The Explainer: Father’s little helper

Is testosterone therapy the fountain of youth? If so, WWWD? (What Would WADA Do?)

As a retired lawyer and long time cyclist, I thoroughly enjoy your column.

Here’s one that might be arising more in the Masters’ ranks, which have had their share of doping positives, recently.

Doctors are increasingly treating below normal testosterone levels with (and Big Pharma is increasingly promoting) testosterone replacement therapy for older men. The therapy is based on research that tends to show that below normal T levels lead to various premature aging symptoms, low energy levels and low sex drive.

For those who race in the masters’ classes, is a TUE available for this therapy, with or without limitations? If not, is there any effort by WADA to consider it?

Given the threshold method of triggering tests, the ratio of epitestosterone to testosterone, would it even come up in testing if the therapy resulted in levels in the “normal” range?

Your hypothetical for the day.
― Larry

Dear Larry,
First off, let me thank you for your kind words. Given my relatively short time as an attorney (I’m just three years out of law school), I am always nervous when other lawyers – especially the experienced ones – read this column. Like anyone, I appreciate the kudos, but I do want to encourage anyone to send me a note if they notice a bone-headed mistake. I will correct those and make note of them.

Now, to your questions. The quick and simple answer regarding testosterone is yes. The World Anti-Doping Agency does make an allowance for the therapeutic use of testosterone. However, before we see the entire middle-aged masters’ peloton veer off to the doc’s office, you need to keep in mind that according to the rules, a Therapeutic Use Exemption (TUE) for testosterone is issued under the narrowest of circumstances. Most of us would probably not qualify.

Under the current WADA Code, a national doping agency is permitted to issue a TUE for testosterone only after an athlete has been diagnosed with primary or secondary “hypogonadism.” In other words, the testes are not producing enough of the hormone to bring the level of what is considered “normal.” (NOTE: While testosterone replacement therapy is offered to women in rare cases, WADA has concluded that there are more effective alternatives, so no TUE for testosterone will be granted to females under current rules.)

The definition of “normal” is based on several factors, chief among them age. Measured in nanograms per deciliter (ng/dL), normally blood testosterone levels in the general population of adult males run anywhere between 300ng/dL and 1000ng/dL. Of course, a 24-year-old with blood levels of 300ng/dL would be a cause of concern for his doctor. That same level in his 85-year-old grandfather might be considered to be within normal parameters.

Generally in a healthy and relatively young male, a serum testosterone level below 350ng/dL is considered to be a cause for concern and would make the patient a candidate for treatment.

However, it’s important to note that low testosterone levels due to the normal aging process are usually characterized as “functional” hypogonadism and would not qualify for a WADA-issued TUE. What would qualify is hypogonadism that is the result of a medically defined cause.

Rather than get into an analysis of each contributing factor recognized by WADA, I am simply including the causes of primary and secondary hypogonadism for which the agency says it would consider a TUE:

Primary hypogonadism
Klinefelter syndrome, bilateral anorchia, cryptorchidism, Leydig cell aplasia, male Turner syndrome, Noonan’s syndrome, congenital adrenal hyperplasia.

Secondary hypogonadism
panhypopituitarism, idiopathic hypogonadotropic hypogonadism, Kallmann’s syndrome, constitutional delay of puberty, LH deficiency, Prader Willi syndrome

That’s the general list and there are other contributing factors for which WADA – or a national anti-doping agency – could consider a TUE request. The bottom line, though, is that anyone seeking a TUE for testosterone must submit a detailed diagnosis, with supporting medical evidence, to justify the claim that his low serum testosterone levels are due to one of the medically recognized causes.

In the words of the U.S. Anti-Doping Agency (USADA), “It is extremely unlikely that a Therapeutic Use Exemption will be approved for ‘functional’ hypogonadism (a diagnosis of hypogonadism based on low testosterone levels but without a defined etiology).”

Getting old sucks. Is there a cure?
So let’s assume that the members of our hypothetical field of masters racers are not suffering from any of the aforementioned afflictions, but merely “functionally” hypogonadistic. The theory is that these men, too, would benefit from testosterone replacement therapy and you’re right, Larry, there has been an increase in interest (and marketing) in recent years, especially as we Baby Boomers get older.

