‘Moving the goalposts’: the worrying rise of testosterone replacement therapy

“There’s more to testosterone than sex,” says David Edwards, a GP and former chair of the Primary Care Testosterone Advisory Group. “I think if testosterone was not involved in sex, it would never have the problems it does.” 

The problem he describes relates to the controversy surrounding testosterone, or more specifically, testosterone replacement therapy (TRT). Online marketing suggests TRT is underused as a tool to improve men’s health, for example by addressing the fatigue, loss of muscle mass and concentration that can accompany low testosterone levels, rather than its use just being confined to improve sex in middle and later life. Edwards says it can help men “who have lost their ‘oomph’.”

Others point to the potential side effects of TRT use, including hypertriglyceridaemia, aggression and loss of fertility, and the growth of intensely marketed private clinics treating often younger men, who may not meet the definition and criteria for a low testosterone or testosterone deficiency (TD) diagnosis^​1,2​. Anyone Googling ‘low testosterone’ will be offered a barrage of low-cost tests and online symptom checkers.  

Low testosterone, which is also referred to as male hypogonadism, can indicate problems with the testes, hypothalamus or pituitary gland. But testosterone levels can also decline slowly from mid-life onwards, and/or owing to comorbid conditions such as diabetes mellitus and obesity in what is termed ‘functional hypogonadism’^​3,4​. Some clinics claim as many as one in four men over the age of 30 years suffers from low testosterone^​5​. 

Inappropriate access

There is empirical evidence that TRT use is increasing: the number of testosterone-related items dispensed in the community increased by 52% between 2020/2021 and 2024/2025, according to data from the NHS Business Services Authority (see Figure 1)^​6,7​.

Figure: Number of testosterone items dispensed within NHS

However, much concern around TRT’s use relates to younger men using it to enhance their muscle mass and physique without having a confirmed TD diagnosis. Pharmacists point to social media posts — especially on TikTok — which promote testosterone. “The patients who follow these are not coming into primary care or our clinics to get it,” says Matthew Heppel, advanced clinical diabetes and endocrinology pharmacist at Hull University Teaching Hospitals NHS Trust.  

It is impossible to quantify how many men are obtaining TRT illicitly, but several sources have suggested to The Pharmaceutical Journal that they tend to be younger and may be involved in bodybuilding. In 2021, it was reported that a bodybuilder had died after injecting TRT and other drugs he had purchased on the internet after his GP would not prescribe TRT^​8​.

Suppliers of illicit drugs do not have access to NHS information about the men’s previous health history and are unlikely to carry out the recommended tests. Nor will they have the ability to check for contraindications or provide information on side effects (see Box)^​1​. The quality of the ‘drug’ supplied is also questionable. According to Channa Jayasena, professor in reproductive endocrinology and andrology, Imperial College London, in some cases it may not be from a pharmaceutical source and may have been “brewed up in someone’s kitchen”.

The lack of control over dosage is also a concern. Jayasena says it can be “supra-physiological” or greater than what would occur naturally, with attendant risks. A Danish study, including 164 participants, showed high cardiovascular risks among those who took illicit anabolic androgenic steroids, but there are also risks around hypertension, infertility and psychosis for those on high doses of TRT, he says^​9​.

Many men are seeking help privately, although the reasons for not using NHS pathways are not clear. Online clinics offer testing from less than £20 and consultations with doctors who then generate a prescription (testosterone is a class C controlled drug)^​10​. 

However, the costs of going private can quickly escalate, with doctors’ consultations, private prescriptions and more blood tests potentially adding up to £2,000 for the first year.  

Jayasena is critical of some of these clinics, which he describes as “moving the goalposts” with a “liberal” approach to reference ranges and sometimes prescribing higher doses of TRT than the NHS would. Some also prescribe short-term injections, which can be self-administered rather than the longer-term injections or transdermal gels used in the NHS. Jayasena suggests this may be associated with higher doses overall.

Declining levels

This increase in patient interest and prescriptions for TRT should not be viewed as wholly negative, because some men will undoubtedly benefit from the treatment. According to a 2025 study that assessed 973 men in the UK, nearly half (49%) reported a “burden” of TD symptoms, while 5% had a formal diagnosis^​11​. While awareness of symptoms was higher in men aged 40 years or younger, men aged over 40 years were 1.6–2.4 times more likely to have symptoms that met the cut-off point for association with low testosterone. 

“TD can have symptoms that are non-specific, but it has significant impacts on quality of life and healthy longevity,” the study authors concluded at the time. 

“Given the increasing focus on age-related hormonal changes in the last five years, as seen in menopause, a similar emphasis is needed towards men’s health,” they added. 

Despite this, the government’s men’s health strategy, published in November 2025, does not mention testosterone, and there are no National Institute for Health and Care Excellence (NICE) guidelines for its use in TD in men^​12​. However, the Scottish Medicines Consortium has accepted some testosterone gels for restricted use^​13​.

