New online men’s health sites divide opinion

The Internet’s impact on people’s health care decision-making has long been an unsettling reality. This is especially true when it comes to men’s health, where the Internet provides privacy and immediate access to information-even services-to men who are by all accounts reluctant to seek medical care.

The Internet’s appeal and doctors’ concerns about quality make sense, researchers reported in “Health information on the Internet: Gold mine or minefield?” published in the Canadian Family Physician (2014; 60:407-8).

“Considering how easy it is to Google-search ‘bad cough,’ it is not surprising that many people make an attempt at self-diagnosis using the Internet before waiting hours in crowded walk-in clinics or emergency departments to consult professionals,” the authors wrote. “The flow of information has fundamentally changed, and physicians have less control over health information relayed to patients. Not surprisingly, this paradigm shift has elicited varied and sometimes conflicting views about the value of the Internet as a tool to improve health care.”

Having a condition like erectile dysfunction (ED) makes going to the Internet even more attractive, researchers say. Despite the availability of oral medicines to treat ED, men seeking treatment face barriers that lead to undertreatment in the U.S., including reluctance to talk about ED and other sensitive issues, high medication costs, inadequate insurance coverage, and in some cases failure to respond to phosphodiesterase type-5 (PDE-5) inhibitor therapy (J Sex Med 2014; 11:2546-53). In addition, research shows that reimbursement policies for ED lack transparency and keep men from pursuing appropriate care (Urology 2017; 102:126-9).

These psychosocial and fiscal barriers, in turn, encourage patients to turn to the online marketplace to research and obtain alternative medical therapies for ED.

Ripe for Internet startups

Sexual medicine is a subspecialty that’s ideal for Internet startups. That’s because male patients tend to suffer with embarrassment, humiliation, and poor self-esteem, and men are notorious for avoiding the doctor. A Cleveland Clinic survey conducted in 2018 showed that 61% of men have neglected visiting a physician even when they needed to go, and more than half (56%) prefer to keep health concerns to themselves. The survey, conducted annually as part of Cleveland Clinic’s MENtion It campaign, also found that 27% of men research their symptoms online when first noticing changes in their health, which is the same percentage who would consult a physician.

And doctors, even urologists, get little training in sexual medicine, so providers might offer little help in addressing patients’ issues, according to Irwin Goldstein, MD, a urologist who practices sexual medicine in San Diego and is president and director of The Institute for Sexual Medicine, a nonprofit agency dedicated to education and basic science research in the field.

Businesses are swooping in to meet the unmet demand in men’s health. Enter web startups, like Hims and Roman, which are promising quick access to treatment and raising concerns about care quality, according to an article published in June in USA Today.

Arthur L. Burnett, II, MD, MBA, professor of urology at Johns Hopkins University School of Medicine, Baltimore, said he has mixed feelings about certain business models that provide urologic care. He understands that men may have psychological and other challenges that make them hesitant to visit the doctor’s office.

“My reservation has to do with whether [online businesses] are actually taking up these medical issues in patients well in terms of addressing medical diagnoses or management issues that deserve medical attention,” Dr. Burnett said.

The concerns, when it comes to Hims at least, are more a prevailing misperception than reality, according to Peter Stahl, MD, clinical director of Men’s Sexual Health at Hims, which launched in 2017.

Direct-to-consumer digital health care companies like Hims have the power to transform men’s health and urology, Dr. Stahl told Urology Times in an email.

First, Hims and similar companies facilitate access to care by reducing or eliminating financial, logistical, and emotional barriers to clinical care, according to Dr. Stahl, who is director of Male Reproductive and Sexual Medicine at New York-Presbyterian Hospital/Columbia University Medical Center and assistant professor of urology at the Columbia University College of Physicians and Surgeons.

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“Financial barriers are reduced through affordable pricing strategies and independence from third-party payers. Clinical encounters occur remotely through a digital interface that is accessible via mobile devices and personal computers, which dramatically reduces the time and logistical burdens that are typically associated with traditional, in-person physician visits. And some men who would otherwise not seek care because of embarrassment about sexual dysfunction may feel more comfortable engaging a physician digitally from the privacy of their home,” Dr. Stahl said.

Second, the direct-to-consumer health care industry has brought an infusion of financial capital and marketing expertise to the men’s health space, according to Dr. Stahl.

“Hims and similar businesses have the resources and expertise to engage a heretofore unprecedented number of affected patients,” he said. “Rather than feeling threatened by [direct-to-consumer] digital health care companies such as Hims, as urologists we should recognize the opportunity to partner with such companies.”

