Unspoken Truths of Testosterone Management: Insights from Dr Amir Eslami

THIS EPISODE unravels the extremely important role of testosterone for men.  It covers:

• The function and regulation of testosterone in the body
• Prevalence and impact of deficiency
• Clinical features of deficiency
• Primary care workup and when to refer onwards
• The importance of testosterone in women

 At least in the UK, this is an extremely important, and yet so often neglected area of clinical care.  It's time to wake-up and give patients the expertise they need.

Special thanks to our guest speaker:
Dr Amir Reza Eslami.  MRCGP MBBs BSc MSc clin endo PGCert Edu (GP and specialist in Testosterone replacement therapy)

SPONSORSHIP: None.

USEFUL LINKS: 

Online learning module:   PCTAG - Primary Care Testosterone Advisory Group

Authoritative reference:  British Society of Sexual Medicine | Founded in 1997 (bssm.org.uk)

European Academy of Andrology (andrologyacademy.net)

Dr Amir Eslami's Service:  Fortis Healthcare (fortis-healthcare.com)

OUR PAGE ON LINKEDIN: www.linkedin.com/company/primarycareuk

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Transcript

Please note:  This transcript is largely AI generated and will contain errors.

[00:00:00] 

Introduction to Men's Health and Testosterone

Munir Adam: Hi guys, welcome back to Primary Care UK. Let's learn together Munir Adam here, and today We're bringing a topic that we haven't covered so far and that's related to men's health And actually, most of us can benefit from this, right? Regardless of what we do working in primary care. Now, what are we going to cover?

We're going to talk about testosterone. What is it? Everybody knows it, recognizes it. What exactly does it do and how do you recognize if there's a problem with it? That's really what we want to focus on. How do you investigate it if you suspect somebody has this? Where would you refer? And then what are the risks and benefits of testosterone therapy?

 And as we'll be finding out from my friend his name is Amir. He's going to be introducing himself in just a moment. You know, one of the things he said to me that surprised me is, this is actually relevant for women as well. Why is that? Well, you're going to find out. So that's the plan for today. So stay tuned and benefit from this and apply it to your practice because [00:01:00] that's what this is all about. 

Meet Dr. Amir Aslami: Expert in Testosterone Therapy

Amir Eslami: Thank you for having me on with you today Munir. I'm Dr. Amir Aslami. I've been a GP for over a decade and a half, nearly two decades.

And now I work as a UTC ST trainer and a UTC provider, urgent care and urgent treatment center in Essex. Also for my sins, I teach Olympic wrestling and I'm a coach and visiting Jiu Jitsu. But , my specialty is in TRT which is testosterone replacement therapy and I've got my master's in endocrinology of which my paper was actually on use of testosterone specifically In the pre as well as postmenopausal women, which we'll talk about at the end if we have a chance And but yeah, that's me in a in summary 

Munir Adam: Right.

Well, there's one thing for sure then you are definitely the right person to be talking about this because I know very little about testosterone actually And in fairness, it doesn't really get taught very much either and I feel it is a gap and that's why i'm [00:02:00] really glad to have you on board. 

So let's get cracking with this. 

Understanding Testosterone: Functions and Effects

Munir Adam: Let's start with the basics. The role of testosterone. What does it actually do in the body? How is it regulated? 

Amir Eslami: Excellent. So, so traditionally testosterone, estrogen, I think is it to be male and female homos respectively. I mean, obviously they, they both have very important roles in both men and women.

Okay. So we'll talk about testosterone specifically around its roles in men and we can look at it in its roles in women as well. , If we were to subdivide that into several sections: testosterone has effects on sexual functions. So regulation of one's libido, sex drive erectile function to an extent, and also people don't realize this actually helps in the maturation and development and morphology of sperm production.

Okay. 

Muscle mass and strength. So it prevents muscles growth and repair. Bone health. Obviously, the bone muscle density can actually become affected and testosterone levels depreciate over time. Fat distribution helps with the regulation of fat around the truncal area of the abdomen. Mood and cognition affects mood, mental capacity energy levels.[00:03:00] 

So one of the symptoms that people do talk about, quote unquote, is brain fog and inability to kind of, you know, Adjust to the environment, to adapt to the environment as quick as they used to. Red cell production, so many, many, many moons ago, you'd use testosterone therapy to help induce erythropoiesis, which is the production of red blood cells, and in doing so, compensate for anemia.

