[dropshadowbox align=”none” effect=”raised” width=”auto” height=”” background_color=”#ffffff” border_width=”1″ border_color=”#dddddd” ]“androgen use and abuse is increasing in our society, either for therapeutic or recreational reasons”.


Vascular Health Risk Management 2008[/dropshadowbox]




Today is the age of twitter, emojis, 30 second commercial ads,  abbreviations, character limitation and limited attention span.   The old adage is ‘brevity is the soul of wit’.  In this new age of character limitation that is the result of limited attention span, brevity is the soul of communication.  To be consistent with the age, I give you brevity in a title: 50–25—21.  


What is 50–25—21?   The 50—25—21 is a rule, a rule to separate therapeutic uses of Testosterone from recreational uses of Testosterone.  The 50—25—21 rule is a reference to the statistics of Testosterone therapy found in the medical science.  The 50–25–21 rule allows one to separate physiologic, evidence-based Testosterone therapy from recreational, non-evidence-based Testosterone therapy—or simply Testosterone doping.  As the quote above points out, androgen use and abuse, at the hands of physicians, is increasing in our society.



Many questions abound.  How can a patient tell the difference between therapeutic Testosterone therapy and recreational Testosterone therapy?  Does this distinction really exist and does it really matter? Can Testosterone therapy really approach the level of a recreational drug?  Is Testosterone just here to ‘pump you up’?

[embedyt] http://www.youtube.com/watch?v=S-GLO_PydqU[/embedyt]


Just because a drug is prescribed by a physician or a prescribed drug is a hormone does not mean that it can not become addictive and can be misused either intentionally or unintentionally.  America represents 5% of the worlds population, yet it consumes 75% of the world’s prescription drugs.  As it relates to Testosterone, this disproportion is no different and in fact maybe worse.



America is addicted to drugs _74454873_testosterone_464_v2and Testosterone is no different.  The graph to the right highlights the extraordinary rise in Testosterone prescription use in the U.S. compared to other countries.  Does the U.S. have a disproportionally higher prevalence of low Testosterone compared to other countries and thus more Testosterone therapy is needed?  Or, does the U.S. simply use and abuse Testosterone more than other countries?  America’s well-documented history of prescription drug abuse answers that question.   The significant difference in Testosterone prescription use in the U.S. versus other countries highlights the Testosterone addiction epidemic in the U.S.  This new addiction epidemic is driven by the 21st century dealer–the physician, the medical provider, and/or the medical system.


There is good reason why I call many of the current clinics prescribing Testosterone as the “methadone clinics of the 21st century”.   The similarities are striking.  Neither has any interest in physiologic dosing.  Neither has any interest in healing, removing or preventing the prescription of Testosterone.  Low Testosterone is the effect of metabolic dysfunction, not the cause.  In both, therapy is titrated to how a patient feels, not to optimize physiologic levels.  Let me repeat that again—Testosterone therapy is titrated to how good a patient feels.  Little if any concern is giving to the actual level of Testosterone.  Physicians and medical providers are not Doctors of “feel good”.  We are practitioners of evidence-based science that is called medicine.  Of course we want our patients to feel great, but cocaine makes people “feel great”, but I don’t hear anyone advocating the use of cocaine to elevate mood and focus.


For the health of our patients, we physicians must follow the science.  Testosterone therapy can definitely help many men improve physiology and many men to feel a lot better.  However, sometimes Testosterone therapy (and other therapies for that matter) optimizes physiology without a significant impact on how the patient feels.  We physicians must follow objective measures i.e. lab values.  We must also follow subjective measures i.e. do you feel better?.  Medicine is a blend of the science and the art of medicine.  Good scientific medicine devoid of art is not good medicine; likewise, good artful medicine devoid of science is not good medicine.  It requires both.


Back to the 50—25—21 rule and how does one distinguish between therapeutic Testosterone therapy and recreational Testosterone therapy?


The 50 of the 50-25-21 rule is the fact that 50% of men on Testosterone replacement therapy have been diagnosed with hypogonadism.  Just in case you missed it, only 50% of men on Testosterone replacement therapy have been diagnosed with hypogonadism.  Hypogonadism is simply the medical lingo for low functioning testes or low Testosterone.  This first rule can be stated another way: 50% of men on Testosterone replacement therapy have NOT been diagnosed with hypogonadism or low Testosterone.  Let that settle for a moment.  What other area of medicine can claim such a fact?  The fact that 50% of a therapy is initiated, usually life-long, without a diagnosed need to begin.  There is no science in that!   What if surgery was approached this way?  Take your pick. brain surgery or hand surgery, it doesn’t matter.  NO therapy should begin, let alone life-long therapy, without a properly determined need to do so.  Such a therapy is, in fact, doping.


The 50% of the 50—25—21 rule helps to separate Testosterone therapy from recreational therapy.


The 25 of the 50-25-21 rule is the fact that 25% of users of Testosterone do not have Testosterone levels checked prior to initiation of therapy.   How can Testosterone therapy be initiated without a diagnosis of hypogonadism (50% rule) or an initial Testosterone level (25%)?  There is no diagnosis of need.  There are no baseline values.  There are no objective measures to follow to ensure proper dosing.  This is simply eye-ball medicine and doping.  It would be better to stick a finger in the air and see which way the wind is blowing.  Today, you have low Testosterone and tomorrow you don’t.   There is no science in that!  I would argue there is no art in that as well.


The 25% of the 50-25-21 rule helps to separate Testosterone therapy from recreational therapy.


The 21 of the 50-25-21 rule is the fact that 21% of users do not have their Testosterone levels tested at any time during treatment.   Restated, Testosterone levels are evaluated prior to therapy (though not well according to the above statistics), but once therapy is initiated, no attempt to reassess objective measures to ensure optimal therapy is repeated.   A treatment without any objective reassessment is not therapy, but is in fact doping.  Without the objective measurements, the physician is simply following the patient based on subjective symptoms which are notoriously unreliable and definitely unscientific.  Don’t get me wrong here, I  want my patients to feel better, as do all physicians.  However, the body is the great masquerader and the physiology of the body is incredibly complex.  As much as we know about the complex physiology of the body, it pales in comparison to what we don’t know.  It is as important to recognize what we don’t know as what we do know.   All physicians want patients to feel better with medical therapy; but not all patients do feel better despite objective laboratory improvement because of this complex physiology.  Physicians are doctors of science, not doctors of feel good.  We physicians just hope that the feel good part comes along with the improved objective lab values.


The 21% of the 50-25-21 rule helps to separate Testosterone therapy from recreational therapy.


The exponential growth of Testosterone therapy in men is staggering.  There are hard questions to ask about the increasing androgen use in our society: is the growth fueling optimal physiology or is the growth fueling a new epidemic of addiction?



  1. FDA. Joint meeting for bone, reproductive and urologic drugs advisory committee (BRUDAC) and the drug safety and risk management advisory committee (DSARM AC). Sep 17, 2014.
  2. Baillargeon J, et al.. Research Letter: Trends in Androgen Prescribing in the United States. JAMA Internal Medicine 2013: 173(15): 1465­ 1466.