Urologists could benefit because these companies will find patients who are too complex for treatment on their platforms or who don’t respond to the first-line therapies offered, he added.

Third, Hims and companies like it in the direct-to-consumer space have the opportunity to improve the quality of care for men’s health conditions that are at risk for suboptimal clinical management during in-person visits with non-specialized care providers, Dr. Stahl wrote.

Only about 1% of urologists have integrated telehealth into their practices, according to Dr. Stahl, so many are unaware of asynchronous telehealth services, how they function, and the potential benefit they offer both patients and physicians.

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“The consultation process is designed to ensure that the health care provider has the necessary information to make an informed and appropriate decision about diagnosis and treatment plans in conformance with the standard of care, and if not, the patient is not treated and is advised to seek care outside of the platform,” he said. “As part of the consultation process, the provider initiates an online dialogue with the patient to address any risks and contraindications, gives the patient the opportunity to ask questions, and if appropriate, recommends treatment. If at any point the provider believes a patient is more appropriately treated in person or does not believe a prescription is the best path forward, the patient is referred out.”

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Some urologists agree the Internet can be a good thing for men’s health.

“I think overall the Internet is a good thing for urologists because what studies are showing is that the majority of men are going to the Internet first when they have concern about their health. The Internet is allowing them to do this privately and, without this access, it’s likely that a lot of these men will just not seek help in the first place,” said urologist Aaron Spitz, MD, a partner in Orange County Urology Associates in Laguna Hills, CA, voluntary assistant clinical professor of urology at UC Irvine, and co-chair of the AUA Telemedicine Taskforce.

After many of those men learn they have a treatable medical condition, chances are good that they’ll go to a doctor, potentially a urologist. The Internet also can disseminate information to a lot of people simultaneously and, in the case of telemedicine, could even help streamline treatment if it complies with licensure and follows sound medical practices, according to Dr. Spitz.

But even Dr. Spitz worries about potential abuse and patient harm that could result when men turn to the Internet instead of a urologist.

In-person exam lacking

Here’s where the bad news comes in: the Internet is giving people access to self-management, including prescription medicine, without having ever had a face-to-face examination, according to Dr. Goldstein. “No prostate exam; no determination if there are masses near the prostate, no PSA examination, no testosterone assessment, no physical examination to see if there’s numbness in the penis or if there’s penile cancer,” Dr. Goldstein said.

The Internet enables patients to procure potentially dangerous substances, such as steroids, tainted PDE-5 inhibitors, and unvalidated nutraceutical supplements, according to Adithya Balasubramanian, a fourth-year medical student at Baylor College of Medicine in Houston. Balasubramanian and Dr. Spitz debated Internet pros and cons during “The New Wild West: Men’s Health and the Internet” session at this year’s AUA annual meeting in Chicago.

“There are many underground websites that sell anabolic androgenic steroids (AAS) directly to consumers. These websites have been noted to tout the benefits of AAS without presenting the potential risks associated with consuming these compounds. Furthermore, the dosing protocols featured on these websites are often considerably higher than the recommended therapeutic dosages,” Balasubramanian said.

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“Patients have also been known to procure PDE-5 inhibitors that are manufactured by non-validated vendors via online websites. Subsequent analyses of these pills have revealed that they are composed of inappropriate dosages of active drug compounds. Online marketplaces like Amazon also feature nutraceutical supplements for erectile dysfunction and hypogonadism.”

Balasubramanian and colleagues authored papers recently published in the Journal of Sexual Medicine analyzing these supplements and demonstrated that human studies evaluating the efficacy of supplement ingredients are limited (J Sex Med 2019; 16:203-12; J Sex Med 2019; 16:843-52).

Urologist Ryan P. Smith, MD, said online prescription services for medications like testosterone often fall dangerously short of providing comprehensive care. Dr. Smith, assistant professor of urology at University of Virginia, Charlottesville, said he commonly sees young men who are prescribed testosterone online for complaints including low energy but aren’t told that the testosterone might affect their fertility. One of his recent patients adopted a child because he and his wife didn’t think they could conceive.

“Then he saw me and I told him that I think this is the testosterone you’ve been on for the last 3 years. Sure enough, we took him off and gave him alternative medication, and he had completely normal fertility,” Dr. Smith said.

Disclosure: Dr. Spitz is a consultant for Foresight Imaging, a telesurgery company. He is a spokesperson for Endo Pharmaceuticals and is on the speaker’s bureau for Abbvie Pharmaceuticals.