Misleading medical reporting in the media: Over-diagnosis of low testosterone levels in men

A story published on Monday 9 September in the Guardian has provoked outrage at the Society for Endocrinology.

Dr Richard Quinton, Dr Channa Jayasena and Dr Ahmed Al-Sharefi, three of our expert Media Ambassadors, contacted the Society Press Office to express their concerns over the lack of accuracy and impartiality in the article: ‘My energy is back: how testosterone replacement therapy is changing men’s lives’ by .

They feel that this article is written and presented in an irresponsible manner that is misleading to the reader and potentially exploitative. The Society is committed to helping promote accurate and responsible reporting of endocrinology-related topics in the media, so we have backed their concerns, in the form of the open letter below, as our official position, and call on the Guardian to retract the article, pending appropriate revisions.

“Dear Guardian,

This article published in the Guardian addresses the important issue of treating hypogonadism. However, we are concerned that the article will (inadvertently) serve as an advertisement for “fringe” private medical healthcare services that contradict the advice and experience of qualified NHS specialists, who have specifically trained in hormone medicine (endocrinology),  with no platform offered to provide a more informed viewpoint.

It is easy to do a blood test for testosterone but it is equally easy for a non-specialist doctor (such as those quoted in the article) to misinterpret the result, and thereby misdiagnose hypogonadism.  In healthy, normal men, testosterone levels peak in the early morning and fall during the day; they also fall after meals, so it’s vital for accurate diagnosis that the blood test (preferably 2 of them on different days) be performed fasted and before 10-11 am. Moreover, testosterone levels also fall naturally below “normal” after a sleepless night, or during any form of illness, and men who are overweight or obese typically have low levels of the testosterone-binding protein, such that their levels of biologically-active free testosterone may be normal, even when total testosterone is slightly low.

What doctors lacking training in hormone medicine may also fail to appreciate is that properly documenting two separate low testosterone levels (total and calculated-free) is not a final diagnosis in itself, but rather an entry point to making a proper diagnosis, which may even involve MRI scanning the pituitary gland. Thus, just starting a man with “low testosterone” on testosterone replacement, not only exposes them to the risks of unnecessary treatment – testosterone-induced infertility, shrinkage of testes, or an abnormal rise in haemoglobin that can predispose to heart attacks, along with the costs to them or the NHS of drugs and monitoring blood tests – but also to the risk of a serious underlying condition being missed, such as a pituitary gland tumour, which could expand and cause blindness.

There has been an explosion in testosterone prescribing in the UK over the past 20 years, much of which has been exploitative of the vulnerabilities and insecurities of middle-aged and older men, but which has sadly passed other men completely by, whose genuine hypogonadism has not yet come to specialist medical attention.

We therefore highlight, four simple red flag features that should make any doctor take the finding of a low testosterone level (fasted & early morning) that much more seriously and refer to an appropriately qualified specialist:

– the presence of anaemia or low haemoglobin
– a history of osteoporosis or fracture
– a history of infertility
– raised levels of pituitary hormones LH or prolactin”

Dr Richard Quinton MA MD FRCP(Edin), Consultant Endocrinologist, Newcastle-upon-Tyne Hospitals & University 

Dr Channa N. Jayasena PhD FRCP FRCPath, Clinical Senior Lecturer in Endocrinology, Imperial College London

Dr Ahmed Al-Sharefi MBChB , MRCP (UK), Senior higher specialty trainee in endocrinology, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation trust

Declaration: Both Richard Quinton and Channa Jayasena are Investigators on the National Institute of Healthcare Research (NIHR) funded Testosterone Efficacy and Safety (TestES) Consortium, and Media Ambassadors for the Society for Endocrinology*

Our Media Ambassadors have successfully worked with Health and Science correspondents at the Guardian in the past to ensure accurate and responsible reporting, and we look forward to continuing to work with them on endocrine-related stories in the future.

The Society is committed to engaging journalists, patients and the public with hormone science to encourage informed health decisions, and to demonstrate the value of endocrinology to the wider world. Our Media Ambassadors are experts that work alongside the press office to help provide expertise, context and analysis to promote accurate and responsible reporting.

If you are interested in helping to improve the quality of science and health reporting, read our Media Ambassador guide or email media@endocrinology.org to find out how you can get involved.