Aging is a key factor in reduced testosterone levels in men. According to one study (Vermeulen A and Kaufman JM [1995] “Ageing of the hypothalamo–pituitary–testicular axis in men.Hormone Research 43, 25–28) about seven percent of men between the ages of 40 and 60 have serum testosterone levels below 350ng/dL. That number increases to 21 percent for men between 60 and 80 and 35 percent for men 80 and older.

The symptoms of low testosterone levels – even those due to aging – are not pretty. There is the whole diminishing libido thing. (Of course, if that’s a problem, then the other common symptom, erectile dysfunction, probably won’t bother a guy as much.) But beyond those, there is a decrease in muscle mass, fatique, increased abdominal fat, loss of bone mass, frequent urination, high cholesterol and depression (probably caused by all of the other symptoms).

Like the Stones said, “what a drag it is getting old.”

So, would restoring those levels back to the way they were when you were 25 help reverse some of the symptoms of the normal aging process? Some studies say yes … and some studies say no. There is a big study going on right now, sponsored by the National Institutes of Health, which involves tracking 800 men over the age of 65 who are using a gel-based testosterone supplement. So, we may have a more definitive answer once all of the data is reviewed in the next year or so.

One thing is for certain, though. While there may be benefits that accompany testosterone replacement therapy for functional hypogonadism, there are risks, too. One key concern is the effect testosterone supplementation will have on the reproductive system, especially the prostate.

Exogenous testosterone can contribute to an enlarged (but non-cancerous) prostate, a problem known as benign prostatic hyperplasia (BHP) and some studies indicate that it can also contribute to the growth of cancer cells in the prostate.

The magic elixir: Daily use and we'll all look like this ... right? | 1982 - Universal Studios

Exogenous testosterone can also result in a decline in the production of natural testosterone, as the body adjusts in response to unnatural increases in serum levels of the hormone. That can also result in decreased production of sperm to the point that fertility may be put at risk.

The natural conversion testosterone to estrogen can also contribute to the growth of the much feared “man boob,” with men experiencing enlarged and tender breast tissue.

Indeed, the aforementioned side-effects are to be considered so potentially serious that any male with high risk factors for prostate or breast cancer (hey, it does happen) is automatically off the list of potential candidates for testosterone replacement therapy.

There are other side-effects, including liver toxicity, sleep apnea, fluid retention and increased risks of other cancers.

On a somewhat positive note, doctors also warn of one side-effect that would actually play pretty well with our little peloton of aging cyclists, though: Polycythemia. Yup, that’s an increase in the production of red blood cells. Unfortunately, that is also accompanied by an elevated risk of heart attack and stroke, not something you want to toy with in an age group whose cardiac risk factors are already on the increase.

Gee … this “therapy” sounds appealing, doesn’t it?

Since we’re in hypothetical mode, though, let’s assume that the NIH study comes back with stellar results and all of the 800 test subjects emerged from their two years with the strength, energy and looks of a 25-year-old. As a result, our masters all opt to take the chance and go with the therapy …. USADA be damned.

You asked if they might test positive in the rare event that USADA’s testers show up to request samples from the men’s 55+ field. The simple answer is yes. The initial test is based on the famed T/E ratio, the same test that caught Floyd Landis at the Tour de France. That test, for all of its flaws, is based on the assumption that the body produces testosterone and epitestosterone at about the same levels. WADA allows for some wiggle room, and the Dope-O-Meter™ isn’t tripped until the T/E ratio exceeds four-to-one (Landis, by the way, was 11-to-1).

Further study – using the Carbon Isotope Ratio test – would show that the elevated ratio is due to the presence of exogenous testosterone and that could result in a two-year suspension. In other words, that lucrative masters’ racing career could be at risk.

So in conclusion, testosterone therapy should probably be considered by a relatively small number of those for whom it might prove beneficial, especially if you want to live by the rules of our sport.

For the rest of us … well, I always like to remember the words of Mark Twain, who observed that “age is an issue of mind over matter. If you don’t mind, it doesn’t matter.”
– Charles

The Explainer is now a weekly feature on Red Kite Prayer. If you have a question related to the sport of cycling, doping or the legal issues faced by cyclists of all stripes, feel free to send it directly to The Explainer at [email protected]. PLEASE NOTE: Understand that reading the information contained here does not mean you have established an attorney-client relationship with attorney Charles Pelkey. Readers of this column should not act upon any information contained therein without first seeking the advice of qualified legal counsel licensed to practice in your jurisdiction.