NICE guidance does recommend considering TRT for women with low sexual desire associated with the menopause, if HRT alone is not effective^​14​.

Suhrab Sayfi, lead specialist pharmacist in diabetes and endocrinology at London North West University Healthcare NHS Trust, suggests the rise in attention of TRT is a shift towards greater health awareness, but the right governance is important. 

Path to diagnosis

For many men, the path to diagnosis may start with a visit to their GP or potentially the pharmacy (see Box 2)^​15​. However, the situation may be different for those seeking private tests. Jayasena says some private clinics diagnose low testosterone where an NHS clinic might deem levels as being within the normal range or borderline.  

Many men will be able to access initial and follow-up tests via their GPs. Edwards says that GPs who are educated about the diagnosis and management of low testosterone are “perfectly happy” to do so. However, some integrated care boards will insist on diagnosis in secondary care, although ongoing prescribing may revert to GPs.    

Heppel sees many men with TD in his clinic in hospital. “The increase we are seeing comes from older men who have some chronic health problems. We have a responsibility to treat those symptoms,” he says.  

But, while they may meet the criteria for being prescribed TRT, it may not always give them everything they want. “People expect to be completely well but it will never get them back to their endogenous state,” he says. 

Lifelong treatment

Men starting TRT can expect to see some changes within three to six weeks — including improvement in sexual interest, depressive symptoms and energy levels. Some changes, such as muscle strength and bone density, can take 6 to 12 months to appear^​16​. For this reason, treatment is normally recommended for at least 6 months, with a target testosterone level of between 15 and 30nmol/L. 

Once TRT is prescribed, the BNF recommends monitoring every three months initially and for the first year, followed by yearly checks. This should include review of haematocrit and haemoglobulin levels, with a baseline established before treatment^​1​. 

Discontinuing TRT is difficult: it can result in the same problems that drove the patient to seek help reappearing^​17​. For many men, medication is lifelong, although Edwards says some patients with T2DM can go into remission while on TRT — often because they lose weight and exercise more. Their natural testosterone levels may recover partially and they may need less TRT as a result. “But in general, it should be considered a long-term replacement — like thyroid treatment,” he says.  

Pharmacist involvement

Community pharmacies are beginning to get involved in testing. Some private clinics have been looking to partner with pharmacies, encouraging them to identify men who might benefit from TRT and to counsel them on the impact of low testosterone before signposting them to its services^​18​. The pharmacies then dispense any resulting prescriptions and retain the revenue from this.   

There may also be opportunities for community and primary care pharmacists to spot men at risk of low testosterone — such as during medication reviews or if they seek advice around symptoms associated with it — and refer them on. 

Edwards says pharmacists may be able to identify men who may have low testosterone levels but have not yet stepped forward to talk about the symptoms. They include men with T2DM and/or high BMIs, as well as those with osteoarthritis or who have had a low-impact fracture. He also says that 40% of men with T2DM have a low or borderline testosterone level^​19​. GPs and practice pharmacists can identify these through records but affected men may also present at community pharmacies.    

Jayasena suggests that pharmacists can play a role in spotting those on TRT who are developing worrying side effects, such as irritability or feeling unwell if they are a day or two late getting an injection. This can be a sign of dependency, he suggests. 

Alwyn Fortune, policy lead for the Royal College of Pharmacy in Wales and a community pharmacist, says pharmacists’ role can include advice on safe use, explaining side effects and reinforcing the importance of clinical assessment and monitoring.

“Pharmacists can support harm reduction by encouraging patients to access treatment through safe, regulated healthcare pathways,” he adds. 

Is there a greater role pharmacists can play in providing access to testosterone? Matthew Dunn, an expert on human enhancement drugs based at Deakin University in Australia, argues that placing testosterone under a new prescribing regime can address some of the concerns about complications from ‘black market’ products^​20​. He sets testosterone in the context of longevity and “ageing healthily”. 

Some experts, such as Jayasena, have concerns about any increased availability through pharmacies, while others argue that the risks of harm from TRT could be seen as relatively low when taken at recommended doses and with awareness of contraindications. In 2025, a US Food and Drug Administration panel called for testosterone’s status as a controlled substance to be removed and eligibility to be extended^​21,22​.

Reclassification has happened with other drugs, of course, such as sildenafil, which had its status changed from a prescription-only medicine to a pharmacy medicine in 2017. The Medicines and Healthcare Products Regulatory Agency said at the time it was to help direct men who “might not otherwise seek help into the healthcare system and away from the risks that come with buying medicines from websites operating illegally”^​23​.

Testosterone, with its need for testing before and after prescription, is a more difficult candidate for a pharmacist-only medicine but it should never be ruled out. 

For men with confirmed testosterone deficiency, TRT can help to manage their symptoms, but for younger men who have been targeted by social media posts and online marketing, there is a risk of poorly regulated access and inadequate monitoring.

For pharmacists, the challenge is to find a balance: helping to prevent harm from inappropriate use, while supporting men with a genuine need for treatment to regain their ‘oomph’.