More men are taking testosterone. What gives?

If you’re a guy – or even just friends with a guy – and on the Internet, you may have noticed that testosterone discourse is everywhere. There’s Defense Secretary Pete Hegseth announcing testosterone screenings for soldiers, Joe Rogan discussing hormone therapy, and influencers discussing high- and low-T levels. Those levels affect more than just sex. They also affect metabolism, bone health, muscle mass, red blood cell production and brain function. NPR science reporter Will Stone https://www.npr.org/people/919093243/will-stone took a deep dive into it all: What deficiency looks like in men, what doctors recommend and what the research says about who actually needs testosterone replacement therapy. Interested in hearing more reporting on popular science topics? Email us what you’d like us to cover at [email protected] mailto:[email protected]. Support public media with NPR+ and enjoy perks for over 25 podcasts like this one. This show’s perks include sponsor-free listening. Learn more at plus.npr.org http://plus.npr.org. See pcm.adswizz.com https://pcm.adswizz.com for information about our collection and use of personal data for sponsorship and to manage your podcast sponsorship preferences. NPR Privacy Policy https://www.npr.org/about-npr/179878450/privacy-policy

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• 0:22Speaker 01

  Hey, Nate Broad here, your resident shortwave dude. And if you're a dude on the internet, basically, at all these days, you might have noticed testosterone is everywhere. Testosterone maxing 101.

• 0:34Speaker 02

  So we got a severe testosterone issue. I can spot low testosterone from a mile away.

• 0:38Speaker 01

  Influencers, podcasters, marketers, and people like Joe Rogan and Health Secretary Robert F. Kennedy are playing up fears of low T, giving advice on T-maxing, how to pump up your testosterone levels, and openly discussing their own use of testosterone therapy.

• 0:55Speaker 03

  Yeah, testosterone replacement therapy, I started doing all that.

• 0:58Speaker 01

  With all that going on, we figured it was important to bring NPR Health correspondent Will Stone on the show to talk about it all. Will? Hey, man.

• 1:06Speaker 03

  Hey, Nate. How's it going?

• 1:07Speaker 01

  Good, man. I'm just sitting here wondering about my T levels.

• 1:11Speaker 03

  Well, let's get into it because it's a huge topic. In addition to everything you just laid out, the military also announced recently that it will begin screening service members for low testosterone levels. And reporting on this, I found there's now a huge industry of online clinics that make it easy for the average guy to get a prescription.

• 1:30Speaker 01

  Yeah, I mean, I see them everywhere. And clearly, the word testosterone has strong cultural associations. Can you remind us what exactly it is, like, how it works in our bodies?

• 1:42Speaker 03

  Yeah, I mean, testosterone is a hormone. It's produced naturally in all human bodies, regardless of sex. But men tend to have much higher levels on average, and those levels are what's responsible partially for the development of male sex traits and reproductive organs.

• 1:58Speaker 01

  Yeah, I remember that part from health class.

• 2:00Speaker 03

  What's not as appreciated is that testosterone is not just about sex. Its effects on physiology extend beyond that. It's also involved in metabolism, bone health, muscle mass, red blood cell production, and even brain function. What experts emphasize to me is that this is why testosterone is actually a very important marker of overall health for men. And when levels are low, when someone has testosterone deficiency, it can have a big impact on their quality of life and their health.

• 2:30Speaker 01

  So today on the show, what's the big deal with testosterone? And what does research say about who actually needs it? You're listening to Short Wave, the science podcast from NPR.

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• 4:11Speaker 01

  All right, Will. So since so much of this trend centers around the question of whether some men have low testosterone, what does low testosterone look like?

• 4:21Speaker 03

  Sure. I mean, the symptoms range. There's depressed mood, fatigue, reduced libido, weight gain, trouble concentrating, loss of muscle mass. All of these can be signs of low testosterone. Now, obviously, Nate, these are pretty broad, and they can be caused by lots of factors, not just low testosterone.

• 4:40Speaker 01

  Okay.

• 4:41Speaker 03

  And I spoke to one doctor about this. His name's Jamin Brombot.

• 4:44Speaker 04

  I personally have thought I have low testosterone a few times. I got it checked, and my numbers have been normal. So it was more my sleep and stress and everything else that was causing these symptoms.

• 4:54Speaker 01

  Yeah, I was gonna say, man, like, I'm getting older, and a lot of those symptoms seem eerily familiar, right?

• 5:01Speaker 03

  Jamin is a urologist at Orlando Health, and he's a specialist in this area. He treats men for low testosterone all the time. So just goes to show, you really do need to get your actual levels tested. Medical guidelines from the American Urological Association and the Endocrine Society require two early morning blood tests taken on different days. And you need to be seen by a doctor who can consider all the factors before considering starting testosterone therapy. Because, again, these symptoms can be really mood and situation-dependent.

