I work in a region where men’s clinics are sprouting like weeds after a springtime soaking rain. Finally, a place where men who’ve lost their mojo can have their unique needs addressed, right?
Before I eviscerate these testosterone-prescribing factories, note that some of these charlatans will stumble onto the correct diagnosis of male hypogonadism (clinically meaningful low testosterone) and actually help their patients. I am not implying that these clinics treat everyone inappropriately – just everyone I see in my office.
Granted, there is sampling bias when it comes to the patients who see me. They sometimes seek a second opinion from me after attending the men’s clinic for awhile, then realizing that something is rotten in the state of Denmark. These are guys who obviously are not satisfied with their current care.
More often, however, a patient’s primary care clinician will look at the ream of lab results and multiple medications prescribed by the men’s clinic, and her Spidey sense starts tingling. She then harangues her patient into a visit with the Endocrinologist.
So where do men’s clinics go wrong?
Everyone Gets a Diagnosis
You know what’s really awesome if you’re a patient? When you go to the doctor with a problem and she says, “I know exactly what’s wrong with you, and you’re going to feel so much better with treatment.” But wait. There’s something you’ll like even more than that. In this next scenario, you’ve already done your research prior to the visit, and you’re convinced that your symptoms of fatigue, low sex drive, weight gain, and low motivation are due to “low T.” Then you see the doctor and she agrees with you that your symptoms sound like low T – ahhh…validation. Wait for it, though…she then runs some blood work which confirms her (and your) suspicions. How amazing is that?!
You didn’t even go to medical school, but armed with a smart phone and advice from your buddies at the gym, you figured it out! In fact, you’re already starting to feel better, aren’t you? Energized a bit? Feel like making love – Bad Company style – right? Man, what a great day!
If you have true hypogonadism, you are probably on your way to feeling better, and I am genuinely happy for you. It’s awesome when I get to see a man turn around 180 degrees after starting testosterone replacement. Unfortunately, this isn’t the case for many of you, who have been suckered into a sham diagnosis.
But I saw the lab results with my own eyes, and my levels were flagged as low! How can you tell me I don’t really have low T?
First, it’s critical to draw testosterone levels in the early morning when trying to make a diagnosis of low T. Testosterone has a diurnal rhythm, meaning that it starts out high in the morning and then falls gradually over the course of the day. Since the normal reference range for testosterone has been determined using early morning measurements, measuring T later in the day is not a valid way to make a diagnosis. Lots of men will have “low” testosterone in the afternoon, which means precisely nothing. (Note: this diurnal rhythm is often lost in graveyard shift workers and elderly men.)
Whenever I see a man who already has a diagnosis of low T, I request the lab results from before he started taking testosterone replacement therapy (TRT). What I’ve found is it’s not uncommon for the original diagnosis to have been made using a late afternoon T level. At best, this represents a knowledge deficiency on the part of the men’s clinic physician. At worst, this is intentional, in order to make more diagnoses and collect more fees.
The second thing I see quite often is a normal T level flagged as low. This is done either by the laboratory or by the clinician, one of them deciding to redefine (by increasing) the lower limit of normal for T. For example, let’s say a 40-year-old man has a morning T of 400 ng/dl, which is normal when using a typical lower limit of 300. But, if the lower limit of normal is changed to 440, this 40-year-old man gets a diagnosis. Winner, winner, chicken dinner. (Look for a future post delving into what constitutes a “normal” T level, which I admit is a controversial topic.)
The third thing I see in the quest to give everyone a diagnosis is a shotgun approach to ordering blood work. Men’s clinic doctors order pages and pages of hormone testing, much of which has no clinical relevance (but is very lucrative for the clinic if they take a taste of the lab revenue). Guess what? Some of those numbers are going to come back high or low. When that happens, you can bet that your men’s clinic doctor will have a medication you can take for that.
In the field of medicine, especially in Endocrinology, we have two axioms that are ingrained in the way we practice: know your assay and know your pre-test probability. Knowing your assay means understanding all the things that can affect a lab test (time of day, food, meds, medical conditions, etc). It also means knowing what kind of conclusions can be drawn from a result and what conclusions can’t be made.
Knowing your pre-test probability means you want to be judicious in what you order, using your degree of clinical suspicion to guide testing. Why? Because lab tests will come back “abnormal” quite often. If the pre-test probability of a patient having the condition is very low, but you order the test anyway and it returns abnormal, what does that really mean? Many times, it means nothing. It is irresponsible – some would say unconscionable – to give someone a diagnosis based on a result that is almost certainly a false positive.
Bottom line, more testing ≠ better care.
