This transcript is automatically generated.
00:00:05 Narrator
Welcome to Rumor vs Truth, your trusted source for factsā¦ where we dissect the evidence behind risky rumors and reveal clinical truths.
00:00:12 Narrator
Today, we'll put claims about testosterone to the test.
00:00:21 Don Weinberger
Hey, Steve, how's it going?
00:00:22 Steve Small
Howdy, Don, how are you doing?
00:00:24 Don Weinberger
Not too, not too bad. So you know, I was at the store the other day and I saw some of these kind of products that were called testosterone booster supplements.
00:00:35 Don Weinberger
Obviously caught my eye and let's just say #1 looks like you've been taking them based off that beard that you have going on right now.
00:00:44 Steve Small
This is all natural, Don.
00:00:46 Don Weinberger
Ok, sure. Yeah, and #2, I did look at those products and I would sayā¦ a lot of bold promises there.
00:00:53 Steve Small
Yeah. And I'm pretty sure it probably had small print that you need a microscope to read.
00:00:59 Don Weinberger
Definitely didn't have it handy with me though, but today we're going to use normal sized fonts and actual evidence, and with that, I'm Don the pharmacist.
00:01:09 Steve Small
And I'm Steve, the pharmacist. And in this episode, we're going to be looking at claims about testosterone to see if they're really as strong as people think they are.
00:01:18 Don Weinberger
So, we know that testosterone replacement has gained a lot of traction over the years.
00:01:21 Steve Small
Yep.
00:01:22 Don Weinberger
Ads and commercials for clinics and online pharmacies are making testosterone front and center with people.
00:01:27 Don Weinberger
And now there are all sorts of products you know, from injections to topicals then going from your nostrils, your armpit.
00:01:33 Steve Small
Yep, everywhere, and that's totally right. And let's check these claims, man to man, to see if they're really legit and stick around folks because we have a guest expert that's gonna help us flex on a couple of claims.
00:01:44 Steve Small
And we'll also answer a listenerās question about acne antibiotics from our last episode.
00:01:49 Steve Small
So, to start off with Don, I feel like a lot of men right now are focusing on their testosterone levels. And guys think that taking testosterone is going to instantly make them into macho men.
00:01:59 Steve Small
And that leaves us to our first claim here that testosterone should be considered for all men with low testosterone levels or low T, right.
00:02:08 Steve Small
And, I could see where that comes from, because testosterone naturally declines in men with age, especially after hitting the big three O. Right?
00:02:16 Steve Small
And you really start to see that ramp up by even 1 to 2% per year after age 40. So it could see again why men are worried about this decline because of that natural sort of pattern there.
00:02:28 Steve Small
And they may ask about testosterone replacement because of thatā¦ whether or not that they actually have symptoms.
00:02:34 Steve Small
But the reality here is that testosterone replacement, or TRT, is only indicated for men with symptoms so low libido, depression, things like that, plus low testosterone.
00:02:47 Steve Small
And we're talking about levels on 2 separate labs, not just a one time deal.
00:02:51 Steve Small
So those levels have to be below 300 nanograms per deciliter. And just by having that low amount again doesn't automatically mean that you get treatment.
00:03:02 Steve Small
You have to have those side effects as well.
00:03:05 Steve Small
And we also have to have side effects of treatment in line with TRT, right testosterone can cause acne from increased even production, gynecomastia, mood changes, fluid retention, you name it.
00:03:17 Don Weinberger
All right, so you'd mentioned you know under 300 nanograms per deciliter is is kind of a.
00:03:24 Don Weinberger
Is one of the basis for getting that TRT right? OK. So let's say a person is actually now on TRT.
00:03:31 Don Weinberger
What is the goal testosterone level to kind of shoot for here?
00:03:36 Steve Small
Yeah. So typically we want it between 300 and 1000 nanograms per deciliter, but we also have to think about when these labs are being taken.
00:03:44 Steve Small
You can't just take them any time of day.
00:03:46 Steve Small
Testing timing is very important, because testosterone levels fluctuate throughout the day, so it's really best to have people test early in the morning to get consistent results to compare overtime.
00:03:55 Steve Small
And again you need two of them to qualify on the lab criteria and you may get patients asking to need to fast for this lab and the evidence behind that and the recommendations are mixed.
00:04:06 Steve Small
Some labs require it, some don'tā¦ have patients fully clarify with their lab beforehand. For more info, it's probably the best bet so.
00:04:14 Don Weinberger
Good points, yeah.
