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Internal medicine physician Scott Selinger discusses his KevinMD article, “The testosterone surge: Are men chasing solutions or creating new risks?“, delving into the rise of testosterone therapy, its trends, and associated risks. Scott highlights findings from recent studies, addressing the shift in demographics using testosterone therapy, safety concerns with injectables, and the rise of virtual clinics. He explores how societal pressures and delayed health-seeking behavior influence men’s health outcomes and advocate for holistic, community-based solutions. Actionable takeaways include prioritizing evidence-based approaches and sustainable lifestyle interventions to improve men’s overall health.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Scott Selinger. He’s an internal medicine physician. Today’s KevinMD article is “The testosterone surge: Are men chasing solutions or creating new risks?” Scott, welcome to the show.
Scott Selinger: Thanks. Long time listener and reader. First time caller, I guess.
Kevin Pho: All right. Well, thank you so much for writing and for joining me. Now, before talking about the article itself, what prompted you to write it and submit it to KevinMD in the first place?
Scott Selinger: I’m a primary care doctor and for years, both in my practice and in just being a guy, you know, driving around on trips, I kept seeing all these advertisements and getting asked questions about testosterone, and it came to be during the pandemic.
I kept seeing more and more guys, progressively younger, coming in saying they were either taking testosterone or asking me questions about it, and I just thought that was weird. I was trying to figure out more about what’s driving this, what the trend looks like—because it was a way to just keep from having individual conversations and try to tackle it in one big fell swoop.
Kevin Pho: All right, so I’m an internal medicine primary care physician myself, and I’m seeing exactly the same things. I’m having younger and younger men ask me about testosterone. They hear it on whatever podcast they’re listening to, so I’m certainly interested in hearing your thoughts on it. So, tell us about the article itself.
Scott Selinger: So, the article itself is based on some research that I started doing because I couldn’t find an answer as to what was going on with these trends. You know, I’m not technically a researcher, but I was able to do some armchair research through my local prescription drug monitoring program here in Texas, and they sent me over kind of all their prescriptions—basically throughout most of COVID and a little bit beforehand—so I could sort through them. I saw a trend of progressive increases in the number of testosterone prescriptions trending toward younger people, and interestingly, it seemed to happen more once COVID kicked in. There was this spike, almost around, you know, March or April 2020, where prescriptions started going up and up and up.
Then I thought that was a little odd. I started looking at the national level and reached out to every state that wanted to cooperate. I got about 25 in total and saw a pretty similar trend across the board. It was definitely more prominently noted in the South and the West than in the Northeast.
It was just striking to see that, during the pandemic—when so many people were struggling to get health care, putting off routine cancer screenings, affording medicines, holding down jobs—people were still more actively getting testosterone prescriptions. That started making me wonder: what do people get out of it?
And when people were prescribed this, they typically weren’t taking it for very long, maybe one or two prescriptions over a year or a couple of years. This was around the time the Traverse study came out, and from that, it looked at whether testosterone is safe for use in older men with diagnosed hypogonadism.
It seems that, in older men with hypogonadism, testosterone gel is probably safe, but it also probably doesn’t have much of the benefits that are purported to it. But we really don’t know what it does for younger guys because they’re just never included in these trials, since they usually never meet the inclusion criteria.
Scott Selinger: My thought in all of this is that, as a group, men are bad at asking for help. We’re bad at seeking health care—we do it at a much lower rate than women. But here, there was this uptick in people asking for the medicine. And when you look at what happened during COVID, people had higher rates of a lot of things—uncontrolled disease, depression, anxiety.
I started wondering: maybe this is a surrogate that makes us feel comfortable reaching out for help when we need it, and then someone swoops in and says, “Try testosterone.”
Kevin Pho: So, the men who ask for testosterone in your exam room, especially the younger men, what kind of symptoms or complaints are they presenting with that make them think they need testosterone?
Scott Selinger: It’s, I mean, it’s a grab bag. I think it’s compounded by the fact that there are no clear predictive symptoms that people present with for low testosterone compared to low thyroid or depression. The ones who come in saying, “I’m feeling more fatigued, I don’t really have the same sex drive,” or, “I’ve noticed I’ve been gaining weight,” are the typical ones who ask about it. It almost mirrors the people who came in asking about thyroid medications in the past; it’s almost like the people who ask more about it are less likely to actually have it, and it’s getting at the question behind the question: what is really feeling wrong? What are your concerns? And I think if someone hadn’t had the idea that it could be testosterone, it might not have even crossed their mind—or ours, either. That’s sort of what I was seeing.
