Hello all, I’m a family physician in the buffalo area, previously practising full spectrum family medicine and now focusing on addictions, urgent care and telehealth (no longer practicing primary care). I have greatly enjoyed Rip’s discussions on TRT and have a number of thoughts in response. I’m not here to defend family physicians, I’m here to explain my understanding of why there is so much controversy and confusion regarding TRT.
1. Your GP has a very broad training, including in obstetrics, pediatrics, newborns, inpatient (hospital) care, outpatient (office) care, ICU, emergency department. Jokingly I say our knowledge is a mile wide and an inch deep. As such we rely on consensus opinions from our own organisations and specialists to provide us with good guidelines and information to help our practice.
2. The American Academy of Family Physicians specifically states in their guideline from May 2019:
Treatment in Adult Men with Age-Related Low Testosterone….
Key Recommendations (shortened by myself for brevity)
For individuals with age-related low testosterone and sexual dysfunction who want to improve sexual function, the decision to initiate testosterone therapy should occur following a discussion of the potential benefits, harms, costs, and patient's preferences.
For individuals with age-related low testosterone and sexual dysfunction who decide to initiate testosterone therapy, intramuscular and transdermal formulations have similar clinical effectiveness and harms. However, intramuscular formulations are preferred as the costs are considerably lower.
Testosterone therapy is not recommended in men with age-related low testosterone to improve energy, vitality, physical function, or cognition.
The last point is the most important part. It is outside the mainstream of medicine to treat low T symptom in the absence of low serum levels . The AAFP spells out in numerous articles, which I have also seen from urologic associations, that serum T should be below normal on 2 separate AM blood draws before starting treatment. Obviously, this is a HUGE barrier to starting testosterone on patients.
3. Testosterone is a controlled substance. This means extra scrutiny for doctors prescribing it from the DEA. It also IS abused, obviously, by bodybuilders and others taking massive doses. I even have a colleague who took a patient off of it because he was taking higher than his prescribed dose in order to “Shoot” his ejaculate further. The family docs were burned in particular by the opiate crisis and averse to prescribing controlled meds in general.
4. Most doctors are not serious lifters. As such we are not exposed to a lot of people who take TRT and profess it’s benefits in our own lives.
5. The mass marketing of SSRI’s is through television is a larger problem in my view than the actual drug reps coming to offices. The influence of drug reps has been greatly curtailed in the last 20 years. Many offices, including the owns I’ve worked in, don’t let them in the door. The stereotype of them being good looking young women has also sadly changed, the field being filled more with middle aged men on their third career desperate to make a buck.
6. TRT clinics are sometimes cookie cutter operations looking to see as many people as possible in order to maximize profit without a serious attempt to rule out and work up underlying conditions driving Low-T symptoms. This stigmatizes the field in general.
Thank you if you read all the way through this. Ive enjoyed exposure to different perspectives on Low-T issues through the SS podcast and am educating myself more on the matter to address it in my practice.