00:04:15 Steve Small
When it comes to, absolutely, and when it comes to this claim that testosterone should be considered for all men with low testosterone levels are low T the verdict isā¦
00:04:30 Steve Small
Rumor. So men do need to have testosterone levels that are low with symptoms so not all men.
00:04:38 Don Weinberger
So this advice isn't just for men, right per sayā¦
00:04:43 Don Weinberger
TRT can be indicated for all genders, and we answer all the questions that you probably have with that, with our resource hormones for transgender patients on our website.
00:04:54 Don Weinberger
So, feel free to take a look.
00:04:56 Steve Small
Great resource.
00:04:57 Don Weinberger
All right. So jump to claim 2 here.
00:04:59 Don Weinberger
This next line is a little concerning. I hope it doesn't rub you the wrong way, Steve, but the claim isā¦ Topical testosterone can transfer to other people and pets.
00:05:10 Steve Small
Oh.
00:05:11 Don Weinberger
So, let's dive into that evidence.
00:05:14 Don Weinberger
As you know, topical versions usually are applied to underarm, shoulder, stomach area, thighs, places like that.
00:05:21 Don Weinberger
But there are case reports where partners, kids and even pets developing male sex characteristics like hair growth, deepening voice after being exposed to patientās testosterone treated skin.
00:05:35 Don Weinberger
You know, diving into this, in fact, you know, over the summer, there was a report of a baby girl who started to form male sex characteristics because she laid on her father's bare chest several times after he applied testosterone gel.
00:05:52 Don Weinberger
You know, you may askā¦ Is she OK? And seems like she is. So once the father stopped using the gel, the child's body began returning to the typical female anatomy. But this isn't always the case.
00:06:07 Steve Small
Yeah, very recent and topical case Don. But what should we really be telling patients then about this?
00:06:13 Don Weinberger
Yeah, good question. Question so how do you avoid these, theseā¦ transference of you know the the testosterone?
00:06:20 Don Weinberger
So advise patients to wash their hands after applying, wearing clothes over the application site after drying, and avoid sharing clothing, towels and anything that could have testosterone on it.
00:06:34 Steve Small
Yeah, those are totally reasonable tips and we obviously know this wouldn't be a concern with injectable forms of testosterone. But what about that nasal topical form we're mentioning?
00:06:42 Don Weinberger
Yeah, sure. So nasal is a topical form. So natural question be well you know, what's the deal with that?
00:06:50 Don Weinberger
Didn't seem to be the case with the nasal testosterone products. The reason being is because as long as it stays within a nostril, you don't see that transference.
00:06:58 Don Weinberger
Now, if the patient were to touch their nostril, have testosterone on their fingers, then touch something else. Well, that case goes out the window. Right? So.
00:07:06 Steve Small
Right.
00:07:07 Don Weinberger
OK, so go back to that claim. And it is.
00:07:10 Don Weinberger
Topical testosterone can transfer to other people and pets, and the verdict isā¦
00:07:22 Don Weinberger
True. Patients need to protect others from exposure after applying TRT.
00:07:29 Steve Small
Yeah, great point. And I guess this is a good way to keep people away from you. I just applied my testosterone, do not touch me and it's also a good chance to point to labels.
00:07:37 Steve Small
Another illuminating fact that patients should think about is they need to keep these products away from fire and heat sources because some of these topical versions of alcohol that can be flammable.
00:07:48 Steve Small
And you do need to allow them to dry first, so keep that in mind.
00:07:51 Don Weinberger
So don't touch me and get that lighter away from me. Right. Those are two kind of things you can say with with.
00:07:55 Steve Small
Right, both. Yeah.
00:07:57 Don Weinberger
With those topical versions.
00:07:58 Don Weinberger
OK, so before we get into our next claim, a quick reminder if youāre enjoying this episode and want to access even more clinical insights, check out pharmacist letter, pharmacy technicians letter and prescriber insights.
00:08:10 Don Weinberger
This episode actually has a companion article on all of those sites and as a listener you can get 10% off a new subscription with the code RVT1025 at check out.
00:08:22 Steve Small
Excellent. And I kind of want to go back to what you were saying before Don about supplements, because this next claim is vitamins and supplements are safe and effective for increasing testosterone levels.
00:08:32 Steve Small
And we see products like this at gas stations on social media. But what's commonly found in them, you could say, who knows, but really what we found is usually it's something like vitamin D or zinc.
