Testosterone and pregnancy

Testosterone therapy uses an artificial version of the testosterone hormone.

It’s given to people for a number of reasons, including as a treatment for gender dysphoria in people who want to change how their body looks and works.

Testosterone can reduce breast tissue, stop periods, and make hair grow on your face.

Testosterone and fertility

It is possible to get pregnant if you’re taking testosterone, but it’s not recommended. This is because taking testosterone in pregnancy may affect the baby’s development.

If you are taking testosterone and want to get pregnant, talk to the doctor who is prescribing you testosterone.

Important: Testosterone and contraception

You can get pregnant while taking testosterone.

You need to use contraception if you do not want to get pregnant.

Testosterone and pregnancy

Taking testosterone in pregnancy is not recommended.

Do not stop taking testosterone before talking with the doctor who is prescribing it for you.

If you stop taking testosterone you’ll probably start to have periods. You may also notice changes in your body shape around your hips, chest and thighs.

You should not notice any changes to your tone of voice or facial hair.

If you get pregnant, you may have mood swings, such as suddenly feeling very irritable or tearful. These are common in most pregnancies.

You may find being pregnant triggers feelings of gender dysphoria.

Urgent advice: Contact the doctor who is prescribing your testosterone immediately if:

Testosterone and chestfeeding

If you have taken testosterone in the past then your milk supply may be affected. So you may not be able to chestfeed your baby.

If you can chestfeed and you also decide to start taking testosterone again, your milk will have small amounts of testosterone in it.

It is unclear what, if any, effect this could have on your baby.

It is also important to consider your own wellbeing if you are finding that not taking testosterone is triggering dysphoria.

Talk to your midwife or doctor about any concerns you may have.

More in Having a baby if you’re LGBT+

Page last reviewed: 22 December 2021
Next review due: 22 December 2024

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Effect of testosterone on muscle mass and muscle protein synthesis

We have studied the effect of a pharmacological dose of testosterone enanthate (3 mg.kg-1.wk-1 for 12 wk) on muscle mass and total-body potassium and on whole-body and muscle protein synthesis in normal male subjects. Muscle mass estimated by creatinine excretion increased in all nine subjects (20% mean increase, P less than 0.02); total body potassium mass estimated by 40K counting increased in all subjects (12% mean increase, P less than 0.0001). In four subjects, a primed continuous infusion protocol with L-[1-13C]leucine was used to determine whole-body leucine flux and oxidation. Whole-body protein synthesis was estimated from nonoxidative flux. Muscle protein synthesis rate was determined by measuring [13C]leucine incorporation into muscle samples obtained by needle biopsy. Testosterone increased muscle protein synthesis in all subjects (27% mean increase, P less than 0.05). Leucine oxidation decreased slightly (17% mean decrease, P less than 0.01), but whole-body protein synthesis did not change significantly. Muscle morphometry showed no significant increase in muscle fiber diameter. These studies suggest that testosterone increases muscle mass by increasing muscle protein synthesis.

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Brodsky IG, Balagopal P, Nair KS. Brodsky IG, et al. J Clin Endocrinol Metab. 1996 Oct;81(10):3469-75. doi: 10.1210/jcem.81.10.8855787. J Clin Endocrinol Metab. 1996. PMID: 8855787

Young NR, Baker HW, Liu G, Seeman E. Young NR, et al. J Clin Endocrinol Metab. 1993 Oct;77(4):1028-32. doi: 10.1210/jcem.77.4.8408450. J Clin Endocrinol Metab. 1993. PMID: 8408450 Clinical Trial.

Welle S, Thornton C, Jozefowicz R, Statt M. Welle S, et al. Am J Physiol. 1993 May;264(5 Pt 1):E693-8. doi: 10.1152/ajpendo.1993.264.5.E693. Am J Physiol. 1993. PMID: 8498491

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10 Benefits of Testosterone Replacement Therapy (TRT)

Men generally don’t know or appreciate the benefits of testosterone until it starts fading away. And it does fade. Regardless of a well-balanced diet and solid exercise regimen, your body changes as you age, and your hormone levels and testosterone naturally decline approximately 1 percent every year starting around age 30 (1).

Maybe you’ve been suffering the symptoms of low testosterone (such as low energy levels, fatigue, excess body fat, erectile dysfunction, and low libido). Perhaps Hone’s at-home testing kit has revealed that you have a testosterone deficiency, and now you’re considering testosterone replacement therapy (TRT) to get back on track.

Or maybe you aren’t quite sure whether testosterone treatment is right for you and you want to know more about what to expect from balancing your hormones, including outcomes and side effects.

There’s a lot of health benefits of testosterone, and advancements in TRT have provided men with a way to reclaim control of their bodies and their lives.

TRT isn’t some sort of miracle, overnight cure. It’s vital that you understand going into the process that the journey to self-improvement is not a sprint, but a marathon. It’s also one that doesn’t really have a set finish line—and that’s all right.

As long as you follow the treatment prescribed by your doctor, you’ll stay ahead of the problem.

Let’s break down some of the biggest benefits of testosterone replacement therapy, share what you should expect to think and feel, and run through which effects of testosterone replacement therapy may take longer than others to notice.

1) You’ll Have More Energy

TRT doesn’t have an immediate effect; you may not even notice a change at first.

But usually, you’ll start feeling better psychologically within three to four weeks of starting treatment (2).

“Most people start to experience less fatigue after a month of treatment, in addition to sleeping better and feeling more rested overall,” says Jack Jeng, M.D., Chief Medical Officer of Hone Health.

One month in, you’ll find yourself feeling motivated to get off the couch and do more. And we all know how important physical activity is to your well-being and quality of life.

2) Your Mental Acuity and Focus Return

Testosterone plays a major role in cognitive performance, including memory, concentration, and reasoning. When your levels of testosterone are low, your mental function can suffer.

When you start TRT, the formidable cloud that has been hanging over your head will start to dissipate.

Your mental focus, cognition, and memory show signs of improvement after the first few weeks of treatment, while feelings of depression and sudden mood swings start subsiding within three to six weeks (2).

By 18 to 30 weeks in, your change in demeanor will support a radically improved self-confidence and clearer mindset, plus an inner strength that’s more ready to go toe-to-toe with whatever life throws your way.