Kevin Pho: So if you have that case scenario—a younger man coming in with this grab bag of symptoms and perhaps he’s interested in testosterone supplementation—what do you do next as a physician?
Scott Selinger: Yeah, my understanding really changed throughout my career because I used to just say, “It’s probably not evidence-based. There’s no real reason to do it.” But now, partly through my research, I’ve found that if people want testosterone, they can get it somewhere else.
So if they’re coming to me, that’s really a compliment—they want my opinion and take on it. I try to talk them through it by saying, “These are the kinds of chances that it is your testosterone. I’m happy to check it for you, as well as a few other things.” But there’s also a good chance it could be due to lifestyle habits or social stressors, among other things.
So if it doesn’t look like your testosterone levels are the cause, can we talk about these other factors that might be more helpful for you? They’re usually receptive to that because most people don’t want to take medicine if they don’t have to.
Kevin Pho: And in what scenarios would you do blood tests or diagnostic studies to measure testosterone levels?
Scott Selinger: I think for a lot of people, if they come in asking about it and we discuss what they’re experiencing and their relative risk, if they still say, “Look, I would really like to have it checked,” then I’m fine with doing it—just making sure we try to do it optimally.
Ideally, we do it in the morning while fasting to hit the best level for them, with the understanding that it’s also important to use a validated testosterone test to ensure there’s no wiggle room in the results. Really, if it’s not related to their testosterone level, their levels are going to be fine, and that at least provides them reassurance that they don’t have that lingering thought in the back of their mind, like, “Oh, is it because I don’t have enough of this?”
Kevin Pho: Now, which type of testosterone test do you typically order? There’s total testosterone, there’s free testosterone, and then when the results come back, how do you interpret those?
Scott Selinger: I usually start with a total testosterone, and the CDC has a list of labs that have validated tests per their criteria. That is pretty reliable for most people.
The free testosterone can be of some value if, usually, the total testosterone is abnormal. The next time we check it—to repeat the test—I’ll include a serum hormone binding globulin plus a free testosterone measurement. This is just to compare, because there will be times when it’s elevated and you get a little wiggle room. But I’d say that for most people, as long as it’s within normal limits, it’s usually not a testosterone issue.
I think research that’s come out shows that symptoms may not develop until levels are in the low 200s. And then a study from last year indicated that, really, unless it’s very low, it’s not even associated with mortality or any other major negative outcomes. And just to clarify, testosterone does decrease as men age naturally, right?
Kevin Pho: Yeah, it does naturally decrease as we get older. It’s a normal part of the process, and over time, you stop having as much diurnal variation as you do when you’re younger. For older men, I actually do see it as a factor—especially in those who don’t even think about it as an issue—but it ties back to the question: what does testosterone supplementation really do?
Scott Selinger: I think the evidence is strongest for it helping with libido and a little bit with mobility and walking distance. Otherwise, it’s almost like a therapeutic trial for some people with low levels—let’s normalize it after 12 weeks and see what changes and what remains the same.
Kevin Pho: How about for the younger man who comes in and you draw a testosterone level and it comes back low? What are some of the possible explanations for why testosterone could be low in a younger man?
Scott Selinger: I think there are a lot of different reasons. There are some quasi-reversible reasons—having obesity, for instance, can tamp down your testosterone levels.
Opioid use can also lower them. Additionally, many people with Klinefelter’s go undiagnosed until later in life. Those are some of the biggest drivers that come to mind right now. And then, knowing that if one level is low, it’s important to repeat the test because there is normal day-to-day variation.
I try to ensure that none of those symptoms or concerns are contributing before moving on to, “Alright, is this something we want to treat?” I’ve seen people who look, you know, have better muscle mass than I do, a higher energy level—like they’re 10 years younger than me—and they get their levels checked. They come back borderline low, and I don’t know what to tell them they will experience if we raise their levels.
Kevin Pho: Alright, so now you bring that patient back after the lab tests, and you’re having a conversation about the potential of testosterone supplementation. Walk us through that conversation in terms of the pros and cons, and in what scenarios you would treat someone—especially a younger man—with testosterone supplementation.
