SS Radio #171: Hormone Optimization with Mike Wittmer MD

[Mark Rippetoe]

Dr. Wittmer - Hormone Optimization Therapy | Starting Strength Radio #171

[Buffaloguy]

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.

[Mark Rippetoe]

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.

Not a joke, at all.

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.

To simplify, the AAFP is more concerned about lab values -- despite all the problems we have identified with them -- that about signs and symptoms.

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.

Yet there remain TRT practices that are apparently capable of dealing with this limitation.

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.

The fact that some of you haven't been exposed to TRT's benefits does not mean that the resources for educating yourselves professionally are not available. In the event that you see a patient who comes to you with low-T symptoms, confirmed by your observations, I suggest that referral to another office would be the best option if you feel inadequately prepared to deal with the patient. But I have a question: What would be the adverse effects of 400mg testosterone cypionate in the glute of a 50-year-old man complaining of hypogonadism symptoms?

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.

This is good to hear.

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.

The very same thing can be quite accurately observed in many General Practice offices. There is one office here in WF that has a 45-second timer running when the door closes on a patient. And yet no stigma is attached to General Practice. Forgive me for trying to attach one.

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.

Thanks for your input.

[Buffaloguy]

Thanks for the response. Again, my point is not to deflect blame but to explain why this is an undertreated problem. I agree there is not much harm in trying Test on the 50 year old you described. I would disagree that there is not a negative stigma among many people with GP offices and the medical system in general. I look forward to reading the book recommended by Dr. Wittmer on the podcast.

[Bill G]

Doctor? If you are not yet lifting, start now. Dan Flanick, the nearest Starting Strength Coach to Buffalo, is excellent. I recommend him to you unreservedly. Skanateles is an easy down and back.

[Buffaloguy]

I restarted the NLP a few weeks ago, thanks for the recommendation. Lifting pretty consistently for the last year.

[Shiva Kaul]

The problem is that uncontextualized, arbitrary statistical “reasoning” has taken precedence over basic cost-benefit analysis. The reference range of 264-916 ng/dL is a 95% confidence interval covering the bottom 2.5% to the top 2.5% of the population. Can you imagine prescribing strength training to only the 2.5% weakest people?

[Mark Rippetoe]

The problem is that uncontextualized, arbitrary statistical “reasoning” has taken precedence over basic cost-benefit analysis. The reference range of 264-916 ng/dL is a 95% confidence interval covering the bottom 2.5% to the top 2.5% of the population. Can you imagine prescribing strength training to only the 2.5% weakest people?

Insightful, as usual.

[Steven Kalin]

The problem is that uncontextualized, arbitrary statistical “reasoning” has taken precedence over basic cost-benefit analysis. The reference range of 264-916 ng/dL is a 95% confidence interval covering the bottom 2.5% to the top 2.5% of the population. Can you imagine prescribing strength training to only the 2.5% weakest people?

This is the best way I’ve ever heard it put.

[Shiva Kaul]

To be clear, the reference range is drawn from healthy, nonobese men. These data show it's possible to be healthy even with low T, says the GP. However, this has little bearing on the actual clinical question: whether increasing T is beneficial.

As a thought experiment, suppose protein, sleep, and T are the pertinent health metrics, and each of these is randomly low or high across the population. Suppose you are healthy if at least 2 of these metrics are high. A quick calculation (below) shows that 25% of the healthy population will have low T. They will serve as "evidence" for the GP to never increase T...even when this intervention is modeled as universally beneficial.

---
p,s,t are iid Bernoullis, and you're healthy if p+s+t >= 2. So half the population is healthy:
P(p+s+t >= 2)
= 1 - P(p+s+t < 2)
= 1 - P(p+s+t <= 1)
= 1/2
The conditional probability of low T:
P(t=0 | p+s+t >= 2)
= P(t=0, p+s+t >= 2) / P(p+s+t >= 2)
= P(t=0)*P(s=1)*P(t=1) / P(p+s+t >= 2)
= (1/2)^3 / (1/2)
= 1/4