Have a Plan – Define Your Signs and Symptoms, What Impact Are They Having on Your Life?
Common Presenting Symptoms:
• Low Libido / ED – We are simple creatures with simple needs (unlike women!). A happy, healthy sex-life not only satisfies a carnal need, it is an important aspect of any healthy relationship. It undoubtedly strengthens the bond between you and your partner, which improves your relationship, your confidence and your self-esteem. This has a knock-on effect on other aspects of our lives, it has somewhat of a Butterfly Effect on how you interact with your environment.
• Brain Fog – Men often describe a “brain fog” that is lifted when testosterone levels are optimised. One of the frustrations of having low testosterone is that recognition that something is missing, without having the power to do something about it, which further exacerbates the problem. This lack of clarity of thought can potentially lead to you not getting that promotion and/or not achieving that goal. Work aside, since work shouldn’t define you, “brain fog” can affect how you communicate with the world.
• Tired All the Time / Loss of Lean Muscle Mass – Testosterone is a Performance Enhancing Drug (PED), it is an anabolic hormone involved in growth and repair. It has been used in sports to gain that competitive advantage for many years. It is endemic, I urge you to watch Icarus. By contrast, low testosterone will cause tiredness and loss of lean muscle mass. Essentially, you won’t be able to keep up with your younger self.
• Loss of Drive & Determination – That surge in testosterone as teenagers is what drove us to do all those stupid reckless things that, hopefully, we got away with. With a little guidance, intellect and luck, we hopefully channelled this into something positive. Ok, not all of us, but hey, whose perfect? There are far more male explorers and inventors for a reason, TESTOSTERONE. To lose that drive and determination because of low testosterone, is to lose part of our identity, it’s part of what makes us men.
• Others – Increased body fat, excessive sweating and night sweats, loss of body, facial and pubic hair, increased breast tissue (gynaecomastia), insulin resistance, loss of bone mass (osteoporosis).
“Within 3 months I have more energy, a more positive outlook and a high sex drive. I have started working out at the gym like I used to when younger, I feel terrific and have my life back.”
Identify and Address Possible Triggers
Are there lifestyle issues that need addressing? Is your nutrition not on point? Are you a couch potato? Or by contrast, are you over-doing it? Interestingly, I see a lot of athletes who are essentially burnt out, they cannot keep up with their younger selves. This also translates to type A personalities in the business world. I’m always talking about balance for a reason. Have a read of my 10 Commandments. Other triggers include drugs such as Androgenic Anabolic Steroids and a number of prescribed medications.
Do Your Research
The internet is a powerful tool but, unfortunately, it isn’t regulated. There are unscrupulous people out there, there are people who put self-interest before altruism and there are people who just plain lie in order to build their brand. The relationship between a doctor and patient is sacred, it isn’t a sales-consumer relationship polluted by greed and financial self-interest.
I hate to say it, but I think we stand alone against the bullish Testosterone Optimisation Therapy subgroup, where Broscience and ignorance prevails. Testosterone Deficiency Syndrome is a medical condition, non-clinicians are posing as ‘TRT Experts’. What other field of medicine has more Bros than doctors? It’s absurd.
Show Your GP or Endocrinologist the UK Guidelines
The UK Policy Statements on Testosterone Deficiency is a good starting point. This is what NHS doctors should be adhering to if you present with signs and symptoms of TDS. If you’ve done your research, you’ll understand the importance of treating the patient not just the numbers. You’ll question why the reference range doesn’t take age into consideration, and you’ll wonder why your treatment options are so limited. There is much room for improvement.
America has a far more progressive healthcare system than here in the UK. We are catching up, but it’s a slow process. I would urge you to not dismiss the NHS as the dinosaur it may seem, but to try and affect a change through educating your doctor. Doctors DO have your best interests at heart, but the working environment is tougher than you could ever imagine. Inclusion not exclusion, but you must ultimately take responsibility for your own health. Information is power, use it to your best advantage.
