Commercial testosterone prescribing is widening beyond strict diagnostic criteria
The rapid growth of testosterone prescribing is moving treatment away from men with well characterised hypogonadism and toward people with non-specific symptoms, borderline biochemical results, and uncertain benefit. In the UK, the market for testosterone replacement was valued at about $205m in 2024 and is projected to reach $365m by 2032. NHS dispensing has already risen sharply, with community supply increasing by 52% between 2020-21 and 2024-25. In England, the number of women aged 50 or older receiving NHS testosterone gel rose from 429 in November 2015 to 4675 in November 2022.
Those figures describe recipients rather than prescriptions, so they cannot show appropriateness. They do show momentum. When prescribing rises faster than diagnostic discipline, the line between evidence-based replacement and lifestyle-driven hormone use begins to blur, and primary care is left to sort out the consequences.
Private testosterone use is harder to measure because national recording does not capture it. Even so, a growing network of private and online clinics, monthly subscription fees of £100 to £375, home delivery, remote monitoring, and heavy social media promotion point to a substantial and expanding market. Prescription-only medicines cannot legally be advertised directly to the public, but indirect marketing through testing packages and service promotion creates a clear route to wider use.
Borderline symptoms are not the same as confirmed deficiency
The clinical problem starts with diagnosis. Testosterone deficiency can cause reduced libido, erectile dysfunction, fatigue, low energy, depressed mood, and impaired quality of life. Yet the diagnostic pathway is deliberately cautious. Two fasting testosterone samples are required, total testosterone below 8 nmol/L confirms deficiency, and values between 8 and 12 nmol/L fall into a possible range rather than a definitive one. Reversible causes must be excluded before therapy is started, including obesity, sleep apnoea, depression, and medication effects.
Obesity deserves particular attention because it can produce low testosterone concentrations without true gonadal failure. This pseudo-hypogonadism often responds better to weight loss than to hormone replacement. In practice, that distinction can be obscured when clinics are designed for speed, not deliberation. Subscription-based models built around rapid access and symptom marketing are poorly suited to a diagnostic process that depends on repeated testing, clinical context, and exclusion of alternative explanations.
General practice is often the place where diagnostic uncertainty lands. Men may arrive already taking testosterone after a private assessment that used a more permissive threshold, sometimes treating symptoms alongside levels up to 15 nmol/L. Once treatment has begun, clinicians in the NHS are asked to continue prescribing without always having the original rationale, the biochemical evidence, or the documentation showing whether reversible causes were assessed first.
Prescribing thresholds differ, but monitoring responsibilities do not
Professional guidance does not speak with one voice. The British Society for Sexual Medicine recommends therapy when symptoms are present with testosterone below 12 nmol/L, or below 14 nmol/L in people with non-diabetic hyperglycaemia. Society for Endocrinology guidance suggests replacement in men with three sexual symptoms — decreased libido, loss of morning erections, and erectile dysfunction — plus testosterone below 11 nmol/L.
Different thresholds reflect different interpretations of the same biological uncertainty. Serum testosterone is only one part of the picture, and symptom burden does not always map neatly onto a hormone value. Even so, once treatment is initiated, the follow-up burden is unambiguous: blood tests, symptom review, dose adjustment, and surveillance for adverse events. When treatment starts in the private sector, that burden can migrate quietly to the NHS.
A national pathway would help clarify documentation, referral, monitoring, and transfer of responsibility. General practitioners need to know why treatment was started, which criteria were used, and whether shared care has been formally agreed. Without that structure, clinicians inherit risk without receiving the full clinical record.
Cardiovascular and thromboembolic risks are likely to reach NHS clinics
The clearest signal of downstream burden comes from adverse-event management. In Traverse, a randomised, placebo controlled trial of 5246 men aged 45 to 80 years with confirmed hypogonadism and cardiovascular risk, testosterone was non-inferior to placebo for major adverse cardiovascular events over a mean treatment duration of around 22 months and a mean follow-up of 33 months. Yet the active arm had significantly higher rates of atrial fibrillation, acute kidney injury, and pulmonary embolism. Atrial fibrillation occurred in 3.5% of men receiving testosterone versus 2.5% on placebo.
The safety profile matters because it matches the physiology. Testosterone can influence haematocrit, fluid balance, arrhythmia susceptibility, and thrombotic risk, so even when major cardiovascular events do not diverge, smaller but clinically important harms can emerge in parallel. Those harms require recognition, investigation, and long-term follow-up. In the NHS, that means cardiology review, renal monitoring, and assessment of venous thromboembolism risk when complications appear after private initiation.
This trial cannot be stretched beyond the population that entered it. It involved men who met inclusion criteria for confirmed hypogonadism and cardiovascular risk, not the wider group receiving testosterone for borderline results or vague symptoms. Still, the adverse-event pattern warns against assuming that replacement therapy is benign once the prescription is written.
Women are entering the same policy gap
Women are also being drawn into testosterone prescribing, mainly for low libido associated with menopause. UK guidance allows use when hormone replacement therapy is insufficient, but the only licensed female-specific cream, Androfeme, is not yet NHS funded. Off-label use of products licensed for men has therefore become common, with careful dose reduction needed to avoid androgenic effects.
Some general practices decline to prescribe and refer to specialist services instead. The volume of private prescribing in women, and the number of NHS referrals that follow it, remains poorly characterised. That missing data leaves a second blind spot: the NHS may be absorbing follow-up, monitoring, and treatment of side effects without knowing how many patients entered the system through private care.
Shared care without documentation shifts risk to the NHS
GMC and BMA guidance makes the prescriber who initiates treatment responsible unless an NHS GP formally agrees to shared care. If the GP declines, responsibility remains with the original clinician. Yet patients often return to general practice informally for blood tests, repeat prescriptions, or management of side effects. In effect, the NHS can absorb the workload without a formal agreement or a complete treatment record.
Audits show that around a third of shared care prescriptions lack up-to-date monitoring. With testosterone, that gap is especially concerning because the medicine is usually intended for long-term use and requires ongoing reassessment. A reporting framework for private prescribers and dispensing pharmacies could capture indications, patient numbers, monitoring, and transfers of care. Without that transparency, clinicians are left to manage a growing treatment stream whose scale, appropriateness, and safety profile remain only partially visible.