A cross-sectional survey of experiences and outcomes of using testosterone replacement therapy in UK men

doi:10.21203/rs.3.rs-5290998/v1

Background

Prevalence of late-onset testosterone deficiency (TD) ranges between 6–30% depending on diagnostic criteria. Recent data highlights various benefits of testosterone replacement therapy (TRT) including increased libido, mood, bone-mineral density and lean body mass. This study investigated the personal experiences of men with TD, including access to TRT.

Methods

Previous or current TRT users were recruited from private clinics' mailing lists, professional medical organisations and researchers' professional networks. Participants completed a 52-item structured questionnaire on Qualtrics addressing perceptions and experiences of TRT and low testosterone symptoms. Associations between demographics, duration of symptoms and effectiveness were assessed using logistic regressions.

Results

Among the 905 men on TD treatment, 86% delayed treatment for > 1 year, while 26% experienced symptoms for > 5 year before seeking care. Older men were 1.79 times more likely to delay treatment. The majority (86%) reported TRT as very effective, with longer-term users 2.6 times more likely to report TRT as very effective compared to recent starters. Primary motivations for seeking TRT included improving personal relationships (79%) and physical appearance (53%). Most (81%) relied on online sources for information; fewer (18%) felt comfortable discussing hormonal health with their peers. Patient expectations during medical consultations focussed on diagnosis (77%), treatment options (64%) and learning about potential side effects (51%). The commonest side effects were acne (24%), testicular shrinkage (24%) and nipple itchiness/gynaecomastia (19%). TRT users reported notable improvements in overall quality of life (75%), mental wellbeing (71%), self-esteem and self-confidence (69%) and appearance (61%).

Conclusions

A significant proportion of men > 50 year surveyed reported experiencing prolonged symptoms of TD prior to seeking care. There is a need for greater awareness and education regarding TD symptoms, including streamlining timely and equitable access to effective treatment options.

Male hypogonadism

low testosterone

men’s health

patient reported health outcomes

qADAM

In the last decade, there has been a significant shift in the awareness of healthcare professionals (HCPs) and the general public regarding the importance of hormonal health in later life, specifically hormone replacement therapy (HRT) to address the symptoms of menopause [1–3]. Despite this increased interest around female hormones, there has been little comparable advancement in the progress of hormonal health for men, including male hypogonadism, also referred to as testosterone deficiency (TD).

There are many reasons for a lack of progression in male hormonal health, including lack of public and HCP awareness about TD, misleading outcomes from historical studies and cultural, and societal misconceptions that testosterone is just a “sex and muscles” hormone, and that optimal levels may not even be required later in life [4–6].

Testosterone is the primary sex hormone in men. It is essential for the development and maintenance of secondary sexual characteristics, significantly impacting metabolism, cognition, personality and mood, sexual function and libido [7]. Because testosterone affects nearly every system in the body, suboptimal levels may negatively impact male health and wellbeing.

TD prevalence varies widely ; the European Male Ageing Study [8, 9], looked at over 3000 men aged 40–79 years old, highlighting that 17% had biochemically low testosterone levels, with 2-11.8% of men over 40 potentially suffering from clinical symptoms of TD. More recently, Ayman et al.[10] assessed the prevalence of low testosterone levels in men with type 2 diabetes, reporting that 37% of the cohort had TD (defined as a total testosterone level below 3 ng/ml), while 29% of the same cohort had symptoms consistent with low testosterone (assessed using the Androgen Deficiency for Aging Male (ADAM) questionnaire) [10]. Pertinently while up to 75% of men maintain normal testosterone levels into older age, 25% do not [11], suggesting that TD is not a function of normal ageing and may have a significant impact on the quality and health outcomes for men.

There is ample evidence that testosterone replacement therapy (TRT) is safe and well tolerated by most men [12], and that the symptomatic and metabolic benefits of TRT outweigh the risks associated with this treatment [13, 14]. A systematic review performed by Araujo et al[15] has suggested that untreated, low testosterone in men is associated with an increased risk of all-cause and cardiovascular related death [15]. As more evidence emerges around the prevalence and negative health impact of low testosterone in men, and as TRT becomes more popular, various institutions including the British Society of Sexual Medicine [11], the Society for Endocrinology [12], and the British Journal of General Practice [16] have published guidance on the symptoms, diagnosis and treatment of TD. This guidance will be critical to support clinicians in treating symptoms of TD. However, alongside this it is also increasingly necessary to have a clear understanding of the needs and experiences of men in this area.