00:08:44 Steve Small
Or maybe some more exotic ones like ginseng or ashwagandha. So I asked our friends over at NatMed to give us a rundown of this and maybe a hand with this claim and they share with us a low vitamin D and zinc levels do have an association with low T levels, but studies are pretty mixed.
00:09:01 Steve Small
Supplementation with these may ultimately increase testosterone levels, but the data with patients who are then deficient with these vitamins is not people of normal levels in their body.
00:09:11 Steve Small
So, for example, ginseng and ashwagandha can increase T levels, but that evidence is mixed, and it really is based on their improvement of sperm counts and motility.
00:09:22 Steve Small
In addition to the increased testosterone levels and it's not all types of ginseng. For example, with ginseng, the Panax version we've studied, not the American version, so you gotta look out for that on labels.
00:09:36 Steve Small
But ginseng does have better evidence in treatment of other symptoms like erectile dysfunction.
00:09:42 Steve Small
And we gotta think about side effects, too. Even with natural medicines, ginseng can cause things like insomnia and ashwagandha we know has GI side effects like nausea, vomiting, diarrhea, and plus, to add to the confusion here.
00:09:55 Steve Small
These supplements really haven't been studied for long term use, so keep that in mind.
00:10:01 Steve Small
Of course, if vitamin supplementation is needed, we should be steering patients towards brands that are certified by a reputable third party.
00:10:08 Steve Small
Folks like USP, because many supplements as you know don't have FDA approval and there could be anything in those packets, who knows?
00:10:16 Don Weinberger
Correct. Yeah, that's that's a very good point.
00:10:18 Don Weinberger
Especially as much earlier about the gas station, kind of promotion of them, it's like wellā¦ you know what do I do here?
00:10:24 Steve Small
So with that, let's go back to our claim that some vitamins and supplements are effective for testosterone, increasing testosterone levels. The verdict isā¦
00:10:37 Steve Small
True, but with conditions. These increases are really only seen in folks who already have vitamin deficiency, and it may help them, but not other groups.
00:10:46 Don Weinberger
Right. So important you did mention earlier about, you know, the USP and you know FDA you know basically USP approval of some of these vitamins so keep in mind these are, you know, approved drugs that they were approved drugs that weāre seeingā¦
00:10:56 Don Weinberger
But when you get them online or you get them at a, you know, a store or whatever.
00:11:03 Don Weinberger
Who knows what the heck is actually in these products? As you said.
00:11:06 Steve Small
Yeah, requires some due diligence for sure.
00:11:08 Don Weinberger
Yes it does.
00:11:10 Don Weinberger
OK. So while we're talking about risks, FDA recently changed some of the warnings for testosterone products.
00:11:18 Don Weinberger
And I would sayā¦ to shortchange, I would say... we've got several, to many questions about the safety claims of, of thoseā¦ that research.
00:11:28 Don Weinberger
One being actually is testosterone products increase cardiovascular risks.
00:11:35 Steve Small
Yeah, and this is a hefty claim. Don glad you pointed it out.
00:11:38 Steve Small
And to help give us some help to unpack the evidence. We reached out to one of our excellent specialty consultants, Dr. Caitlin Prather, PharmD.
00:11:46 Steve Small
She's a board-certified ambulatory pharmacy specialist at the Inova Health system, and I had a chance to actually ask her about this exact claim last week. Let's hear what she had to say.
00:12:00 Steve Small
Welcome, Doctor Prather. Thank you for joining us and jumping into this question here. This claim testosterone products, increase cardiovascular risk. What's your take on that? What's the evidence behind this?
00:12:12 Caitlin Prather
Yeah. Thanks. So today's best evidence really is that when testosterone is prescribed to truly hypogonadal men and titrate into a normal range.
00:12:22 Caitlin Prather
It really does not increase major adverse cardiovascular events. That's really kind of the key take away from the TRAVERSE trial that came out in 2023 and that's why the FDA recently updated their class labeling to focus on more so with the blood pressure increases rather than a broad CV risk warning.
00:12:42 Caitlin Prather
So, in TRAVERSE, which was published in the New England Journal of Medicine in 2023, we had about 5200 men 45 to 80 years old who had confirmed hypogonadism and had established or high CV risk.
00:12:57 Caitlin Prather
And these men were either given transdermal 1.62% testosterone gel or placebo for a medium median of about two years, and the authors found that the primary major adverse cardiovascular events, or MACE, was similar between the two groups. So in other words, it was non inferior.
00:13:15 Caitlin Prather
Now there were a few safety signals, so they did see slightly higher rates of Afib and AKI, but not major adverse cardiovascular events.