And secondary sexual characteristics in young men, the deepening voice, broadening of shoulders, and also the production of hair growth. Interesting enough, it makes hair grow everywhere, but it actually depreciates hair in one particular part of the body, which is the crown, which we can talk about as well and why that happens.

And it's kind of, it's interesting, it's inverse on the crown, but it's exponential. Right. 

Munir Adam: Okay, do you mean that the higher the testosterone, the more likely to have that problem, that type of ?

Amir Eslami: Yeah, to have the balding over the actual crown of the scalp. So yeah, and that's to do with a particular part of testosterone which is the active ingredient that we benefit from.

Testosterone Deficiency: Symptoms and Diagnosis

Munir Adam: Can I just say, a lot of the symptoms and manifestations that you just discussed, they sounded a bit [00:04:00] like menopause. I mean, testosterone deficiency, you mentioned about brain fog and you mentioned about bones getting weaker and some of some of the other things you mentioned So so actually in a way Estrogen deficiency as women experience once they go through the menopause so testosterone deficiency is causing a similar kind of picture Do you think that's a fair comment to make? 

Amir Eslami: Absolutely, so there's a terminology that a lot of endocrinologists are not using and they call it the I want to equal when I say it because I might get told off for using this term, andropause. So, it's a terminology they use. I mean, the menopause is a therioterminology. We have got strict criteria. There's a certain number of months without, you know, the productivity of having a menstrual cycle. We're not really guided by blood testing unless it's primary ovarian failure or very early menopause. As you know, you could criteria for menopause is 12 months of that period. You more or less tick the box with symptomology. 

In men, it's slightly different because the andropause can start at any point, really, and it's a depreciation over [00:05:00] time and it can take several years, maybe longer, maybe shorter before they start showing all the signs.

And because it's such a slow, gradual, very mild, marginal change, you don't really feel it until you actually look back and whenever I do ask patients about their symptoms and we do use a particular questionnaire, which I'll talk to you about a little bit later they will not acknowledge. It's happening because it's such a slow change, 

but when you say to them, I want you to take a point in your life where you feel you're probably at the best in terms of your productivity, your ability to maintain yourself and performance wise, and then use that as a principle perspective. And you just say to them, late twenties, early thirties, compare it to then, and they'll say, Oh, crumbs, you're right. I, I actually do feel tenfold worse. 

Munir Adam: Right, right, right. So whereas the menopause happens almost all of a sudden in a woman's life, with men it's a very gradual, steady process, usually. Absolutely. 

Amir Eslami: And also [00:06:00] the body adjusts to those changes, and I use the the idea of a thermostat and a boiler when it comes to looking at hemostasis. 

Regulation of Testosterone in the Body

Amir Eslami: Which brings us nicely onto the topic of how do you regulate this? Mm. So the pituitary gland, which sits just behind the eyebrows, I would say properly center point of the head in that beautiful little pocket on as the Turkish saddles. That master gland produces a plethora of hormones. The ones that we particularly look at in terms of testosterone for homeostasis is LH and FSH.

So LH is luteinizing hormone, FSH is follicular stimulating hormone. Now, luteinizing hormone, just remember the letter L, it's really important because we're remembering this. Okay. LH. stimulates a part of the testes known as Leydig cells. So L for L. 

Munir Adam: Oh yeah, right. That's my medical school teaching coming back. Very good. It's been a number of years, but it's in there somewhere. 

Amir Eslami: It's there, it's there. And then the Leydig cells [00:07:00] produce testosterone as a consequence of that production. And then FSH, which kind of comes down pulsatile with LH, synonymously at times, but most of the time, however, is follicular S for stimulating hormone.