To address this gap in knowledge, the aim of this study was to characterise the personal perceptions and experiences of men who sought TRT treatment for low testosterone symptoms. Specifically, we sought to explore associations between demographics, duration of symptoms, side effects and the effectiveness of treatment in past and current users of TRT.

We conducted a cross-sectional survey of adult men with TD and experience using testosterone replacement therapy (TRT) in the UK to explore the knowledge, attitudes and perceptions regarding symptoms and treatment options for low testosterone. This adopted a quantitative methodology, using adaptive questioning with data collected via an online tool comprising a total of 52 questions. The online survey could be accessed using a personal computer or smartphone.

Consent and data protection

The Participant Information Sheet (PIS) included information regarding the study’s aims, the protection of participants’ personal data, their right to withdraw from the study at any time, which data were stored, where and for how long, who the investigator was, the purpose of the study and survey length. Participants were informed that this was a voluntary survey without any monetary incentives but were offered the possibility of accessing findings at a later stage. Data collected was stored on a secure encrypted database at Imperial College London, and only the research team could access the eSurvey results. All responses were pseudo-anonymised to ensure confidentiality by assigning each respondent a unique study ID. Only the participants’ demographic data including age in years, gender, ethnicity, residence, education level and employment status were recorded.

Participant recruitment

The link to the electronic survey was published and made available on the Imperial College Qualtrics platform between 25 April 2024 and 10 September 2024 (5 months). The open survey could be accessed by anyone with a link and took 10 minutes to complete. Survey participants were recruited through private clinics' mailing lists, professional medical organisations and the researchers' professional network of doctors.

Electronic survey setup

The survey consisted of a structured questionnaire designed to assess knowledge, attitudes and behaviours around low testosterone and available treatments, adopting a quantitative methodology drawing upon comparable research design in women’s health [17]. The survey comprised a total of 52 items distributed over 20 pages (1–4 questions per page). The survey is available to review in Supplementary File 1.

The survey was designed to capture opinions from a diverse cross-section of UK adult men. All survey items were conditional and required a response; respondents were prompted to complete outstanding items before leaving the survey page on which the item was contained. Items were not randomised or alternated, and most items included a ‘None of above/ prefer not to say’ option. To prevent participants from completing the survey more than once, the Qualtrics XM platform uses browser cookies to bar repeat attempts. Respondents were able to review their answers before submitting them (through a back button). Usability and technical functioning of the online survey was tested before publishing.

Respondents were not excluded from the survey if they completed the items too quickly. The minimum completed survey was timed at approximately 3.4 minutes. Incomplete surveys were timed out after 7 days. Only completed responses were included in the dataset for analysis.

Data analysis

Medians and interquartile range (IQR) were calculated for continuous respondent characteristics, and N (%) was calculated for categorical characteristics, overall and by length of TRT usage (in years). We examined attitudes and behaviours by age group and TRT experience and perceptions using Chi-squared test and Kruskal-Wallis tests. Associations between demographics (including age) and delayed access to care (defined as 2 + years of experiencing TD symptoms without seeking treatment) were assessed using univariable and multivariable logistic regressions. A p-value < 0.05 was considered statistically significant.

All analyses were performed using STATA, version 15 (StataCorp LP, College Station, TX, USA). The Checklist for Reporting Results of Internet E Surveys (CHERRIES) was used to guide reporting [18]; Supplementary file 2.

Ethics Approval

The Imperial College Research Ethics Committee (ICREC) granted ethical clearance for this study (ICREC #6990009). All experimental protocols were approved by ICREC. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards [19]. All subjects provided consent by selecting the relevant tick box at the start of the online survey. Consent for publication is not applicable.