• 5:32Speaker 04

  The questionnaire for low testosterone is, most of the questions were so vague. Like, if you ask me on a Monday after a night of call, like, I'm gonna say yes to all that stuff. But then you ask me on vacation, I'm gonna say no to all that stuff.

• 5:45Speaker 03

  And Jamin's big concern is that men end up pursuing it based just on symptoms, without seeing if they're actually deficient. And because of marketing, that frames testosterone as something you do to enhance yourself, not necessarily to treat a diagnosed medical condition.

• 6:01Speaker 01

  Yeah, I mean, that seems to be a theme. Like, I remember when the military announced it would be screening for low testosterone in their soldiers. Secretary Pete Hegseth played up this idea that it would make them, I think, more lethal. Warfighters age 30 and older are going to be tested annually as part of their periodic health assessment. It's a health assessment that happens every year. Give us a sense of how this is marketed online.

• 6:24Speaker 03

  Yeah, it's pretty in-your-face. It plays into strong ideas of masculinity, for sure. And just the broader wellness kind of biohacking themes that we're now pretty accustomed to around optimizing yourself. But here's the thing.

• 6:39Speaker 05

  It's not some drug to promise peak performance, this fountain of youth, or this longevity. You know, those are really compelling and, like, strong marketing messages, but they aren't actually what the evidence supports.

• 6:50Speaker 03

  That's Dr. Helen Burney. She's the Director of Sexual and Reproductive Medicine at Indiana University. And Nate, I gotta say, despite this, it doesn't seem hard to get your hands on some testosterone if you wanted.

• 7:02Speaker 01

  No.

• 7:03Speaker 03

  Yeah. In fact, a study I found, published in JAMA Internal Medicine in 2022, sent a secret shopper to seven of these clinics. They found almost all of them were ready to prescribe to the patient in question.

• 7:15Speaker 01

  Oh, wow.

• 7:15Speaker 03

  Even though that person had normal levels.

• 7:18Speaker 01

  I mean, what do we know about who should actually be taking testosterone?

• 7:22Speaker 03

  Well, our understanding has been shifting. Currently, testosterone therapy is only approved for men whose low levels can be traced to an identifiable medical condition. So, for example, certain genetic conditions or disorders of the pituitary gland. Now, most men who have low testosterone don't fit that description. They have low testosterone that's idiopathic, meaning they can't quite identify the underlying cause. Obviously, I think folks are aware, testosterone levels decline gradually with age.

• 7:53Speaker 01

  Yeah.

• 7:54Speaker 03

  But Helen and other experts told me, if men are middle-aged or older and they're deficient, age, you know, usually is not the primary driver. There are often other contributing factors. Some of the big ones are obesity, diabetes, problems with sleep, sleep apnea, especially for younger men.

• 8:12Speaker 01

  Yeah.

• 8:12Speaker 03

  Drug use, and there are other medical conditions as well. There are a few big studies in the past decade that have helped form the modern evidence base about the risks and benefits of this therapy.

• 8:24Speaker 01

  Okay, so give us a sense of those. Like, what are the risks of taking testosterone?

• 8:30Speaker 03

  Sure. And just to give you a bit of context, in the early 2000s, testosterone took off, in part because topical gels came onto the market, which meant you didn't have to inject yourself. Drug companies also aggressively pushed disease awareness advertising around low testosterone, low T. It was one of the fastest growing prescription drugs at the time. But things actually started to shift after some data suggested testosterone increased the risk of heart attack and stroke. Now, this wasn't from well-controlled human trials. It did spark a lot of concern, though. The FDA placed warnings on the products and they requested the drug companies conduct a major safety study. That trial was called Traverse.

• 9:14Speaker 03

  It 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 it found a higher risk of fractures.

• 9:28Speaker 01

  Like bone fractures?

• 9:29Speaker 03

  That's right, which was surprising to them. I spoke to the lead investigator on that trial, Dr. Stephen Nissen. He's a cardiologist at the Cleveland Clinic. He emphasized to me that they studied testosterone in a very specific way. They gave it to middle and older age men in the form of a gel, and they ensured that the testosterone levels did not go above the upper range of high normal, meaning they made sure it didn't get too high.

• 9:53Speaker 06

  We used the drug in a very specific way, and we have a very reasonable answer. But I would not feel good if our study resulted in the unrestrained use of testosterone in ways that we didn't study.

• 10:09Speaker 01

  Yeah, because obviously, not everybody's going to take testosterone in these very clinical settings that he's describing.

• 10:16Speaker 03

  That's right. Or, or at least they're taking it in ways that weren't studied specifically in this trial. You know, for example, lots of people are taking it by injection. They're also pellets. They may be taking higher doses, you know, things like that.

• 10:29Speaker 01

  And like, what are the potential risks of taking testosterone if you don't have low levels already or taking too much of it?

• 10:36Speaker 03

  Well, there are some well-known downsides that come with testosterone therapy, you know, even if you're on, you know, reasonable levels. I mean, the biggest one is that taking it basically signals to your body that it should shut down its production of sperm and testosterone in the testicles. And that can lead, in some cases, to permanent infertility.

