Testosterone Replacement in Athletes: Part 2

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


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.