Patient and public involvement

Patients primarily from Manual, Optimale and H3Health were involved in the conduct of this research. The study protocol and online survey were developed in collaboration with Menwell Ltd, which included feedback from 15 lay members representing diverse employment roles and cultural backgrounds. The Survey was reviewed during beta testing to improve usability and wording of questions.

Demographic profile of respondents

A final sample of 905 out of 1,386 total responses were included in the analysis (completion rate: 65.2%).

Participant characteristics are summarised in Table 1. The median age of respondents was 44.0 years (IQR 38.0, 52.0), with a median BMI of 28.4 (IQR 26.2, 31.4), classifying most as overweight, and a median self-reported overall health score of 8.0/10.0 (7.0. 8.0), as assessed via EQ-5D. The majority identified as White (93%), sexually active (91%), employed (90%), partnered or married (77%), and 51% had completed a university degree or higher. Individuals who reported delayed symptom presentation were more likely to be slightly older with a higher BMI. All respondents reported their assigned sex at birth as male, with 99% maintaining the same gender identity, while the remaining 1% identified as "other," including non-binary, agender, or "prefer not to say." In view of this, we opted to refer to respondents as "men" throughout this article, however we acknowledge that low testosterone and symptoms relating to low testosterone are not limited to cisgender men.

The vast majority (96%) of respondents were active TRT users (compared to past users), with 38% starting within the past 6 months, 27% within 7–12 months, and 21% between 1–2 years. Subcutaneous and intramuscular injections were the most common methods of administration (66% and 37%, respectively), followed by creams and gels (12%). Specifically, 53%, 24% and 6% used these methods exclusively in that same order, while 15% utilised a combination of testosterone therapies.

Health-seeking behaviours

Among the 905 men who sought TRT, 85% delayed presentation for at least one year, with 24% experiencing symptoms for more than 5 years before seeking treatment. Age was a significant predictor: those who were older than 50 were 1.79 times more likely to experience prolonged symptoms compared to those who were younger (OR_{51 + yrs_vs_≤40yrs}: 1.79; p = 0.001). Multivariable associations adjusting for ethnicity, marital status, employment status and education confirmed these findings, with men older 51 and older 1.61 times more likely to have delayed presentation than those aged 40 or younger (OR_{51 + yrs_vs_≤40yrs}: 1.61; p = 0.01); Table 2.