They stimulate Sartoli cells, S for Sartoli, to produce S for sperm. FSH, Sartoli, sperm, as well as Inhibin B, which is another hormone, it tells the brain about the productivity of sperm production as well. Now, when testosterone and sperm produce an Inhibin B, testosterone, if you look at it specifically, then converts into two other major hormones.

hormones. Testosterone turns into DHT, which is dihydrotestosterone, which is which is basically the effective, powerful testosterone, which causes all of these amazing effects. And there's a reason why you get balding on your scalp. 

And we can talk about how you manage that and where the amazing story came about that five alpha reductase enzyme [00:08:00] inhibitors.

So Finasteride? Absolutely. Yeah. Good. Well done. So if you look at if you look at testosterone's conversion to THT is because of their five alpha reductase enzyme. So you use a five alpha reductase enzyme inhibitor to stop that process specifically in something like prostate cancer. Okay. But obviously finasteride, which actually blocks that process.

Munir Adam: Okay. So just to recap on what we've, what we've got so far. So we've got LH and FSH from the pituitary gland. LH, Leydig cells. FSH Sarto cells, and then you've got the inhibit inhibit inhibit B, which comes with sperm. Which comes with sperm. Okay. And then there's some conversion to dihydrotestosterone.

Testosterone, which is the thing that make, gives you the male pattern. Baldness as well. Abso 

Amir Eslami: as well as the strength. And then the testosterone for another enzyme called aromatase enzyme converts to estrogen. And as we said, respectively, estrogen is traditionally for women, but in men really important. There's a plethora of estrogen receptors in the brain for [00:09:00] men with cognition, with mindfulness, really important. So when estrogen levels go really high, really low, it can actually cause severe mindfulness issues, as well as people don't realize bone protection. So estrogen is really important in men.

 Unfortunately there's a cohort of people who are using, which I say, abusing certain medications to help their aesthetics in terms of the world of bodybuilding. Mm-Hmm. They will block the eastern considerably to the point where they don't realize they've actually caused bone problems later on in life. They can actually induce osteoporosis osteopenia quite early, so the brittle bone formation early in life. So 

Munir Adam: of course they don't think of that, do they? that age? Obviously 

Amir Eslami: in their head they're thinking I need to get the best outcome, 

Munir Adam: and is, is that to build muscle mass or, or is that to become more.

Amir Eslami: What they believe is what they believe is the more you block these, which is actually inappropriate, the more you're going to be refined and defined looking and the less you're going to be carrying water because there is this element of water carriage with issues and productivity. But again, they don't really understand what they're really doing. They need a harm reduction principle where people can support them and guide them and kind of, get them [00:10:00] off that pathway. But then looking through regulation again, so estrogen, Testosterone inhibit B have a negative feedback mechanism on the brain.

Okay. Life at the hypothalamus and the pituitary. So the hypothalamus is the portion just above the purity gland, which also has another releasing mechanism called GnRH. So then those two processes are given this negative feedback. So it's quite a complex situation, but I'll give you the best way to look at it.

A thermostat and a boiler. The thermostat you keep somewhere in the corridor and it kind of gives you an ambient idea what's happening in the house. So if you set the thermostat at 21 degrees, if it shoots down to about 18 degrees it will then tell the boiler come on turn on we haven't got enough and then it heats the house up until eventually the thermostat gets to about 21 or 22.

If it gets to 22, 23 by accident, it can happen. It'll then switch off the boiler to go back down again. So there's constant conversation between boiler and thermostat, exactly the same as the testes in the brain, constant conversation happening every microsecond telling us whereabouts it should be. And that hemostasis is [00:11:00] kept quite, quite well.

And I use that same example when it comes to treatment and what happens when you start treatment. 

Munir Adam: Which we'll come on to as well. Well, actually that's a good reminder for you. I mean, I'm, I'm familiar with that part of it, the feedback mechanism. And I like the example you give because everybody can relate to that.

What we can also relate to is that how we feel in the house. And if it's getting really cold. And the heating's on, we know something's gone wrong. Absolutely. How do we know something's gone wrong or perhaps there's some sort of deficiency? What do we look out for as, down to earth primary care clinicians?

