Doctors question Pentagon testosterone screening plan

Defense Secretary Pete Hegseth said the military will require testosterone-deficiency screening for active-duty and reserve personnel ages 30 and older, a move endocrine specialists say could lead to mistaken diagnoses and unnecessary treatment. The screenings are set to be added to annual health assessments, while service members under 30 may request testing.

In a social media video, Hegseth said the effort was meant to improve performance, resilience and long-term health. He said the initiative was not aimed at artificial enhancement and that troops could decline treatment, while describing the goal as restoring or optimizing physical capacity.

The Endocrine Society, a medical group focused on hormone disorders, said after the announcement that evidence does not support broad screening of symptom-free men for hypogonadism, the condition in which the body produces too little testosterone. The society said testosterone therapy is intended for diagnosed hypogonadism, not for improving strength, athletic performance, appearance or aging-related concerns.

Diagnosis can be complicated

Bradley Anawalt, chief of medicine at the University of Washington Medical Center and an endocrinologist who studies men’s health, told Ars Technica that broad mandatory screening raises ethical and medical concerns. He said he worries about unnecessary evaluations, wrong diagnoses and testosterone prescriptions that patients may not need.

Anawalt said clear medical causes of low testosterone include genetic conditions such as Klinefelter syndrome and problems involving the pituitary gland, including damage, dysfunction or tumors. He estimated those conditions affect at most about 1 percent of men.

Many other factors can lower testosterone, according to Anawalt, including cancer treatments, corticosteroids, opioids, anabolic steroids, obesity, HIV, surgery, trauma, stress, lack of sleep and aging. In some of those cases, testosterone replacement may not be the right response; for sleep deprivation, he said, rest would be the appropriate treatment.

Symptoms of true hypogonadism can include low libido, erectile dysfunction, reduced sperm count, breast enlargement or tenderness, fatigue, lower muscle mass, smaller testes, mood changes and hot flashes, according to the medical description cited by Ars Technica. Over time, low testosterone can also affect body hair, bone density and red blood cell counts.

Anawalt said the difficulty comes when men report common, vague problems such as low energy, poor concentration, mood changes or sexual changes. Those symptoms can have many causes and are not specific signs of testosterone deficiency, he said.

Testing and treatment carry risks

Anawalt also said testosterone testing can be unreliable unless laboratories use assays certified by the Centers for Disease Control and Prevention. He said hormone levels fluctuate, are usually highest in the morning and should be checked with repeat early-morning fasting tests before a diagnosis is made.

The Endocrine Society said a commonly used clinical threshold is near 300 nanograms per deciliter, though some clinicians use slightly lower cutoffs. Anawalt said some labs use unusual reference ranges, which can label men as deficient even when their levels would usually be considered normal.

Total testosterone results can also mislead clinicians, Anawalt said, because the unbound “free” form appears to be the active hormone. He said some men with higher body weight or diabetes may have low total testosterone but normal free testosterone.

For patients with clear hypogonadism, testosterone replacement therapy can restore bone density, muscle mass, strength and libido, Anawalt said. For men with normal levels, or only slightly low levels, he said the treatment is unlikely to improve performance.

Testosterone therapy can suppress sperm production, which may affect fertility plans, Anawalt said. Other risks include high red blood cell counts, acne, enlarged prostate and sleep apnea, while the TRAVERSE trial found conventional therapy did not further raise cardiovascular risk in high-risk older men but did show a possible increase in pulmonary blood clots, according to the Endocrine Society.

Anawalt said he fears the Pentagon plan could turn into a large uncontrolled experiment and fuel unnecessary testing outside the military. He said the available evidence and past experience support caution and further study before treating testosterone as a broad performance tool.

This story draws on original reporting from Ars Technica.