Table 1

Participant demographics, overall and by duration of symptom experience prior to seeking care.
Demographic	Symptom length
	06 months		712 months		12 years		25 years		5 + years		Total
	(N = 25)		(N = 104)		(N = 252)		(N = 300)		(N = 224)		(N = 905)		p-value
	N	SD / %	N	SD / %	N	SD / %	N	SD / %	N	SD / %	N	SD / %
Age	44	(38.0, 48.0)	41	(35.0, 49.0)	44	(38.0, 51.0)	45	(40.0, 53.0)	45.5	(39.0, 53.0)	44	(38.0, 52.0)	0.002
BMI	27.8	(25.7, 32.9)	28.1	(25.6, 30.7)	28.7	(26.3, 31.4)	28.3	(26.2, 31.2)	28.9	(26.8, 32.3)	28.4	(26.2, 31.4)	0.194
EQ5D (Overall health score)	8	(7.0, 9.0)	8	(7.0, 9.0)	8	(7.0, 8.0)	8	(7.0, 8.0)	8	(6.0, 8.0)	8	(7.0, 8.0)	0.059
qADAM score	34	(31.0, 36.0)	35	(30.0, 37.0)	34	(30.0, 37.0)	34	(30.0, 38.0)	33	(28.0, 36.0)	34	(30.0, 37.0)	0.078
Male Gender at birth	25	100%	104	100%	252	100%	300	100%	224	100%	905	100%
White ethnicity	24	96%	94	90%	237	94%	272	91%	215	96%	842	93%	0.342
Education status													0.716
Alevels or equivalent	4	16%	14	13%	37	15%	36	12%	29	13%	120	13%
GCSEs or equivalent	1	4%	10	10%	24	10%	37	12%	27	12%	99	11%
Other	0	0%	3	3%	9	4%	6	2%	11	5%	29	3%
Postgraduate degree (e.g. MA, MS	4	16%	21	20%	52	21%	63	21%	32	14%	172	19%
Primary school	0	0%	0	0%	2	1%	2	1%	0	0%	4	0%
Secondary school / high school	3	12%	3	3%	8	3%	20	7%	11	5%	45	5%
Undergraduate degree (e.g. BA, B	9	36%	36	35%	77	31%	96	32%	75	33%	293	32%
Vocational qualification (e.g. N	4	16%	17	16%	43	17%	40	13%	39	17%	143	16%
Employment status													0.487
Employed fulltime	21	84%	97	93%	226	90%	262	87%	190	85%	796	88%
Employed parttime	1	4%	3	3%	4	2%	8	3%	5	2%	21	2%
Prefer not to say	0	0%	1	1%	3	1%	10	3%	3	1%	17	2%
Retired	3	12%	2	2%	15	6%	14	5%	21	9%	55	6%
Student	0	0%	1	1%	1	0%	3	1%	3	1%	8	1%
Unemployed	0	0%	0	0%	3	1%	3	1%	2	1%	8	1%
Current healthcare professional													0.063
No	20	80%	93	89%	238	94%	280	93%	208	93%	839	93%
Yes	5	20%	11	11%	14	6%	20	7%	16	7%	66	7%
Marital status													0.193
Divorced	1	4%	3	3%	16	6%	22	7%	21	9%	63	7%
Married	14	56%	52	50%	132	52%	169	56%	124	55%	491	54%
Partnered / in a domestic relationship	4	16%	26	25%	67	27%	67	22%	44	20%	208	23%
Single	5	20%	21	20%	37	15%	41	14%	33	15%	137	15%
Widowed	1	4%	2	2%	0	0%	1	0%	2	1%	6	1%
Smoking status													0.323
No	16	64%	55	53%	114	45%	154	51%	104	46%	443	49%
Current smoker	0	0%	2	2%	15	6%	10	3%	12	5%	39	4%
Past smoker	9	36%	47	45%	123	49%	136	45%	108	48%	423	47%
Sexually active													0.414
No	1	4%	6	6%	22	9%	27	9%	26	12%	82	9%
Yes	24	96%	98	94%	230	91%	273	91%	198	88%	823	91%
Mental condition													0.475
No	24	96%	97	93%	235	93%	276	92%	200	89%	832	92%
Yes	1	4%	7	7%	17	7%	24	8%	24	11%	73	8%
Depression													< 0.001
No	16	64%	57	55%	130	52%	147	49%	69	31%	419	46%
Yes	9	36%	47	45%	122	48%	153	51%	155	69%	486	54%
Anxiety													0.012
No	11	44%	48	46%	113	45%	129	43%	69	31%	370	41%
Yes	14	56%	56	54%	139	55%	171	57%	155	69%	535	59%
Eating disorder													0.292
No	24	96%	100	96%	246	98%	297	99%	216	96%	883	98%
Yes	1	4%	4	4%	6	2%	3	1%	8	4%	22	2%
Diabetes													0.051
No	25	100%	104	100%	245	97%	295	98%	213	95%	882	97%
Yes	0	0%	0	0%	7	3%	5	2%	11	5%	23	3%
Cardiovascular Disease													0.262
No	25	100%	104	100%	250	99%	294	98%	218	97%	891	98%
Yes	0	0%	0	0%	2	1%	6	2%	6	3%	14	2%
Stroke													0.302
No	25	100%	103	99%	248	98%	300	100%	221	99%	897	99%
Yes	0	0%	1	1%	4	2%	0	0%	3	1%	8	1%
Hypertension													0.543
No	21	84%	88	85%	201	80%	241	80%	172	77%	723	80%
Yes	4	16%	16	15%	51	20%	59	20%	52	23%	182	20%
Cholesterolemia													0.003
No	19	76%	92	88%	209	83%	230	77%	160	71%	710	78%
Yes	6	24%	12	12%	43	17%	70	23%	64	29%	195	22%
TRT status													0.301
Currently using TRT	25	100%	101	97%	236	94%	289	96%	216	96%	867	96%
Past user	0	0%	3	3%	16	6%	11	4%	8	4%	38	4%
Access to NHS													0.478
No	18	72%	56	54%	152	60%	166	55%	136	61%	528	58%
Yes	3	12%	23	22%	53	21%	60	20%	48	21%	187	21%
Unsure	4	16%	25	24%	47	19%	74	25%	40	18%	190	21%
Access to private healthcare													0.775
No	4	16%	16	15%	33	13%	52	17%	34	15%	139	15%
Yes	21	84%	84	81%	203	81%	229	76%	179	80%	716	79%
Unsure	0	0%	4	4%	16	6%	19	6%	11	5%	50	6%
Received low testosterone diagnosis													0.04
No	2	8%	1	1%	11	4%	5	2%	3	1%	22	2%
Yes	23	92%	103	99%	241	96%	295	98%	221	99%	883	98%
TRT type													0.684
Intramuscular testosterone (injection)	13	52%	34	33%	92	37%	114	38%	83	37%	336	37%
Intramuscular testosterone (injection)*	8	32%	17	16%	68	27%	67	22%	55	25%	215	24%
Intranasal testosterone gel
Intranasal testosterone gel*	0	0%	0	0%	0	0%	2	1%	0	0%	2	0%
Subcutaneous testosterone (injection)	14	56%	72	69%	162	64%	204	68%	147	66%	599	66%
Subcutaneous testosterone (injection)*	10	40%	59	57%	136	54%	158	53%	120	54%	483	53%
Topical testosterone gel/cream	4	16%	19	18%	24	10%	31	10%	27	12%	105	12%
Topical testosterone gel/cream*	2	8%	7	7%	16	6%	16	5%	13	6%	54	6%
Combination of methods used	5	20%	21	20%	29	12%	55	18%	33	15%	143	16%