Essential Bloods – Testosterone, FSH, LH, Prolactin, PSA & FBC
• Testosterone – The male sex hormone is a quantitative marker of your body’s current testosterone level. It is used in the diagnosis and management of Testosterone Deficiency Syndrome. The test should be performed ideally in the morning when your natural physiological levels are at their highest.
• Follicle Stimulating Hormone – A hormone produced by the pituitary gland that is involved in the testes producing sperm and hence, fertility.
• Lutenising Hormone – A hormone produced by the pituitary gland that stimulates intratesticular production of testosterone.
• Prolactin – Low levels have been linked to several signs of poor sexual health, as well psychological health. High levels interfere with the male’s ability to produce testosterone, and may be associated with a prolactinoma, a pituitary space occupying lesion.
• Prostate Specific Antigen – An antigen produced by the prostate gland. Testosterone does not increase risk of Prostate Cancer, but it can increase Lower Urinary Tract Symptoms and worsen existing Prostate Cancer as it is androgen receptor positive. A PSA measurement of >4 is a contraindication to receiving Testosterone Replacement Therapy. It should therefore be measured three months after commencing TRT, and then six monthly.
• Full Blood Count – Testosterone stimulates erythropoiesis (i.e. production of red blood cells). This can increase the viscosity of the blood, increasing the chances of clotting. A raised haematocrit (>54%) is a contraindication to Testosterone Replacement Therapy.
Add – SHBG, Oestrodiol & Free Testosterone
• Sex Hormone Binding Globulin – This protein binds to testosterone rendering it ineffective. You need this level to calculate your free testosterone.
• Oestrodiol – Oestradiol is a bi-product of the breakdown of Testosterone. It affects male libido and overproduction can cause development of female characteristics.
• Free Testosterone – This is a measure of your bioavailable testosterone. It is a more accurate marker of your current usable testosterone level.
Ask to be Referred to an ENDOCRINOLOGIST or See a Private Doctor Who Specialises in TRT
If you are lucky enough to be referred to an Endocrinologist, the good news is that the NHS will foot the bill. The bad news is that most UK Endocrinologists are not up to date with the current state of TDS and TRT management.
In the UK, the licenced treatment for TDS is Testosterone Undeconate (Nebido), a long acting ester that is unfortunately suboptimal. The other common option offered is the gel. This has its place in the management of TDS but again has limitations. You may be fortunate and be offered a short acting ester such as Enanthate, but you’d be one of the lucky few. Sustanon is also available, but the blend of four esters significantly increases the need for an aromatase inhibitor over a single ester such as Enanthate.
Unfortunately, most Endocrinologists do not recognise the importance of oestrodiol, nor HCG. They have to adhere to the BSSM guidelines.
You do have the option of going private. There are specialist TRT Clinics run by medical doctors here in the UK. Private healthcare allows you autonomy in the decisions you make about your care.
Questions to Ask:
• Are you CQC Registered? The answer should be YES. All healthcare providers providing regulated services must be registered with and regulated by the Care Quality Commission (CQC).
• What Choice of Esters Do You Offer? The answer should include a short acting single ester such as Cypionate or Enanthate. The Men’s Health Clinic is the first TRT clinic in the UK to have access to Testosterone Cypionate, the preferred TRT choice in the USA.
• Do you Prescribe HCG? The answer should be YES.
• How Do You Manage Oestrogen? If the immediate answer is an aromatase inhibitor, they are WRONG. It should be dose adjustment +/- change in injection frequency. An aromatase inhibitor should be a last resort.
• How Would You Monitor Me? The answer should be through regular blood tests and regular review with the doctor responsible for your care.
• How Much Does it Cost? The cost of services should be fully transparent. TRT is a financial commitment, make sure you can afford it.
So, should you go through the NHS or go Private? Can you really put a price on your health?
Dr Robert Stevens MBChB MRCGP Dip.FIPT