TRT: Testosterone Replacement Therapy Posted on 10 Apr 20:57 , 0 comments

todds2015headshotBy Todd Lee M.D.

In medical school our ethics professor taught us there are 5 rules to medicine:

  1. Don’t get sued
  2. Don’t get sued
  3. Don’t get sued
  4. Make money
  5. If you can, help people

Since he was O.J. Simpson’s golf partner I didn't really listen.

When being taught how to interview for a job at a hospital we were told that when asked the question “Why did you choose to become a doctor?” the only wrong answer is “Because  I want to help people.”  The reason? Because it would be perceived as a BS answer. They told us no one wants to help others that bad that they would actually put themselves through this life.

Wait it gets better; The head of Pediatrics told us you can't try to force pregnant women not to drink, they they just fire you and go to someone who will tell them what they want to hear. Good thing there is 'No child left behind', right?

Why am I bursting your bubble? Why am I shattering your illusion that doctors are the priests of science? Because I care.

Turf Wars

You have heard of turf wars between rival gangs over a corner which is used to sell drugs before right? Drive by shootings over who gets to sling crack in the vicinity of 7 mile and State Fair? Well, medicine has turf wars as well.  My favorite example is that war between orthopedic surgeons and neurosurgeons over spinal cases.  You see, the spinal CORD is part of the nervous system, the spinal COLUMN is part of the skeletal system. So who gets to do the spinal cases? Both.  Back when I was assisting in spinal cases at Henry Ford Hospital, the average popular spinal surgeon was making up to 1.6 million a year. Read that again.  If you're a good spinal surgeon then you make over a Million dollars a year.

Non spinal orthos and neuros only make $500,000. I know right? Who could possibly live with only making 500K when you could be making 1.6M.  So the result is ortho and neuro surgeons fight over who gets to perform these lucrative surgeries.

A good example of this turf war was at the Henry Ford Hospital soccer game.  An ortho resident punched a neurosurgeon physician's assistant in the face, breaking his jaw.  Now the neurosurgery department was out a pair of expertly skilled hands, and more cases would land on the ortho department desk.

So How Does This Apply To Testosterone Replacement Therapy?

In the ‘80s athletes were crucified like frankenstien’s monster for using steroids. The same steroids the US government developed. They were developed for the US olympic team to beat the russian athletes because the russians beat the USA at the space race; they launched the first people into space.  So America needed to win a measuring contest and developed synthetic hormones to make american athletes superhuman like Captain America.  Then decades later baseball players are being treated like child molesters for doing what all pro athletes do; anything they can to win.

Jump ahead twenty years.  Now that the baby boomers are getting old enough to have erectile dysfunction they flood into doctor’s offices across america to ask for THE EXACT SAME DRUGS they were crucifying our national heroes over just twenty years earlier.  I guess when it’s you, it’s ok. If an athlete gets drugs from the team doctor, he’s an evil monster.  But if you get the exact same drug from your doctor it’s ok, because it’s you.

Truth is this; follow the money.  If every single man would pay handsomely for steroids, if they could avoid the social stigma, then it’s simple.  Just call steroids “TRT” or “HRT”. Then all their uneducated judgmental friends and family have no idea they are doing the same drugs a Jose, and Barry.

Now The Turf War

Hormones should be the province of endocrinologists.  They are the hormone doctors after all.  But from what I’ve seen urologists are getting involved. They are surgeons which specialize in the urinary tract and male genitalia.  Basically here is the problem; having the guy you does penis surgery controlling your hormones and not the guy who does hormones.  Why does this happen? You guessed it, turf.  The argument is this, since testosterone is made from the testicles and the testicles are urology turf, then the hormone testosterone is the turf of the urologist. Its as If Tony's turf is all the strip clubs in a city, and Christopher has all the coke sales. But Tony gets control of the income from cocaine deals conducted in the strip clubs, not Christopher.

Why Is This A Problem?

From what I’ve seen the patients are mismanaged.  The primary source of information the surgeons use is from the drug reps.  They don’t have the patients get their blood drawn early in the morning when they are supposed to, this results in a false negative reading. The testosterone comes back falsely low, and if it’s below the minimum threshold then treatment is started.  If the test was run at the correct time of day then the results may have been accurate and some people may not need treatment.  Another problem I see is that the patients are under dosed. This just shuts off natural production without increasing the test level to a higher level.

For example: Let’s say Marcus has a test level of 230.  This is just below what you need to get an erection. His wife insists he goes to the doctor about his impotence despite him not caring about sex.  The doctor prescribes 2.5 g of androgel and now marcus feels good for a week then he feels worse.  The problem is that now his level is LOWER because he was given a super low dose below the minimum prescribable amount and it shut off what little testosterone his testicles were producing.  This wouldn't be a problem if Marcus’ doctor had his blood work re done every 2 weeks until the levels were at 500 or so, but instead he has a follow up in 4 weeks then it takes 2 more weeks for a nurse to leave a message on his voicemail that he needs to make an appointment, when the levels came back low. 4 weeks later his doctor sees him and realizes he under dosed marcus, then adjusts his dose. Now Marcus has been losing muscle and gaining fat for 8 weeks and his wife is one foot out the door.

There are many different ways we can look for flaws in a broken system. But what it comes down to is when there is money to be made, greed rears its head. You will find more insight and knowledge on a forum then you will elsewhere.  Thats real sad.  With all the money that’s being made with TRT and HRT it would be nice if the people making all the money with their license to deal drugs actually paid attention to what they were doing and treated the patients as well as starbucks treats a customer.  Where else do you hire someone for a service, have to kiss their butt, and be legally bound to a fee you weren't even made aware of, let alone agree to, before service was provided….poorly. No where else, that's where.

If you're another physician and you don't like what I'm saying then prove me wrong.  Actually do what you're paid to do or say  "Sorry, I don't know, and it's unethical and dishonest to take your money and not do what I'm paid to." Chances are if you're taking this personally then it applies to you.

Your best bet is to see an andrologist that started as an endocrinologist.

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