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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24 Replies to “How Men’s Clinics Create Drug Addicts”
Love this. Thank you. You should write a guest post for Science Based Medicine. Com. (Although they may not allow anonymity.)
Thanks, Kelley. Yeah, I like SBM a lot. I will have to look into their policy on guest posts.
I always amazed that there are still snake oil salesmen in this day and age. Instead of no information like in the old days, now we have excessive and wrong information out there.
I guess there will always be vulnerable people out there, a sucker born every minute.
I personally worry about the increased risk of prostate cancer and coronary disease. I have seen patients come in with excessively concentrated hemoglobins and aberrant lipid profiles.
Thanks for the excellent article!
In patients with jacked up hemoglobins and crazy high T levels, we should worry more about cardiovascular complications and the facilitation of growth of a pre-existing prostate cancer. In normal TRT performed by a real doctor, the risks are much lower.
Me, 25 y/o, doing strenght training at an advanced level decided to measure my testosteron 8 times within a month of heavy lifting (5 workout per week) with the intensity and volume of the workout progressively increasing over that month. I scheduled it correctly so that i had overreached my capacity at the end of week 4, meaning i got weaker, felt extremely exhausted and motivation to train was low (classical signs of overtraining).
The testosterone (total and free) i measured throughout the experiment went down – being half as high at the end (in an overtrained exhausted state) compared to the beginning (well recovered).
I then deloaded (a week of very little “recovery style” training) and started the whole experiment again.
After this deload my testosterone has increased again to normal levels and then again, as in the first month progressively decreased.
–> similar pattern in both months.
For me, it went as expected… high training stress correlates with lower T (“it got used up” i would say… faster than it is produced).
What are thoughts on this? Do you think this is reasonable and makes sense in general?
Or is this whole idea bogus, lucky correlation, no relation between the two, etc, …?
Here are two abstracts that seem to support your observation that T goes down with intense weightlifting:
Although I (and most Endos) am not an expert in exercise physiology, this would appear to be a normal physiologic response to the exercise load. During and immediately after intense exercise, I would surmise that the body is more focused on the catabolic functions it has been performing. Once an appropriate period of rest occurs, the body can focus more on anabolic functions. That may be an oversimplification of the issue, but it seems to make sense.
Thank you a lot, that makes a lot of sense.
would you say that in such a situation of increased demand, ingesting extra things like zinc, boron, maca, etc would work rising it?
I think the first question is, why try to raise it? It’s just a number that reflects the dynamic physiology of the body. Lower does not necessarily = worse. If the body doesn’t want to make as much T at any given moment – in the absence of pathology – why even care?
If its just a question of whether or not the body WANTS to make testosterone then i dont understand why we see this substantial drop of around 1% each year over the last decades…
This would assume, all males suddenly collectively decided to decrease their T production by around 1% per year.
Wouldnt it be more obvious to asume that something is concerningly wrong? That certain lifestyle factors, whatever they might be, impair the production and disrupt the balance?
Daniel, I’m not sure to what you are referring. Are you saying that age-matched populational levels of T are lower now than they were decades ago? If so, please cite your source.
If you’re referring to the natural decline in T as we age, that’s just normal physiology.
As far as measuring T goes, it can be quite different on different days, suggesting that there is variability in the assay, variability in the diurnal rhythm, and variability in the day-to-day physiology of each person (is he sick, has he been overtraining, etc). It’s best not to jump too quickly to the conclusion that there is something wrong that needs to be fixed.
Yeah i agree.
I think many dont realize how powerful plants are. They believe that just because its natural it is automatically good whereas in reality it may cause disturbances in a balanced body.
In my opinion plants and esspecially herbs are medicine and should be used as such.
Can estrogen be too low in men?
And thank you for your awesome article!!
Yes, it can be too low – particularly because estrogen protects the bones from osteoporosis.
Interesting.. is there a certain cut off point for estrogen which it shouldnt go below or any symptoms that may indicate it (besides osteoporosis)?
And what would cause low estrogen?
I wouldn’t worry about it. Estrogen levels in men won’t get too low unless they are taking stuff they shouldn’t, like aromatase inhibitors. I wouldn’t even check an estradiol level in a healthy man – there’s just no reason for it.
-> The source i was refering to… yes exactly – age-matched populational levels of T are lower now than they were decades ago. During the studied 20 years T-levels declined 1,2% each year (apparently it was not attributable to obesity).
In my opinion this suggests that the body is designed to actually have higher T levels. (If the rate of decline (1,2% per year) would have continued after the study ended till today, men nowadays would on average have around 1/4 less testosterone than they had in 1987).
Thats why i would say something is wrong, but im with you, TRT is probably not the answer.