3) You’ll Have Better Sexual Health & Higher Libido

Diminished sexual function (low sex drive, erectile dysfunction) is one of the most common reasons men seek treatment for low T ( 4 ).

For good reason: research shows that libido and testosterone levels are strongly correlated (5).

Thankfully, TRT can quickly improve your love life with your spouse or partner. Increased levels of testosterone in men often correlate with heightened sexual activity.

Several Hone customers have shared in our community forum that their sex drive started to come back within the first three to four weeks of treatment and that their erections were stronger and longer lasting, too.

Hone delivers treatments for low T to your doorstep, if prescribed.

The first step: Order an at-home hormone assessment, which comes with a free telehealth consultation.

4) Your Red Blood Cell Count Rebounds and Flourishes

Your body produces red blood cells through a process called erythropoiesis. Those cells made in your bone marrow contain hemoglobin, an essential protein that carries oxygen.

When you suffer from hypogonadism (low T), red blood cell production can slow to a crawl and even lead to anemia.

As your T level decreases, you’re left feeling progressively fatigued and weakened. Your blood pressure may also test higher than normal. The rest of your body has to work that much harder to get oxygen to your cells and keep your organs operating as they should.

TRT, fortunately, gets your red blood cell count back into the flow of things.

Results can vary based on your age and the dosage prescribed by your doctor, but the improved formation of your red blood cells will produce a noticeable effect after three months (3).

As that happens, those bouts of fatigue you’ve been fighting will lessen, and your blood pressure should stabilize closer to within normal range.

Your maximal output should peak between nine and 12 months. By then, your body is producing enough hemoglobin on its own to keep you energized, and the measurement of your red blood cells (known as hematocrit) reaches its maximum level. Some people on TRT may have higher hematocrit levels than normal (>51%) and need to donate blood regularly as a result. That’s why it’s important to work with an experienced healthcare provider when receiving treatment.

5) Your Blood Sugar Levels Normalize

When you’re hypogonadal, your sensitivity to insulin can be compromised, your blood sugar levels can spike, and you have an increased risk of developing type 2 diabetes (6).

TRT increases your insulin sensitivity, meaning it enables your body to effectively absorb glucose, or sugar, from your blood after a meal. Improvements in blood glucose levels and insulin sensitivity are usually seen after about three months, with the full effect happening after a year (2).

Also remember: one little spark is all you need to motivate you into becoming more physically active, which also increases your insulin sensitivity.

Estrogen Dominance Test

Estrogen dominance test is used to test one of the most common hormonal imbalances, which can often lead to significant health problems in women.

More Information

Estrogen dominance is a term used to describe a condition in which there is an imbalance between estrogen and progesterone levels in the body, with estrogen levels being relatively higher. Estrogen and progesterone are two key hormones involved in the menstrual cycle and reproductive system.

In a healthy menstrual cycle, estrogen levels rise during the first half of the cycle, leading up to ovulation, and then progesterone levels increase during the second half of the cycle. If the balance between these hormones is disrupted, estrogen dominance can occur.

Estrogen dominance can have various causes, including:

Hormonal imbalances: This can happen due to factors such as excessive estrogen production, decreased progesterone production, or impaired hormone metabolism and elimination.

Environmental factors: Exposure to certain environmental toxins, such as xenoestrogens (synthetic chemicals that mimic estrogen), can contribute to estrogen dominance. These toxins are found in many common products, including plastics, pesticides, and personal care items.

Diet and lifestyle: Poor diet, high-stress levels, lack of exercise, and obesity can also influence hormonal balance and contribute to estrogen dominance.

Symptoms of estrogen dominance can vary and may include:

• Irregular or heavy periods
• Breast tenderness
• Mood swings
• Fatigue
• Weight gain
• Water retention
• Decreased sex drive
• Fibrocystic breasts
• Headaches
• Insomnia

Who should be tested for estrogen dominance?

The decision to test for estrogen dominance should be based on an individual’s symptoms, medical history, and physical examination. Testing for estrogen dominance is not typically done as a routine screening test but may be considered in certain situations.

Persistent and troublesome symptoms: If an individual is experiencing persistent and significant symptoms associated with estrogen dominance, such as irregular periods, severe PMS symptoms, or other hormonal imbalances, a healthcare professional may recommend testing to assess hormone levels and determine the underlying cause.

Unexplained infertility or reproductive issues: Estrogen dominance can sometimes contribute to fertility problems or difficulties conceiving. In such cases, hormone testing, including estrogen and progesterone levels, may be recommended to evaluate hormonal imbalances and guide appropriate treatment.

Monitoring hormone replacement therapy (HRT): For individuals undergoing hormone replacement therapy, monitoring hormone levels, including estrogen and progesterone, can help ensure the appropriate balance and effectiveness of the treatment.

Evaluation of certain health conditions: Estrogen dominance may be associated with specific health conditions, such as endometriosis, polycystic ovary syndrome (PCOS), or fibroids. In these cases, testing for hormonal imbalances may be considered as part of the diagnostic process.

How to Decrease Estrogen Dominance?

If a patient has been diagnosed with estrogen dominance, there are several lifestyle changes and treatment approaches that may help decrease estrogen dominance.

Eat a balanced and healthy diet: Focus on a diet rich in whole foods, including plenty of vegetables, fruits, lean proteins, and healthy fats. Consider including foods that support hormonal balance, such as cruciferous vegetables (broccoli, cauliflower, kale), flaxseeds, and fermented foods. Reduce intake of processed foods, sugar, and caffeine, as they can contribute to hormonal imbalances.

Manage stress: High levels of stress can disrupt hormone balance. Engage in stress-reducing activities such as exercise, meditation, deep breathing, and relaxation techniques.

Maintain a healthy weight: Excess body fat can contribute to estrogen dominance. Regular exercise and a balanced diet can help maintain a healthy weight and promote hormonal balance.

Avoid environmental toxins: Minimize exposure to xenoestrogens and other environmental toxins by choosing organic produce, using natural personal care products, avoiding plastic containers and food packaging, and filtering your drinking water.

Food supplements and herbs: Some supplements and herbs may help support hormonal balance. Examples include vitex (chaste berry), evening primrose oil, DIM (diindolylmethane), and calcium D-glucarate.

Hormonal therapy: In some cases, hormonal therapy may be recommended. This can involve the use of bioidentical hormones, progesterone supplementation, or other hormonal interventions to rebalance estrogen and progesterone levels.

