Ex-MMA fighter, sports therapist and osteopath Rosi Sexton considers the thorny issue of testosterone replacement therapy (TRT).

These days, whenever performance-enhancing drugs are in the MMA news, the subject of hormone replacement therapy isn’t far behind. Once upon a time, HRT was reserved for menopausal women. Nowadays, it’s been increasingly prescribed to male athletes in their 30s and 40s to treat for ‘low testosterone.’

Is this all a scam, as many believe? Are fighters simply seeking a way to ‘bend’ the rules on steroid use? Or are there legitimate medical reasons why athletes may need to supplement testosterone? 

Testosterone is the best known of the androgenic hormones. It’s responsible for many of the features we associate with male-ness. In men, it’s mostly produced in the testicles, but its release depends on the levels of other hormones that are released by the hypothalamus and the pituitary gland in the brain. Women also produce a much-lower level of testosterone than is found in a healthy male.

Testosterone is associated with muscle growth and strength, and many athletes have tried to gain an advantage in competition by supplementing their natural levels with synthetic versions of the hormone, or drugs that mimic its effects. Used inappropriately, without medical supervision, this can potentially cause serious health problems, whilst the use of anabolic steroids is banned by the governing bodies of most sports. Most cases of steroid use are fairly black and white.

When a fighter takes a banned substance for the purposes of performance enhancement he can be fined or suspended by the relevant athletic commission. 

TUE

A problem occurs when a banned ‘performance enhancing’ drug also has a legitimate medical use. When this happens, an athlete who needs the drug for a medical reason can apply for a ‘therapeutic use exemption’ (TUE).

To do this, they must have been prescribed the drug by a doctor for a specific medical condition. In some cases, documented test results are needed to confirm the diagnosis. Drugs covered by TUEs include certain asthma medications, some powerful anti-inflammatory drugs – and testosterone. 

There are a number of medical conditions that can result in reduced testosterone levels. Damage to the testicles – as a result of treatment for testicular cancer is an obvious one. Other causes can include head injury with damage to the pituitary gland or long-term medical conditions such as diabetes. In these cases, supplementation with synthetic testosterone may be prescribed to enable the patient to lead a normal life.

Here’s where it gets tricky, though.

Testosterone levels have a large variation, with some men naturally producing more than twice as much as others. Levels also normally decrease with age. Where you draw the line between ‘low’ and ‘normal’ testosterone can be largely a matter of opinion. This has led to a whole industry promoting TRT to otherwise healthy middle-aged men. Advocates are quick to point out that common and non-specific symptoms such as tiredness, lack of energy and loss of libido may be symptoms of low testosterone, and can thus be cured by supplementation. 

MMA TESTING 

So, are fighters using ‘low testosterone’ as a ruse to get away with using steroids? It’s not as easy as you might think. In order to be granted a therapeutic use exemption for TRT, fighters need to go through a rigorous process to demonstrate that their levels are indeed low. 

Testosterone levels after supplementation are checked and have to be below a certain value – certainly much lower than the levels of androgens taken by athletes who are using steroids for performance enhancement. It was his doctor’s failure to adhere to this protocol which ultimately led to Nate Marquardt’s dismissal from the UFC. 

Many people point out that genuine testosterone deficiency is rare; seeing young, healthy looking fighters claiming they need TRT doesn’t sit well. 

Indeed, one possible cause of low testosterone in a fighter is a history of previous steroid abuse. 

However, some argue that we should allow even fighters with normal but lower than average level of the hormone access to TRT to ensure an even playing field. And, as low levels of testosterone are commonly associated with ‘overtraining syndrome’ testosterone supplements may help MMA athletes to cope with the rigors of a tough training camp.

Others argue that the long-term effects aren’t understood, and that by disrupting the body’s natural hormone balance fighters may be setting themselves up for health problems in the future. 

It’s a debate which is set to continue for some time to come.