Testosterone Replacement in Athletes: Part 2

As this trend coincides with the massive increase in testosterone prescription, many unsuspecting athletes are doping.

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In recent years, prescriptions for testosterone in the US have skyrocketed.  There are now “Low T” clinics popping up in suburban strip malls across the country, and you can even find treatment online!  Prescription testosterone fuels a business which brings in over $2 Billion a year, yet there is debate over the appropriateness of the therapy.

Aside from what I see as the frequent medical impropriety involved in this Low T popularization (see last week’s post), there is another very real concern which impacts recreational and elite athletes.  Today it is common to see many active individuals remaining competitive into their fourth, fifth, or even eighth decades!  As this trend coincides with the massive increase in testosterone prescription, however,, many unsuspecting athletes are doping.  Sure, “doping” might be a harsh term for a recreational runner who is only taking the medication recommended by his doctor, but it is a technically accurate characterization.  That said, I think the vast majority of these athletes are doing so without any knowledge they have broken a rule.

Many Americans will enter their local 5K or marathon this year.  They will sign up for triathlons, duathlons, and bike races.  For those races sanctioned by a national governing body (which is the majority, even on a smaller local level), the athlete agrees to abide by the United States or World Anti-Doping Agency’s (USADA or WADA) code pertaining to banned substances in competition.  If you have a racing license, buy a one-day license, or sign a lengthy form to enroll in one of these events, chances are very good that you are agreeing to abide by this code and to be drug tested if requested.  If you look at the number of people participating in these sports, and then cross-reference that against the number of prescriptions for testosterone, you can bet there are significant numbers of athletes in violation of this code.

Simply having a valid prescription for a banned medication is not sufficient to permit its use during competition, and as the code is written, the onus is on the athlete, not the doctor, to know the rules.  Honestly, most doctors are not aware of the anti-doping rules, but any certified Sports Medicine specialist should be able to help you navigate the process.  

If you do require the use of a banned medicine but wish to compete on a local or national level, you may need to file for a Therapeutic Use Exemption (TUE).  This is a process by which a panel of specialists reviews your case and decides whether use of the medication is warranted under the WADA code.  In 2016, USADA added a special process for “Recreational Competitors”.  Application for a TUE does not guarantee its approval, and with approval comes an agreement for further follow-up testing throughout the course of the TUE’s validity.

So, what do you do if you are an active, competitive, or even non-competitive recreational athlete who is on testosterone replacement treatment?  First, I would suggest you stop competing at any level until you investigate your responsibilities under the anti-doping code.  You should talk with your doctor and/or a knowledgeable Sports Medicine doctor.  

It’s unlikely that your prescribing doctor is a Sports Medicine specialist, as most do not prescribe testosterone replacement.  I believe it creates an apparent conflict when a doctor routinely treats athletes and also commonly prescribes substances banned for athletes.  However, I often consult with elite and recreational athletes regarding their prescribed medications and their duties under the anti-doping code.  Any Sports Medicine specialist would be happy to help explain the system and process.

To be clear, it remains highly unlikely that a recreational athlete will be tested at their local race, but it is starting to happen more frequently.  Studies suggest that doping is now more prevalent in amateur sports than in professional sports, so testing resources are being deployed on the amateur level.  Much of this type of testing is focused on national-level events or athletes for whom there is reason to suspect cheating.  (Hopefully your 10K age group rival isn’t calling the anti-doping tip line and complaining about you!)  A positive test and the ensuing public embarrassment would be devastating to anyone.  But more than the risk of public humiliation, I believe most people truly want to compete within the rules.  To the extent that these athletes are breaking those rules, I think they are probably unaware.

At the end of the day, the problem of testosterone therapy in recreational sport is a multifaceted one.  There is a very high likelihood that the medication is inappropriately prescribed.  Finding and treating the underlying cause for the low testosterone should be the primary objective.  When testosterone therapy is warranted, ensuring proper adherence to the rules of competition is paramount.  We all want healthy athletes and clean sport.  A knowledgeable medical advisor can help ensure both. 