Every individual is unique, and the appropriate approach to decrease estrogen dominance may vary. It is crucial to work with a healthcare professional who can evaluate a patient’s specific situation, provide personalized guidance, and monitor the progress.

Diagnostiki Athinon’s Estrogen Dominance test includes the following tests:

The measurement of the Estrogen Dominance test is performed on a saliva sample which can be done in the following ways:

• Upon receipt of the suitable tubes from Diagnostiki Athinon. Delivery of the tubes should be done by you in the laboratory. Book your appointment in real-time and purchase the test online appointment
• By sending the appropriate sample collection kit to your home via courier. The return of the sample collection kit to the laboratory is also done by courier. Purchase the test online
• By one of our associates throughout Greece and internationally. Call at +30 210-7777654 for more information

Testosterone

A testosterone test measures the amount of the male hormone, testosterone, in the blood. Both men and women produce this hormone.

The test described in this article measures the total amount of testosterone in the blood. Much of the testosterone in the blood is bound to a protein called sex hormone binding globulin (SHBG). Another blood test can measure the “free” testosterone. However, this type of test is often not very accurate.

How the Test is Performed

A blood sample is taken from a vein. The best time for the blood sample to be taken is between 7 a.m. and 10 a.m. A second sample is often needed to confirm a result that is lower than expected.

How to Prepare for the Test

The health care provider may advise you to stop taking medicines that may affect the test.

How the Test will Feel

You may feel a slight prick or sting when the needle is inserted. There may be some throbbing afterward.

Why the Test is Performed

This test may be done if you have symptoms of abnormal male hormone (androgen) production.

In males, the testicles produce most of the testosterone in the body. Levels are most often checked to evaluate signs of abnormal testosterone such as:

In females, the ovaries produce most of the testosterone. The adrenal glands can also produce too much of other androgens that are converted to testosterone. Levels are most often checked to evaluate signs of higher testosterone levels, such as:

• Acne, oily skin
• Change in voice
• Decreased breast size
• Excess hair growth (dark, coarse hairs in the area of the moustache, beard, sideburns, chest, buttocks, inner thighs)
• Increased size of the clitoris
• Irregular or absent menstrual periods
• Male-pattern baldness or hair thinning

Normal Results

The examples above are common measurements for results for these tests. Normal value ranges may vary slightly among different laboratories. Some labs use different measurements or test different specimens. Talk to your provider about the meaning of your specific test results.

What Abnormal Results Mean

Certain health conditions, medicines, or injury can lead to low testosterone. Testosterone level also naturally drops with age. Low testosterone can affect sex drive, mood, and muscle mass in men.

Decreased total testosterone may be due to:

• Chronic illness
• The pituitary gland does not produce normal amounts of some or all of its hormones
• Problem with areas of the brain that control hormones (hypothalamus)
• Low thyroid function
• Delayed puberty
• Diseases of the testicles (trauma, cancer, infection, immune, iron overload)
• Benign tumor of the pituitary cells that produce too much of the hormone prolactin
• Too much body fat (obesity)
• Sleep problems (obstructive sleep apnea)
• Chronic stress from too much exercise (overtraining syndrome)

Increased total testosterone level may be due to:

• Resistance to the action of male hormones (androgen resistance)
• Tumor of the ovaries
• Cancer of the testes
• Congenital adrenal hyperplasia
• Taking medicines or drugs that increase testosterone level (including some supplements)

References

Rey RA, Josso N. Diagnosis and treatment of disorders of sexual development. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 119.

Rosenfield RL, Barnes RB, Ehrmann DA. Hyperandrogenism, hirsutism, and polycystic ovary syndrome. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 133.

Swerdloff RS, Wang C. The testis and male hypogonadism, infertility, and sexual dysfunction. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 221.

Version Info

Reviewed by: Sandeep K. Dhaliwal, MD, board-certified in Diabetes, Endocrinology, and Metabolism, Springfield, VA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

What is estrogen dominance?

Estrogen gets a bad rap for so many things. Women hear that too much estrogen causes breast disease, and too little causes everything from hot flashes to hair loss in menopause. We also hear from many women with concerns about “estrogen dominance” — a state of high estrogen levels blamed for a wide range of distressing symptoms as well as fibroids, endometriosis, hypothyroidism and breast cancer, too.

While excessive estrogen can lead to problems, it’s a little more complicated than simply “too much estrogen.” To manage all your symptoms, it’s important to understand how your individual estrogen levels are related to your other hormones — particularly progesterone and testosterone. For example:

Some signs & symptoms of high estrogen-to-progesterone ratio

• Unwanted hair growth
• Irritability
• Breast tenderness
• Water retention
• Weight gain
• Cyclical migraines
• Headaches
• Mood swings
• Skin outbreaks
• Digestive imbalance
• Fuzzy thinking
• Irregular periods / anovulatory cycles
• Breakthrough bleeding, spotting

Some conditions associated with relatively high (or “unopposed”) estrogen levels

• Uterine fibroids
• Menorrhagia (heavy bleeding)
• Endometriosis
• Menstrual migraines
• PMS
• Breast/gynecological cancers
• Lupus

• Are your estrogen levels holding steady in perimenopause, while your progesterone levels are plummeting?
• Have your estrogen and testosterone levels been well above normal reference ranges, while progesterone has always been low?
• Or, are you adding extra estrogen unknowingly through certain lifestyle choices?

Each of these common scenarios — and many others — can create imbalance between the ratio of estrogen to other hormones and lead to problematic symptoms.

The good news is that by better understanding what underlies estrogen imbalance, you can determine your best natural options for feeling better. Let’s take a closer look.

Why estrogen dominance is about progesterone and testosterone, too

A healthy woman’s body maintains appropriate ratios of estrogens, progesterone and testosterone throughout life. A complex set of feedback loops determines how much or little of each hormone is being made at any one time. This ongoing communication takes place between the brain, the ovaries and the adrenal glands, acting in concert with all your other bodily systems.

That’s why we use the phrase hormonal balance when we talk about “normal” ratios of hormones. But hormonal balance doesn’t mean a steady-state, equal balance — like the scales of justice or a perfectly balanced see-saw — but a dynamic equilibrium. Within this dynamic there are reference ranges. When your hormones fluctuate outside of these ranges, that’s when you are most likely to experience symptoms.