• 10:54Speaker 01

  Oy.

• 10:55Speaker 03

  Yeah, it's a big consideration for younger men who start on this therapy. Also, if you do go too high with testosterone, you know, you go above normal physiologic levels, there are more substantial risks potentially. Testosterone, for example, stimulates red blood cell production. Your blood can actually get too concentrated, and you can develop a disorder known as polycythemia, and that increases the risk of clotting. There are other less serious issues that come along with, you know, higher testosterone use, you know, for example, just it can lead to kind of oily and acne skin.

• 11:29Speaker 01

  I remember that phase of middle school very well. Have never really completely exited it, but you know. So what are the established benefits of taking testosterone if you have lower than normal amounts?

• 11:41Speaker 03

  Sure. I mean, some of the best data we have comes from another large trial, actually. This was also published in the New England Journal of Medicine. It was in 2016. That followed about 800 men in their mid-60s and older. Some were given a gel and others a placebo. And the top-line findings here were that it improved libido considerably, sexual function considerably, energy a little bit, red blood cell count, and bone density to some degree.

• 12:08Speaker 01

  That sounds great, right?

• 12:10Speaker 03

  Yes. But remember, these were older men who had a true deficiency, that they were restoring to normal levels. An area of debate and, you know, tension in the field has to do with the other benefits that aren't necessarily supported by well-controlled trials like the ones we've just been talking about. For example, there are strong associations between low testosterone and poor metabolic health, diabetes, and men with low levels have a higher risk of dying from a variety of causes. The question is, can raising testosterone levels through treatment actually cut these risks? Some experts in the field argue, yes, they say testosterone therapy should be thought of as preventative health for men. Some are

• 12:52Speaker 03

  even connecting it to GLP-1 weight loss drugs. They're saying all these men are on GLP-1s now. They're losing lots of muscle on these drugs as they lose fat.

• 13:01Speaker 01

  Interesting.

• 13:02Speaker 03

  And testosterone can potentially guard against that by helping preserve muscle.

• 13:07Speaker 01

  I mean, that's very convenient for the drug makers.

• 13:10Speaker 03

  Sure. I mean, on the other hand, these are associations that we're talking about, right? They do not prove men live longer when they get testosterone. We just know that low levels correlate with higher risk of death and other issues. And some argue, you can't necessarily extrapolate too much from these studies and say, oh, we need to begin giving people this because it will therefore promote longevity, for example.

• 13:35Speaker 01

  Totally.

• 13:36Speaker 03

  The experts in men's health, you know, and a lot of urologists I spoke with, said, you need to meet patients where they're at, meaning if they do have low testosterone, you might be able to address some of the underlying reasons first. You know, that could be related to lifestyle, and you can try to get them into the gym, improve their diet, do other things that can naturally boost their levels, you know, before getting them on a medication. That is not always realistic, though. Take a listen to what Helen Bernie told me.

• 14:04Speaker 05

  Think of the 60-year-old guy who's got low testosterone. He's tired. He's overweight. You know, he feels terrible. And now I'm telling him, go to the gym, man. Go work out. Well, it's kind of like pushing a huge boulder up an uphill battle hill, right?

• 14:19Speaker 03

  Makes sense, right? And in those cases, Helen says, it can be smart to start a man on testosterone therapy to kind of help jumpstart these other lifestyle changes.

• 14:30Speaker 01

  So it sounds like there might be some positives about all this attention around testosterone right now. And at the same time, there's also a lot of hype, overmarketing, that goes beyond the actual evidence of what it can do. Two things can be true.

• 14:42Speaker 03

  Definitely. That's right. The doctors I spoke to who work in this area say, you know, they're happy that men's health issues are being discussed much more openly with less stigma. We do have a substantial gap in life expectancy between men and women in this country.

• 14:59Speaker 01

  Yeah.

• 15:00Speaker 03

  Cultural norms for men tend to encourage toughness and independence. Men in this country are way less likely to visit a primary care physician already. So some of the experts told me, you know, that a man coming to get his testosterone checked can be an entry point into preventive health more broadly.

• 15:16Speaker 01

  Yeah, that checks out. That makes sense.

• 15:18Speaker 03

  And I did speak to a few guys in my reporting who basically echoed this. They said that they were gaining weight, they were tired, the testosterone really helped get them moving, catalyzed kind of weight loss and other lifestyle changes that ended up being pretty transformative for them.

• 15:33Speaker 01

  Yeah.

• 15:34Speaker 03

  I mean, we'll see how all of this comes together, whether the end result is more men who really need testosterone are able to access it, and how much of this will race ahead of the evidence in ways that may ultimately be not good for men's health overall.

• 15:49Speaker 01

  Well, this is a lot to think about. I've got a lot to discuss with my buddies because many of them are discussing to you. So thank you so much for doing all this reporting.

• 15:58Speaker 03

  Of course. It was fun talking to you.

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