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  1. Jesus from Cancun

    Very interesting read. I am 45 and sooner or later I will be getting there…
    However, shouldn’t this be filed under “body” rather than “mind”?

  2. David Hendry

    I keep wonedring when this whole drug banning culture is going to go away. There is not a single person participating at high level competition in any sport that would meet the criteria laid out by the Olympic committee from a century ago. Things that are considered normal and legal now, protein supplements were unavailable then. you need a doctor and a lawyer on your team now to stay on the right side of all these arcane rules and for what reason. Because self serving anti drug crusaders want to pretend that what athletes are putting themselves through in the name of better performance is normal and healthy. When we get past all this everyone will be able to ingest whatever they want, the playing field will still be even and the true potential of the human body and spirit will be challenged.

  3. Charles Pelkey

    In reply to: David Hendry,
    I would welcome the opportunity to debate this issue in greater detail at some point, but the comments section of a column probably isn’t the place to do it. Nonetheless, let me offer a couple of observations.

    You assert that “anti drug crusaders want to pretend that what athletes are putting themselves through in the name of better performance is normal and healthy.” Frankly, I am not sure that anyone is claiming that putting the body through the stresses, strains and damage of, say for example, a three-week grand tour is normal or all that healthy. What bothers me, though, is that you appear to use that as an argument in favor of doping.

    I would, on the other hand, point to that as an argument AGAINST doping. At best, modern medicine’s efforts to adjust the human body’s reactions to those stresses is quite crude. Diminished testosterone? Well, let’s just add more. The consequences – the aforementioned side-effects of drugs – are often more serious than the original illness, leading to the medical issues described in the article and worse.

    Your let-them-all-dope approach would then put the onus upon those clean athletes, who chose to compete without drugs, to make that horrible choice of either keeping up or taking drugs. Call me an anti-doping crusader, David, but I would much rather do what I can to root out the cheats than to make cheating legal and force the honest competitor into even considering that Faustian bargain.

    If you think I am missing your point, or summarizing your arguments inappropriately, let’s debate this thing in greater detail. Just drop me a line at [email protected].

  4. ken c

    Totally disagree w/ previous poster. The rules aren’t that difficult, the list is published, if your taking something on the banned list, your cheating. You stated that you need a doctor and a lawyer on your team to stay on the right side of the rules, I would argue that if you feel you need a doctor and a lawyer, chances are your probably violating at least the spirit of the rules. Remember when all the pro teams had blood centrifuges to make sure the riders made the red blood cell limit? My point is that while you may be within legal limits (e.g. 50% red blood cells, 4:1 testosterone) your certainly playing a game w/ the rules. I don’t think anyone wants to return to the late 90s early 00s, where drug use was so rampant in the sport. Sure it was spectacular, guys drilling it up hill day after day. But you also had a trail of medical waste (blood bags syringes etc) left at hotels etc. Remember we’re not dealing with a few pills or injections in the off season, it was doctors IV bags, refrigerated blood. I don’t think the viewing public wants that.

    On to the topic of low T and masters. There is no doubt in my mind that there are more than a handful of masters doping. Everyone wants to win, that’s why one races. But I promise you johan bruyneel is not scouting the 40-45 looking to fill a spot on his TDF team. That ship sailed 20 years ago and you/we were not on it. Not the end of the world, but get over it. What is/was great about masters racing is that a bunch of working stiffs could get out there on the weekend knock the crap out of each other, hopefully stay up right, and grab a beer afterwards. There’s no payday, there’s no mega contract in the balance, so why would one risk health, family etc.

  5. Bikelink

    The therapeutic use of testosterone is perhaps different than the use of other drugs for performance. IF the current study (and others over time) show that testosterone improves health and is safe (when used as they did in the study, etc etc), then that’s markedly different than injecting epo, getting blood transfusions, or taking amphetamines, none of which make you healthier (though the level of hazards with them vary). As a 42 y/o cat 4 road and track racer, I hope they don’t allow testosterone supplementation for anything but severe disorders (from what you described, sounds good). Hey, if you want to take testosterone for the perceived health benefits, more power to you, but then don’t compete. If you compete on testosterone legally, that essentially forces the rest of us (who may be eligible to take testosterone in that scenario) to do so to be ‘competitive,’ and believe me just because one study has good results, that doesn’t mean it’s all good/safe (e.g., longer term safety will still need to be studied, other studies will validate it, etc).

