Maxxing out on t-maxxing

A 34-year-old man complaining of sluggishness and a low sex drive went looking for testosterone replacement therapy. It didn’t take long.

After a brief consultation with seven telehealth companies, six said they would set him up with TRT injections and various off-label medications. Just one asked about his cardiovascular health — a standard question when prescribing hormones. Most skipped any mention of possible side effects, like a reduced sperm count and a higher risk of stroke.

Lab results showed his levels hovering around 600 nanograms per deciliter, which put him squarely within the healthy range for his age. The clinics proposed doubling it, effectively boosting his T level to that of an adolescent boy.

“Testosterone really used to be considered the old man’s medication. Now, every young guy is talking about it.”

What the clinics didn’t know was that the patient wasn’t actually a patient. Dr. Justin Dubin, a urologist, was conducting an experiment to assess how easily a healthy man could obtain testosterone. He had followed a script with the clinics while providing real lab results.

The answer: very easy.

Dubin’s study was conducted in 2022, as researchers were noting a surge in TRT use. Since then, prescriptions have continued to climb, particularly among men between 25 and 44.

“Testosterone really used to be considered the old man’s medication,” Dubin tells me. “Now, every young guy is talking about it.”

T-maxxing — once a trend among social media influencers — has gone mainstream, fueled by a booming telehealth industry that makes access easier than ever, and anxiety over a supposed virility crisis plaguing American men. Last December, an FDA advisory panel recommended loosening some warnings and restrictions around testosterone therapy. The agency has not yet said whether it will act, but the move stirred a debate over whether efforts to expand access to TRT are trumping safety.

As Dubin’s experiment showed, reversing a testosterone deficit is, very often, no longer the point. Clinicians say many men — and some women — are turning to TRT to boost their natural levels, with targets ranging from 2 to 6 times the upper limit considered normal.

Testosterone has quietly shifted from a medical treatment to something else. And when enhancement is the goal, the risks start to multiply.

The promise of T-maxxing is that it will make you sexier, more energized, and better able to perform at work, in the gym, and in the bedroom. Older men can restore their youth. Younger men can optimize their bodies.

But increased interest in testosterone is also grounded in a public-health trend that’s been worrying doctors and researchers.

For decades, average T levels have been declining among men of all ages, while hypogonadism, the clinical diagnosis of low T, now affects about 40% of men over 45. For some men, a drop in testosterone — a hormone that’s vital for our bones, muscle mass, and sexual function — can cause low libido, erectile dysfunction, depression, and fatigue.

An increase in obesity and chronic illnesses like diabetes is partly to blame, doctors say. Fat tissue has an enzyme that breaks down testosterone, and higher body fat levels disrupt hormone regulation. Too much stress, too little sleep, diets high in high-processed foods, and sedentary lifestyles have exacerbated the problem, doctors say.

The good news is that testosterone therapy can be a safe way to restore normal hormone levels.

Complications from high testosterone are not rare. Every endocrinologist has seen them.

But a TRT regimen can feel like a hormonal roller coaster, intensifying issues like mood swings, depression, and erectile dysfunction instead of alleviating them. And up to one in four men on T don’t have their levels tested when they start the hormone, and nearly half don’t have follow-up testing to check that their T stays within normal therapeutic levels, according to the American Urological Association.

People who are older and overweight are especially susceptible to side effects. TRT causes blood cells to multiply, making the blood thicker, which can impair circulation, raise blood pressure, and strain the heart. In some men, high testosterone can decrease fertility by slowing sperm production.

“When the red blood cells get high, you can have a heart attack, stroke, sudden death. It happens fairly frequently,” says Dr. Scott Isaacs, a board-certified endocrinologist who specializes in obesity and cardiometabolic disease. “Complications from high testosterone are not rare. Every endocrinologist has seen them.”

Concerns that testosterone could be abused led to it being labeled a controlled substance in 1991. This means, in theory, that prescriptions are strictly regulated and monitored, including the amount of T that can be obtained with a single prescription.

The question now is whether those restrictions should be pulled back because they create barriers for people with low T to get treatment.

The issue of access was at the forefront of Landon Trost’s mind when he recommended easing restrictions on TRT at the FDA panel meeting last year.

Trost, the director of the Male Fertility and Peyronie’s Clinic in Orem, Utah, argues that outdated warnings and classifications have created unnecessary stigma and barriers to accessing what is a “normal physiological hormone.” Treating someone who wants T “like a criminal” only creates stigma, he says.

The FDA panel that Trost participated in, which included researchers, clinicians, and the CEO of a pharmaceutical startup, overwhelmingly recommended loosening restrictions on testosterone and getting it to more men. Trost said he was the most conservative of the bunch and that other panelists were much more enthusiastic about getting T to more men.

“We don’t talk about this stuff enough,” FDA commissioner Marty Makary said during the panel discussion. “This is central to the health and well-being of many Americans.”

The debate over the safety of TRT hinges, in part, on a 2023 study that challenged assumptions about the link between the therapy and heart attacks. The study, commissioned by the FDA, found no increased risk of heart attacks among men on testosterone, assuming there was strict medical supervision and that levels stayed below 800 ng/dL.

But Dr. Steven Nissen, the study’s senior author, points out that consumers are being offered far higher doses of testosterone. That’s a gamble for heart health, he says.

“I don’t want our study to be used to facilitate abuse of the drug,” he says.

Nissen says he’s concerned that the hype around testosterone has gotten out of control. He said that research on the carefully-controlled, responsible use of TRT may be taken out of context to make misleading claims that testosterone is risk-free.

“The scary part here is that this is just not wacky people on TikTok advocating this,” Nissen says. “This is actually people in authority that are implying that men have too low testosterone levels, which of course sets the stage for them to take supplements that they shouldn’t take.”

The Trump administration has both sounded the alarm about low T and explored ways to get TRT to more people.

Robert F. Kennedy Jr., the 72-year-old health secretary who’s been known to show off his buff physique, touts TRT as part of his antiaging regimen and calls falling sperm counts among teenagers an “existential problem.”

The revised Dietary Guidelines for Americans have a dozen new references to testosterone, including naming nutrients and supplements that can help boost T .

What alarms some doctors is that TRT use is actively encouraged and made more accessible, even as consumers lack sufficient information about the risks.

“We need good, careful studies to understand all of this, and we certainly shouldn’t be telling men that they can enhance their testosterone level with dietary changes,” Nissen says. “Testosterone does not belong in the dietary guidelines.”

In fact, most of the habits recommended for normal testosterone coincide perfectly with the overall health advice we’ve heard for decades: eat mostly whole foods with enough protein and healthy fats, get plenty of physical activity, and manage your stress and sleep.

But as Bobby Najari, a urologist at NYU Langone, points out, “it’s not like eating a steak is going to boost testosterone.”

Far less controversial is the idea that some people who could benefit from TRT are reluctant to seek it out.

“People are suffering in silence with low testosterone, either because they’re embarrassed to talk about it or scared of the potential side effects, and you have people very interested in taking it and one way or another, they’re going to find someone to put them on testosterone,” Dubin says. “We need to do better in both situations.”

Still, consumers should be clear-eyed about what testosterone can do for them, Dubin and other clinicians say.

“There’s this idea that treating low testosterone is going to solve all your problems, that if you want to feel like a man, lose weight, and gain all this muscle, just take testosterone,” Dubin says. “It’s not a magic pill.”

Read the full article here