Fluctuations in estrogen can have dramatic effects on how we feel, think and function. Compared to other hormones, estrogen is very tightly regulated by the body, and it’s more powerful in smaller amounts than other steroid hormones. Even tiny changes in estrogen levels can cause symptoms.

When ratios aren’t normal: Three experiences

Keep in mind that your hormones are continually changing — even on a moment-to-moment basis. Diet and lifestyle have a tremendous effect upon your entire neuroendocrine (brain-hormone) system — and directly impact your estrogen and overall hormonal balance. So do your genes, which influence not just how your body produces hormones, but how it responds to them.

Let’s look at the experiences of three women, each of whom has “estrogen dominance” issues.

Scenario 1: Adding estrogen through lifestyle

Kylie, 23, is in her last year of college — squeezing in every party while still keeping her 4.0 average. Lately, she’s felt fatigued, anxious and tense just before her period, and her irritability quotient is off the chart. She’s had these problems since puberty, but they’ve gotten much worse in college.

What’s happening? Many women unknowingly alter their estrogen metabolism through lifestyle choices. Kylie’s social drinking is moderate, but she regularly burns the candle at both ends and relies on a caffeine fix the next day. And her college-student diet of fast food isn’t helping. All these factors could be slowing her liver’s capacity to metabolize estrogen, and Kylie could also be lacking key nutrients.

What could she do to help her symptoms?

A daily, top-notch multivitamin–mineral complex could help Kylie get more B-complex vitamins and omega-3 fatty acids — nutrients that favor proper energy regulation and estrogen metabolism. This in turn will help improve her sleep, decrease her cravings, and reduce the fatigue, irritability, and anxiety she experiences.

Scenario 2: Plummeting progesterone in perimenopause

Sue, 46, has had occasional menstrual migraines for years, but now she’s experiencing unpredictable and extremely heavy periods, too. An ultrasound revealed she has a large uterine fibroid. Her practitioner is recommending a hysterectomy, but Sue is looking for a less invasive alternative.

What’s happening? A sharp decline in progesterone right before your period can trigger a menstrual migraine. And if it occurs when your estrogen is also declining (which is common at Sue’s age), the drop-off can lead to erratic or excessive bleeding. Also, the relative abundance of estrogen in comparison to progesterone can support development of uterine fibroids. Our article “What is perimenopause?” can help you understand more about hormonal imbalance during this time.

What could she do to help her symptoms?

Women with plummeting progesterone in perimenopause have several natural options to consider. A good place to start is with an endocrine-balancing phytotherapeutic formulation, especially effective along with dietary and lifestyle changes. Sue may also want to consider acupuncture and/or a trial of prescription-strength bioidentical progesterone before opting for a surgical solution.

Scenario 3: Extra estrogen after menopause

Valerie, 55, is in early menopause. Despite constant dieting, she is struggling with steady weight gain. She’s always been a little heavy in her hips and thighs, but now it seems like the less she eats and the more she exercises, the more weight she gains.

What’s happening? Some women’s bodies are more prone than others to accumulate fat — especially around the waist, hips, and thighs. This is a survival feature that can be beneficial for women in menopause because body fat produces estrogen and other hormones.

But in this day and age, extra fat in menopause can be problematic. Our fat cells produce excess estrogen, and we often have trouble metabolizing it, especially when our food is less than ideal. Endocrine disruptors in our environment known as xenoestrogens cause even more excess estrogen to accumulate in our fat cells, disrupting our hormonal metabolism and balance still more.

What could she do to help her symptoms?

Valerie shares a problem with many women today, who would benefit greatly from piling on the vegetables. It sounds simplistic, but plant foods contain two things — phytochemicals and fiber — that enhance estrogen metabolism in the body and support healthy weight. Adding phytotherapy, including soy isoflavones and herbs such as red clover and kudzu, can further benefit her estrogen metabolism, help her detoxify any toxins in her system, and promote healthy estrogen metabolism.

Resolving estrogen dominance — the Women’s Health Network approach

No matter what your age or individual levels of hormones, there are ways to give your body the natural support it needs to build better hormonal health. For most women, a combination approach works beautifully.

Phytotherapy — a gentle approach to a complex issue. If you are like many women, you can probably benefit from an approach that incorporates phytotherapy. We’ve found the following medicinal herbs to be beneficial for women with symptoms of estrogen dominance:

The use of a well-balanced botanical formulation such as our Herbal Equilibrium is most effective when combined with nutritional and lifestyle modifications.

Dietary and lifestyle changes. Lifestyle is a critical factor in the production and storage of estrogen, progesterone and testosterone to support hormonal balance. Here are four simple elements to start with today.

• Limit exposure to xenoestrogens. Choose organic foods when possible, and wash your produce. If you include animal foods in your diet, select those that were sustainably raised without hormones and harmful chemicals. Avoid plastics for heating or storing food, and limit body care and cleaning products to those with all-natural ingredients.
• Eat a natural, plant-based diet. Eating lots of vegetables provides fiber, which feeds the beneficial flora in your intestines, which help you metabolize your hormones the way Mother Nature intended. Plant foods also provide your body with phytoestrogens, which protect your body from damaging xenoestrogens. Good choices include legumes, licorice, yams and anything in the broccoli/cabbage family. Foods to avoid include those made with refined flours, sugars, partially hydrogenated fats and artificial ingredients.
• Restore balance with supplements. We generally recommend high-quality daily nutritional supplements to help restore a woman’s hormonal balance. Because they work as molecular messengers, nutrients such as B-vitamins and omega-3 fatty acids can help increase your body’s ability to balance its hormone ratios.
• Manage stress levels. Most women have skipped a period or two while under stress — one obvious effect of stress on our hormonal cycles. In relation to estrogen dominance, one theory is that stress fuels chronically high levels of adrenaline and cortisol, stress hormones known to alter the feedback loops regulating our sex hormones.

Even with this type of support, there are still many women whose bodies produce an abundance of estrogen. These women may continue to experience symptoms and conditions associated with estrogen dominance. Such women may find dramatic improvement by adding bioidentical progesterone. If this describes you, then it’s probably worthwhile to talk to your practitioner.

