I occasionally get asked on the Peak Testosterone Forum what questions I might ask if I was going to interview a doctor to handle my TRT (testosterone replacement therapy). This is tough for most men just starting on TRT, because they are just beginning to understand the different TRT delivery systems, possible side effects, potential benefits and so on. Of course, this is obviously an important decision. Of course, you can always switch doctors later, but, even so, how do you know if a physician is knowledgeable or a newbie? Most doctors know very little about TRT and have maybe been to a few seminars and read a few articles from the drug manufacturers.
So here are a few questions that you can ask that will really help find a well-trained physician:
1. Target Testosterone Level.
Q. "What will your target testosterone level for me be and why?"
A. A knowledgeable physicain will know that you don't want to go too high with testosterone, because it can lead to an increased risk of side effects such as high hematocrit, acne, high estradiol (bloating, moodiness, E.D., low libido). Likewise, beware a physician that thinks most guys will feel good in the 300's and 400's (ng/dl). I had lackluster results for years, because my urologist refused to raise my testosterone over about 480 ng/dl. I was not getting morning erections for example.
2. Type of Hypogonadism.
Q. "Am I primary or secondary?"
A. Doctors may or may not be willing to investigate whether or not you have primary or secondary hypogonadism, but they should know and understand the difference between the two and how to diagnose them at a minimum. LH and FSH within range are general guides, and the acid exam is the HCG Stimulation Test.
3. TRT Failure.
Q. "What would cause you to take me off of TRT?"
A. A medium high PSA is fairly common and this happened to me once. I had a read of 6.3 and my clinic (at the time) immediately took me off of TRT. Some physicians will not do this to you: they will give you time to make an appointment with a urologist and discuss it with him. High hematocrit is another reason doctors will take you off of TRT. You need to know if your physician knows how to handle this situation and under what circumstances they would force you off of TRT. Other issues could be high blood pressure. The key is to find your doctor's parameters, so that you don't end up like I was - without TRT and not understanding what just happened to you and why no one ever told you! See my story of High PSA But No Cancer to see a personal example as to how this can happen. (I was back on TRT a month later.) You may also want to read through my page on Ways to Lower Hemoglobin.
4. Estradiol Management.
Q. "Do you monitor estradiol and, if so, how do you handle high and low values?"
A. In my opinion, a well-trained TRT physician knows the proper test for estradiol and the symptoms, ranges and issues associated with low and high values. That said, the great majority of doctors out there have absolutely no knowledge of estradiol in men and its importance, so don't be too surprised if you get a blank stare or an uninformated answer like "that's a woman's hormone!" I have tons of information on the subject here: My Pages on Estradiol. Just scan through some of these key pages, and you'll a reasonable background knowledge to know whether or not your doctor has done his or her homework or not.
5. Pre-TRT Tests.
Q. "What tests will you run beforehand to see if I am a good candidate for TRT?"
A. At a minimum the physician should look at testosterone, liver function, RBC/hematocrit/hemoglobin, blood pressure and PSA. Ideally, he or she would also pull LH, FSH, DHEA-S, SHBG, progesterone, DHT, thyroid and cortisol as well, because these can be altered by TRT according to considerable anecdotal, clinical and/or research-based evidence. Thus it is helpful to have baseline values beforehand.
6. Post-TRT Tests.
Q. "What tests do you typically pull post-TRT and how often?"
A. Savvy physicians typically monitor PSA, hemtocrit/hemoglobin, and blood pressure every 3 months and estradiol 1-2 months afterward and then every six months after you get dialed in. (It is hard to monitor estradiol if you are using Nebido/Aveed [undecanoate] or pellets.) Liver and kidney function are also typically monitoried every six months or annually.
7. HCG and Testicular Volume / Libido.
Q. "Do you use HCG to restore testicular volume and libido?"
A. The great majority of physicians will know very little to nothing about HCG, or they may think of it as a fad hormone used for weight loss purposes. However, HCG is very commonly used by fertility specialists, anti-aging doctors, TRT clinics, etc. to restore testicular volume - yes, your testes will shrink on TRT - and to restore libido and fertility. For more information, see My Pages on HCG.
8. Delivery Systems.
Q. "What types of testosterone do you offer your patients and why?"
A. Beward of urologists that push pellets - they get nice insurance reimbursements - and endocrinologists that administer testosterone cypionate (or enanthate) every two to three weeks! Physicians should have a variety of options available and considerable flexibility, including (ideally) Subcutaneous and Intramuscular Testosterone Cypionate (or Enanthate), Compounded Testosterone Creams and brand name topicals such as Androgel. Some men also like the longer term delivery systems such as testosterone undecanoate and pellets: you just don't want them pushed on you at the exclusion of other options.
OPTIONAL BUT CRITICAL FOR SOME YOUNGER MEN: Fertility
Q. "How can I maintain my fertility?"
A. Some men want or need to be fruitful and multiply. This can be done through three methods: a) TRT + HCG, b) HCG Monotherapy or c) low dose Clomid. If this is a concern for you, read this page for more details: TRT (Testosterone) and Fertility.
CONCLUSION: A doctor that cannot answer or defend his positions on most of the above questions is not, in my opinion, someone who should be running your TRT program on an ongoing basis. Sometimes you have to just take any doctor to get "into the system." But having a knowledgeable doctor over the years can greatly help one's long term success. It is not uncommon for the benefits of TRT to fade with time, and it is important to have a physician who knows what to do about it and when.
By the way, good luck getting even half of these questions answered: most doctors feel like they can only afford to spend 15-20 minutes with you! However, keep in mind that, even if they do cut it short, you should still be able to get an idea as to how well-versed they are in the basic issues of TRT.