Are private clinics selling men expensive testosterone they will never need?

David McCaffrey insists he has never been short of vim and vigour, despite a pretty active life: a father of three and a busy NHS infection control nurse, he manages to go to the gym at least five times a week, but says he still always has energy to burn.

Or at least, he used to. Because David’s physical and mental wellbeing have both recently declined: as well as becoming severely overweight — putting on nearly 2st in just a few months — he has lost his sex drive and finds it difficult to focus on the simplest of tasks.

‘At first, I blamed the weight gain on the Covid-19 pandemic because the onset of some of my symptoms coincided with the first lockdown in March 2020,’ says David, 47, from Redcar, near Middlesbrough.

‘The gyms were closed so I couldn’t get my regular exercise — I used to go at least five times a week for 45 minutes each time — so I just assumed that was what led me to put on so much weight and caused the lethargy.

‘And as for my dwindling libido, I put that down to the fact that in January 2020 my wife Kelly had undergone major surgery, so sex had been out of the question for a while anyway.’

There were other troubling symptoms, too. David started getting headaches every few days and waking three or four times a night drenched in sweat.

These, too, he blamed on lockdown-induced lethargy, combined with the fact that he was just getting older.

Then in the summer of 2021, his local gym finally reopened, offering free blood tests to check for potential health problems such as raised cholesterol.

David took up the offer and was shocked when, a few days later, the clinic that processed the samples called to say he had extremely low levels of the hormone testosterone and should see a doctor as soon as possible.

‘Kelly and I looked online and saw a long list of the symptoms for testosterone deficiency — including loss of libido, lethargy, low mood, weight gain and fatigue,’ says David. ‘Suddenly it all clicked into place.’

He believes testosterone deficiency also explained the depression he had experienced since 2016, for which he had been prescribed antidepressants.

It seems he is far from alone —according to some experts at least, testosterone deficiency in men, often referred to as the male menopause, is a significant yet unrecognised health burden.

It has been estimated that the testosterone levels of 40 per cent of men aged over 45 are low enough to warrant treatment, reports the American Urological Association.

Yet despite the large number of men affected, low testosterone as a medical issue has long been neglected, says the British Society for Sexual Medicine.

This is despite the fact that treating a deficiency is simple, with three-monthly testosterone injections (usually into the buttocks) or a daily dose of a gel (rubbed into the skin).

In fact, GP practices in England already spend about £14 million a year on jabs, gels and skin patches for men with hypogonadism, or low testosterone.

But there seems to be a larger, unmet need, to judge from the surge in the number of private men’s health clinics now testing and treating low testosterone.

There were other troubling symptoms, too. David started getting headaches every few days and waking three or four times a night drenched in sweat

Even High Street pharmacy giant Superdrug has got in on the act, offering a home test for £50 — men complete an online questionnaire which is reviewed by a doctor, before a supply of testosterone gel is despatched in the post.

Superdrug told Good Health it has had ‘a consistent increase in demand for its male testosterone test-and-treat service’, adding that over the past 12 months, ‘there has been a 190 per cent increase in orders for this service’.

And while testosterone, as a prescription medicine, cannot be advertised to consumers, there is no bar on promoting a service that offers to test a man’s hormone levels for depleted testosterone.

It seems seductively simple. In its marketing literature, the newly launched Ted’s Health scheme says less than 10 per cent of men with testosterone deficiency currently receive treatment. It offers testing at home for £50, followed by a monthly £99 fee for testosterone supplies and regular blood tests.

Another private provider, Optimale, promises ‘top doctors, fast, convenient diagnosis and the highest-rated testosterone replacement therapy from home’.

The treatment is not cheap —typically costing between £900 and £1,100 a year. But do so many men really need testosterone replacement therapy (TRT)?

Proponents insist it could help millions more men in the UK, while sceptics fear it is being over-marketed as an expensive cure-all for the ageing process.