Scott Selinger: Yeah, I try to talk with them about the things we know testosterone does help with. As I mentioned, it can definitely help with libido for some people, a little bit with muscle mass, and a bit with energy levels. Aside from that, especially for younger guys, there’s not a ton of extra benefit they may experience.
The pros are evident, but the downsides include, first, that it’s a medicine you have to deal with on a daily or weekly basis; second, is this a medicine you want to be on for the rest of your life? It’s similar to what we see with any medicine we start—what is our natural endpoint for this?
Third, especially for younger guys, you have to have the conversation that taking testosterone will basically eliminate your ability to have kids for a while. You can regain that ability, but it takes some time off the treatment to do so. Many people may not have thought that part through.
The lesser risks include its effect on your blood counts. For instance, if you see erythrocytosis, that may mean we can’t proceed with it. We need to monitor your levels to make sure they’re within range. I think many people can be successfully managed on testosterone if they’re at a steady state and are seeing benefits from it very safely.
Most of the other risks are very uncommon, such as a remote risk of blood clots. Otherwise, it’s more a matter of monitoring and having conversations about how people are responding to it.
Kevin Pho: Any cardiovascular concerns for testosterone supplementation?
Scott Selinger: That’s a good question. The whole impetus of the Traverse trial was to answer that, and the overall takeaway was that, for these older men—whose average age was around the 60s—with diagnosed hypogonadism, using a gel version of testosterone daily, there was no real difference in cardiovascular outcomes.
However, that trial didn’t look at injectable testosterone, which, according to more remote data, probably does have a higher cardiac risk because of the peaks and valleys in hormone levels. It has never been studied in younger men, so we don’t know what the short- and long-term risks are, or what the additive effects might be. I raised that as a possibility as well if we’re considering long-term use.
Kevin Pho: Now, what about the potential increased risk of prostate cancer, or even in men with an elevated PSA?
Scott Selinger: Yeah, I think a PSA is always important to check at baseline before starting testosterone, especially in older men. A lot of the links between testosterone and prostate cancer have been largely dissuaded by more recent studies. It probably doesn’t increase your risk of prostate cancer over baseline.
That said, if you’re already at higher risk or have an elevated PSA at the start, then yes, it could exacerbate the condition, but it’s not a deal breaker. I’ve seen some men develop more urinary issues if it leads to prostate enlargement, and that’s more of a discussion I have with my older patients than with the younger ones.
Kevin Pho: So in terms of the treatment options, we typically have the shots you mentioned, as well as topical treatments—whether it’s a patch or a gel. What considerations make you choose one over the other?
Scott Selinger: I think, unfortunately, it often comes down to affordability. Some insurers may only cover injections, and injections are more convenient if patients can stick with them. Many appreciate that more than the gel. However, when you look at what provides a more physiologic release, the gels actually work a little better than the high burst and release that comes with injections.
Also, endocrinologists tend to use gels more because they understand that. You’ll also see people getting pellets, though those are a bit less studied in terms of long-term effects. And I believe there’s an oral testosterone that is coming out, or just came out, that I can’t say too much about as another option.
But I think the predominant methods I’ve seen are mostly injectables, with gels as a secondary option.
Kevin Pho: And what would be your first line? Is it purely dependent on insurance coverage? Let’s say for a younger man versus an older man—do you have a preference for treatment modality for these different age groups?
Scott Selinger: I would prefer to use a gel, honestly, for both groups if it’s feasible. I think people respond well to it. It’s just a matter of getting used to the routine—making sure it doesn’t wipe off onto anything you don’t want it on. You don’t want it getting on other people. And if that’s a non-starter, then we can switch to injections.
I have found that some people have more trouble with injections because they require syringes and needles, you have to remember when to do it, and then you need to balance the timing when you check their levels between injections.
Kevin Pho: So, for the topical version—a gel—what dose would you start at? And from the patient standpoint, what can they expect in terms of using the gel and any effects after starting it?
Scott Selinger: I think the typical starter dose is 25 grams per pump, usually if it comes in a pump system. It’s pretty easy to rub on in the morning.
Most people will apply it on their upper extremities, typically underneath the T-shirt line. I think that with any hormone—testosterone, thyroid, estrogen, prednisone—any changes seen in the first couple of days are usually just a brief mood change due to the influx of the hormone.