Men’s Clinics Rarely Employ Endocrinologists
If you have shoulder pain, I would strongly recommend that you don’t come see me for an evaluation. I think I learned a bit about the rotator cuff in medical school 20+ years ago, so do you really want me to muddle through a physical exam with that knowledge base? On second thought, maybe I could help you. I mean, I exercise a lot. Over the years, I’ve had my share of injuries needing Sports Medicine input. That clearly gives me a passing familiarity with shoulder problems, which should be enough to sort you out, no?
Running in the opposite direction yet? Of course you are. Then why would you go to a men’s clinic staffed by general practitioners and ex-surgeons, among other non-Endocrinologists? Endocrinologists spend 2-3 years in subspecialty fellowship training after 3 years of residency in Internal Medicine. That level of subspecialty experience will not be replicated in a weekend “low T” seminar, or whatever cursory training these clinicians receive.
The folks who practice at these clinics will tell you it isn’t rocket science – anyone can be trained to do it. These are the words of people who do not appreciate the nuances of medical care. You should be frightened of clinicians like these, as they are the ones most likely to hurt people. Let me put this another way: do you want your doctor to be intellectually curious, interested in finding the truth? Or would you prefer someone who acts like the first person you talk to when you call tech support, reading from a script, with no ability to synthesize information independently based on what you’re saying and what they’re seeing?
Is it possible to train a non-Endocrinologist clinician to practice nuanced care of men with low T? Absolutely. My partners and I have trained nurse practitioners to take care of diabetes and many of the conditions that go along with it, including male hypogonadism. The NPs still need to ask us questions about hypogonadal patients on occasion, but they do solid work in that area. Have I seen this play out in the real world of men’s clinics? Not so much.
Bottom line: spend at least as much time checking out your “hormone doctor” as you did vetting your personal trainer.
Men’s Clinics Prescribe a Cocktail of Medications for Low T
If you care to read The Endocrine Society’s clinical practice guideline for the treatment of male hypogonadism, you will notice that there is just one medication recommended – testosterone. Have low T? Take T. Simple, right?
Not so fast. Men’s clinics justify their existence, in part, by offering something that your doctor won’t give you. In fact, this is what most charlatans do (a certain infamous TV doctor promising some new herbal supplement will melt away fat…you know the type). The irony here is that they know very little about evidence-based treatment, yet they concoct a treatment plan that is more complicated than any I would ever design.
At best, they do this because that’s how they’ve been trained by their supervisors, and they simply never questioned their training. At worst, they deliberately obfuscate to solidify the patient’s total reliance on everything they say. Again, a brilliant strategy.
Think about the first time you applied for a mortgage. Remember the complexity of that process? At some point, you just figured, “Well, my broker seems to know what he’s doing, so I’ll just run with it.”
Your broker had a fiduciary responsibility to his business – not to you. Was he using sleight of hand to drain more money from you, or was he doing right by you and just not explaining himself well? If you’re not in the finance world, you probably don’t know the answer.
Well, if you’re not a medical professional, it’s the same deal. You just don’t know if the complexity is warranted. If a doctor makes something sound reasonable, how are you supposed to know it isn’t?
Testosterone Replacement Therapy (TRT) Demystified
In the case of treating low T, all you need is testosterone. You do not need an aromatase inhibitor (anastrozole) or a selective estrogen receptor modulator (tamoxifen), nor do you need human chorionic gonadotropin (hcg). I’ll address clomiphene in a future post, as its use in men is still primarily in research settings.
Hold on. What about all that estrogen my body produces from the T I’m taking? How do I block that? And what about my nuts? Don’t I need to keep them from shriveling up like raisins?
Look, your body is supposed to convert testosterone into estrogen. Estrogen is responsible for modulating libido, erectile function, maintenance of strong bones, and other important bodily functions. Your body needs it. However, if your blood estradiol level is high enough during TRT to cause new-onset gynecomastia (tender enlargement of the breasts), the answer is usually to decrease the T dose.
Think about it: your body is very good at maintaining balance in many ways. If you push your T level higher than what your body deems appropriate, it will implement measures to get rid of that extra T – namely shuttling it along a path to conversion into estradiol. That’s your body’s way of saying, “Hey dummy, you’re giving me too much T. Keep messing with me like this and I’m going to grow you a sweet pair of mammaries.”
Does it make sense to use a second drug to combat the excess estradiol that resulted directly from an excessive dose of the first drug? Or might it be more straightforward to simply decrease the dose of the first drug?
But bodybuilders and professional athletes use this kind of stuff all the time, plus more!
What they do for performance enhancement bears little resemblance to treating the typical, slightly out-of-shape 20-something to 60-something male with low T. You would probably sing a different tune if you could see the former juicers who come to my office, clearly expressing regret for ever getting started with that nonsense. Their bodies are often so wrecked after experimenting with mega doses of anabolics that they can barely get out of bed in the morning.
