Low T, or Faux T?
In the current world, we have access to an amount of information that just a few years ago would have been unimaginable. We are constantly surrounded by streams of information and data, and it can feel like drinking out of a firehose.
Unfortunately for us, as individuals and as a society, the tools we use to interpret and judge that information have not evolved or kept up with the times.
So when we hear about a different approach to a problem, how do we know if it truly is correct or appropriate or helpful to our goals of living long, healthy lives?
Fads come and go. Sometimes you know right away that a certain trend isn’t going to deliver on its promises, but other times it can take years before we really know whether it is harmful or helpful.
One fad that probably falls into the first category is the use of testosterone replacement therapy, especially for women.
A recent study in the journal JACC: Advances highlighted this problem. As reports of testosterone use in women have surged in popular media, influencers and so-called “experts” claim it leads to improved libido, energy, and cognitive clarity, particularly among midlife women.
This recently published study looked at medical records representing more than 300 million patients from over 1,915 hospitals and 42,600 clinics.
It revealed that overall testosterone prescribing rates rose 2.6-fold between 2016 and 2025, but the trend is exploding in the last few years: From 2022 to 2025, they increased at 31.8% per year with a 58.7% year-over-year increase from 2024 to 2025.
And of course, these statistics likely underestimate the acceleration in usage, as this database only reflects “official” prescriptions from providers using EPIC. Naturalists, pellets and compounded formulations weren’t able to be measured.
The problem with this trend is that there is really no long-term safety data, and cardiovascular risk remains uncertain.
There was a trial that was supposed to let us know whether this was safe and/or effective. The BLISS (BioSante LibiGel Safety Study) trial was designed to assess the long-term cardiovascular safety of testosterone gel in women with hypoactive sexual desire disorder (HSDD). This trial was funded by BioSante, a pharmaceutical company that wanted to market a testosterone gel for women. The trial was completed…but the results were never published after companion efficacy trials failed to show benefit. Unsurprisingly, BioSante buried those results, likely because it would hurt their business.
Can testosterone ever be used in women? Sure. It can be used short-term in postmenopausal women with low libido, or “hypoactive sexual desire disorder”
The American College of Obstetricians and Gynecologists recommends consideration for transdermal testosterone therapy in these women, after they have been appropriately counseled about potential risks and unknown long-term effects.
What are those potential risks and long-term effects? Well, the main adverse effects include getting hairy, acne, and also virilization (voice deepening and clitoral enlargement), which may be irreversible. Other reported adverse effects of testosterone include mood swings, anxiety, and weight gain.
Even worse, there may also be harmful heart effects. While a 2014 systematic review found no evidence that transdermal testosterone increased cardiovascular disease risk, the effects of long-term use on cardiovascular disease and cancer risk are really unknown at this time.
Cardiovascular safety data derive predominantly from trials in men. The 2023 TRAVERSE trial (Testosterone Replacement Therapy for Assessment of Long-term Vascular Events and Efficacy Response in Hypogonadal Men) enrolled 5,246 men aged 45-80 years with hypogonadism and preexisting cardiovascular disease or high cardiovascular risk. This trial suggested that testosterone replacement therapy was “non-inferior” to placebo for major adverse cardiovascular events after an average follow-up of 33 months.
But this trial also showed higher rates of atrial fibrillation and pulmonary embolism in the testosterone group.
There may be a bigger issue with the TRAVERSE trial: it was funded by AbbVie, makers of testosterone replacement therapy. And it followed people for less than 3 years. Is that the right time frame to judge the safety of something upon heart health? Should we be concerned about testosterone causing a problem that doesn’t show up until many years later? Possibly.
Testosterone therapy in men may be associated with greater progression of non-calcified coronary plaque (“soft plaque”) on coronary CT scans.
A substudy of the Testosterone Trials (2017) using coronary CT angiography in 138 men found that testosterone treatment was associated with a significantly greater increase in noncalcified coronary plaque volume after 12 months (estimated difference 41 mm³). Total plaque volume also increased more with testosterone.
Accelerating the build-up of plaque in mid-life may be a problem that does not manifest itself until many years later.
