04 Jun Vetting your doctor: Know what to ask before getting started with a TRT doctor
If your doctor is truly an expert in the field of hormone optimization therapy, here are the following questions you should ask them and the answers you should receive from a true expert.
1st Q: How long have you been managing patients on testosterone optimization therapy, and how much of your total practice do those patients represent?
Best Answer: 3 Years Minimum and 5-10 Years preferred. If the doctor is an Age Management, Endocrinologist, or Urologist, the answer should be 25% of total practice at a minimum and preferably 50% or higher.
2nd Q: Do you have a preferred form of hormone therapy like injections, gels, creams, rapid dissolve tablets, or pellets?
Best Answer: I prescribe what the patient requests. I TRY TO AVOID pellets and intranasal therapies. I preferably recommend injections with an insulin syringe, but if a patient is needle-phobic, I will cater to their needs using rapid dissolve tablets or a lipo-derm base cream, with no gels as they are trash. Long-term patient adherence is what is most critical when prescribing hormone therapy.
3rd Q: How do you determine your dosing schedule for Testosterone, aromatize inhibitors on a new patient?
Best Answer: I start low (dosage-wise) and go slow measuring blood work before starting therapy to establish a baseline. Once a clinical need is established (due to symptoms first and blood work second), I will begin Testosterone in isolation (by itself) to best understand what T is doing in that patient’s endocrine system solely. However, for men concerned with maintaining fertility, I recommend starting with a stimulant therapy like Gonadorelin, Kesspeptin, or Clomiphene therapy. If the patient is overly concerned about the effects of testosterone therapy on sperm, then I would recommend the patient to get his sperm count measured and freeze his sperm to be extra safe. In addition, there is now a lot of data confirming that 90-95% of men on testosterone therapy will recover their fertility on a 2-6 month fertility program. For men educated on the process, I will offer them the option of using Testosterone along Gonadorelin, Kesspeptin, or Clomiphene therapy concomitantly. Labs should be drawn 6-8 weeks after therapy initiation to understand the balance between Testosterone and Estrogen, which is of utmost importance. Symptoms/side effects and patient feedback is a very effective measuring tool. The goal is for the patient to feel a balanced sense of well-being. We as practitioners have to beware of making the mistake of getting stuck treating lab results rather than the actual patient.
4th Q: What is your opinion of the usage of Aromatase Inhibitors (AI’s)?
Best Answer: AI’s are harsh chemicals designed for women’s cancer patients. They have been shown in multiple clinical studies to cause issues with bone mineral density and HDL cholesterol. Both of which can be harmful to male health when negatively affected. When AI’s are scripted, there must be an indicated clinical need for the patient as measured by side effects, symptoms, and elevated readings of Estrogen via blood work. There are no specific threshold or Estrogen measurement levels where a man is ‘too high’ or ‘too low’. It has to be based on side effects or symptoms. Usually, when men are below 10 on their estrogen readings, you’ll find there’s usually sexual dysfunction, brain fogginess, and joint pain. This should be avoided, and why indiscriminate prescribing of AI’s should be avoided at all costs. Also, when AI’s are indicated, the minimum effective dosage principle should always be followed with the ultimate goal of removing the patient from the AI once the balance between Testosterone & Estrogen is achieved. This is measured by feeling good and the absence of side effects. In addition, the AI is only considered when natural E blocking alternatives have been shown not to work on the patient. Then and only then, should I consider using an AI with the patient.
5th Q: What laboratory blood tests are you going to draw before initiating hormone optimization therapy? When do you draw labs again once the patient gets started?
Best Answer: For a successful and accurate assessment to see if therapy is suitable for the patient, there should be a pre-complete hormonal blood test. The following panels should be measured before any hormone therapy is considered: CBC, CMP, Lipids, Total & Free Testosterone, Sex Hormone binding Globulin, Estradiol, FSH & LH, Dhea-Sulfate, IGF-1, Magnesium, Vitamin D & B, TSH, Free T4 & T3, Thyroid Peroxidase, PSA, Uric Acid, Ferritin, Iron, Insulin, and Hemoglobin A1C. If the patient is approved for therapy, then there should be another follow-up blood test 6-8 weeks into treatment to measure changes to the initial baseline readings.
6th Q: How many times will you want to draw labs per year?
Best Answer: There should be as many labs as needed based on individual patient responses to the tailored hormone optimization therapy. Typically, in the first year, 2-3 lab draws per year upon initiation of treatment. If the patient progresses and is confirmed to be “dialed in” correctly, then labs should be drawn twice yearly for optimal medical supervision or once a year at the bare minimum.
7th Q: What is your preferred therapy for maintaining fertility? Gonadorelin, Kesspeptin, or Clomiphene therapy?
Best Answer: As previously mentioned Gonadorelin, Kesspeptin, or Clomiphene therapy are all options for men who want to maintain fertility throughout their hormone optimization treatment. Each strategy can work as it depends on individual patient responses. Most doctors will choose the least invasive route to preserve fertility (using testosterone as the last course of action) due to its disruption of endogenous production of testosterone and the HPTA (hypothalamic-pituitary-testicular-axis).
8th Q: Will you use these sperm stimulating medications with or without concomitant hormone optimization therapy, that is, at the same time as hormone optimization therapy? Explain your dosage strategy to me?
Best Answer: The doctor can choose either course of administration depending on the patient’s wants in maintaining fertility while also selecting the best path of hormone optimization. Most doctors who are highly skilled at managing a patient’s endocrine system can utilize hormone optimization therapy while also administering Gonadorelin, Kesspeptin, or Clomiphene at the same time. Some doctors will use the medications regularly while others will use them intermittently (think of it as day-to-day administration versus 2-3x weekly usage). Both strategies are proven to work, and a skillful physician will likely have their own tried and true system.
9th Q: How long does it typically take before I start seeing results or ‘feeling’ any different?
Best Answer: Studies show that all the noticeable effects of hormone optimization therapy are at specific time intervals. Typically brain fogginess and indecisiveness are removed within 10 days of administration. Physical effects regarding better energy, sex drive, more noticeable muscle mass, weight loss (specifically fat), sleep improvements, and stamina are all felt anywhere from 8-16 weeks after therapy initiation. However, many patients notice things happening before 6 weeks. It is an individual basis and biochemical individuality, so anything is possible and dependent on the patient’s current health status and exercise activity.
10th Q: Will you allow me to administer my injections upon scripting injectable testosterone?
Best Answer: Of course, we provide detailed internal written instructions along with videos and pictures on how to administer the injections successfully. We like to make our patients autonomous so they are not dependent upon anyone to safely administer their testosterone injections. Testosterone therapy is a lifetime journey where patient expertise is necessary to reduce costs and inefficient use of the person’s time. Most clinics require patients to drive to their facility to get their injections. That is neither time-efficient nor cost-effective for the patient and is a way of keeping the patient dependant upon another party for their health. A good doctor will educate the patient and promote their independence. Injecting professionally is a learned skill, and it’s one of our signature moves– creating autonomous patients. You should make sure that you work with someone highly skilled who makes it his/her business to ensure you learn how to administer these medications for the rest of your life.