Common Presentations and Risk Factors

Amir Eslami: From a clinical point of view, the presentations, they are quite varied, so, We'll talk about the presentations and we can talk about the ADAM questionnaire or the androgen deficiency in the aging male questionnaire which we use which is quite sensitive. So common symptoms presentation wise, and these are gradual onset again, 

 Patients, especially men, if you look at the studies with the BSSM and a lot of studies online they don't present as well as they should, they wouldn't come forth.

We are getting [00:12:00] better. As time goes by, we're getting much better with expressing our symptoms, what have you, but generally they wouldn't come forth because there is an element of vulnerability, actually. Yes. When you come and present your symptoms and you feel 

Munir Adam: It's embarrassing, isn't it? 

Amir Eslami: Yeah. I don't need the word demasculated, but it's telling someone I'm having these symptoms. It's quite, and you need to put them in a safe space where they can feel supported and guided rather than told, well, there's not much we can do, really do here. This is quote unquote aging. So one of the symptoms of things like low libido, so it'll say I don't desire having relations as much, which can put a lot of pressure on relationships, especially marital discord and relationships and the like thereof, so accompanied that is erectile dysfunction.

So when we think of erectile dysfunction, we think of things like, you know a five, you know, phosphos phosphodiesterase inhibitors, the PPI's and stuff like that. 

Munir Adam: The old viagra. 

Amir Eslami: Viagra and Sultanafil and Cialis, when really we haven't treated the root problem, just like you would say if someone had erectile dysfunction, you'd think, Oh, could they be diabetic or could they have [00:13:00] problems with their, with their blood pressure?

Fatigue is a big one. So lethargy, tiredness again, could be synonymous with hypothyroidism, with low vitamin D levels, with mood, and again, mood changes. I think things like, you know, cognitive. Decrease in cognitive function, decrease in motivation.

Physical signs: they might even say to you, I've lost a lot of muscle. I'm putting on fat quite easily. You know, I feel, you know, they'll just present, but the problem is a lot of these presentations, apart from the low libido and the erectile dysfunction, that if you see them synonymous, you should really be thinking about low testosterone.

A lot of them are very vague, tiredness, lethargy, poor mood. Could that be depression? Could it just be life's pressures? Could it be stress orientation? Could it be vitamin D deficiency? 

Munir Adam: They are very vague and they're very common in primary care. But even the specific symptoms you mention of you know, erectile dysfunction or low libido, we don't automatically go and check their testosterone, do we?

 We jump for the Viagra and say, here you are, your blood pressure is normal. Off you go. 

Amir Eslami: Absolutely. So I have a, I had a really nice [00:14:00] GP, a fellow GP doctor. We worked together for years and it was GPs together in Dagenham.

She said to me, whenever I see a young man with depression, anxiety, I would check their testosterone. I was like, that's really amazing. Why? She goes, because I've realized actually that it's associated with testosterone. And she goes, I'm getting a high pickup rate. 

Munir Adam: Wow. 

Amir Eslami: And she's referring a lot to endocrinology and unfortunately, we'll talk about the roadblocks that come unfortunately in the world of primary care and secondary care when it comes to TRT you know, supporting treatment she used to pick them up quite a bit and I think, I think what we have to look out for as well as risk factors, so obviously age.

Obesity. Because obviously when when your weight goes quite high, if you don't realize this, you get more aromatase enzymes sitting in the fat. 

Munir Adam: And 

Amir Eslami: that actually helps with production of more oestrogen, which actually has negative feedback mechanism, which actually tells you what to do to produce less testosterone.

 So another risk factor is dietary lifestyle. We had a patient once who was living purely on soya. 

Munir Adam: Okay. Yeah. One of those extreme diets. [00:15:00] 

Amir Eslami: Absolutely not going to live on soya only. and came in with all the hallmarks of testosterone deficiency syndrome.

When you've done the blood test, you had a blocked LH,FSH suppressed you had obviously you had heightened estrogen and no testosterone like so then you think straight away You think am I am I missing an Oestrogen bearing producing cancer, which is rare as hen's teeth and I said to him turn about your diet because I only have nothing but soy and I was like, okay So soy is packed to phyto estrogens.

