The demand for testosterone therapy has skyrocketed in the United States, with more men looking to boost hormone levels in hopes of increasing virility, strength, and energy. Testosterone therapy has become a fast-growing business with online men’s health platforms going direct to consumers in recent years. While testosterone therapy benefits some men, it can harm others, making it critical that patients understand the benefits and risks before beginning therapy.
A new study from Northwestern Medicine published in JAMA Internal Medicine found that many of these platforms do not provide care consistent with American Urological Association (AUA) and Endocrine Society (ES) guidelines for the safe and effective management of men undergoing testosterone therapy.
“Low testosterone testing and treatment is more accessible than ever before thanks to these online platforms. Men can be evaluated and even start testosterone therapy without leaving home,” said Joshua Halpern, MD, MS, assistant professor of urology, the senior author on the newspaper and a urologist at Northwestern Medicine. “While there is benefit in improving access, there is also potential for harm when providers fail to adhere to evidence-based guidelines, or when the benefits and risks of treatment are not communicated appropriately.”
Men with low testosterone levels, or hypogonadism, may experience symptoms such as erectile dysfunction, decreased libido, fatigue, and depression, among others. While therapy to increase the hormone may improve these symptoms for some, it may be ineffective or even harmful when prescribed to men who do not meet criteria for hypogonadism, which include an increased risk of infertility and cardiovascular events, as well as other side effects.
Using a secret shopper, the study authors evaluated seven US-based online companies offering testosterone therapy in all 50 states. Using a script to inquire about and initiate testosterone therapy, the secret shopper identified himself as a 34-year-old man with hypogonadal symptoms, including low energy and low libido, who was interested in future fertility. For each of the platforms, he completed the intake evaluation, required diagnostic lab tests, and an initial telemedicine consultation, which was conducted by a nurse practitioner, physician assistant, or unlicensed person.
“While my interactions with the telemedicine platforms have been pleasant and efficient, I was surprised by some of the gaps in their counseling and their recommendations that I pursue testosterone therapy,” says Justin Dubin, MD, the first author and secret shopper for the study.
The authors found that online platforms offer therapies to men who do not meet testosterone deficiency guidelines, while also failing to convey the risks and benefits of therapy. The study is the first to identify guideline discordant practices by direct-to-consumer testosterone therapy platforms, with the following key findings:
- 85.7% of the platforms offered testosterone therapy despite the secret shopper having normal total testosterone (TT) and free testosterone levels and desiring future fertility.
- Only one of the seven platforms asked the secret shopper about recent cardiovascular events or his desire for future fertility.
- Criteria for offering testosterone therapy were inconsistent with AUA and ES guidelines, with one platform only providing treatment for men with TT below 450 ng/dL (normal range = 264-916 ng/dL), while the other six have no threshold for starting treatment.
- Half of the platforms cited a treatment goal of greater than 1,000 ng/dL TT levels and did not discuss the fertility risks of testosterone therapy.
- 83.3% did not discuss the risks of polycythemia, which is an increase in blood thickness.
- In addition to testosterone therapy, the secret shopper was also offered a wide variety of off-label drugs.
As the popularity of direct-to-consumer testosterone therapy grows, the authors hope that future policy initiatives will facilitate more consistent and guideline-based care by these entities.
“Online platforms have great potential to expand access to men’s health care screenings and treatments, especially for issues like erectile dysfunction and infertility,” Halpern said. “However, until these services offer therapies based on established guidelines, it is important that patients and healthcare providers are educated about the potential pitfalls of seeking these types of treatments online.”
For men who are concerned about their testosterone levels, Halpern recommends seeing a healthcare provider with expertise in hypogonadism, such as a urologist, endocrinologist, or even starting with their family doctor. For some men, lifestyle changes alone can improve their physical symptoms and mood.
“Testosterone isn’t a magic fix, but it can be a very effective therapy if prescribed properly and within guidelines,” Halpern said. “For others, making lifestyle choices that emphasize exercise, healthy eating, and getting enough sleep may be the answer. Working with an experienced health care provider is the first step to finding the right individualized care plan that fits your personal needs.”
Justin M. Dubin et al, Guideline discordant concern among direct-to-consumer testosterone therapy platforms, JAMA Internal Medicine (2022). DOI: 10.1001/jamainternmed.2022.4928
Offered by Northwestern University
Quote: Direct-to-consumer online platforms expand access, but often fail to convey the risks of testosterone therapy (2023, January 6) Retrieved January 6, 2023 from https://medicalxpress.com/news/2023-01-direct- to-consumer-online-platforms-access-convey.html
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