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• Improvement in performance after exogenous testosterone supplementation does not prove that endogenous testosterone levels are associated with performance.
  Luci Olewinski
  Published on: 16 February 2021

• Published on: 16 February 2021

  Improvement in performance after exogenous testosterone supplementation does not prove that endogenous testosterone levels are associated with performance.

  • Luci Olewinski, Primary Care Sports Medicine Physician University of Tennessee Medical Center, Knoxville

  In their May 2020 article, Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study, Hirschberg, Elings Knutsson, Helge, Godhe, Ekblom, Bermon, and Ekblom1 attempt to apply their findings of improvement in individual performance in women given exogenous testosterone to the topic of exclusion from sport of women with higher than average levels of endogenous testosterone. This is not a valid conclusion to make from the study they performed. While this study adds to the body of literature on the effect of exogenous testosterone on performance times and efforts in cisgender women, it is not reasonable or logical to extrapolate these results to the performance times and efforts of women with higher levels of endogenous testosterone. The authors previous work was unable to demonstrate a consistent association between endogenous levels of testosterone and performance2,3. Research on international and Olympic athletes has found wide variation in endogenous testosterone in males and females with no consistent association of endogenous testosterone levels with athletic success2,4,5.
  In the discussion section of this article, that authors state “the physiological effect of testosterone is the same whether the source of testosterone is exogenous or endogenous,” citing their own narrative review as the source for that statement6. The studies they cite in that review to support their st...

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  In their May 2020 article, Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study, Hirschberg, Elings Knutsson, Helge, Godhe, Ekblom, Bermon, and Ekblom1 attempt to apply their findings of improvement in individual performance in women given exogenous testosterone to the topic of exclusion from sport of women with higher than average levels of endogenous testosterone. This is not a valid conclusion to make from the study they performed. While this study adds to the body of literature on the effect of exogenous testosterone on performance times and efforts in cisgender women, it is not reasonable or logical to extrapolate these results to the performance times and efforts of women with higher levels of endogenous testosterone. The authors previous work was unable to demonstrate a consistent association between endogenous levels of testosterone and performance2,3. Research on international and Olympic athletes has found wide variation in endogenous testosterone in males and females with no consistent association of endogenous testosterone levels with athletic success2,4,5.
  In the discussion section of this article, that authors state “the physiological effect of testosterone is the same whether the source of testosterone is exogenous or endogenous,” citing their own narrative review as the source for that statement6. The studies they cite in that review to support their statement are two of their own articles, one in which they conclude endogenous serum testosterone isn’t related to performance3, and one where eight oligomenorrheic athletes with elevated levels of androgens were found to have better aerobic but not strength performance than the other 43 normoandrogenic participants7. With conflicting results, small sample sizes, and a focus only on endogenous testosterone, these sources should not be used to support the stated conclusion. Additionally, Healy’s study of 689 elite athletes and the authors’ own study of 1332 female and 795 male elite athletes showed that performance was not consistently linked to endogenous levels of testosterone2,4.
  Hirschberg, et al found that supplemental testosterone improves aerobic capacity but not anaerobic capacity or strength performance in female athletes1. Yet their introduction and conclusion focus on performance related to endogenous testosterone, going so far as to say their results are “of great importance for the ongoing discussion of whether it is fair to allow athletes with naturally producing high testosterone to compete in the female category without reducing their hormonal concentration to the female range. ” That conclusion is far outside of the scope of their study. There is much to be gained by having reliable and valid studies examining influences on performance across classes, ages, and specialties of athletes, but there is also much harm that can be done when conclusions are misrepresented to advocate for the exclusion of athletes from sport. Policies that have drastic effects on individual athletes’ lives are often based on our sports medicine literature, and we must be sure that our published conclusions match the data we have gathered.

  1. Hirschberg AL, Elings Knutsson J, Helge T, et al. Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study. Br J Sports Med. 2020;54(10):599-604. doi:10.1136/bjsports-2018-100525

  2. Bermon S, Garnier PY. Serum androgen levels and their relation to performance in track and field: mass spectrometry results from 2127 observations in male and female elite athletes. Br J Sports Med. 2017;51(17):1309-1314. doi:10.1136/bjsports-2017-097792

  3. Eklund E, Berglund B, Labrie F, Carlström K, Ekström L, Hirschberg AL. Serum androgen profile and physical performance in women Olympic athletes. Br J Sports Med. 2017;51(17):1301-1308. doi:10.1136/bjsports-2017-097582

  4. Healy ML, Gibney J, Pentecost C, Wheeler MJ, Sonksen PH. Endocrine profiles in 693 elite athletes in the postcompetition setting. Clin Endocrinol (Oxf). 2014;81(2):294-305. doi:10.1111/cen.12445

  5. Sönksen PH, Holt RIG, Böhning W, et al. Why do endocrine profiles in elite athletes differ between sports?. Clin Diabetes Endocrinol. 2018;4:3. Published 2018 Feb 7. doi:10.1186/s40842-017-0050-3

  6. Handelsman DJ, Hirschberg AL, Bermon S. Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance. Endocr Rev. 2018;39(5):803-829. doi:10.1210/er.2018-00020

  7. Rickenlund A, Carlström K, Ekblom B, Brismar TB, von Schoultz B, Hirschberg AL. Hyperandrogenicity is an alternative mechanism underlying oligomenorrhea or amenorrhea in female athletes and may improve physical performance. Fertil Steril. 2003;79(4):947-955. doi:10.1016/s0015-0282(02)04850-1

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  Conflict of Interest:
  None declared.

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