With more American men turning to testosterone therapy as a way to boost energy levels, build muscle and tackle erectile dysfunction, it's no wonder that web-based merchants have stepped into the breach, seeking to grab market share away from doctors and pharmacies.
But are online testosterone purchases safe? No, a new investigation warns.
The conclusion follows an anonymous testing of seven U.S.-based online entities that sell testosterone therapy to consumers across the country.
The upshot: The vast majority of online portals are perfectly willing to sell the hormone to patients who are not, in fact, testosterone-deficient. Most also fail to inquire about potentially problematic underlying conditions and neglect to caution patients about the possible risks involved, including infertility.
“We found that most of these platforms offer treatment to men who are not considered appropriate candidates according to existing medical guidelines, and many platforms were not offering appropriate counseling regarding the risks of treatment,” said study author Dr. Joshua Halpern. He is an andrology and infertility specialist and assistant professor with Northwestern University's Feinberg School of Medicine, in Chicago.
This is a potentially big and growing concern, the study team pointed out, given that between 2017 and 2019 there was a 1500% jump in the number of visits to direct-to-consumer online portals that claim to treat erectile dysfunction.
That said, “testosterone therapy is a well-established medical treatment for men with the condition of testosterone deficiency,” Halpern acknowledged .
Testosterone deficiency “is the combination of having low testosterone levels in the blood and having symptoms that are classically associated with low testosterone, [such as] low energy and low libido," he explained.
“Men with these symptoms seeking testosterone treatment are often trying to improve their quality of life,” Halpern noted, “although some men may pursue testosterone therapy for other reasons, [including] building muscle mass.”
When prescribed to those who need it, taken as instructed and monitored appropriately, it “is generally considered safe,” he said.
Still, Halpern and his colleagues stressed that per the U.S. Drug Enforcement Administration, testosterone is deemed a controlled substance. That means that — alongside similar drugs, like anabolic steroids and the anesthetic party drug ketamine — there is a low-to-moderate risk for becoming addicted.
For that reason, Halpern said, “testosterone is typically prescribed through a local pharmacy by a health care provider, such as a primary care provider, urologist or endocrinologist.”
Even when administered appropriately and under ideal medical conditions, testosterone therapy is not without risks. Those, said Halpern, can include a thickening of the blood and infertility. It can also trigger a rare but serious rise in red blood cell counts, which can lead to blood clots and bleeding and/or raise the risk for heart attacks or stroke.
Given such concerns, Halpern and his associates wondered if approved prescribing guidelines and risk disclosures are a routine part of the online purchasing process.
Apparently not, as became evident after the team set up a “secret shopper” online profile to surf the web-based testosterone therapy options.
Fashioned as a 34-year-old man struggling with low energy and low libido — both of which typify low-testosterone levels — the “dummy” profile made clear that the patient in question was interested in trying testosterone while also remaining fertile down the road.
The profile was submitted to seven U.S. online portals that sell testosterone. Intake procedures variously involved providing lab testing results and engaging in telemedicine consults conducted by nurse practitioners, physician assistants or individuals with no medical license of any kind.
The end result: Nearly 86% of the sites offered to sell testosterone even though the dummy profile clearly noted testosterone levels that fell within the normal range. Six of the seven portals had no testosterone level threshold for providing treatment.
Only one of the portals asked about the patient's specific heart health history or personal interest in future fertility, while only half raised potential fertility concerns. More than 83% of the time, blood thickness concerns were never mentioned, the investigators found.
“Testosterone therapy has many benefits, but it also has risks and is not appropriate for everyone,” Halpern stressed. “While online direct-to-consumer platforms offer great promise in expanding access to care for men with low testosterone, there are some drawbacks. Men should start by talking with their local health care provider before considering testosterone treatment.”
The findings were published as a research letter in the December issue of JAMA Internal Medicine.
Dr. Pieter Cohen is a general internist with Cambridge Health Alliance and an associate professor at Harvard Medical School in Boston.
Though not part of the study team, his takeaway is that the new investigation “elegantly highlights many of the pitfalls of obtaining testosterone from an online provider, even after completing blood tests.”
Cohen noted that “the patients were not properly screened, the testosterone prescription was not appropriate and, in addition to testosterone, patients were encouraged to use a host of other questionable and potentially dangerous drugs.”
Beyond that, he added that in many cases the symptoms people are quick to attribute to low testosterone are really just a function of normal aging or other illnesses. “But that hasn't stopped the marketers of testosterone to try to start everyone they can on the drug,” Cohen said.
There's more on the pros and cons of testosterone therapy at the Mayo Clinic.
SOURCES: Joshua Halpern, MD, MS, andrology and infertility specialist, and assistant professor, Feinberg School of Medicine, Northwestern University, Chicago; Pieter Cohen, MD, general internist, Cambridge Health Alliance, and associate professor, Harvard Medical School, Boston; JAMA Internal Medicine, December 2022