Testosterone Replacement Therapy. The new way to win wars?

US Defence Secretary Pete Hegseth announced last week that all military personnel aged 30 and over will be annually screened for testosterone deficiency. Those with “low testosterone” will be offered testosterone replacement therapy (TRT). “Warriors” under 30 will be able to opt in for testing but the Pentagon is saying nothing on whether TRT will be available to women.

The evidence for an association between aggression and testosterone levels exists but it is weak according a 2019 study (a meta analysis) https://pubmed.ncbi.nlm.nih.gov/31785281/. This weak association only exists in men, and has a greater link to stressful situations that result in more aggressive outcome. Secretary Pete might not have considered the impact of his policy on domestic violence and bar room brawls when his warriors are not fighting “bad people” but trying to live civilian lives.

So if you think that this is about soldiers “growing a pair” and improving battlefield effectiveness, think again. Rather it is a blatant marketing exercise on behalf of Big Pharma who have been for years trying to normalise TRT as an essential life-long therapy for all men and with some success. It is part of a broader push by the Trump administration to make it easier for medical professionals to prescribe testosterone. Its all about business Donald.

I first came across TRT marketing about 15 years ago. I met Debbie, a young trendy GP from Dublin at a professional meeting who told me that the big new thing in the Republic of Ireland was TRT; a sure-fire therapy for the flagging middle-aged male. She was being encouraged by her medical partners (males) to discuss with male patients the possibility that their; tiredness, low mood, general difficulties with life may not be just symptoms of a mid-life crisis; but may be symptoms of the male menopause. “If testosterone levels are sub-normal each man is a candidate for TRT” she cynically confided.

Feeling not just on top form that evening and looking pretty washed out, was I a potential candidate? I saw a lot of myself in her description; the train-crash that is the male middle-age but I could not agree with a clinical “male menopause”. “Your right, its bollocks”, she replied with forthright clarity “and a shame on my profession” she continued. “the male menopause is merely a symptom of the financial down-turn since 2008 affecting Irish GPs bottom-line”.

Bollocks it is according to the learned New England Journal of Medicine. A study into the safety and efficacy of TRT was stopped in 2009 on grounds of safety; a small matter of a four-fold increase in cardiac events and the appearance of that appalling phenomenon “man-boobs” plus increases in prostate cancer prevalence and breathing problems during sleep.

The male menopause is a myth confirms the British Medical Journal as only 0.1% of men over 40 years have low testosterone and this goes up to only 5% of men in their 70s. Yet the marketing men persist as we now live in a “Your-Only-Think-Your-Fine” culture so when you start gaining weight, have a noticeable reduction in energy and start to lose interest in (or performance during) sex then sensibly something is wrong and seeking a medical solution seems only rational.

Yet according to BMJ the link to an age related reduction in testosterone levels and specific clinical symptoms remains weak. Notwithstanding this there is a section of the medical profession committed to making all age-related phenomenon into diseases. And 13 million Americans cannot be wrong which is the number that have been converted to monthly TRT.

Small testicles

I was remined of my evening with Dr Debbie while sitting outside a Belfast bar recently. A friend of old with her new partner happened along. They joined us and John, in his early 50s, was introduced. As we finished the second cocktail John, getting more relaxed, asked me if I had ever considered TRT telling me it had done wonders for him.

He stood up from his chair, placed his palms on his flat stomach and slid them up to his shapely pectorals. “See that” he said, “that’s the benefit of TRT.

After he turned fifty, he awoke regularly without an erection and therefore had a sense something was seriously wrong. Having sold a successful business in England he is now retired and lives in Spain. When he presented his “serious erectile problem”, to his Spanish doctor, the physician suggested blood samples and surprise, surprise, found his testosterone to be sub-normal; he needed TRT.

On questioning what a “normal” testosterone level is, he confirmed it ranged from 225 to 1100 unsure if the units were; milli, micro, nano or pico grams (they are ng/dL). Anyway he was 229 ng/dL and as a result he now spends over £150 a month on a testosterone gel which he applies (to his arm).

Side effects? None other than the fact that his testicles have reduced in size from “peach-stone size” to “pea size” and not even the marrow fat variety – we are talking sweet garden pea here. This is to be expected as the testes are the main glands for production of testosterone and, since it’s on a negative feedback systems; when you inject synthetic testosterone, testicular production stops; thus the change in size. It had no impact on his hair which he claimed to be as bushy as it was when he was 18. He claimed to have read extensively on the topic and for this reason he also takes an anti-oestrogen to stop him developing “man-boobs”. He has never felt or been better and yes, each morning he awakes, his is impressed.

The Science Bit

Males with clinically low testosterone benefit from TRT and this is a well-defined field of clinical practice. The marketing men are seeking to change the definition of low to include a much wider cohort of the male population. This risks medicalisation of the aging male but given that the supply of TRT is already occurring in a gym near you without any clinical supervision its already a serious public health concern. TRT is widely used in N. Ireland and used illegal, but it would not appear so.

This is clearly a complex clinical area. Accepting that TRT has an important clinical benefit, wider use of TRT is not a risk free panacea for the ills of the aging baby-boomers or the battlefield performance of American Marines.