Hegseth wants a "High-T" military; doctors call it a clinical minefield

According to the report, on Wednesday, Defense Secretary Pete Hegseth made the startling announcement that the US military would begin requiring all active duty and reserve personnel aged 30 and older to undergo mandatory screening for testosterone deficiency. The screenings will take place during yearly health assessments. Those under age 30 can also get screened on request. In a short video posted on social media, Hegseth explained to the military community that the screenings and possible subsequent treatments are intended to “optimize your performance, your resilience, and your long-term health.” While saying that the initiative wasn’t about “artificial enhancement” and that members could decline treatment, Hegseth claimed that the testing and potential treatment was for “restoring and optimizing” capabilities, protecting “longevity,” and “ensuring you have the biological foundation required to sustain the fight.”

But will testosterone screening and treatment actually “optimize” our “warfighters”? Will it help most of them live longer? Should everyone else get screened and treated, too? Screening people widely for medical conditions and then treating those who need it may sound like a huge social positive. But issues around male hypogonadism—the condition in which the body doesn’t produce enough testosterone—can be complex. That’s why the Endocrine Society—made up of experts in the complex systems that release hormones in the body—posted a statement on the topic in the wake of Hegseth’s announcement. The document notes that “there is insufficient evidence to support a general recommendation to perform population-level screening for hypogonadism in asymptomatic men with measurement of blood testosterone level.”

To find out why, Ars Technica spoke with Professor Bradley Anawalt, chief of medicine at the University of Washington Medical Center. He specializes in endocrinology and men’s health. “This is a great big fat ‘Oh, no,’” Anawalt said in reaction to Hegseth’s announcement. “We’re turning the clock back on rational healthcare. … I’m worried about the ethics. I’m worried about the health consequences. I’m worried about unnecessary evaluations, incorrect assessments, and incorrect diagnoses that lead to inappropriate prescriptions of testosterone.”

To understand why, let’s start with the basic question: Why might someone have low testosterone? Disease states that can cause low testosterone include genetic conditions, such as Klinefelter syndrome (when a male has an extra X chromosome) or a problem with the brain’s pituitary gland, which controls hormone levels in the body. Pituitary problems may come from damage, dysfunction, or tumors (which are often noncancerous). For these patients, “It’s not difficult to make the diagnosis,” Anawalt said. Genetic tests can detect Klinefelter disease, for instance, confirming an explanation for low testosterone levels. Similarly, in patients with pituitary problems, tests for other blood hormones (such as luteinizing hormone and follicle-stimulating hormone) can confirm the source of the problem. But these conditions are uncommon, affecting maybe 1 percent of men at most, Anawalt said. Meanwhile, many other things can lower testosterone levels, such as: cancer treatments, medications (such as corticosteroids or opioids), anabolic steroids, obesity, HIV, surgery, trauma, stress, sleep deprivation, and the natural process of aging. Many of these causes would not necessitate testosterone replacement therapy. For someone with sleep deprivation, the best treatment would be rest, for instance. In patients with true hypogonadism, the primary symptoms are lower libido, erectile dysfunction, lowered sperm count, breast enlargement or tenderness, reduced energy, reduced muscle mass, shrinkage of testes, mood changes (such as irritability or depressed mood), and hot flashes. Over time, low testosterone can cause loss of body hair, muscle bulk, and bone density, and it can reduce red blood cell counts. In clear cases of disease, these symptoms are easy to spot. In the general population, it’s much harder. “What’s more difficult to suss out is the men that have vague symptoms,” Anawalt said. “‘I don’t feel so good. I’m tired. My energy’s not so good. My erections aren’t what they used to be. My mood is not very good. I’m not concentrating well.’ These are all common things that people are concerned about, but they’re neither specific nor particularly common symptoms of testosterone deficiency.”

The actual testing mechanics can also be tricky. “Tests that measure testosterone are a disaster unless you use a CDC validated or certified testosterone assay,” Anawalt said. In recent years, the Centers for Disease Control and Prevention began certifying testosterone blood tests for quality, accuracy, and reliability. Still, not all laboratories use certified tests. This can lead to unusual results. In addition, some laboratories use nonstandard reference ranges for what they consider “normal.”

The Endocrine Society reports that a common, generally accepted clinical threshold is near 300 ng/dL, though some clinicians may consider the threshold slightly lower, such as in the 260s. Anawalt recalled a patient who had been diagnosed with low testosterone based on a normal testosterone test result of 489 ng/dL. The patient’s previous doctor had used a lab that considered the minimum threshold for normal to be 700 ng/dL. “It’s a whole other topic to get into the ‘whys’ and the ‘wherefores’ of that, but it’s largely to promote prescriptions of testosterone,” Anawalt said. Even if you use an accurate test with a high-quality reference range, testing for testosterone isn’t simple. Hormone levels fluctuate and tend to be highest in the morning. Thus, experts say the testing must be done early in the morning before eating breakfast to get morning fasting levels. They also recommend doing repeat early morning tests to confirm that a low level is consistent and not a one-off. Standard testosterone tests also look for levels of total testosterone. “But the evidence indicates that the active form of testosterone hormone is the hormone that is not bound to anything. It’s called free testosterone,” Anawalt explained. (A key binding protein for testosterone is called the “sex hormone binding globulin.”)

This is critical because some patients may have lab results indicating a low level of total testosterone but still have completely normal levels of free testosterone—the form that seems to matter most. This is sometimes the case for men with excess weight (a body mass index of 27 or higher). Evidence suggests that these patients have a decline in sex hormone binding globulin and that their levels of total testosterone will be low. But their levels of free testosterone may be completely fine. This can also be the case for patients with diabetes. Even if all these issues are accounted for, testosterone replacement therapy may not be recommended. For instance, if a patient with obesity is diagnosed with hypogonadism and no other condition explains the low testosterone levels (such as a pituitary tumor), the first-line treatment is weight loss. Assuming a clear diagnosis of hypogonadism, TRT can reverse some of the dramatic effects of disease. Anawalt gave the example of a man with cancer who has his testicles removed. That man will face decreased bone density, muscle mass, strength, libido, and probably a shorter life expectancy. “If you give testosterone therapy to restore that man into the normal range, you will bring bone density and bone mass up, and muscle mass and muscle strength up,” he said. “And it’s possible that it might address the concern of a shortened lifespan by a couple of years.”

For people without such a clear need, though, benefits may be nonexistent. If you give a man with normal testosterone levels a TRT dose intended for someone who has testosterone deficiency, “You’re not going to do anything for performance,” Anawalt said. Generally, the benefits of TRT will depend on the severity of the deficiency. But “for a 50-year-old soldier who comes back with a testosterone that is just a little low, most of these men are not going to have any substantial benefit with testosterone therapy,” Anawalt added. The benefits Hegseth mentioned in his social media video do not appear to be widely supported by evidence. There’s no evidence testosterone will extend a healthy person’s life, for instance—though it may restore natural longevity in people with clear disease. Additionally, studies looking into the effects of TRT on cognition have found no measurable benefit. One of the obvious concerns about Hegseth’s plan to screen young men—those in their 30s or even younger—is that TRT has real side effects. TRT shuts down sperm production, for instance, which can thwart plans to start a family. Sperm counts can rebound once off the therapy, but the higher the dose and longer the treatment, the longer it takes to

المصدر: Ars Technica