Okay, and the consequence again, can you see another environmental factor that can put pressure on testosterone. So, by just simply stopping his soy diet, within three to four months, his levels need to reset back to normal again. So, that's another risk factor. So, type 2 diabetes risk factor, chronic illnesses, metabolic syndrome, medications, you know that using regular opioids. on a regular basis, depreciates testosterone. There's more studies coming out about people who are living on painkillers being told actually depreciating their testosterone levels.

Munir Adam: Now that is a very useful thing for me to learn [00:16:00] cause there's quite a number of them and as you know, a couple of years ago the MRHA guidelines was to take people off opiates. Maybe maybe this tactic will work. 

Amir Eslami: Absolutely. And they say it is potent on testosterone levels. It's to do with the hypothalamus and how the brain manages those receptors. And then things like chronic stress, so sleep deprivation sleep apnea these are all associated associated risks to actually look for.

And also I've had a lot of young men just coming in I feel awfully tired. I feel lethargic. And honestly, Dr. Munir, if you check their test levels, they're awfully low. They're, they're ridiculously low. We're talking in a single figure.

Munir Adam: My mind is blown away. I must have seen at least a hundred people last year where I should have checked the testosterone level, but I didn't. I mean, it just, you know, you take the old thyroid box and FBC and, but you don't think of testosterone. And in many of these, that may have been exactly what's going on. 

Amir Eslami: No and these young, I'm talking about men in their late twenties have come to me. Who, when I've seen them and we have to take into [00:17:00] consideration environmental effects of food lifestyle.

I mean, Putting your mobile phone in your pocket. We know that women who use to put their mobile phones in their bra Increased the risk of metastatic lesions in their breast. Oh, is that right? Yeah So this is the whole thing about breast tissue and not putting, don't put the mobile phones in there because it could be a Correlation.

We're talking about the 90s, late 90s, early 2000s. So again, could there be an increase of you know Microradiation in and around the testes etc? putting pressure. You couldn't really study that with this one, but you've got to look at all of these factors. Again, a lack of posterior chain movement. So the more you sit, the more you don't mobilize, the more you don't exercise and, and activate the gluteus muscle, the hamstrings, the soleus, the gastrocnemius, the calves all of the process of the procedure being from anything from the lumbar spine all the way down to the heels.

That also has a hindering effect on testosterone, you know, that activation of those things increase testosterone. So and we spoke about the foods. So all of these effects are having a [00:18:00] negative impact on your testosterone levels more so than we've seen. So we're saying that men in their twenties to thirties are having testosterone levels of men in their fifth and sixth decade.

That's what we're seeing now. 

Gosh, 

Amir Eslami: there's been exponential depreciation over time. 

Munir Adam: You've answered the question really, which was going through my mind, which is why on earth is this happening so much these days? Why is everybody got a low testosterone? And you've alluded to things in the diet, you've alluded to the sedentary lifestyle and then a variety of medication and other factors that might be contributing. As well to low testosterone. Absolutely. But that sounds, when you say it like that, it looks like every single man coming in, coming to us needs to have a test. But how common is the problem? 

Amir Eslami: Yeah, so if you look at the aging males, so they say between 20 30 percent of men over their 4th to 5th decade, may well have testosterone deficiency between 20 to 30 percent of men who are basically 50 and above, easily, 

and what they're saying is the general population is just a general [00:19:00] lower than it should be for that age No, there should be for that age 

So we're talking about a third of men after 50 Well say 20 to 30 percent and in the general adult population They're saying between 5 to 12 percent of men collectively 

Munir Adam: Mm.

Amir Eslami: So that could be in their twenties. Dr. Munir, people don't realize that. Wow. That's really common. That's really, that's really common. Isn't so think about even 5%, if you, if you were to say you saw one in 20 a hundred men. Yeah. One in, exactly. So five men outta a hundred, you know, we've got at least over 300,000 men,, and that's the tip of the iceberg, we're saying 5 percent of it being white. Could it, 

Munir Adam: could it be, I mean I'm trying to play devil's advocate here now, I mean I, for me, hands up, I just didn't know about this. Erectile dysfunction. Fair enough. That's probably a bit of a low testosterone with that, but I didn't realize that all of these other symptoms and manifestations and the contributory factors that you've alluded to , but maybe could it be that people don't test it because they're thinking, well, you know, you can't really do anything like how would you investigate it?