Find your unique path to hormonal balance

The concept of estrogen dominance came to the forefront of women’s health through the work of Dr. John Lee, who pioneered the idea that low levels of estrogen are not the only cause of menopausal symptoms. While we understand now that the equation isn’t as simple as “Too much estrogen — just add progesterone,” Dr. Lee captured the public’s attention and moved us all forward in how we view the complexities of hormonal balance. As we continue learning more, we intend to keep looking for gentle interventions that restore balance best — and most naturally.

1 Diaz–Cruz, E., et al. 2011. Comparison of increased aromatase versus ER in the generation of mammary hyperplasia and cancer. Cancer Res., 71 (16), 5477–5487. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/21840986 (accessed 08.17.2011).

[No author listed.] 2011. Increased estrogen production could increase risk of breast cancer. Ivanhoe Newswire. URL: https://www.ivanhoe.com/channels/p_channelstory.cfm?storyid=27830 (accessed 08.17.2011).

2 Hays, B. 2005. Chapter 19. Hormonal imbalances: Female hormones: The dance of the hormones. Pt. I. In Textbook of Functional Medicine, 216. Gig Harbor, WA: Institute for Functional Medicine.

Testosterone deficiency

Testosterone deficiency (TD) afflicts approximately 30% of men aged 40-79 years, with an increase in prevalence strongly associated with aging and common medical conditions including obesity, diabetes, and hypertension. A strong relationship is noted between TD and metabolic syndrome, although the relationship is not certain to be causal. Repletion of testosterone (T) in T-deficient men with these comorbidities may indeed reverse or delay their progression. While T repletion has been largely thought of in a sexual realm, we discuss its potential role in general men’s health concerns: metabolic, body composition, and all-cause mortality through the use of a single clinical vignette. This review examines a host of studies, with practical recommendations for diagnosis of TD and T repletion in middle-aged and older men, including an analysis of treatment modalities and areas of concerns and uncertainty.

Copyright © 2011 Elsevier Inc. All rights reserved.

Comment in

Keller DL. Keller DL. Am J Med. 2012 Mar;125(3):e5; author reply e7. doi: 10.1016/j.amjmed.2011.07.041. Am J Med. 2012. PMID: 22340937 No abstract available.

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Testosterone is primarily a male hormone, but it is also present in women. Weight gain, acne and hair loss are symptoms of hormonal changes, including high testosterone.

Doctors may inform patients of high testosterone levels, but they may not always offer much advice on how to lower your testosterone levels to help you feel better.So, what are the reasons women have high testosterone and how can you lower it?

It’s important to understand what is happening in your body so that you can return to normal. In most cases (95% of the time), high testosterone is caused by something else, like another hormonal imbalance. Tackling the root issue will help improve your high testosterone levels.

Understanding symptoms is very critical in diagnosing high testosterone, as each individual varies in terms of what is considered too much for their body. There are plenty of women who have “normal” testosterone levels, but have all the symptoms of too much testosterone, because what is considered the average normal is actually high for them individually.

Fat cells can contribute to androgen production, thus overweight and obese women may experience higher levels of testosterone. — Filepic

While the testosterone levels in these patients may appear relatively “normal”, they will still benefit greatly from treatment to help manage their symptoms. Some common symptoms of high testosterone levels in women include:

• Imbalances of other hormones, including the ratio of oestrogen and progesterone, other androgens like dehydroepiandrosterone (DHEA), and thyroid hormone.
• Changes in mood, including depression, irritability or anger.
• Weight gain (especially if it is unexpected), or inability to lose weight.
• Acne, changes in complexion or very oily skin (deep cystic acne, usually at the jawline, is common with high androgen levels).
• Hair loss (especially if thyroid function and other hormones are normal and if the hair loss is “male-patterned”).

Many of these symptoms tend to be non-specific, hence there will be some overlap with other hormone imbalances in your body. For example, weight gain and hair loss are also signs of thyroid problems, but not male-patterned baldness.

Additionally, thyroid issues can cause acne, but such acne usually isn’t cystic or located on the jawline. If you use these specific clues, you might be able to accurately guess where your hormonal problems are coming from. However, due to the overlap of symptoms, it is always best to consult your doctor and get the relevant hormone levels tested.

Managing high levels of hormones can be challenging because it requires digging into the root cause. Anything that increases certain hormones can also increase your total testosterone (even if it is taken as a supplement!).

As a result, when evaluating testosterone levels, it’s a good idea to also check serum DHEA levels, in addition to cortisol levels. The following are common causes of high testosterone, but do note that there are also other causes not in this list.

Imbalance in oestrogen and progesterone

Hormones in your body interact with one another. When one hormone is imbalanced, it will ultimately impact other hormones in the body. Despite the lack of clarity about the exact mechanism, there is definitely a correlation between testosterone, and progesterone and oestrogen.

Treatment: Check for oestrogen and progesterone imbalances through blood serum levels. Maintain optimal thyroid function as hypothyroidism can cause low progesterone levels and oestrogen dominance.

To ensure optimal oestrogen excretion and metabolism, make sure your liver is functioning properly, and that your B vitamins and nutrients are methylated. Consider supplements to help with oestrogen metabolism.

These include vitamin B12 (preferably methylcobalamin), 5-MTHF (methyltetrahydrofolate), DIM (diindolylmethane) or indole-3-carbinol, milk thistle, MSM (methylsulphonylmethane) and bio-identical progesterone (20-40mg transdermally on days 14-28 of your menstrual cycle).

Insulin resistance usually causes low testosterone in men, but it can cause high testosterone in women. If you have both high testosterone and high insulin levels, then insulin is definitely contributing to your hormone imbalance. Check your HbA1c and fasting insulin levels, in addition to free and total testosterone levels.

Treatment: Consider insulin-sensitising medications such as SGLT-2 (sodium-glucose co-transporter 2) inhibitors, metformin, GLP-1 (glycogen-like peptide 1) agonists and alpha-amylase inhibitors. Increase thyroid function and insulin sensitivity by using T3 hormone supplements.

Consider supplements such as berberine (1,000-2,000mg per day), alpha lipoic acid (600-1,200mg per day), magnesium, chromium and glucomannnan, which have been shown to reduce blood sugar and insulin levels. Insulin resistance is common among women with weight-loss resistance (and problems losing weight). Do not ignore this hormone and make sure you get properly evaluated if you have insulin resistance.

Women with excess fat also have higher levels of testosterone as fat cells increase androgens in the body. Additionally, these cells increase insulin resistance, resulting in further androgen excess (high testosterone). To normalise testosterone levels, you must lose weight in addition to the other therapies above.

