The booming online testosterone trend and its hidden risks

With the rise in popularity of testosterone therapy, more and more men are seeking treatment to combat symptoms of fatigue, low energy, and cognitive decline. The accessibility of testosterone products, combined with a growing awareness of hypogonadism symptoms, has led to an increase in patients being diagnosed with low testosterone levels.

For many men, like the ones interviewed for this article, testosterone therapy has been life-changing. One man, who asked not to be named to protect his privacy, found that his energy levels increased and he felt sharper after starting testosterone therapy. Another man, J.S., reported that his strength and endurance had improved considerably, making him feel like a younger version of himself.

However, the popularity of testosterone therapy has not come without controversy. The sudden surge in prescriptions for testosterone cypionate, the injectable form of the hormone, has raised concerns about the potential risks and side effects associated with testosterone treatment.

Despite these concerns, many men continue to seek out testosterone therapy as a way to improve their quality of life. Online influencers and celebrities have also played a role in promoting the benefits of testosterone treatment, further fueling its popularity.

As the debate around testosterone therapy continues, it is important for individuals to weigh the potential benefits against the risks and consult with a healthcare provider before starting any treatment regimen. Ultimately, the decision to pursue testosterone therapy should be made on an individual basis, taking into account the unique health needs and circumstances of each person.

For Lipshultz, the priority is the patient’s symptoms. “If the patient has symptoms that are consistent with low testosterone, and it is not due to another cause, then I think it’s reasonable to treat,” he said. “If the patient is just tired because they’re not sleeping well, that’s a different story.”

There is no one-size-fits-all answer to testosterone deficiency, and whether or not someone should start treatment is a nuanced decision that should be made in consultation with a knowledgeable healthcare provider. As with any medical treatment, it is important to weigh the potential benefits against the risks, and to consider all factors that may be contributing to the symptoms.

In the meantime, if you’re looking to naturally boost your testosterone levels, one simple step you can take is to increase your egg intake. Eggs are a great source of protein and healthy fats, and they also contain cholesterol, which is a precursor to testosterone production. So, go ahead and up your egg intake – however many eggs you’re eating now, times ten!

“I don’t want to be a purist about saying no, I won’t give you testosterone because you’re overweight and that’s the cause,” said Lipshultz. Morgenthaler said it’s moralizing to not give patients testosterone until they make lifestyle changes. “I will treat men even if they are obese and not working out,” he said. “Everyone who’s overweight knows he’s overweight and is supposed to diet and exercise. There’s no value in my being the 27th person to tell them this.”

It’s no wonder, then, that many men are embracing a simpler alternative.

‘Click here for testosterone’

Enter testosterone clinics — providers focused on male health, often with evocative names such as DudeMeds, MaleExcel, Maximus, Titan — where the pendulum has swung all the way to the other side. Their patients typically can bypass traditional physician or specialist visits. A potential customer may get their testosterone levels tested through at-home tests, or sometimes not at all, and are often offered a prescription even if their lab values don’t align with established diagnostic criteria. Testosterone is then delivered to their home — for a monthly fee ranging from under $100 to several hundred dollars a month.

Alpha MD, one such clinic, serves many thousands of patients around the country through about 10 providers, who Soames says all take testosterone themselves. “We all kind of have been through the runaround. We’ve all experienced being denied by our doctors,” he said. Typically, Alpha MD patients, too, have been turned away from their physicians, who either didn’t think they needed their testosterone levels tested, or found them to be sufficient.

“In our practice, we turn away or deny about 10% of patients,” he said, usually ones whose testosterone levels are already at the high end of the range and are more likely to experience concerning side effects of excess testosterone, in particular erythrocytosis — increased red cell count.

Their business is booming, and so is their industry overall. A 2023 study of men’s online health clinics providing testosterone therapy identified 223 online clinics, of which a third had multiple physical locations, too. The numbers have only gone up. A reported 325 new clinics with several locations and online presence have opened since early 2024, and although there is no unified registry of clinics offering testosterone, the total number may well be in the thousands. And now, some of the bigger players in telehealth prescribing — Ro, Hims, Hone — have entered the field, or are planning to.

