‘I’ve got my mojo back, Doc!’ - would you take over Alan’s testosterone prescription?

Alan is 68. An online private clinic has diagnosed him with the ‘manopause’ after a blood test and prescribed testosterone gel. ‘It’s been amazing. I’ve got my mojo back, Doc!’  he enthuses, but (and there’s always a but…) he can no longer afford the private prescriptions. He hands you a letter and some blood test results and asks if you’ll take over prescribing. What would you do?

This is a scenario for all sorts of prescription requests that we are all increasingly familiar with, often driven by social media influencers and marketing. And for men, at the moment there are plenty of influencers and ads out there encouraging them to think if they may be ‘hormonal’ and lacking testosterone? Ask middle-aged and older men if they feel more tired than they used to, if their sex drive is lower, if sometimes they struggle to get an erection, and you will get a lot of positive responses. And who can blame men who say ‘yes please, I’d love some of that!’ - after all,  who doesn’t want to feel less tired, more energetic and have better sex?

So, it was timely that last week the BMJ published an excellent editorial BMJ 2026:395:e101080, discussing the rapid rise of commercial testosterone prescribing in the UK and the implications for the NHS. The potential market is huge, of course, since slowly falling testosterone levels are part of the natural ageing process. But we have to balance the risk of overdiagnosis of men with ‘non-specific symptoms and borderline biochemical findings’ and exposing them to unnecessary and potentially harmful treatment, whilst not missing cases of true testosterone deficiency when there is a significant fall in testosterone levels, which can have significant health implications and benefit from treatment. 

So, how do we balance these risks of potential under- and overdiagnosis? The editorial quotes the BSSM Guidelines on Testosterone Deficiency, which we also discuss as the primary reference in our recently updated Men’s Health Course for 2026. These guidelines recommend testing in men with suggestive symptoms, especially erectile dysfunction, loss of early morning erections and low libido, but deficiency can also present with more vague and varied symptoms, including fatigue, mood and cognitive changes. Diagnosis requires clinical features of testosterone deficiency plus a low, fasting morning testosterone level (< 12 nmol/L) on two tests at least 4 weeks apart. If true testosterone deficiency is confirmed, then testosterone replacement is indicated and can improve sexual function, muscle mass, bone mineral density, mood and cognition, which, if left untreated, could lead to long-term health problems including osteoporosis and sarcopenia. However, for men without true testosterone deficiency, treatment is not indicated and may expose them to long-term risks. 

There are also further complicating issues that we need to consider, such as excluding other causes for the presenting symptoms, interpreting borderline results, potential secondary causes of testosterone deficiency, thinking about potential contributing co-morbidities and the necessary monitoring on treatment. All of this is complex, takes time and is unlikely to have been provided by a rapid, online private clinic or pharmacy.

So, what about Alan? He shows you his results; he has had symptoms of sexual dysfunction and fatigue plus a testosterone level of 14 nmol/L. Regarding prescribing, GMC guidance is clear that the responsibility of care rests with the private clinic that initiated the prescription. We are not obliged to continue the prescription, and in Alan’s case he has not met the level of deficiency recommended by national guidance for treatment anyway. So, you listen and sensitively explore things with him, but you also advise that you cannot continue the prescription, that it would not be indicated with this result on the NHS, that the long-term benefits and risks are uncertain and that he needs to return to the private provider. But, of course, if he is unable to afford to do so and has to stop the treatment, you can of course explore his symptoms further and re-investigate. This is good for Alan, but has significant workload implications for us. As the editorial states, when patients who started treatment privately then return to us, it ‘will lead to the NHS absorbing the workload’.

For more on understanding this fascinating topic of testosterone deficiency, check out our brand new Men’s Health course, which is available now on demand. As well as a deeper dive into testosterone deficiency and prescribing, we also cover men’s mental health, the latest on PSA screening, LUTs and much more!