Testosterone, which is produced in the testes, plays a wide range of crucial roles in the male body. It drives libido and sperm production, helps with the manufacture of red blood cells, maintains bone density and increases muscle strength. It also keeps memory sharp and helps sustain healthy blood flow from the heart.

Healthy testosterone levels in men are 12 nmol/l (a measure of how much hormone there is in a litre of blood) or above.

A reading between 8 and 12 is considered borderline — while any reading below 8 is usually defined as hypogonadism.

Once men hit their 30s, their hormone readings start to tail off at a rate of about 1 per cent a year, simply due to ageing.

But these numbers don’t tell the full story — for while some men who have low levels of testosterone experience no symptoms, others have symptoms when they appear to have good levels of testosterone.

So it is suggested that treating testosterone in isolation may miss the bigger problem. According to some research, depleted hormone levels are much more than just a warning sign that things might be a bit flat in the bedroom.

There seems to be a larger, unmet need, to judge from the surge in the number of private men’s health clinics now testing and treating low testosterone

A landmark 2007 study at the University of California at San Diego, which tracked nearly 800 men aged over 50, found that those with low testosterone scores were 33 per cent more at risk of premature death than those with healthy readings.

Separately, testosterone has also been linked to type 2 diabetes. Last year, researchers in Australia found that regular injections of the hormone could prevent men aged 50 to 74 developing the condition.

The two-year study, reported in The Lancet Diabetes & Endocrinology, tracked around 1,000 overweight men who were classed as pre-diabetic (i.e. with blood sugar levels higher than normal).

All the men had low testosterone and were signed up to a healthy lifestyle programme to improve their diets and exercise routines. Half also received a testosterone jab every three months, while the rest received dummy jabs.

The researchers found that the testosterone jabs had a much greater impact than simply having a healthier lifestyle, with just 12 per cent of the testosterone group developing type 2, compared with 21 per cent in the placebo group.

Those on the hormone jabs also reported increased muscle mass, strength and improved libido.

TRT — and the broader health claims made for it — has parallels with hormone replacement therapy (HRT).

Yet mainstream medicine has yet to embrace it to the same extent, says Dr Anand Patel, a GP in London and a member of the Primary Care Testosterone Advisory Group (who are doctors with an interest in TRT).

Dr Patel, who treats men with low testosterone on the NHS and privately, says: ‘We accept the fact that women get older and need help with the menopause, but not with men. Yet testosterone deficiency is on the increase as people are getting fatter.’

This is because fat cells convert testosterone into oestrogen — so the more fat you have, the lower your ‘male’ hormone levels.

Excess fat also reduces levels of sex hormone binding globulin (SHBG), a protein that carries testosterone in the blood to vital organs and muscles. Less SHBG also means less circulating testosterone.

‘Usually men present because they’ve been Googling their (often long-standing) symptoms online and wondered if it was testosterone deficiency — or their partner has sent them in,’ says Dr Patel.

‘They often feel as if someone has turned the colour down on their life and they want it back.’

Dr Patel says most NHS and private GPs prescribing testosterone to men do so responsibly: ‘We are not dishing it out like sweets,’ he says.

‘To begin with, we advise men to adopt lifestyle changes for three to six months, as losing body fat makes testosterone levels go up.’

But often, GPs will also simultaneously add in a low dose of testosterone therapy from the outset.

‘Many men find it really difficult to boost hormone levels through lifestyle changes alone, so we often encourage them by also putting them on a small amount of TRT, as it creates a sense of wellbeing.’

But he adds: ‘Not all men with typical symptoms will have testosterone deficiency. They may have thyroid problems or anaemia which are making them feel unwell.

‘If a patient has the classic symptoms — loss of libido, fatigue, weight gain — but normal testosterone readings, then we would investigate other possible causes.’

So why would these symptoms occur if a man has normal testosterone levels?

When testosterone enters any cell in the body, it latches on to a receptor — triggering the release of an enzyme called 5a-reductase.

This enzyme converts the testosterone into a turbo-charged version called DHT, which is ten times more powerful than the testosterone itself.

