo. The UK has witnessed a massive 90% increase in testosterone prescriptions.
But unnecessary treatment can have catastrophic results, from infertility and shrunken testicles to heart problems.
Unnecessary supplementation will also cause your body to switch off your natural testosterone production.
“That's a road to ruin,” warns Professor Richard Sharpe, of the MRC Centre For Reproductive Health at The University of Edinburgh.
“If you (wrongly) start taking exogenous testosterone, that suppresses your endogenous, which means that your sperm production process will suffer.”
Beware of prescriptions from private clinics
While there are many respectable private clinics offering help to men, less reputable companies are happy to wrongly diagnose men with low testosterone in order to make money from selling testosterone treatments.
“Men should be aware that there are a raft of private clinics out there who will basically prescribe testosterone on demand, without any rigorous diagnostics,” says Dr Quinton.
“And testosterone is the lowest grade of controlled drug. There are no restrictions on who can prescribe it.”
Many clinics dish out low-cost, short-acting testosterone products with a high price mark-up. “My own view would be to avoid seeing any specialist who doesn’t also do an NHS clinic,” advises Dr Quinton.
“If the person you are seeing is pure private sector, and particularly if they’re not a registered endocrinologist, think twice. Think three times.”
You could be more at risk of low testosterone than others
If you have certain medical issues, it would be worth getting your testosterone levels checked. A lot of men with low testosterone aren’t aware that this could be linked to their other health problems.
“There are a number of clues (for low testosterone),” says Dr Quinton. “If you have anaemia, or osteoporosis of if you have sexual dysfunction or infertility, or you develop painful breasts, or menopausal symptoms like flushing or sweating.
"These men (with low testosterone) won’t necessarily complain of sexual dysfunction, but they might turn up (with symptoms) in a fertility clinic, or in an osteoporosis clinic with fractures or unexplained anaemia, and most of these men aren’t really getting diagnosed.”
Anyone who uses SSRIs (antidepressants) and antipsychotics should also check their testosterone levels, as these are known to lower testosterone.
“Low testosterone post–Covid is another thing that we haven't touched on, but there's a lot of papers on that,” adds Dr Hackett.
“We know that about 20–30% don't recover their testosterone levels afterwards. And erectile dysfunction seems to be three times more common. But nobody's asking about this in long Covid clinics.”
Always do two tests at the right time of day
Anyone can order a testosterone test online, or from a local pharmacist. But testosterone readings will fluctuate wildly based on the time of day.
They are usually higher in the morning, and lower in the afternoon. They can also be affected by food intake and sleep quality.
That is why doctors always insist on two tests, in the morning, after an overnight fast, four weeks apart. “It is really easy to measure a low testosterone level,” warns Dr Quinton.
“That can be done by doing a blood test in the afternoon or evening, when you’re unwell, after a big meal or after a poor night’s sleep.”
There is no male menopause
The term ‘male menopause’ is sometimes used, but this is unhelpful. All women experience the menopause, which involves a rapid decline in hormone levels.
But the majority of men don’t suffer from low testosterone, and most changes are glacially slow. “There's no such thing as the male menopause,” insists Dr Hackett.
Don’t expect your testosterone levels to soar into old age
Most endocrinologists adhere to the ‘enough is enough’ theory when it comes to testosterone. 'Lower–level' testosterone is not the same as 'low' testosterone.
"If your testosterone is within the normal range – from around 8–10nmol/L (nanomoles per litre) of blood to 30–31nmol/L – variation within this range doesn’t matter much.
“I keep expecting to be contacted by Premier League clubs to be given a trial every season,” jokes Dr Hackett.
“But you've just got to look at the fact that the value of a footballer begins to decline from about age 28. So there's always got to be an age–related decline.
"And if everybody is seeking to reverse that, as Tom Cruise seems to have done, then I think we're mostly going to be disappointed, aren't we?”