WHOOP Article About Dr. Sprouse

WHOOP makes one of the most advanced tracking bands on the market right now.  They recently posted an article about how Dr. Kevin Sprouse uses this technology with his patients around the world.

Many doctors struggle to figure out how best to motivate their patients to engage in daily physical activity. Not me.

As a Sports Medicine physician, I work with elite and professional athletes from multiple disciplines, as well as many hard-charging “weekend warriors.” The vast majority of my practice consists of advising and treating this demographic. I’m also the Head of Medicine for a World Tour professional cycling team, with athletes scattered across the United States, Europe, Australia and South America. Whether they are cyclists, triathletes, runners, golfers, obstacle course racers, baseball players, CrossFitters, or athletes from any other sport, my patients tend to go hard.

In working with this driven athlete population, I focus not only on injury and illness treatment, but also on health, performance, and injury prevention. When I order blood tests, I’m often not looking for disease. Instead, I’m looking for early signs of imbalance, dietary deficiency and physiologic response to training stress. I evaluate lactate threshold profiles, continuous glucose monitors and training logs.

In my opinion, you can’t separate health from performance. A healthier athlete performs better, it’s that simple.

Testosterone Replacement in Athletes: Part 1

Low testosterone is usually not the underlying problem but rather a symptom of the underlying problem.

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In recent years, prescriptions for testosterone in the US have skyrocketed.  There are now “Low T” clinics popping up in suburban strip malls across the country, and you can even find treatment online!  Prescription testosterone fuels a business which brings in over $2 Billion a year, yet there is debate over the appropriateness of the therapy.

Without a doubt, there are cases of low testosterone (termed “hypogonadism”) for which testosterone replacement is crucial.  The ability to replace this hormone through medication is another example of the miracles offered by modern medicine and science. Yet, this could be said of any medical condition and its associated treatment.  You don’t see strip mall clinics set up to manage conditions like high blood pressure or psoriasis.  Why testosterone?

There is no definite, agreed-upon definition of hypogonadism in medical literature.  Most studies use some combination of testosterone levels in the blood, along with the presence of multiple symptoms.  As there is no consensus for diagnosis, and since treatment is a multi-billion dollar cash business, you can imagine there might be some room for…shall we say, “bias”.

In addition to this lack of agreement on diagnostic criteria, a major problem that pervades this Low T industry is a disinterest in diagnosing or treating an underlying cause for low testosterone.  Many doctors are happy to simply prescribe enough hormone to take a patient from “low” (or even “low-normal”) to the upper reaches of “normal”, or even higher.  This is an easy fix for both the doctor and the patient, and often the patient is unaware of the alternatives or the risks of treatment.  While the underlying problem is addressed, sometimes a short course of hormone replacement is all that is needed.  The patient and their symptoms are rarely addressed in this manner, often being treated for years, or even indefinitely 

As time goes by, the patient may require greater amounts of hormone to keep testosterone numbers elevated.  In fact, symptoms are often not alleviated with a raise in testosterone levels, so sometimes a doctor will just prescribe more, despite normalized levels. Many doctors have simply stopped looking for a reason for the low levels in the first place.  

The human body is comprised of a complex interplay of systems, and hormonal systems are perhaps the most complicated.  It is exceedingly rare that an isolated hormone will just take a nosedive for no underlying reason.  Yet some doctors see a low testosterone level and just throw more hormone in the mix.  In medical school, we’re all told, “Don’t treat the number, treat the patient.”  It seems there are many who have lost sight of this.

The cause(s) of low testosterone can very often be treated, allowing the body’s own hormonal system to return to normal.  There are many variables that may decrease testosterone production.  Low testosterone is usually not the underlying problem but rather a symptom of the underlying problem.  

