Middle-aged Swiss men are chasing testosterone. Doctors aren’t sold.

Testosterone levels have declined by around 54% between 1972 and 2019. Keystone / Urs Flueeler

Widely prescribed in the US, demand for testosterone replacement therapy (TRT) is rising in Switzerland, putting pressure on doctors to get a complex diagnosis right.

N.U., a 47-year-old man living in Switzerland wasn’t feeling like himself. Fatigue, lack of libido, and reduced mental and physical performance were negatively affecting his life. N.U, who wished to remain anonymous, suspected low testosterone could be responsible for his symptoms.

Testosterone is the major male sex hormone that is responsible for puberty and increases muscle size, bone density, sex drive and sperm production. Low testosterone can cause fatigue, as well as reduce sex drive and muscle size. A new scientific analysisExternal link published in July based on data from 12 studies covering seven countries and over 100,000 participants shows that testosterone levels have declined by around 54% between 1972 and 2019. Obesity and diabetes likely played a role, according to the researchers. Chemicals in the environment and household goods are the other suspects.

A Google search led N.U to the website of TRTDoc, an online Swiss medical consultancy specialising in testosterone deficiency diagnosis and treatment. The consultation platform is run on a part-time basis by doctors who were seeing an uptick in patients enquiring about TRT in their regular clinical practice.

“I looked up the symptoms a lot on Google, as well as studied research findings and realised that very little is discussed about this topic in Switzerland and that doctors have almost no knowledge of it. No doctor had previously pointed out to me that these symptoms are possible with low testosterone levels,” N.U told Swissinfo by email.

N.U booked an online consultation with TRTDoc via Zoom and got the recommended two blood tests done two weeks apart at a nearby clinic. Both tests showed very low levels of the hormone, and a diagnosis of low testosterone levels, also known as hypogonadism, was made by TRTDoc based on his symptoms. He was prescribed a self-injectable testosterone therapy.

N.U told Swissinfo that TRT has improved his quality of life and that his libido is back. According to him, he also has more energy and is more productive.

“I would take this step again in a heartbeat,” he says.

According to Andreas Gutwein, one of the three doctors who run TRTDoc, most of his patients are middle-aged men working in a highly stressful job and they are looking for a solution to have more energy through the day. They’ve often failed to get the help they need from the Swiss healthcare system because they feel their family doctor dismisses or overlooks their concerns.

“So many men do not receive adequate support. Some do not talk about their symptoms because of shame. Others consult their family doctor but feel that their concerns are not taken seriously or that the doctor is not sufficiently familiar with the topic,” says Gutwein.

In the US, TRT for men’s health is all the rage

Someone who knows all about testosterone deficiency is 99-year-old Bruno Lunenfeld. He studied medicine in Geneva from 1945 to 1954 and is Professor Emeritus of Endocrinology at Bar-Ilan University in Israel. He is known for his pioneering work in the role of hormones in post-menopausal women and their applications in treating infertility. Lunenfeld realised that men were also suffering from similar problems as they aged.

Ageing male research pioneer Lunenfeld has been on testosterone therapy for nearly three decades. Bruno Lunenfeld

“We saw symptoms like drop in sex drive, loss of muscle, fatigue and testosterone was decreasing with age in men to levels consistent with hypogonadism. So we assumed and demonstrated that testosterone would be an ideal solution to re-establish the quality of life of men,” he told Swissinfo.

Lunenfeld founded the International Society for the Study of the Aging Male (ISSAM) in 1997 in the UK to promote research on the health of men over the age of 30 and he was the editor of its of its official journal Aging Male until 2024. The Society and the Journal helped destigmatise the use of testosterone in age-related hypogonadism through research, addressing fears surrounding testosterone use and liver toxicity, prostate cancer and cardiovascular problems.

The Austria-born, Israeli national, now lives in Delray Beach, Florida and practises what he preaches. He has been taking testosterone for nearly three decades since the age of 70. His second wife, who is two decades younger than him, injects him with a long-acting version called Nebido every three months. He is certain that testosterone and his wife’s care have improved his quality of life and allowed him to travel around the globe.

