Low T and Missed Reps

[J. Keith Nichols MD]

Dr. Nichols, I am a 60 y/o with a total T level of 640, with the arguably mild symptoms of poor concentration, bad sleep, less interest in things that used to interest me, and less energy. Do you think that I should consider the TRT? I’m thinking that despite my Primary doctor saying “you’re over 300, you’re fine, in fact you’re a rock star,” that perhaps MY optimal T level is much higher. He would hear none of it. Also, if I do not seem to have a propensity to lose hair already, would TRT make me lose hair?

Honestly everyone over 40 would benefit from testosterone. Maintaining optimal levels is one of the keys to Health as we age. It's the free testosterone level that matters not the total and my guess is that you're free is not very good at all. Doctors have this fixation with the normal range because they don't understand that it is a normal range for unhealthy people. Life is much better outside than normal range in the so-called supraphysiologic range. If you're already losing hair then yes you will continue to lose hair and maybe even more rapidly. Sometimes it is a decision between hair and health. There are treatment options available to slow the loss of hair but nonetheless hair should not be the deciding factor with regard to improving your health.

[Steven Z]

Honestly everyone over 40 would benefit from testosterone. Maintaining optimal levels is one of the keys to Health as we age. It's the free testosterone level that matters not the total and my guess is that you're free is not very good at all. Doctors have this fixation with the normal range because they don't understand that it is a normal range for unhealthy people. Life is much better outside than normal range in the so-called supraphysiologic range. If you're already losing hair then yes you will continue to lose hair and maybe even more rapidly. Sometimes it is a decision between hair and health. There are treatment options available to slow the loss of hair but nonetheless hair should not be the deciding factor with regard to improving your health.

Is it correct to say that it is the DHT levels which would cause hair loss and that the theory is that TRT can increase DHT levels? Isn't it correct though that there is no data to suggest that TRT does in fact increase DHT levels? I thought I read somewhere that that there was no data to support that theory. Am I misinformed?

[J. Keith Nichols MD]

Is it correct to say that it is the DHT levels which would cause hair loss and that the theory is that TRT can increase DHT levels? Isn't it correct though that there is no data to suggest that TRT does in fact increase DHT levels? I thought I read somewhere that that there was no data to support that theory. Am I misinformed?

As you increase testosterone you increase its active metabolites DHT and Estradiol. That's how it works. When you block the formation of the active metabolites you block the beneficial effects of testosterone.

[Smyth]

Honestly everyone over 40 would benefit from testosterone. Maintaining optimal levels is one of the keys to Health as we age. It's the free testosterone level that matters not the total and my guess is that you're free is not very good at all. Doctors have this fixation with the normal range because they don't understand that it is a normal range for unhealthy people. Life is much better outside than normal range in the so-called supraphysiologic range. If you're already losing hair then yes you will continue to lose hair and maybe even more rapidly. Sometimes it is a decision between hair and health. There are treatment options available to slow the loss of hair but nonetheless hair should not be the deciding factor with regard to improving your health.

Thank you, Doctor. The blood panel did not provide free testosterone level, so I have no idea what it might be. I am not at all losing my hair, but I do appreciate the info, and your SS interview with Rip was most helpful.

[Shiva Kaul]

When treating low T, internists and GPs are supposed to follow this systematic review. Dr. Nichols, what do you think about their methods and conclusions? It is always fascinating to see authoritative medical recommendations based on a few opaque SMDs, rather than any meaningful mechanistic reasoning or quantitative modeling.

[Mark Rippetoe]

When treating low T, internists and GPs are supposed to follow this systematic review. Dr. Nichols, what do you think about their methods and conclusions? It is always fascinating to see authoritative medical recommendations based on a few opaque SMDs, rather than any meaningful mechanistic reasoning or quantitative modeling.

This is a fascinating document. I recommend that you all read it, so you know where all this silly bullshit comes from. ACP Journals

Clinical Guidelines Committee (CGC) members (clinicians and nonclinician public members) and CGC Public Panel members were asked a priori to independently rate the importance of evaluated outcomes. Quality of life; erectile function; cognitive function; and harms, including serious adverse events, major adverse cardiovascular events, deep venous thrombosis or pulmonary embolism, mortality, and prostate cancer, were rated as critical outcomes. Energy and vitality, physical function, mood (depression), fracture reduction, libido, and lower urinary tract symptoms were rated as important outcomes. All critical and important outcomes were considered in developing the recommendations. Sexual function included self-reported overall sexual function and erectile function and was measured by the Aging Males' Symptoms (AMS) and International Index of Erectile Function (IIEF) scales. The IIEF domains include erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction; the AMS scale assesses disturbances in potency, decreased morning erections, decreased libido and sexual activity, decreased beard growth, and the “impression of having passed the zenith of life.” Data reported in standardized mean differences (SMDs) were interpreted as small (SMD, 0.2), medium (SMD, 0.5), and large (SMD, 0.8) effects (12).

We have sildenafil for our erectile problems. We need the testosterone for all the other shit these people know nothing about.

But really, here's the problem: "The role of testosterone treatment in managing age-related low testosterone is controversial. The U.S. Food and Drug Administration (FDA) requires the pharmaceutical industry to label all testosterone medications to clearly state that their products are approved for use only in persons with low testosterone levels due to known causes."

Controversial? Why? Known causes, like being an older male?

[Shiva Kaul]

The role of testosterone treatment in managing age-related low testosterone is controversial. The U.S. Food and Drug Administration (FDA) requires the pharmaceutical industry to label all testosterone medications to clearly state that their products are approved for use only in persons with low testosterone levels due to known causes.

The full underlying review describes, in this context, a diligent and insistent FDA:

Because of concern about inadequate data regarding harms of testosterone treatment in older men with age-related hypogonadism, the FDA has required companies that manufacture these products to conduct a controlled clinical trial to evaluate the effects of testosterone therapy on cardiovascular outcomes (1). This trial, TRAVERSE (Testosterone Replacement Therapy for Assessment of Long-term Vascular Events and Efficacy ResponSE in Hypogonadal Men), began enrollment in May 2018 and will follow participants for up to 5 years for cardiovascular safety and prostate safety, as well as efficacy outcomes (107).

[Mark Rippetoe]

The full underlying review describes, in this context, a diligent and insistent FDA:

An FDA we have not seen for 2.5 years.

[francesco.decaro]

Oh and I'm getting a nice shade of pink to me.

Finally after all these years we discover the cause of Rip's skin color.

[J. Keith Nichols MD]

Most guidelines are completely biased against the use of testosterone. I've stated this previously and I'll say it again: I can pull dozens of studies to prove that testosterone doesn't work just like these guidelines did. It's all right there nobody can argue with it they gave me an testosterone and it didn't improve the condition they were studying. The devil is always in the details. The common denominator in the studies where testosterone didn't work is that they only raised testosterone a little bit. I can also prove that antibiotics don't work. I can design a study and give only a little bit of the antibiotic and prove that it doesn't work for a specific infection. The same holds true for testosterone. When you only raise testosterone a couple of hundred points it will not have a significant effect on most men.