Why Testing Testosterone Level is So Important

Munir Adam: What would you actually do if they come to you? 

Amir Eslami: So [00:20:00] there's a really good study and I'll send you the papers from, it's from Australia and Professor Hackett from the, he's one of the lead figures for testosterone therapy in the UK. I actually have peer reviews every three to four months with him, so I'm really grateful to have him with me.

And he was telling me about a paper that came out last year. There's another paper called the Traverse paper, there's a paper actually done in Australia called the LT4 let me double check, I think it's called the LT4 study. And what they found. It's going to blow your mind. It's already blown, but go on.

Honestly, the single one thing. So, you know, when you look at diabetes and prediabetes, you have several things, lifestyle modulate, comorbidities, you know, smoking issues, you can try to do all these things to try to reduce the diabetic schedule and hopefully get them out of prediabetes and normality to even curate the diabetes through, you know, gastric bypass and like thereof and .

Now. What he said in this paper was, men who had diabetes and prediabetes, who also [00:21:00] had hypergonadism, so that's basically the medical term for low testosterone levels, if you corrected their testosterone, up to 40 percent of them, reverted to normal. 

Munir Adam: Oh, well, their diabetes went away or the pre diabetes went away.

but we don't even ask, we don't even bring this up, do we? I mean, we're testing for pre diabetes routinely now, right? In primary care. 

Amir Eslami: Yeah. So you should look for a hypogonadism or low testosterone levels because you know that, um, that actually the study says that between 30 percent of men with type 2 diabetes actually had low testosterone and they all had it.

And men with significant, so men with diabetes are significantly more at high risk of developing testosterone deficiency than men without diabetes. So correcting their testosterone deficiency up to about 40 percent of them actually curated. See, that's 

Munir Adam: the thing that I'm finding incredible. You're right, it does blow my mind away.

Because one of the things I've learned about hormones over the years is, you can sometimes find correlations between [00:22:00] hormones and symptoms, reversing it doesn't necessarily undo the problem. What you're saying here is that this can actually make the difference.

Amir Eslami: Yeah, but not, not in every case, but I'm talking about 34%, but the point is That's a lot. Exactly. And this is what he was saying. What he said was, when we're talking about those, we've never seen one thing you change cause that outcome. It's usually a multiple, a plethora of things that you do together to get that kind of beneficial outcome.

And, and that, that for me would be my mind. Even chronic illnesses like things like chronic liver disease, chronic kidney disease, cardiovascular disease, they're all associated with low testosterone. 

Munir Adam: Okay. So I'm convinced we've got to do something about this. From our side, actually checking the testosterone, testing the, testing the testosterone.

I think I've got to make that my mantra now, test the testosterone. So testing the testosterone isn't easy enough thing to do, just send them for a blood test. The result comes back and it's low. And I'm thinking, Amir, thanks to you, I actually bothered testing it, and now this explains their depression, or it explains well, to some [00:23:00] extent, might explain their sugar levels, or whatever it might be, 

now, here's the bit where I would get stuck. I don't know why I'd feel confident to just start them on testosterone therapy. Is that something we can do in primary care or should we refer 

Amir Eslami: onwards? 

Workup & When and Where to Refer

Amir Eslami: Now, if like anything, if you feel you have got the competencies to manage an ailment, you would. So you get people who manage specialist interest.

, you have to feel it's like some of our colleagues who feel confident managing the menopause, some of us don't, that's absolutely fine.

If you don't feel competent and don't feel confident, then you shouldn't actually do it. You should refer it somewhere. Now, the problem with referring onwards is, I know many endocrinologists that will say to me, my apologies, say to me quite comfortably, I don't think he needs testosterone. Well actually.

This is the problem we're having now. So 

Munir Adam: even though it's low, 

Amir Eslami: well, this is the issue, right? So what is low? This is another point. So there's the classification of low. So when you check testosterone blood testing, you don't only check testosterone, you have to check all the other hormones that come with it.