00:13:25 Caitlin Prather
So you know more recently in February of 2025, the FDA did remove that broad CV risk box warning and replaced it instead with that warning about blood pressure across all testosterone products. And that was really primarily because of the results of that TRAVERSE study.
00:13:41 Steve Small
Sure. And are there any limitations to that study, maybe the patients that were involved, can this apply to younger men? What's your thoughts there?
00:13:50 Caitlin Prather
Sure. So the study was, like I said, you know, 45 to 80 years old in hypogonadism. So if we're applying this to those who are younger or perhaps using testosterone for other indications that may not apply. And in fact, it may even be a lower risk than what we saw there.
00:14:07 Steve Small
Good point.
00:14:08 Caitlin Prather
So we do still have that concern of of hypertension, but I think it's still important that even though maybe that risk has been removed as a boxed warning, we still want to do what we can to reduce cardiovascular risk in terms of, you know, other risk factors, quitting smoking, maintaining a healthy weight, keeping blood pressure or control things like that.
00:14:28 Steve Small
Those are excellent points and thank you for breaking, breaking down that study and I'm going to take this info back to Don and see what he thinks. Thank you so much for joining us.
00:14:35 Caitlin Prather
Alright.
00:14:40 Steve Small
So two things. One, I'm impressed by how fast my beard grew in that week since we recorded that. And two, I really liked her points there Don.
00:14:49 Don Weinberger
Right. I did. Yeah. So especially when coming back to well, it may not be causing cardiovascular, you know, negative outcomes in these in this patient group.
00:14:59 Don Weinberger
The blood pressure risks. You know, the bumps are still there, so it's kind of let the important patients know about that kind of stuff. So yeah, I do that.
00:15:06 Don Weinberger
OK. So let's go back to that claim, right?
00:15:09 Don Weinberger
So the claim is testosterone products increase cardiovascular risks and the verdict isā¦
00:15:17 Don Weinberger
Rumor with conditions, even though box warnings are removed, blood pressure should still be monitored.
00:15:24 Don Weinberger
Prescribers should be prepared to reassess the benefits versus risks of testosterone if they start to notice an uptick in blood pressure it may be better just to stop testosterone in some cases.
00:15:34 Don Weinberger
Practitioners need to separate rumors and truths, get through patient histories and discuss risks and benefits with the patient first.
00:15:41 Steve Small
And thank you again, Doctor Prather, for helping us sort that out.
00:15:44 Steve Small
And it kind of goes into our next claim here. I've heard patients voice concerns about other issues out there with testosterone and questions, for example. This next claim is testosterone can cause prostate cancer, which sounds pretty scary, right. But what's the latest evidence regarding this?
00:16:01 Steve Small
It's true that testosterone has a role in prostate functioning, and we do use testosterone blockers in some cases of diagnosed prostate cancers or key they're diagnosed.
00:16:13 Steve Small
But studies show that patients without prostate cancer don't have an increased risk when using testosterone products.
00:16:22 Don Weinberger
Wow. OK so. What about patients who have enlarged prostates, like in cases of BPH? Can giving testosterone make that worse?
00:16:31 Steve Small
Yeah, benign prostatic hyperpathy is definitely a common issue. I can see where there's concerns with that.
00:16:37 Steve Small
Speaking with Doctor Prather about this, it turns out studies don't support this really either as a general problem, you may see this in package warnings or testosterone products, and it is something to monitor for, but it's not actually commonly seen based on her experience.
00:16:51 Steve Small
But again, it's good to ask patients about symptoms like urinary hesitancy and things like that.
00:16:57 Steve Small
So when it comes back to this claim that testosterone can cause prostate cancer, the verdict isā¦
00:17:08 Steve Small
Rumor. Studies so far show there isn't a direct link to causing prostate cancer, but it should be avoided in patients with diagnosed prostate cancer.
00:17:18 Don Weinberger
Well, you know, that's a relief, especially since TRT is geared towards older men, right? I could definitely see that being a concern.
00:17:26 Don Weinberger
Iām glad studies show that it really isn't.
00:17:28 Steve Small
Yes, finally. And that brings us to our bottom-line truth folks.
00:17:32 Steve Small
We should weigh the risks and benefits of testosterone replacement and medication options, because every patient is different and so are obviously testosterone products.
00:17:43 Steve Small
And I gotta say, Don, for a hormone that focuses on, you know, physical strength. Some of these claims are pretty weak.