OK, whatever. You still haven’t addressed my shrinking testicles. Shouldn’t I at least be on hcg?
If you take a reasonable dose of T, you may see some testicular atrophy, but they likely aren’t going to shrivel up to raisins unless you’re taking huge doses. Cosmetically, most men don’t find the mild atrophy to be that big a deal.
From a fertility standpoint, it is recommended that men who desire future fertility consider banking sperm prior to starting therapy. Is that expensive and inconvenient? Yes. But so is taking hcg injections indefinitely, and banking doesn’t involve taking a medication you don’t really need.
Even if you don’t bank sperm before starting TRT, it is quite possible that your sperm count will be good enough to fertilize an egg. But if your swimmers aren’t quite up to the task, you can always take the hcg injections when you and your partner are finally ready to conceive. They are not guaranteed to work, but it may be worth the effort at that point.
Men’s Clinics Create Drug Addicts
You need to understand that there is a huge difference between hormone replacement therapy and using hormones as stimulants. When you are deficient in a hormone and then take that hormone as replacement therapy, it should restore your level to whatever would be most physiologic for you, given your age, gender, other medical conditions, etc.
When you are not deficient in a hormone, but then take that hormone anyway, your body reaches a supra-physiologic (higher than normal) level of that substance. Your body will often interpret that as a good thing, giving you a buzz or other favorable feeling. Most people assume that the therapy must be working, which of course means that the original diagnosis was correct, right?
Absolutely not. Humor me by running through this thought experiment: give me a urine sample right now, and we’ll perform a drug screen on it. If you test “low” for opiates, benzodiazepines, and methamphetamine, we’ll swing by the local drug dealer and purchase some product to correct your heroin, alprazolam, and meth deficiencies.
Sound ridiculous to you? Of course it does. But this is analogous to what happens when a patient gets “hooked” on testosterone, dessicated thyroid hormone, hydrocortisone – you name the “-one” – that he didn’t need in the first place. The body gets used to higher levels of the hormone in question, and it really likes the stimulant effect. Over time, the stimulant effect will usually wane, leading the person to believe that the therapy is no longer working.
What happens then? The dose is increased by the know-nothing charlatan, naturally! And on goes the cycle, until the patient winds up in my office, and it takes me a year or longer to wean him off this stuff, all the while attempting to manage his (understandable) frustration. After all, if testosterone isn’t the answer for him, then what?
Men’s Clinics Use an Unethical Business Model
If protecting your health isn’t a compelling enough reason to avoid these clinics, then do it to protect your wallet. You will find that many of these places encourage or require you to sign up for a bundled plan, which may cost several thousand dollars over the course of a year. The plan may cover office visits, medications, and supplies, which may or may not be covered by your medical insurance.
Regardless of whether this is paid by your insurance, it is typically unnecessary to see a doctor for low T more than once yearly after finding a stable regimen for you. In my practice, I usually create the treatment plan in 1-2 visits, then follow up with the patient in 3 months for the second or third visit, then perhaps see him another 6 months after that for the third or fourth visit, and then go to once yearly visits. The ultimate goal is actually to turn his T care over to his primary care provider, as yearly monitoring is relatively straightforward once on a stable regimen.
If I prescribe T injections, I certainly don’t sell them out of my office. I give him a prescription and have my nurse teach him or a partner/family member how to give injections at home. It is cheaper and more convenient for the patient to do that, as opposed to coming in for a “nurse visit” every 1-2 weeks to do the injection.
Likewise, if I prescribe an oral (e.g. sildenafil) or injectable (e.g. alprostadil) medication for erectile dysfunction, I send the patient to the pharmacy with a prescription. I don’t stockpile this stuff in my office and then sell it at a markup.
Male hypogonadism is a real problem that affects too many men. In a future post, there will be more about some of the causes of low T (particularly obesity) and how T levels may be restored to normal without medication (weight loss).
If you have been diagnosed with low T or think you might have it, please go to a reputable doctor to get checked out. As with everything else in medicine, be open to the possibility that this one diagnosis may not explain all of your symptoms.
After a thorough evaluation, if you find yourself still searching for answers, you’re not going to find them at the local men’s clinic. What you will find are charlatans who will give you a diagnosis, load you up with medications you may or may not need, and charge you a pretty penny for the privilege.
Are you a physician who manages low T? What’s been your experience with men’s clinics? Do you think TRT really helps most of your patients? Are you a physician at a men’s clinic? What do you think about all this? Are you a patient with low T? Are you happy with your medical care? Why or why not? Comment below!
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