Treatment: You might want to consider diets like nutritional ketosis if you want to decrease carbohydrates (especially refined carbohydrates such as sugar, bread, pasta, etc.) A prolonged or intermittent fasting programme may be beneficial.

Meditation and spending time in nature are two ways we can tackle stress and ameliorate adrenal disease. — Filepic

Consider exercise as an additional way to prevent your body from developing high levels of testosterone. Lack of exercise does not cause high testosterone levels directly, but exercise does help prevent high levels.

By sensitising your cells to insulin, exercise lowers insulin levels. Exercising may help balance testosterone to boost muscle mass and libido.

Treatment: Strength-training or high-intensity interval training (HIIT) can increase insulin sensitivity.

When you don’t receive the signal to burn fat, your brain does the opposite instead. Fat cells produce leptin, a hormone that controls appetite and metabolism. Leptin levels are high in women with polycystic ovary syndrome (PCOS), and insulin resistance further worsens testosterone levels in women with leptin resistance. Therefore, high insulin levels lead to elevated testosterone levels in women with PCOS.

Treatment: Consider leptin-sensitising medications like exenatide and liraglutide.

While there are no specific supplements to treat leptin resistance that have been shown to work consistently, you can try the insulin-sensitising supplements listed above, as well as fish oil, zinc and leucine.

Cut down your carbohydrate and fructose consumption as both make leptin levels worse. Treat underlying thyroid resistance and insulin resistance if present.

There are several precursors to testosterone, including DHEA, pregnenolone, progesterone and androstenedione, which are produced by the adrenal glands in this condition.

Treatment: Add consumption of salt like Himalayan pink salt or Celtic sea salt.

Manage stress levels with relaxation techniques like yoga, meditation, spiritual contemplation or prayer, time outside or in nature, and so on. Reduce caffeine and alcohol consumption. Avoid other stimulates like amphetamine-based medications (amphetamine, methylphenidate hydrochloride, phentermine, etc).

Get eight hours of sleep per night, and avoid high-energy tasks late at night, as well as taking naps during the day. Consider the following supplements: vitamin B6, adrenal glandulars, adrenal adaptogens, vitamin C, and low doses of melatonin.

High testosterone levels can be treated, but the underlying cause must be addressed. You should be able to reduce your symptoms dramatically if you diagnose and treat the underlying cause properly.

The most common causes of high testosterone are insulin resistance, leptin resistance, oestrogen/progesterone imbalances, adrenal dysfunction and poor diet/lifestyle. If you are serious about treating your high testosterone levels, find a doctor who knows how to balance hormones and is willing to dig into the cause of your problem.

By Datuk Dr Nor Ashikin Mokhtar
Published in Star Newspaper, 09 Jan 2023

The Primary Differences Between Free Testosterone vs Total Testosterone

When considering the differences between free testosterone and total testosterone, it’s important to first understand what testosterone is.

Testosterone is the primary sex hormone found in males. Testosterone production is regulated by the hypothalamus and pituitary gland in the brain. These two glands signal the secretion of testosterone from its storage site, the Leydig cells of the testes. Aside from that, small quantities of testosterone are also produced in the adrenal glands of both sexes.

It is essential for males’ physical and sexual development, as well as muscle growth, bone density, and strength. While it’s dominantly found in a male body, women produce it too but in much smaller amounts compared to men.

Testosterone’s effects range from the development of physical characteristics to mental or behavioral changes. These include:

Total testosterone production naturally peaks during adolescence and early adulthood. Testosterone levels remain stable in a man’s 20s, then begin to gradually decline after the age of 30 by about 1.6% per year.

Moreover, it’s a misconception to think that testosterone’s only function is to boost libido. According to a study performed by Dr. Joel Finkelstein at the Massachusetts General Hospital, patients aged 20 to 50 who were given less testosterone underwent a significant reduction in lean mass, muscle size, and leg-press strength.

Needless to say, testosterone is crucial in a man’s body. But testosterone isn’t just a singular hormone—there are multiple types of it with their own distinct functions.

What is Free Testosterone?

Free testosterone is the unbound form of testosterone in your body. Unlike total testosterone which has SHBG or albumin chemical receptors bound to it, unbound testosterone can act as receptors to any cell in the body.

As free testosterone can readily combine with any available receptor site on a cell, it can freely combine with any T molecule and execute functions such as regulate metabolism and execute cellular functions. Under normal circumstances, the cellular function can’t be performed when testosterone is bound to a protein already.

If you have more SHBG in your body, it means that there are more chemical receptors attached to SHBG (or bound testosterone) rather than free testosterone.

Only 1 to 2% of circulating testosterone around your body is classified as free testosterone. An average of 80% of testosterone found in men is bound to sex hormone-binding globulin (SHBG), while smaller percentages are bound to albumin and cortisol-binding globulin.

It’s also important to differentiate free testosterone from bioavailable testosterone, although they are fairly similar. Bioavailable testosterone is the combination of free and weakly bound (such as T bound with serum albumin) testosterone circulating the body.

What is Total Testosterone?

Your total testosterone level includes both bound and unbound fractions of testosterone. These are calculated in a simple blood test that determines whether you have low testosterone levels (aka testosterone deficiency) or normal readings.

According to the American Urological Association (AUA), the current clinical threshold for low testosterone in men is less than 300ng/dL.

How Does Free vs Total Testosterone Affect Male Health?

Total testosterone levels have been the main indicator of a man’s health and fertility for many years.

Now, as doctors are starting to learn more about free testosterone, it is becoming apparent that the true indicators of a man’s strength and virility include both bound and unbound fractions of this hormone.

What does this all mean? Suppose that you feel symptoms of low testosterone levels, such as:

Then, suppose that you took a testosterone test that only accounted for the grand total testosterone levels – and it shows that you have normal total testosterone levels.

Without taking into account your free testosterone levels, your doctor may wrongly attribute these symptoms to another condition and prescribe treatment plans for said condition.

While in fact, the problem may lie in the insufficient amount of free testosterone circulating your body.

Since free testosterone is important since it helps in cell replication and bone and muscle strength, it plays a vital role in a man’s body.

If you worry about worsening sexual health, consulting your doctor to gain normal testosterone levels is recommended.

How Can I Check My Testosterone Levels?