After that, I tell them they may notice a change in their libido, and over time, a change in their body appearance, muscle mass, and distribution.
Kevin Pho: And in terms of monitoring, do you have these patients come back after a certain period of time?
Scott Selinger: Yeah, usually we have them come back after about three months to repeat their levels and see what they’ve come up to. We also check their hemoglobin levels as a comparison from before and after starting, just to make sure they haven’t jumped too high.
If you’ve checked a PSA level at baseline, you recheck that as well. Then, if they’re stable, some societies recommend checking it once a year and just keeping them on the usual routine. For others, you might do it every six months for a year and then switch to annual monitoring, or whenever they feel like they need to reassess what this medicine is doing for them.
Kevin Pho: And from your experience prescribing testosterone, what range of outcomes are you seeing in your own practice?
Scott Selinger: I’d say the main outcome I’ve seen is people saying, “I feel more energetic, I’m going to the gym more, I feel like my body looks different.” I’ve seen some people get improvement in their blood sugar levels.
On the other hand, I’ve seen some people who haven’t noticed any difference at all. It has been quite variable, which I think is reflected in the fact that most people who start on it do not continue it. In my experience, most stay on it for a couple of months. I’ve seen dropout rates of 60 to 70 percent for a free medicine that’s being given to you.
I’d say that’s about one in three people who get a good response from it.
Kevin Pho: Let’s get back to the larger trends you mentioned at the beginning. You see a lot of catchwords like “low T” and this being marketed to younger men especially. What does this say about the trends of testosterone therapy going forward?
Scott Selinger: That’s a good question. I think, thus far, there’s no reason to believe that anything is going to change. A lot of people still get their health suggestions from social media. These companies are very well set up to market themselves because it’s a good business model to get someone started on something they have to stick with. With any hormone replacement or supplement, once you stop, you’re likely to feel worse for a little while until things balance out.
I see that as a potential outcome moving forward. But I’ve also started to see some of these places recognizing, “Hey, we can provide more wraparound care” and also screen for cholesterol issues, sleep apnea, and so on. I would love to see that happen, because I think men are already starting to feel more comfortable talking to someone under the guise of, “I want to talk about my testosterone,” and the more people we have out there who say, “That’s great,” maybe we can also incorporate overall health. That would be wonderful. I hope that’s the trend we see. It’s always hard to predict where health care support is going, especially right now with the administration change.
Kevin Pho: Now, after doing all this research and reading, have your own attitudes and perspectives changed regarding testosterone supplementation?
Scott Selinger: I think they have. They have largely been supported. I will say, right now, I feel more comfortable with people who actually do have low levels—counseling them and doing a trial of medicine to see what happens. My concerns about some of the negative effects have been, in some cases, dissuaded, and in others, validated.
When I looked at it, on average, people prescribing testosterone were treating somewhere between three to five patients a year, and that’s still about the same for me. At least I feel more like I can counsel people who don’t need it better, as to why they probably don’t need it or what we can do if they really want to move ahead with a trial.
Kevin Pho: We’re talking to Scott Selinger, an internal medicine physician. Today’s KevinMD article is “The testosterone surge: Are men chasing solutions or creating new risks?” Scott, let’s end with some take-home messages you want to leave with the KevinMD audience.
Scott Selinger: I think my biggest take-home is that when a man comes in asking about testosterone—or really, when anyone comes in asking about something specific—you always have to get to the question behind the question before addressing it.
So if someone says, “I think I need more testosterone,” you’ve got to ask, “Why do you think that?” They may have been sold the idea that this is the thing that will make them better, bypassing the real issue of what’s causing the problem. I believe we have a huge amount of unaddressed mental health issues in men that can be driving these dietary and lifestyle factors that might help.
We, as men, tend to feel more comfortable asking about testosterone than talking about our feelings and concerns or changing our lifestyle habits. As a primary care doctor, I know that men generally ask a lot fewer questions, and I’ve taken that for granted in the past.
But it’s important for all of us to realize that when a guy is quiet or not asking the usual questions about what’s going on in his life, it’s a cue to delve in and ask, “What else can we do here?” Because these are the people who end up reaching out later, saying something feels wrong and they think they need this to fix it.
Kevin Pho: Scott, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Scott Selinger: Pleasure to be here.