  6. Chris Lumley

    Does DHEA trip the dopometer? I take it because it makes me feel marginally less nearly dead, and from what I’ve read it leads to more testosterone production. I don’t compete- old tired fat people waddling on their bikes?- but I’m curious. I think I remember Tyler Hamilton testing positive for it, but have not seen it mentioned otherwise.

  7. Steve

    I’m torn. I want to win. I don’t want to win by cheating.
    I haven’t won shit since my 20s. I’ve always had low testosterone. (47 yr old who can’t grow a full beard!)
    I have not yet see a doc to find out my testosterone level is, but I would bet you a beer it’s lower than yours. If its 349, is it cheating? How about if it’s 351? What is the difference?

    I should just give up and get fat!

  8. Steve

    I want to win, but I haven’t won shit since my 20s. I have low testosterone (I am 47 and still can’t grow a full beard.)
    If my test put me at 349, would I be cheating if I supplemented with testosterone? what about if I scored a 351? What’s the difference?

  9. Rod

    With regard to what David Hendry mention about the “playing field being even” – that’s a widespread fallacy.

    It is true that doping wouldn’t make a Cat3 like me challenge the KoM on the Tour. But remember that the physiology of every athlete is different. An easy example are the hematocrit markers; none of the Pro riders are anemic, but their base levels are different. Imagine two athletes; one who started at 42% and another that started at 45% and another whose baseline is to 48%. Now take it to an egregious level that’s just below lethal with the proper care (say they take old Riis and blow it, to 65%). The gains on the second athlete are SMALLER than for the first. So it wouldn’t be a level playing field – it would be a new playing field. Now consider the recovery aids, etc. It becomes very complex.

    If we are going through that path, might as well make a “full open” competition. Allow for mechanized limbs, servo-assisted joints, muscle grafts… Those cyborgs would be very fast, I bet the kilo would be under 50 s. But it is no longer cycling as we know it. It’s a different sport.

    I don’t know the opinion of the rest of the field, but I get the same excitement watching riders struggling up a hill at 18 km/h and at 20. I don’t need a new record every time there is a race, would rather they not have people screw up their health (e.g. Pantani, F. Griffith, and the poor bastards that discovered that slurry for blood can cause a stroke).

  10. Fat Monte

    As a 47 year old, I’ve been tested for testosterone levels several times in my 40s. On a couple occasions, I’ve tested on the low side of normal. My family doctor was quick to put me on AndroGel. Ta-da, problem solved, right? A follow-up with the endocrinologist proved testosterone replacement therapy isn’t quite so cut-and-dried.

    It seems that as you take the testosterone supplement, your body comes to rely solely on the AndroGel and stops making its own testosterone. In short, you become completely dependent upon the supplement (see side affects in the story).

    So understand, once you start, you can’t go back, much to the delight of Abbot Laboratories. You’re on it for life.

    Therefore, I remain a borderline-low testosterone bike rider, where I’ll probably stay. It’s just not worth it to risk manboobs, cancer and other side affects — and to have to pay for the privilege the rest of my life.

  11. The_D

    Aging is not all bad. As someone who loves cycling but naturally sucks at sprinting, is slightly-above-average in climbing and is a middling time trialist on a good day, I am planning on using aging as a the great leveller; basically, I will just try to “out-health” more gifted people so that at some point in the distant future, I will have aged slightly less than my peers, and will finally be able to win one. Oh, and out-healthing, but its very nature, requires the avoidance of all leading edge and high-risk pharma.

  12. bbrackem

    Fat Monte you are not quite right. Coming off T shots or gels is possible and happens frequently with male patients. It is not a lifetime commitment as you state. You are correct, your body does produce less of its own testosterone when exogenous T is used. But once stopped, the body will trigger the appropriate mechanism to restore production to previous therapeutic levels.

  13. Paul

    I look at this slightly differently: young men and women should have a chance to compete without having having to destroy their bodies through chemistry. If we accept the arms race, it means nobody has a chance to win without being willing to gamble away their health. Young people are not equipped to make those decisions.

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