There are many factors that need to be analyzed together before an accurate diagnosis can be given, including SHBG levels, erectile dysfunction due to low testosterone, testosterone deficiencies, among other conditions.

As such, it’s critical for patients to tell their doctors of any medications and their history to fully account for these variances.

Advanced medical technology is capable of extracting your testosterone count from your blood sample. Fortunately, there are now many labs offering testosterone blood tests for men.

Male health clinics, such as Prestige Men’s Medical Center, provide testing for testosterone and low-T treatment for patients struggling with low-T levels.

How to Increase Free Testosterone Levels

There are several methods to improve free testosterone levels in men. As a rule of thumb, the majority of healthy methods for elevating total testosterone also work for increasing free testosterone.

• Lift Weights: Increase muscle mass to speed up your metabolism rate.
• Eat Healthily: Avoid trans and saturated fats. A good diet that helps to unclog arteries and overall health is always a healthy choice to boost your free testosterone.
• Take Vitamin D: Take foods rich in Vitamin D such as fortified dairy and beef, or opt for a D3 supplement.
• Medical Therapy: Aside from the aforementioned techniques, medical intervention in the form of testosterone replacement therapy (TRT) could also be considered for some men.

Consult a Medical Clinic Specializing in Low Testosterone for a Professional Diagnosis

Free testosterone is a small but important component of the total testosterone in a man’s body. It’s responsible for key cellular functions since, unlike bound Ts, they can act as receptors for many cells in the body to perform functions like cell replication.

Many factors need to be analyzed together before an accurate diagnosis can be given. Some of these factors include SHBG levels, estrogen levels, prolactin levels, thyroid levels, and DHEA-S levels.

Before you begin supplementing with any testosterone booster or drug, it’s important to have an accurate diagnosis for low T first.

For more information on the matter of low or high testosterone, erectile dysfunction, hormone imbalances that may require therapy, or other sexual issues, call the team at Prestige Men’s Medical Center now to schedule an appointment to have a consultation with an experienced and specially trained medical staff for a clinical diagnosis.

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Experts writing in The BMJ warn that new rules to curb high testosterone levels in female athletes risks setting an unscientific precedent.

Prof Ieuan Hughes, Paediatric Endocrinologist and Emeritus Professor of Paediatrics, University of Cambridge, said:

“The Editorial by Tannenbaum and Bekker on Sex, Gender and Sports is peppered with inaccuracies, yet the authors emphasise “evidence based, benevolent ethos that underlies medical practice”. What is evidence based is the biology of fetal sex development which orchestrates a usually binary sex at birth, male or female. Testosterone is a key and essential component in the male, but not so for the female fetus. And that is driven by fetal blood testosterone levels commensurate with the lower end of the adult male range. The second key component is genetic, gonad-determining genes which elicit either testis or ovary development. The next relevant phase of evidence based biology occurs at puberty when a profound increase in testosterone levels mediates not only male genital development but also greater muscle strength and skeletal growth compared with the female which is long lasting in to young adulthood. The Editorial omits these physiological facts. Data are robust on male and female testosterone levels being markedly distributed bimodally with no overlap: the highest testosterone value in the male range is 15 times greater than the equivalent value in the female range and even the lowest testosterone value is 4-5 times greater than the highest testosterone value in the female range.

“The authors highlight the case of the elite athlete, Caster Semenya, to promote their argument that the proposed cut-off value of 5nmol/l proposed by the IAAF for female athletes with a difference of sex development is arbitrary and discriminatory. Some rare medical conditions can produce in females, testosterone levels well in to the adult male range. Such exposure during pubertal development and thereafter will have produced the androgenic effect on muscle and bone development (a clear index of androgen sensitivity) which sports physiologists recognise to be advantageous in highly competitive events. The authors quote from a study of post competition testosterone levels in 693 elite athletes which reported overlap testosterone levels in a minority of male athletes with low levels and female athletes with high levels. However, they fail to mention these results included outliers in testosterone values (some males with levels as low as 2nmol/l and some females as high as 30nmol/l). Such rogue results raise questions as to the validity of the measurement technique used.

“This Editorial was commissioned by the journal and was not subject to external peer review. The senior author is an expert on gender and health, but does not appear to have published any original endocrine-related or sports physiology-related studies. The Editorial is based on reviewing the literature but not all evidence seems to have been taken into account. The authors refer to “decisions about genetic superiority” (not an appropriate use of that word, in my view) being “supported by objective, rigorous and reproducible data” but they do not convince me about those important criteria.”

Prof Peter Sonksen, member of the Society for Endocrinology, Emeritus Professor of Endocrinology at St Thomas’ Hospital and King’s College and Visiting Professor at the University of Southampton, said:

“This is a very good editorial, fairly balancing a precis of the evidence that CAS has to consider, before ruling on the Semenya case. Like the authors, I don’t believe the new proposed rule of the IAAF is ‘fit for purpose’. It is not compatible with the science behind the issues and greatly overestimates the role of endogenous testosterone. It is also personal and unfairly targets a brilliant athlete.”

Prof Chris Cooper, Emeritus Professor of Biochemistry in the School of Sport, Rehabilitation and Exercise Sciences, University of Essex, said:

“First, the closer overlap between male and female plasma testosterone levels in elite sport noted in this paper is perhaps not surprising for a number of reasons:

“(a) Increases in plasma testosterone in female athletes (in part due to differences in sexual development, DSD) are likely to improve performance more than similar increases in men. Therefore women with higher testosterone levels will probably be overrepresented in elite athletes. It is well known that the proportion of conditions leading to high testosterone levels is higher in elite female athletes compared to the male population. For example at the Atlanta 1996 Olympics several female athletes tested positive for the SRY gene on a Y chromosome. SRY induces testosterone production during puberty so this likely led to increased levels of plasma testosterone. This testosterone was considered not to be having an effect on their body (androgen insensitivity syndrome, AIS). So an XY apparently “male” genotype led to a female phenotype. The prevalence of AIS in the non elite athlete population is much lower than the 7 in 3387 found in this sample of Olympians. This suggests that increased testosterone levels either do still slightly increase performance in some AIS females OR make them more likely to choose to become athletes. Either way, this is ONE example of why testosterone levels in female elite athletes may have a closer overlap with male elite athletes than in the population at large.