To be sure, online clinics aren’t the ideal solution to the challenges of getting testosterone. Lack of proper oversight, a bias toward prescribing (as it’s the basis of the business model), even to men who may not need it, and inadequate education about possible side effects worry experts and make many patients uneasy, though they are willing to take the risk to find treatment.

Soames says his clinic is changing lives, the way testosterone changed his, and claims its providers — who are primarily not physicians — have better knowledge and understanding of the workings of testosterone than most doctors. For instance, he said, one criteria they use to decide whether a patient would benefit from testosterone is “relative hypogonadism,” which means someone’s testosterone is in the normal range, but lower than what it used to be.

Many experts in hormonal health are skeptical of such an approach because testosterone levels fluctuate greatly even in a single day, so it would be hard to establish a baseline. Unsurprisingly, these experts are more broadly critical of online testosterone clinics.

“There are a lot of clinics that are just out to make money,” said Irwig. “They’re not taking good histories, they’re often not even doing physical exams, they’re not even counseling patients about possible side effects … they’re just eager to enroll them in programs where they’re selling them testosterone.” He added that he knows of clinics that tell men a testosterone level of 400 or 500 ng/dL is low when it’s not. Men with such levels who report feeling better after testosterone therapy are probably experiencing the placebo effect, he said.

Patients also lament the minimal oversight at some clinics. As one wrote in an online review: “My only phone call with the physician to begin my TRT last[ed] about 20 seconds. It went like this: ‘I’ve seen your blood work and you qualify for TRT. You can go online and place your order. Any questions?’ Not the experience I was hoping for.”

Herrera Pena, the Minnesota endocrinologist, said he is especially worried by the lack of thorough lab workup to carefully diagnose testosterone deficiency, as well as identify any underlying cause of such deficiency. Further, he said, when patients who have been going to online clinics come to him, they often use higher doses than recommended in standard medical practice. “I always tell people, be careful when you’re going to a cash pay clinic, just be careful on what they’re selling to you.”

There are significant health risks, too, beyond red cell count. They include infertility, which is especially concerning for younger men. External testosterone reduces the body’s own production of the hormone, which can lead to low sperm count. Reversing these effects can take several months to more than a year.

Asima Ahmad, a reproductive endocrinologist at the Reproductive Medicine Institute in Chicago, and the chief medical officer and co-founder of fertility platform Carrot Fertility, says she is seeing an increase in infertile men as a consequence of unnecessary testosterone therapy.

Testosterone therapy is a common treatment for men with low levels of the hormone, but it comes with its share of side effects. One of the most common side effects is gynecomastia, or enlarged breasts, which can be distressing for many men. While this side effect can sometimes subside with time or medications, in some cases surgery is required to correct the issue.

In addition to gynecomastia, men undergoing testosterone therapy may experience a range of other side effects. These can include anxiety, insomnia, irritability, hypertension, acne, and a fear of discontinuing treatment due to potential rebound effects. Dr. Irwig, a specialist in the field, explains that when the body becomes accustomed to high levels of testosterone, stopping treatment can lead to a host of symptoms, creating a difficult cycle for patients.

Despite the potential side effects, many men find that testosterone therapy significantly improves their quality of life. However, some patients express frustration with the lack of options for obtaining care. Luca Candela, for example, feels that if testosterone therapy were more readily available through regular physicians, he would switch clinics in a heartbeat. He emphasizes the importance of feeling safe and supported during treatment.

Physicians like Dr. Mulhall at Memorial Sloan Kettering recognize the benefits of testosterone therapy for certain patients. He believes that there is a larger population of men who could benefit from this treatment but are not encouraged to pursue it. Dr. Morgentaler echoes this sentiment, expressing concern that many men who could benefit from testosterone therapy are not receiving the care they need.

Overall, the debate around testosterone therapy continues, with some advocating for broader access to treatment and others cautioning against unnecessary use. As research in this area continues to evolve, it is essential for patients to work closely with their healthcare providers to determine the best course of action for their individual needs. With the rise of technology and social media platforms, the way we communicate and interact with one another has drastically changed. From instant messaging to video calls, there are now countless ways to stay connected with friends, family, and colleagues all over the world.

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