You could call me the hesitant endocrinologist.
After all, I might be a hormone specialist (and I use the term specialist very loosely. Maybe only my wife and mother think I'm special), but I really don't like to prescribe these things unless the needs exceed the risks.
In this case, I'm a sceptic, I'm old-fashioned, I'm cheap.
I ask for the evidence behind the treatment. Good old EBM.
And so, it is a challenge when in the recent years, I see so many men asking for testosterone treatment.
The mild: older men with mildly low free and total testosterone. Studies suggest mild hypogonadism do not need treatment. Most feel no improvement.
The wild: young men in their 20s, who despite having normal testosterone labs, believe their levels should be "higher". Because they work out. Or believe they should be more virile. Or because their personal trainer told them so (I kid you not).
Where do we draw the line? Our lab's normal range is 350-1000. I've had guys say their 450 isn't normal. They should be at 800. I saw a chap whose T was 1200 last week (on replacement), refusing to budge his doses down because he feels good.
The winner in my short career thus far, is probably the very muscular, athletic man I saw 3 years ago- with a total T of 8000. Refused to believe me when I advised him for safety reasons to reduce. Never came back to see this quack endocrinologist, because I obviously don't know what I'm talking about.
And just weeks ago I saw a man who is a professional athlete (apparently is involved even in the Olympics), who had normal levels but feels he should be higher. And when I told him I couldn't in good conscience suggest treatment, his last words to be as he left the exam room were: "Well, if you won't prescribe it, I can easily get it from the gym...".
Why is there a need to justify medically how we feel? Low energy, fatigue, low sex drive, ED, lack of stamina, inability to lift XX lbs of weights?
If I looked at the list of hypogonadism symptoms so artfully advertised by pharma, I personally have 6 of them (don't ask me which).
And so, why do we need a medical diagnosis for what could be life? More importantly, why are we so keen on taking hormonal treatment for a mild low, or even a normal? I imagine a large part has to be the misconception that all fatigue must be low T. And all low T must be treated. If you get treated, you'll feel like a new man. A devious, ingenious scheme of pharmaceutical advertising.
While the risks have been known all this while, the more recent cardiovascular studies remind us this is not to be toyed with. Not just amongst the elderly or those with a history of CAD, but even the younger male population.
And so, while I usually cringe when I see lawsuit ads on TV by greedy lawyers, when the testosterone lawsuit ads started appearing 2 weeks ago, a part of me was somewhat pleased.
Perhaps this will give some caution to pharma to back off on their aggressive direct-to-consumer advertising.