Most of my Medscape pieces receive between 20 to 30 comments; the most I had ever received prior to this was 67 for my analysis of the CDC's opioid prescribing guidelines. I was surprised by the fast and (mostly) furious responses that came in, eventually well over 100. Several suggested that I was "cherry picking" or taking a selective approach to the evidence, even though I placed the new trials in the context of a recent, meticulous systematic review of previous RCTs. A medical student (!) and an endocrinologist questioned my breadth of clinical experience. One physician (not knowing my age) opined that I was obviously too young to have any sympathy for men suffering from the indignities of older age. Another physician (not knowing my testosterone level, which has never been measured) accused me of having a "normal testosterone bias" against low T sufferers. A registered nurse felt that I was motivated by an anti-Trump bias - which I freely admit, but I was not making fun of the President, whose testosterone level was normal. Finally, many disagreed with my contention that testosterone supplements are currently overprescribed, in large part due to aggressive direct-to-consumer (DTC) advertising.

It was a fair point of disagreement. Although testosterone prescribing has skyrocketed (to the tune of $4 billion per year) since televised DTC advertising for prescription medications became legal in 1997, that is an association, not necessarily cause-and-effect, and implies nothing about the appropriateness of such prescribing.

Just in time, a March 21 study in JAMA provided stronger evidence to support my assumptions. Dr. J. Bradley Layton and colleagues linked Nielsen ratings for television programs during which DTC ads for "low T awareness" and specific supplements appeared to a population-level database of testosterone testing and prescriptions from 2009-2013. They found that "each exposure to a testosterone advertisement was associated with monthly relative increases in rates of new testosterone testing of 0.6%, new initiation of 0.7%, and initiation without a recent baseline test of 0.8%." In other words, not only did testosterone-related DTC advertising pay off in thousands of new prescriptions, but many of them occurred without prior testing, despite the Endocrine Society's Choosing Wisely recommendation against doing so.