Intended for healthcare professionals

Rapid response to:

Letters Reflections on testosterone

Many men are receiving unnecessary testosterone prescriptions

BMJ 2012; 345 doi: (Published 21 August 2012) Cite this as: BMJ 2012;345:e5469

Rapid Response:

Re: Many men are receiving unnecessary testosterone prescriptions

The article is blaming pharmaceutical marketing campaigns for the increase in testosterone prescriptions and boldly states that “many men are receiving unnecessary testosterone prescriptions”. Indeed these marketing campaigns will increase the likely hood of the public whom have symptoms of hypogonadism to ask their GP to screen them for testosterone deficiency. However, the authors are potentially wrong to come to a conclusion that “many men are receiving unnecessary testosterone prescriptions”. They base their argument on statistics; the article states that prescriptions for testosterone in the UK have increased by around 90% (from 157,602 to 298,314) since 2000 to 2010, while the estimated population of men suffering from unequivocal hypogonadism has only increased from 5.2% to 6.3% during the same time period. They are in effect using these statistics to conclude that too many men are receiving testosterone replacement therapy because the suspected number of men with what they estimate to have “unequivocal hypogonadism” has not increased very much while the number of prescriptions has. I have a number of issues with this reasoning:

• If the 298,314 figure represents prescriptions and not patients who are prescribed testosterone then the number of men being prescribed testosterone is in fact far lower than 298,314. This is because prescriptions will not generally be given to last for a 12 month period. For example, the transdermal gel’s come in boxes of 28 sachets, generally one sachet will be used daily, therefore one prescription will only last 28 days in this instance then another prescription is needed.

• A total testosterone level below 6nmol/L is a very low reading. The article states that 6.3% of the male population in 2010 have unequivocal hypogonadism (testosterone below < 6nmol/L) this doesn’t even take into consideration men who above 6nmol/L and still suffer symptoms of hypogonadism that are successfully treated with testosterone. So the number of men who could benefit from testosterone replacement therapy could be higher than 6.3%.

• They are using the year 2000 as a standard and stating now there are too many prescriptions of testosterone. From their data they claim 5.2% of men in the year 2000 had unequivocal hypogonadism (which doesn’t take into consideration men slightly above that range and still suffering from symptoms), while only 157,602 prescriptions were given out. Well, 5.2% of the adult male population is higher than the 157,602 testosterone prescriptions that were handed out in 2000. Again like I already said prescriptions don’t mean patients being treated. I see no reason to assume that the year 2000 should be the gold standard of optimal testosterone prescribing.

A logical explanation of why prescriptions have increased is that if you increase public awareness of an issue, whether it is through private business or governmental interests, then obviously more people will become aware of that problem and seek help if they believe it affects them. I gather more men are coming forward and asking for their testosterone level to be checked because of the increased public awareness of what testosterone deficient symptoms are due to these so called “aggressive marketing campaigns”. Also new guidelines screen diabetic patients for testosterone deficiency, which will add to the numbers of men who test positive for low levels of testosterone. This will co-inside with statistics that this article presented for increase requested testosterone tests that a primary care trust reported, from 347 requests in the year 2000 to 823 requests in the year 2010. Obviously if more people are screened then more people will be diagnosed with hypogonadism.

Let us not forget that most often a specialist and not a GP will diagnose and treat the problem; a patient cannot write their own prescription for testosterone. We should have some faith in the abilities of our specialists to prescribe and treat patients. The British Society for Sexual Medicine released guidelines for doctors to treat sexual dysfunction. It states that patients who don’t respond with improved sexual function after six months of testosterone treatment are to be withdrawn from treatment. If these guidelines are being followed then no honest patient after six months of treatment is being prescribed testosterone that doesn’t improve his libido. Therefore patients are being prescribed a medication that is treating their condition(s). I see no unnecessary prescribing in that circumstance.

I assume the NHS is concerned for the best interests of the patient and that raising awareness of a problem is in the interests of the public or is there a possible conflict of interest? Are there some bodies out there that are concerned more about costs that will rise due to pharmaceutical companies increasing public awareness through their marketing campaigns? If so I fear a push for regulations so that only men who have very low levels of testosterone (<6nmol/L) will be offered treatment and men slightly above that range will not, regardless of their symptoms. The latter mentioned group of men may needlessly suffer a very frustrated and unhappy life.

Lastly, I agree more long term trials should be carried out. However, let us remember that testosterone has been used in the medical field for a long time, far longer than some of the synthetic hormones that are used in the newer generations of contraceptive pills that are offered to females for birth control.

Competing interests: No competing interests

17 May 2013
Malcolm Hoar
Cornwall, UK.