Is it safe for women? We literally have no data to suggest it is. The TRAVERSE trial only looked at men and evaluated transdermal testosterone over 22 months, a duration, dose, and formulation that may not reflect real-world use in women.
Midlife is a critical period for atherosclerotic disease development in women, with the first myocardial infarction occurring on average 2 decades after menopause.
And the formulation may matter. Many women are choosing to have pellets of testosterone injected under their skin.
Major medical societies recommend against pellet hormone therapy for women, primarily due to concerns about higher-than-normal hormone levels, inability to remove pellets once inserted, and lack of high-quality safety and efficacy data.
A retrospective study of 539 postmenopausal women comparing pellet hormone therapy to FDA-approved hormone therapy found significantly worse outcomes with pellets:
- Overall side effects were 8-fold higher with pellets (57.6% vs 14.8%)
- Abnormal uterine bleeding occurred in 55.3% of pellet users vs 15.2% of FDA-approved users
- Hysterectomy rates were 3-fold higher with pellets (20.3% vs 6.3%)
- Peak estradiol and testosterone levels were too high in the pellet group, with some women reaching extremely high levels.
So far, we have a fair amount of data that testosterone replacement therapy may not be safe. Then why are so many people using it, and what is the popularity of testosterone therapy based on?
In a word: marketing.
Simply put, testosterone replacement therapy is the product of a highly successful marketing campaign.
In the early 2000s, AbbVie (then Abbott Laboratories) began promoting a new concept: “Low T”, which they said was a common, underdiagnosed condition in aging men.
The marketing campaign included symptom checklists (fatigue, low libido, weight gain, irritability), online quizzes (“Do you have Low T?”), direct-to-consumer TV ads (e.g., “Is it Low T?”) and dedicated clinics and screening events
Of course, many of these symptoms are nonspecific and common with normal aging, stress, or chronic disease.
Why did AbbVie embark on this marketing campaign? They wanted to sell more AndroGel, a testosterone gel that they created. AndroGel was easier to use than injections, lowering the barrier to entry for people to fix a problem that they may not have had.
So they created strong brand recognition with heavy advertising, positioning AndroGel as something that could restore vitality, energy, masculinity.
And sales reflected the shift: testosterone replacement prescriptions in the U.S. roughly tripled from ~2001 to 2013, with annual sales for AndroGel reaching ~$1–2 billion at its peak
Since then, AbbVie has faced thousands of lawsuits alleging that they misrepresented the risks of AndroGel and improperly marketed it for age-related low testosterone rather than just approved medical conditions.
AbbVie has of course consistently denied wrongdoing and maintained that AndroGel was appropriately labeled and supported by scientific evidence. In 2018, they entered into a large master settlement agreement covering thousands of AndroGel-related claims.
Where do we stand now?
Just like TV shows from 20 years ago are getting rebooted and updated now, we are witnessing in women a reboot of the experience we saw with men.
In the 2000s, an aggressive marketing campaign led to an increase in prescriptions of testosterone therapy for men.
Now that marketing campaign is exploding for women. Back then, these marketing campaigns focused on magazines and TV commercials. Now, it’s happening through social media influencers and quasi-medical professionals.
But the end result is the same: We continue to seek out the magic fix, rather than focus on the things that we have known for decades work best: healthy lifestyles.
The most evidence-supported strategies to treat low testosterone are weight loss, exercise, and sleep optimization.
The “Low T” story for women and men is a case study in the medicalization of normal aging, the powerful effects of direct-to-consumer pharmaceutical marketing, and the tension between information and evidence-based medicine.
But it is also a case study of how we are all pawns being moved around by large corporations simply trying to sell products, flooding us with information when we don’t have the skills to determine what is true and what isn’t.
At this time in history, we have access to so much information. But we are just as naive and clueless as we ever were about how to judge the quality and truth of that information.
At Wisconsin Cardiology Associates, we always counsel our patients to focus on healthy lifestyles, rather than targeting the latest fads and trends. Aim for a healthy, plant-based diet, exercise regularly, reduce stress and make sure you are getting enough sleep. Have questions about the best way you can improve your health? Call us and make an appointment for a consultation.
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