00:17:50 Don Weinberger
And some patients have high expectations for this med and hopes could be deflated, right?
00:17:55 Don Weinberger
So it's important to treat the patient and not just the testosterone level number. TRT should be reserved for patients with symptoms.
00:18:05 Don Weinberger
And address other factors like stress, depression while on TRT.
00:18:10 Steve Small
Right. And also remember that testosterone products are a Schedule 3 controlled substance. And yeah, they have a high likelihood of being misused for other non-medical purposes, things like bodybuilding, right.
00:18:21 Steve Small
So we have to make sure that our prescriptions are from authorized prescribers.
00:18:25 Steve Small
Based on a legitimate patient provider relationship and we should continue checking stateās, you know, prescription drug monitoring programs when dispensing folks may forget that those products will be listed there too.
00:18:37 Don Weinberger
Yeah, that's a good point. And even if that prescription is legitimate, right, what are some other things that patients should should be concerned about, with TRT?
00:18:46 Steve Small
Yeah. Yeah. Like also have folks monitor for those side effects we mentioned with you since again, it may outweigh testosterone benefits. It may not be worth all the emotional changes, acne.
00:18:55 Steve Small
My goodness, adolescence was hard enough, and now youāre doing it again.
00:18:59 Steve Small
And patients may have injection related adverse effects too. If you're using those versions, things like pain or infection even and pharmacists can be a great resource to teach patients the safest injection technique. If that's the case.
00:19:14 Don Weinberger
Yeah, that's a good point, Steve. I like that.
00:19:17 Don Weinberger
And speaking of that, it's now time for our audience question from the last episode on managing acne. We can't really get away from those, they pop up all the time, right?
00:19:27 Don Weinberger
So, this audience member asked. You talked about oral tetracycline antibiotics for acne being equally effective. But are the topical versions equally effective as the oral ones?
00:19:43 Don Weinberger
And you know, I, you know, I love, give cut and dry answers when we can, but this one is not really a cut and dry answer because there's a lot of factors that come into play.
00:19:51 Don Weinberger
It can come down to like how severe the acne is.
00:19:55 Don Weinberger
Where the acne is. What other option the patient can afford that kind of goes into payer coverage gauging to take consistently.
00:20:03 Don Weinberger
Are they going to apply something full body every single day, twice a day, where may be right, and tolerating medications.
00:20:11 Don Weinberger
So going to the dosage forms orals are usually safe for moderate to severe acne where topicals don't work or for the more widespread acne like on the trunk of the body or like the back, right?
00:20:24 Don Weinberger
Or the top of the, of the back where, you know, maybe hard to apply topicals.
00:20:28 Don Weinberger
Topical Minocycline which you mentioned, it's available on a foamā¦ but it's tends to be pretty pricey and not covered by payers at first.
00:20:40 Don Weinberger
Where usually you try other topical antibiotics like Clindamycin with benzoyl peroxide first.
00:20:46 Don Weinberger
And the use of both topicals and orals is used fairly commonly as a as a 1-2 punch against acne on the face and body.
00:20:53 Steve Small
Yeah. Good answer, Don. And I'm loving these questions from the audience. If you'd like to have your question about this episode answered next month, send us a message. We're looking forward to it.
00:21:02 Don Weinberger
Yeah, it's, it's all we live for people, so please send them.
00:21:07 Don Weinberger
So we also use your suggestions to plan our episodes. So send us your ideas for rumors and truths to analyze.
00:21:13 Don Weinberger
Using the contact US link at the bottom of your TRC healthcare homepage or the send us a text link right from the podcast show notes.
00:21:23 Steve Small
Yeah, we'd love to know what you've got in terms of ideas for us to demystify and a couple more things here if you like what you heard on this episode, be our friend. Tell a friend about our show.
00:21:35 Don Weinberger
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00:21:47 Don Weinberger
And if youāre a student, even better, students can access a free version of pharmacist letter and you know, Steve, we were students at one point, anything is free, it's me, right?
00:21:56 Steve Small
Yeah. I'll even take free stuff now, I think that's great. We've got links in the show notes that take you directly to the right places to take advantage of these awesome deals. So go check them out.
00:22:05 Steve Small
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00:22:13 Don Weinberger
And join us next time where we'll take a bite out of the claims about medications and dental health.
00:22:19 Steve Small
Iāll try to put a smile on for it, Don, and thanks for joining us on rumor versus truth. Your trusted resource for facts where we dissect the evidence behind risky rumors and reveal clinical truths. See you next time.