“(b) Taking artificial anabolic steroids will likely lower the levels of the natural anabolic steroid (testosterone) in athletes. These effects can potentially be quite long term. Without knowing the number of athletes previously steroid doping in any sample this is difficult to correct for. I suspect because of the greater adverse side effects in female athletes rather than males, males take higher steroid doses than females. This would result in anabolic steroid use lowering the natural male testosterone levels more than the female levels, again closing the gap and increasing the overlap.

“(c) The major physiological effects of plasma testosterone levels occur during puberty. However, it is not possible to test at puberty in future elite athletes. By its very nature any later testing is of somewhat secondary value. So an elite male athlete might have low testosterone now, but at the crucial time in their development it was significantly different from the future elite female athlete. It is hard to see how any data can be collected in this area. So the IAAF make do with what they can actually measure.

“Second, gathering hormone data in elite sport is difficult. It is even harder (and potentially unethical) to gather performance data under conditions where these hormone levels are made to drop or rise due to external factors. Therefore by its very nature correlation data of the type described in this article will become important. But it is individual data that really matters, and this is even harder to get access to for the obvious grounds of medical confidentiality. As the authors mention Caster Semenya, it is perhaps instructive to look at her 800m times* at global championships when the IAAF testosterone levels were in place or not. This is worth mentioning as you can be sure the same discussion has been had amongst other female elite athletes (and also athletics fans). In periods when the testosterone regulations were not in place Semenya won all the global championships she competed in. When they were in place she ran slower and was second to cross the line at global championships. The winner those times (Mariya Savinova) was banned for doping (possibly by taking substances including anabolic steroids) and thus possibly giving her the same advantage by cheating that Semenya (who was not cheating) had been denied by the IAAF regulations.

“Third, the IAAF tesosterone regulations regarding DSD (differences in sexual development) – although not mentioned explicitly – need to be seen in the light of their (and the IOCs) anti doping and transgender regulations. This is not mentioned by the authors of this article, but seems relevant. This is NOT to say that females with DSD or male to female transgender athletes are cheating of course. But the science underpinning the possible performance benefits of their situation is related. And in many cases – perhaps surprisingly – the doping data is easier to access.

“On doping regulations: there is good evidence that increasing exogenous testosterone levels (or taking artificial anabolic steroids) enhances sport performance. This effect is greater in females than males. It is (partially) reversible if anabolic steroids stop being taken. It is no surprise that anabolic steroids preferentially enhanced performance in female athletes in the former East Germany (where they were likely given to junior athletes). Nor that the Russians state doping system had some of its greatest ‘successes’ when giving anabolic steroids to female middle distance runners. Therefore doping is banned.

“On transgender regulations: lowering plasma tesosterone levels is the main goal of male to female transgender hormone therapy. Transgender women, who are transitioning or have transitioned from male to female, are treated with hormones (by choice) to lower their plasma testosterone levels to similar levels as required by the IOC regulations. This decreases their performance. Therefore they are allowed to compete in a female category after hormone therapy to lower their testosterone.

“Nothing about elite sports performance is ever going to be amenable to scientific conclusions “beyond reasonable doubt”. This is because the fractional differences in competition at the highest level are so small and the population so difficult to study ethically and practically. In my opinion the current evidence is as good as we are going to get to show that both endogenous (natural) and exogenous (doped) testosterone levels enhance female sports performance. In the terms of the Court of Arbitration of Sport, I am personally “comfortably satisfied” that both exogenous and endogenous testosterone increases sports performance in elite female athletes. Of course a lot of other factors, genetic and environmental, also affect sports performance, but that is a separate story.

“Summing up, in my personal opinion, the IAAF regulations have as good a scientific basis that they are going to get in the foreseeable future. HOWEVER, this does not mean that they are ethically “right”. That is a separate matter. I write as someone who personally cheered Caster Semenya on to victory in the 800m in the 2017 World Athletic Championships in London (when the DSD regulations were not in force). However, we should focus on the ethics of what we want to encourage as participation in female sport, and not get hung up on criticising the fine details of science that is never going to be as conclusive as we would like.

“Finally I caution against the authors making too much of the effects sport has on the real world. They say “History compels us to ensure that decisions about genetic superiority are supported by objective, rigorous, and reproducible data” and“These issues highlight the fact that although sports policies exist to serve the organisations that develop them, the effect of these policies on individuals, societies, and even medical science has far reaching implications.” Sport – and especially elite sport – as we know it is a social construct created by (largely) males at the end of the 19th Century. We have chosen in society to place a huge value on it and honour its participants with wealth and fame. But it is inherently sexist. Biological females have no chance of competing on an equal footing with males – in terms of physical sports performance they demonstrably can’t compete. Equality of opportunity in sport does NOT equal equality of outcome. In fact it does not come close. In nearly all adult sports there would be NO female winners if we did not have a separate female category. This is unlike any other activity we value in our society. Therefore elite sport has created a special protected space for females (female sport). Inevitably this creates tension at the interface as noted in this article. But it is important that writers – such as the authors – do not try and put sport on a pedestal. Decisions, such as those of the IAAF, relate to the rather special social construction of the sporting world. We should note give them added importance by trying to translate them into more important parts of life and society. The Olympic Charter claims that the practice of sport is a human right. Well this may be the case, but in my opinion it is low on the list of ones that we should use as an example of how to construct how we run our society.”

Pre regulation requiring testosterone levels to be dropped (2009 World Championship Berlin): Winner, 1:55.45

Post Regulation (2011 World Championshios Daegu): Second*, 1:56.35

Post Regulation (2012 Olympics London): Second*, 1:57.23

Regulations dropped (2016 Olympics Rio): Winner, 1:55.28

Regulations dropped (2017 World Championships London): Winner, 1:55.16.

* upgraded to Winner after Mariya Savinova disqualified for doping offences (likely including anabolic steroids).

‘Sex, gender, and sports’ by Cara Tannenbaum and Sheree Bekker was published in the BMJ at 23:30 UK time on Wednesday 20 March 2019.

Prof Ieuan Hughes: “I am a member of the IAAF panel of experts for reviewing the diagnosis of athletes who may have an underlying cause for difference (also referred to as disorder) in sex development. However, I confirm I have not been involved in the assessment of the athlete referred to in the Editorial not am I party to any medical information about her.”

Prof Peter Sonksen: “No interests to declare.”

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