If a patient presents with chest pain, we don’t just give them enough pain medicine to make them feel better.  We quickly look at why they are having pain.  When they present with anemia, we don’t just transfuse them with blood and send them home.  No, we look for the reason behind their low blood counts.  Why should we treat low testosterone differently?  

There are many things that can lead to abnormally low hormone levels including excess body fat, sugar consumption, stress, overtraining or lack of proper recovery, poor sleep, sleep apnea, lack of exercise…and the list goes on.  In some conditions, testosterone treatment might actually make the problem worse!

If you are an endurance athlete, it is very likely that your total testosterone levels are on the lower end of normal.  This is common, even expected.  I work with recreational and professional endurance athletes who, at the top of their game and with no symptoms of hypogonadism, have testosterone levels in this low-normal range.  It is not pathologic.  It’s an expected response to extended endurance training.  There is absolutely no reason to treat these athletes with testosterone replacement.  Notably though, we do follow levels of total testosterone, free testosterone, and cortisol to evaluate response to training regimens.  In those scenarios when testosterone drops, an adjustment in training load and recovery will rectify the problem.

Adding exogenous hormone can disrupt the balance of other hormones and impact the body’s ability to produce its own testosterone in the future.  It also can lead to an overproduction of red blood cells, making the blood “thick”.  This can result in blood clots, heart attacks, and strokes.  The medical literature establishing the safety of liberal hormone replacement is woefully lacking, but these adverse events are becoming more recognized.  In fact, it’s come up on numerous occasions as I converse with doctors at the hospital during my ER shifts.  While this is only my opinion and conjecture, I fully expect that we will start to see these treatments lose favor and very likely be subject to class-action suits against manufacturers and Low T clinics in the coming years.

To be clear, I am not placing any blame on patients.  There is a vast marketing machine behind the proliferation of Low T treatment.  When someone is experiencing concerning symptoms and a doctor offers what seems like a reasonable diagnosis and a simple fix, patients are going to take it!  As doctors, the responsibility rests on us to determine when treatment is appropriate and when it is merely a symptomatic cover-up of a true underlying problem.  I think we as doctors are failing in this regard - too many quick fixes prescribed to well-meaning patients.

Next week I’ll talk about the implication of testosterone treatment for recreational athletes and their responsibility under the World Anti-Doping (WADA) code.

Testosterone Replacement in Athletes

The Evolution of Medical Care, or Bandwagon Treatment Lacking Evidence?

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Across the US, hormone replacement therapy is becoming more popular every year.  Recreational athletes are no exception to this trend, and this is perhaps most prevalent among the “weekend-warrior” masters crowd.  But just because it is a common theme in treatment, does that mean it’s good medicine?

I’m going to post a two-part series of articles examining hormone replacement therapy and its use in athletes.  Without a doubt, there are clinical conditions which require this treatment.  There are a growing number of patients, however, who are being treated without meeting accepted diagnostic criteria.  This could be the evolution of medical care, working to aggressively treat previously unrecognized conditions.  Or it could be a bandwagon on which patients and doctors are hitching their hopes, exchanging large amounts of money, yet missing the underlying problem.

Additionally, since this series is specifically aimed at an active patient population, I will discuss the implications of these treatment protocols when it comes to competition.  Athletes who register for an event sanctioned by a national federation often agree to abide by the code of the World Anti-Doping Agency (WADA).  If you are running your local 5K or marathon, you likely agreed to this code (and to be tested!).  If you sign up for the local sprint triathlon or cycling crit, the same thing applies.  Far too often, I see athletes in my office who have been placed on treatments which technically amount to doping!  I don’t believe they have any intent or awareness that they are breaking the rules, and many are stunned to find this out.  My goal in discussing this is not to point fingers!  Rather, it is to inform athletes of all levels that there are expectations and rules to which they have agreed and can be publicly punished for breaking.  And often times, there is a safer and healthier way to address their symptoms.

**Stay tuned for this two-part series.  The first article will be posted on Thursday afternoon, and the second on Tuesday of next week.**