“I spent my 99^th birthday on a cruise from Melbourne to Singapore and plan another cruise in September and hope to spend my 100^th birthday with my family,” he says.

Research and surveys suggestExternal link that around 40% of men in the US under 40 years of age have shown interest in TRT, and nearly 14% are using or have previously used TRT. Even though US Medicare and private health insurers have strict requirements for covering the costs of TRT, the number of people treated with testosterone increased by 27% between 2018 and 2022, most of which occurred after the onset of the Covid-19 pandemic in 2020. Researchers believe that magnitude of change in new patients on TRT may stem from treatment outside standard medical protocols offered by direct-to-consumer platformsExternal link given their ease of access.

“TRT requires time, individual care and close follow up” says Gutwein.

He says one reason men are resorting to specialised US-style clinics is because they are not completely satisfied with the treatment offered by their healthcare provider.

“Public hospitals often have limited resources for this type of long-term personalised care, which contributes to the shift towards private providers,” says Gutwein.

Swiss caution

Like the US, Swiss health insurers only reimburse TRT costs if prescribed by a doctor and only the long-acting testosterone version called Nebido that retails for around CHF83 ($102) per 4ml dose. For other versions, like short-acting Testoviron (a pack of three ampoules totalling 250mg costs around CHF52 and lasts between two to four weeks) or testosterone gels, the patient’s doctor will have to make a special request to the insurer or supplementary insurance is required.

Doctors who suspect their patients may be showing signs of low testosterone will ask them to get two blood tests done before diagnosis because levels can be skewed by illness or poor sleep. According to Gutwein, even if doctors are aware of the symptoms, diagnosis remains challenging because there’s a lack of strict and universally accepted cutoff values for low testosterone. This creates uncertainty, especially for less experienced physicians and can lead to underdiagnosis.

In most labs in Switzerland, the normal range for testosterone is between 10 and 30 nanomoles per litre (about 288 to 865 nanograms per decilitre), according to endocrinologist Georgios E. Papadakis, who works at the Lausanne University Hospital (CHUV) in western Switzerland.  He expects a man under the age of 40 to have at least 12 to 14 nanomoles per litre of testosterone but the cutoff depends on the age.

To make things more complicated, blood tests only measure total testosterone. The biologically active part called free testosterone (it accounts for between 1% to 3% of total testosterone) is much harder to measure and depends on the levels of other hormones in the body. Papadakis acknowledges that there is a grey zone where patients have borderline levels of total testosterone and show some symptoms but it’s not clear if they are related to testosterone deficiency.

“Sometimes we will try treating such borderline cases for six months and see, if there is a positive effect on well-being, on symptoms, on quality of life. For these cases we do a trial using testosterone gel first as it has a short-term effect and does not shut down the body’s own testosterone production,” he says.

The disadvantage of testosterone gels is that they must be applied every day.

Benefits versus risks

The endocrinology department of CHUV under the supervision of Papadakis treats around 500 men with testosterone. His clinic has seen a 50% increase in the number of patients over the last ten years but this is likely the tip of the iceberg. Papadakis believes that the majority of those on TRT do not have doctor’s prescription and have bought it off the internet.

“I think the real health crisis is the overuse of testosterone, which of course was already the case in the US 20 years ago. And now it’s coming to Europe. What is also contributing are all these theories about how testosterone helps build your leadership and how it helps rediscover your masculinity,” says Papadakis.

He warns that few men realise that injecting testosterone reduces their own production of the hormone and also negatively affects their fertility. Overdosing on testosterone for long periods of time stimulates the creation of too many red blood cells which in turn can cause cardiovascular problems and strokes.

“The problem with testosterone treatment is that it’s safe when it’s used for the right patient and when it’s prescribed by a doctor who has experience, but it needs monitoring. Also, it’s a treatment that is difficult to stop,” says Papadakis.

This precautionary approach to testosterone replacement therapy can give patients the impression that doctors are reluctant to take their symptoms seriously. The fact is that only a small minority of men are candidates for TRT.

 “I’d say only 10% qualify for TRT. The biggest part of our job is to inform the patient that there is no problem. And they should address obesity in most cases and other problems, but not testosterone deficiency,” says Gutwein.

Edited by Virginie Mangin/ds