**p-value refers to chi squared test or Fisher’s exact test for categorical variables, or Kruskal Wallis test for continuous variables

* Exclusive use of TRT method.

Table 2

Associations between age group and delayed access to care*
	Univariable			Multivariable**
Age group (years)	OR	95% CI	p-value	OR	95% CI	p-value
≤ 40	1 (Ref)			1 (Ref)
41–50	1.30	0.95, 1.89	0.10	1.25	0.91, 1.731	0.17
51+	1.78	2.36, 2.50	0.001	1.61	1.13, 2,39	0.01

*Delayed access defined as experiencing symptoms for more than 2 years prior to seeking care.

**Adjusted for ethnicity, marital status, employment status, and education

The majority (81%) of respondents turned to online sources to learn about TD, while fewer (18%) felt comfortable discussing hormonal health with their peers (Supplementary File 3). Less than a quarter (24%) felt adequately equipped with the knowledge and resources to manage their symptoms and navigate treatment options within the UK healthcare system. When seeking professional advice, 44% consulted their general practitioner (GP), 29% saw a specialist (e.g., urologist) and 28% consulted another healthcare professional. Nearly a third (31%) engaged with online forums, and 20% relied on websites to explore hormonal health and treatment options.

Before considering TRT, the most common lifestyle modifications included changes to exercise routines (66%), dietary adjustments (62%), the use of testosterone boosters including non-TRT supplements (46%) and stress management techniques (32%). The primary motivations for seeking treatment for low testosterone were the desire to improve personal relationships, including intimacy and communication (80%), and/or to enhance physical appearance (55%). Most respondents were not influenced by concerns about social acceptance of TRT or societal perceptions of masculinity when considering treatment for TD (59% and 58%, respectively).

Experience with testosterone replacement therapy

Patient expectations during medical consultations primarily focused on obtaining a diagnosis (77%), understanding their available treatment options (64%), discussing potential side effects (51%) and understanding the long-term implications of TRT (50%). Most patients (71%) anticipated a gradual improvement in symptoms with TRT, although 24% expected a more rapid response. Preferences for consultation format varied, with 19% favouring in-person consultations, 18% opting for telephone or online consultations, and the remainder expressing no strong preference.

A significant proportion (86%) of patients reported TRT as highly effective, with longer-term users (defined as having used TRT for more than 1 year) being 2.6 times more likely to rate TRT as effective or very effective compared to recent starters (OR_{1 + yrs_vs_0−6months}:2.6, p < 0.0001; data not shown).