So LH, [00:24:00] FSH, because then that will guide you into, is this type one, type two or functional hypogonadism. We'll talk about that. We'll have to look at testosterone, your free testosterone, your prolactin. Your estrogen, your SHBG, which is your sex hormone binding globulin, which is the one, the protein that mocks up testosterone as well as things like full blood count, because don't forget there are contraindications to using testosterone.

Having a very high hematocrit level, you have to remedy that before you go on testosterone because testosterone will increase your hematocrit levels because it increases red cell count. Okay. Looking at your liver function test, looking at your kidney function test, because there's a very small cohort of patients, very small, I've seen probably one in 10 years who can have testosterone inducing focal segmental glomerulophytis.

However, most patients with chronic illnesses, when you give them testosterone replacement therapy, they actually get better. And there's a study on this talking about how kidney function, which is deteriorating, can actually get better on testosterone function. And there's also a study that Professor Hackett shared [00:25:00] with me, which was about how actual patients with chronic liver problems, if you correct their testosterone, actually resolves it.

 And I think, Most of that in parts to do with the anti inflammatory or the pro anti inflammatory effect testosterone has on the body. Then you have to check things like your PSA really important because again, contraindication to you should, if your PSA is raised, you've got to rule out prostate cancer.

So there's a peripheral test you have to do. Now, when you do those tests, what is the parameters? So between 12 and 30, you are kind of stuck because you're saying the test levels are okay. Okay. I'm going to talk to you about this cohort. It's really important because there's a group within that group in 12 and 30.

And you can see 12 and 30, huge parameter difference there. 

And 

Amir Eslami: then between eight and 12 you have the ones who you say, well, they could be deficient and they might benefit through. So 

Munir Adam: what's the normal reference range? Between 12 and 30. Okay. So the problem is, can you see the variance there?

Yeah. Like if you're 12. 1. You're not [00:26:00] like somebody who's got 29. 9. Yeah. Yeah, 

Amir Eslami: exactly. So, and even if you've got 29. 9, we can talk about those groups because just like we have insulin resistance syndrome, there is a real thing called testosterone resistance syndrome, which is They're a group called, who have what's known as androgenic polymorphism.

That's another topic in itself. Okay, that's, that's getting complicated. That, that, that's, that's a subtopic of endocrine within endocrine. 

Munir Adam: We get, patients coming along saying I know my thyroid is normal, but it's the lower end. You know, or the TSH is on the higher end and so I, and similarly we have, we now recognize that somebody might not be a diabetic, but we then have pre diabetic, because human beings are sort of on a continuum really, aren't they?

It's 

Amir Eslami: not, and I think you have to remember it is testosterone deficiency syndrome. Syndrome is , presented with symptoms and guided by biochemistry, not diagnosed by biochemistry. The diagnosis is aided by biochemistry. And I think, but we, but as clinicians, we have to do our due diligence.

We have to follow guidance to the best of our ability. [00:27:00] We shouldn't go outside of the realm of what is guidance book, unless you gone through all of the process of the patient.

, these are the kinds of things that will make you you shouldn't manage it if it's in the gray, leave that to the sub super special. I'm not saying leave that to me, but no, no, I'm perfectly happy leaving it to 

Munir Adam: you. Can I recap on where we are? So one way, one of the ways that I'm finding this easier to internalize in terms of the sort of tests that I need to do.

I'm a lot more familiar. a lot of the listeners will be a lot more familiar with female sexual dysfunction and menopause and and we're very comfortable and very familiar with doing things like FSH, LH, well, and prolactin actually, and testosterone and serum sex, hormone binding, globulin, all of that we're familiar to do it, but we're often only in women.

So for a man, if we're suspecting the may have testosterone deficiency, we can do the testosterone. And if it's low, if you are going to refer onwards before you do, make sure you do all of those tests that you would have done in a female As well as the routine tests and on top of all of that, you mentioned one other one that I don't always routinely do.

Oh yeah, not for the younger men anyway. It would be the PSA. [00:28:00] So add all of those and then you've got your results. And then, unless you've got somebody in house who's got a flair for this thing, who's got an interest in this. Refer them on. Refer them on. Where do we refer? So when would you refer actually?

When? Less than, so yeah, so less than eight. Less than eight. Oh, if the level is less than eight. Testosterone level. Okay. Between eight and 12. 