But those receptors can vary in sensitivity from one man to another, which may explain why some can have blood tests showing they have sufficient hormone levels circulating but still feel unwell.

However, TRT is not without risks. A 2019 study by McGill University in Canada, involving nearly 15,000 men, found that those on it for flagging libido were 21 per cent more likely to experience a heart attack or stroke than those not on it.

It is not clear why this should be so, but one theory was that raised testosterone may damage heart muscle cells or reduce levels of the so-called ‘good’ cholesterol, HDL, which is thought to protect against heart disease.

Those findings have since been called into question by a major review in June 2020, involving researchers at Imperial College London, which examined all the evidence to date and concluded that men on TRT are in fact at no greater risk of a heart attack or stroke.

Some small studies even suggest it has a protective effect.

Yet even the world’s leading medical authorities can’t quite make up their minds on safety.

In 2015, the U.S. Food and Drug Administration demanded that testosterone replacement products carry a warning on the label of an increased risk of blood clots, based on studies suggesting a heart risk. But the European Medicines Agency concluded that there is not enough evidence to show this.

Another worry is about prostate cancer. While injections of the hormone are unlikely to cause prostate cancer, most prostate cancer cells do rely on testosterone to grow.

For this reason, patients on the treatment should have regular blood checks for their levels of the protein prostate-specific antigen (PSA), as an increase could indicate prostate cancer.

Dr Channa Jayasena, a consultant in reproductive endocrinology and andrology at Imperial College London and one of the researchers involved in the 2020 heart disease review, says that even though TRT appears relatively safe, ‘it should not be given indiscriminately’. He told Good Health: ‘There is a proliferation of private clinics that are encouraging widespread use of testosterone — and a small number of them are prescribing inappropriately.

‘Some patients will benefit from it but it’s a mistake to encourage every man to have testosterone testing.

‘I am not anti-TRT but encouraging men to think there is a simple cure out there that in many cases may have no effect is not right. If you have low testosterone but no symptoms, you are almost certainly not going to benefit from treatment.’

He says part of the problem is that low testosterone is ‘a spectrum’ — not just a number on a blood test result.

‘If you have below 8 nmol/l you are unequivocally low in testosterone. Above 12, you are definitely ok.

‘But between those two numbers you can be either — some men happily go around feeling fine with readings of 8.5 or 9. The blood test is merely a brick in the wall of making an accurate diagnosis.’

He adds: ‘Men each need slightly different natural levels of testosterone — and there is no evidence that men with the highest levels of testosterone are any healthier than men with lower normal levels.’

Dr Jayasena adds that, 20 years ago, TRT was mostly reserved for men with an undeniable clinical need, such as those who had lost a testicle to cancer.

‘Now it’s mostly just men who are older, less healthy or obese. Yet for many it will make no difference. It’s like having an old car and putting shiny new wheels on it — there are still lots of other things that can go wrong.’

According to the NHS, the term male menopause is ‘unhelpful’ as it implies that men endure symptoms such as depression and waning libido as a result of a sudden drop in testosterone in middle age, just as women do with oestrogen.

It adds: ‘This is not true — in many cases the symptoms are nothing to do with hormones but caused by poor diet, lack of exercise, excess alcohol consumption or low self-esteem.’

Meanwhile, the American College of Physicians — having scrutinised the evidence for and against TRT in older men — ruled it should only be prescribed as a pick-me-up for sexual function. For everything else, it says, there is insufficient evidence.

But David is convinced that taking testosterone gave him back his life.

When it was first tested, his reading was just 6.9 nmol/l. After he began having injections in autumn 2021, his energy levels, sex drive and muscle strength all bounced back to normal within weeks. He has even been able to come off his antidepressants.

‘I felt a lot stronger and could lift more weights at the gym,’ he says. ‘The night sweats disappeared and my libido was restored to its healthy level. Without that blood test, it would never have crossed my mind that all these problems could be down to a lack of testosterone.’

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