Thanks for the link to the article. I wish the paper was written in a more direct manner, as I had some trouble following the convoluted text. But I get the point that there may be something out there – not captured by typical diet and environmental history – that is lowering T levels in men (maybe some kind of endocrine disrupting chemicals?). And this lowering of T seemed to be greater than what would be expected for normal aging. Interesting and provocative, for sure.
Thank you for the great article. I do realize I am 10 months late and do not know the answer. Environmental factors are one of the suspects (phytoestrogens?), but sitting all day possibly contributes to lower sperm count, and this phenomenon may or may not have any connection with decreasing T levels. Another possible factor I can imagine is the high density of the population, and there are less definitive high-ranked males. (I mean you may be a boss at your workplace, but nobody recognizes it during the remaining 128 hours a week.) In rodents, there is a strong correlation between rank and T levels, and T is also responsible for aggressive behavior. (Women also have androgens, it is needed to maintain muscle mass, and yes, we also need to show aggression.) More people with whom we live in peace (or indifference), lower muscle mass, higher sexual steroid intake with food, that inhibits endogenous sexual steroid production, and we have a hypothesis to work with.
Another issue is testing. I have learned that some unfortunate guy was suspected of having colon cancer when digested blood was detected in his stool sample. After gastroscopy and endoscopy, a medical expert started to talk with this patient, at last, only then it was realized that the digested blood was of swine. (In my country, a food item similar to black pudding is quite popular. It contains pig blood.) As far as I know, the diagnosis of diabetes mellitus usually depends on two independent measurements (if the blood glucose level doesn’t go viciously high for the first time). As you have emphasized and Dominik also mentioned earlier, the circumstances can cause a significant deviation in hormone levels in a healthy person.
Therefore, at the end of the day, the problem is the patient, who wants an immediate diagnosis instead of a month-long series of examinations:-)
Thank you for a great article. I have been battling with this issue because of the normal range aspect. I have been tempted to go to a mens clinic ( I initially had blood drawn there) and it showed well below range… however I wanted a second opinion from my PCP and his labs showed a little above range. (DependIng on “normal” range of course)
Could you offer some insight on the ranges and whether or not placing low in them matters based on age? I am very symtompatic but disappointed that once again I am told, tests are low but normal, youre fine. Especially considering a very healthy lifestyle (fitness and diet). He has referred me to an endo but I am concerned about endless testing and still no outcomes. It is very tempting to go to a clinic to at least see if it helps, but I know thats exactly what they want you to do.
Ryan, you raise an issue with which I’ve struggled. I have seen a few younger guys in their 30s with classic symptoms and borderline total and free T levels (but just on the “right” side of normal), with no evidence of any other pathology to explain their symptoms. I think it’s more likely that a 30 year-old guy with a total T of just over 300 and classic symptoms has hypogonadism, than a 60 year-old guy with the same presentation. That said, the younger guy could still be normal; it’s just that I’ve been very suspicious that a few of the guys I’ve seen really have hypogonadism, but I haven’t been able to make the diagnosis using accepted criteria.
This gets very tricky, because:
– Testosterone is a controlled substance, meaning that prescribing it outside of clinical guidelines potentially puts a doctor’s license at risk. Interestingly, the men’s clinic docs do not seem to worry about this – but I do.
– Insurance companies generally will not cover TRT unless there have been two measured morning T levels <300.
- Many more men will have borderline T levels and "symptoms" without actually having true hypogonadism, than will men who do have true hypogonadism, making the pretest probability for disease fairly low.
One potential strategy is to continue testing morning T levels periodically until getting two levels <300, so then at least a trial of TRT can be justified. Chances are, since T levels vary a fair amount from day to day, someone with borderline numbers will eventually test low a few times.
Can elevated T at upper level or slightly above the reference range of 250-1100 ng/dL increase blood pressure?
Replacing T to higher than normal levels can cause high blood pressure. As with most things, there is a spectrum of effect, based on how high one pushes the level, in addition to other factors – baseline BP, presence of sleep apnea, etc.
My husband (age 37) chose a men’s clinic because that’s all they do everyday, they have experience in this. He had 2 doctors (our primary, and a functional medicine) recommend treatment for symptoms and a level of around 300 and just under 300 (both morning). He didn’t want to take Test. So he tried a year of exercise, diet, supplements with no improvement. After that he was started him on cream which lowered levels to 150. At that point he wanted to work with someone who had lots of experience. He now has been self injecting 2x per week for a year with levels 600-700 and feeling great. I’m sure not everyone has such good experience but I did want to share a positive one.
Never stumbled upon this post, funny and to the point, the core of this blog
Watching the fitness industry over the years, AAS abuse looks the “norm”
Good post 🙌