Figure 1 details the occurrence of side effects, overall and stratified by TRT duration. Overall, 29% of respondents reported no side effects. The most reported side effects included acne (23%), testicular atrophy or reduced sperm production (24%), nipple sensitivity or gynecomastia (18%), increased blood viscosity (16%) and fluid retention (15%). Analysis of TRT treatment duration was conducted and found a significant increase in incidence of self-reported testicular atrophy (p < 0.001) and increased blood viscosity (p = 0.002). However, the incidence of other side effects remained low and showed only minor variation between short- and long-term users, suggesting a consistent safety profile of TRT over time (Fig. 1).

Overall, TRT users reported the positive impact of TRT in their overall quality of life (including work performance, social interactions and personal satisfaction; 75%), mental wellbeing (71%), self-esteem and confidence (69%) and appearance (61%).

Summary of key findings

We analysed data collected from 905 British adult men aged 21–80 years with TRT experience. This study expands on previous suggestions that there are significant challenges in the management and treatment-seeking behaviours of men with TD. Despite the considerable impact of TD on quality of life, 85% of the respondents surveyed delayed seeking care for more than a year, with 24% of patients experiencing symptoms for over five years before consulting a healthcare provider. Older men, who are at higher risk for TD, were also significantly more likely to delay seeking treatment.

TRT was reported as highly effective by 86% of respondents, noting overall increased quality of life (75%), mental wellbeing (71%), self-esteem and confidence (69%), appearance (63%), with few experiencing side effects from treatment. However, the lack of routine testing and awareness in the English primary care setting remains a major barrier to streamlining timely access to effective treatment regimen, particularly patients with TD symptoms.

Comparison with existing literature

Few studies characterised the average time from the onset of symptoms to a formal diagnosis of TD in men due to symptoms TD being relatively nonspecific, and consequently misinterpreted as part of the ageing process or as a result of apathy or depression [20, 21]. Studies that evaluated this diagnostic delay more often focused on symptoms of erectile dysfunction as the primary presenting complaint [22, 23], despite TD manifesting in a broader range of symptoms such as loss of libido, oligospermia, weakness, increased anxiety, fatigue and anaemia.

Conversely, several studies have assessed healthcare professionals’ awareness and understanding of TD diagnosis and treatment, highlighting the gap between clinical knowledge and patient engagement. Anderson et al surveyed 443 participants, including 88 HCPs, and found that while over 90% new TD cases were considered treatable, half of HCPs reported that patients rarely initiated conversations about their condition [24]. Similarly, a study in British Columbia investigated the awareness of TD among Primary Care physicians, reporting that while 96% were aware of TD and its health implications, more than half (57%) of the surveyed physicians encountered difficulties in diagnosing or treating TD due to a lack of education and awareness around hypogonadism care [25]. These findings suggest general awareness of TD may not translate into clinical confidence in managing the condition, resulting in delays to providing timely and effective care.

Several studies reported that education around the benefits and possible risks of TRT remained a key determining factor for whether a patient-initiated treatment. Gilbert et al [26] surveyed 97 urological patients and found that half were unsure of the risks of such treatments. Other studies that assessed patient satisfaction and motivation while on TRT indicate that patients were generally satisfied with their treatment, with mood and concentration being reported as some of the biggest improving factors [27]. These observations are supported by a wealth of evidence more recently summarised in the British Society of Sexual Medicine Guidelines on Male Adult Testosterone Deficiency, with Statements for Practice [11] also highlighting the metabolic, physical, mental, sexual and long-term health benefits of TRT. Interestingly, despite the evidence of the effectiveness of TRT and the positive impact it has on health and wellbeing outcomes, there was a high dropout rate from TRT [26, 28]. Whilst the reasons for this dropout rate are unclear, they may potentially be associated with cost (out of pocket expense) of accessing TRT outside of NHS, changing priorities, and/or because the patient was able to resolve their symptoms of testosterone deficiency to the extent that they felt TRT was no longer required. There is a need for continuous patient education, emphasising both the potential benefits of TRT and the importance of adhering to longer-term treatment plans to maintain the achieved results.

