Testosterone Replacement (2 of 2)
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 athlete 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 therapies and their 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.
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. We have been fortunate to see many more people remaining active and competitive into their fourth, fifth, or even eighth decades of life. As this trend coincides with the massive increase in testosterone prescription though, many unsuspecting athletes are doping. Sure, “doping” might be a harsh term for a recreational runner who is only taking the medication his doctor recommended, but it is a technically accurate characterization. That said, I think the vast majority of athletes who fall into this category are doing so without any knowledge of their rule breaking.
Many Americans will enter their local 5K or marathon this year. They will sign up for triathlons, duathlons, and bike races. For those races which are 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 to do so. If you look at the number of people participating in these sports and cross-reference that against the number of testosterone prescriptions being handed out, then you can bet that there are significant numbers of athletes who are 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 antidoping 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 antidoping code. You should talk with your doctor and/or a knowledgable Sports Medicine doctor. It’s unlikely that your prescribing doctor is a Sports Medicine specialist, as most Sports Medicine doctors do not prescribe testosterone replacement. I believe it creates an apparent conflict when a doctor routinely treats athletes and also commonly prescribes substances which are banned for athletes. However, I often consult with elite and recreational athletes regarding their prescribed medications and their duties under the antidoping 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 this amateur level. Much of this type of testing is focused on national-level events or athletes for whom there is reason to suspect cheating may be occurring. (Hopefully your 10K age group rival isn’t calling the antidoping 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 knowledgable medical advisor can help ensure both.