The rapid expansion of private testosterone prescribing risks extending treatment beyond men with clearly defined need to people with non-specific symptoms and borderline test results, for whom the balance of benefit and long term risk are less certain, warn experts in The BMJ today.
Stephen Atkin and Eric Kilpatrick argue that the complexity of care is seldom covered in commercial testing, so managing the longer term risks of testosterone therapy will likely fall to the NHS.
In 2024, the UK testosterone replacement market was valued at around $205 million and is projected to reach $365 million by 2032. NHS figures show community dispensing increased by 52% from 2020/21 to 2024/25 alongside a ten-fold rise in testosterone gel prescriptions for women aged 50 and older in England between 2015 and 2022.
Private prescriptions are not recorded nationally, so the scale of private testosterone provision is unknown, explain the authors. However, several indicators suggest rapid growth: a proliferation of private and online clinics, subscription pricing of £100-375 a month (to cover ongoing monitoring, remote consultations, and home-delivered medication), and heavy marketing via social media, influencers and outdoor advertising.
The market is potentially large, they add. Declining testosterone and libido are natural aspects of ageing, and up to a fifth of men over 50 may report deficiency symptoms, although under 1% receive treatment in the NHS.
Diagnosis takes time and repeated testing. It is not established how consistently private providers do this, but they warn that rapid access subscription models built around marketing non-specific symptoms "are unsuitable to handle the complexity of the diagnostic process and risk unnecessary lifelong treatment and a resulting NHS monitoring burden."
For testosterone therapy in men, clinicians rely on professional society guidance with differing thresholds, they write, meaning NHS clinicians may see patients who have already started taking testosterone against a more permissive private threshold.
They point to the longer term risks of testosterone therapy, such as heart and kidney problems that need ongoing monitoring which they say will likely fall to the NHS. There are also concerns about private off-label testosterone prescribing for women, mainly for low libido associated with menopause.
As stated in official guidance, the responsibility of care rests exclusively with any private sector clinician who initiates treatment unless an NHS GP formally agrees to shared care, they explain. In practice, however, patients who started treatment privately may return to their GP informally for tests or managing side effects, leading to the NHS absorbing the workload without any formal agreement.
The authors stress that testosterone replacement remains a valuable treatment for carefully selected patients, but say national data are needed to close the evidence gap on private prescribing of testosterone.
"A reporting framework for private prescribers and dispensing pharmacies could capture indications, patient numbers, monitoring, and transfers of care," they write. "This would lead to transparent prescribing and demonstrable adherence to evidence based care, protecting patients while preserving access to effective treatment."