Implications for policy, practice and research

Delays in seeking care for TD may be indicative of broader systemic issues, including insufficient awareness amongst both the public and healthcare providers. The reliance on online information, with 84% of men turning to the internet for guidance coupled to the discomfort some men face in discussing hormonal health with their peers (18%), highlighting both how individuals access information today and the lingering stigma around TD. Furthermore, many healthcare providers are unfamiliar with the nuances of TD, often leading to delayed diagnoses and treatment. Combined, this knowledge gap may further discourage patients from initiating care during their interactions with their HCPs. In this regard, a more focused approach to TD management through guidelines may promote health and wellbeing outcomes for men by addressing common misconceptions and gaps in general awareness about the benefits and risks of TRT among both patients and healthcare providers.

There is also a need for greater attention to ensure more equitable access to TRT across diverse populations. More research is needed to understand the underlying socioeconomic and racial barriers (such as healthcare costs, lack of awareness or cultural stigma) to accessing TRT care, as these factors may prevent underrepresented groups from seeking and receiving timely care. Further research into TD that evaluates the health economic impact and lost productivity to economies would highlight the pressing unmet need in men’s health provision. Population health data could also support the case for streamlining timely and equitable access to care, coupled to policy directions, that call for further investments in men’s health. This research could be used to guide the development of policy directives to promote further investments in men’s health which is an area that continues to be overlooked, and to address disparities in equitable access of care and support from underserved segments of society.

Study strengths and limitations

To our knowledge, this is the first quantitative study to investigate perceptions and experiences of TRT users in the UK and includes a large sample size of 905 participants with a diverse demographic profile. We acknowledge several limitations including the electronic distribution of the survey which may have inadvertently excluded individuals with limited digital access. The principal limitations of this study are concerned with (i) reliance on self-reported data which may introduce bias as participants’ responses may be influenced by social desirability or lack of understanding around hormonal health, and (ii) the cross-sectional nature of the study which precludes the determination of causality between variables. We also acknowledge that the demographic profile of study participants largely consisted of white and university-educated men. Although this demographic may align with the broader population accessing TRT in the UK, it may also limit the generalisability of our findings.

Despite the positive health effects of TRT, the vast majority (85%) of men with testosterone deficiency surveyed delayed seeking care for their symptoms for more than a year, likely due to a combination of factors including cultural and societal narratives that trivialise TD and incorrectly associate symptoms with ‘normal ageing’.

As the prevalence of TD continues to increase, more research coupled to coherence education and awareness campaigns are needed to help educate men and healthcare professionals alike, regarding the signs and symptoms of TD, and possible treatment options.

Conflicts of interest

VL, DH, HJ, and JF are employees of Menwell Ltd. JF is the founder of H3Health. All other authors declare no competing interests.

Funding

This research received no funding. Austen El-Osta and Benedict Hayhoe are supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) Northwest London. The views expressed are those of the authors and not necessarily those of the NHS or the NIHR or the Department of Health and Social Care.

Acknowledgments

The authors wish to thank staff at Menwell Ltd for their support in survey beta testing and development.

Author Contributors

All authors provided substantial contributions to the conception (AEO, VL, DH, AA, BH and AEO), design (AEO, DH, VL, BH), acquisition (VL, DH, AA) and interpretation (VL, DH, JF, HJ, AA, BH, AEO) of study data and approved the final version of the paper. AEO took the lead in planning the study with support from co-authors. VL carried out the data analysis with support from HJ. AEO is the guarantor.

Twitter: @austenelosta @ImperialSCARU

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Competing interest reported. VL, DH, HJ, and JF are employees of Menwell Ltd. JF is the founder of H3Health. All other authors declare no competing interests.

A cross-sectional survey of experiences and outcomes of using testosterone replacement therapy in UK men

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Methods

Consent and data protection

Participant recruitment

Electronic survey setup

Data analysis

Ethics Approval

Patient and public involvement

Results

Demographic profile of respondents

Health-seeking behaviours

Experience with testosterone replacement therapy

Discussion

Summary of key findings

Comparison with existing literature

Implications for policy, practice and research

Study strengths and limitations

Conclusions

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1