Amir Eslami: Think about it. You think about it. More than 12, you're going to say to them, look, even if I refer you to endocrinology, they probably will say no to you. And and I spoke to a lot of endocrinologists who say that's not my thing.

I reasoned my professor that I had done my MSc with and we spoke about it. He goes, you probably know more about testosterone than I do. I mean, I was like, well, maybe so I think it's one of those established departments that If you don't, even if you shy away from it, they're more into diabetes or thyroid dysfunction.

 Maybe it's, you know, into adrenal crisis and things like that. But androgen [00:29:00] deficiency, probably not their forte as much. So I would say less than a, They're probably a good candidate. Now, if you're talking about guidelines, guidelines, the BSSM or the British Society of Medicine say you should do at least two testosterone blood tests over a space of say 10 to 14 days on specific occasions, because if the test levels are low, it could have been an interim infection, could have been ill. Also, we know that eating a big meal in the daytime before the blood test can drop your testosterone. There's loads of things. Sure. 

Munir Adam: So two, two tests. And if they're both low, Then refer and refer to your local endocrinologist. Refer

Amir Eslami: local endocrinologist, but in the back of your mind, remember that the patient might not get the therapy they need as opposed to the therapy that the endocrinologist wants to give them.

And this is where our TRT clinic is coming to, into power.

Munir Adam: Well, can I call you in that situation? You said you've done a bit of wrestling, so maybe you can 

Amir Eslami: Can wrestle the endocrinologist to do what we have to [00:30:00] do. 

Shared Care Principles in Management

Amir Eslami: As in As in to say so imagine management is a primary care clinician.

We always talk about shared care principles, right? Now, from a CQC point of view, you have to show variation and say to the patient, we have these options. Not you're going to do , . That's all we've got. When you go, well, I'm talking about endocrinology when I used to refer years ago, they would just say, well, these are the options you've got.

You either take tablets or one injection. And you're like, I don't want that because I because patients have come much more savvy, they're reading more, they're studying more, they're learning more online. Oh yeah. There's a lot more people who are doing podcasts about clinical things. You've got no clinical background, but they've read a lot. There's an interesting person online. He's not, he's not a doctor. He's got over millions of followers, but he's actually set up a TRT clinic in America. And he's very open about what he says, but because he taught, he, he, he he, he kind of addresses the audience and makes things clear to them that it's not one. Size fits all and everything should be bespoke around your therapy. 

TRT and Personalized Therapy

Amir Eslami: So the same with TRT, Testosterone Replacement [00:31:00] Therapy, when you're managing patients You're managing that patient for their needs and expectations, and you're also managing the expectations So if they say to you, look, I've read that, you know You're meant to take a small dose two or three times a week to try to mimic your hormones You kind of say, well, actually there are studies that explain it.

Well, actually, no, that's not the best thing because that particular testosterone can induce certain other effects that you don't really want from a local level. And they say, okay, brilliant. So tell me more about that. As opposed to, well, look, you either take a tablet, we're going to get this one injection every four months, and that's all you're going to get.

Endocrine was very much like that. And if you didn't like it, well, that's what we can offer you. So I had one case I was working in Walthamstow nephrologist. I said to the patient, look, I'm not keen on what they're suggesting. They're saying that you should take this injection every three to four weeks. Okay. And I'm telling you as a TRT specialist, this injection will stop working after 10 days. So I had to write back to endocrine saying, I'm really sorry, but I think you're using some outdated data. And then I showed my data. I showed the studies I showed about the half life of the end of the drugs, [00:32:00] specifically, it's called testosterone sustenon.

And I got a letter back saying, well, look, you seem to know what you're doing. We're happy for you to manage. I was like, Oh, okay. So I kind of like, you know, started a patient as I would have started them in my clinic. And I think that's the issue. maybe now it's much better, but it still seems to be a situation where patients struggle.

So when patients, you meet me online for my clinic and I guide them, I say, look, please speak to your GP. I'm happy to write to your GP because I believe it's, I'm losing a clamp by saying this, but why NHS? Yes. And then what happens is I've had several clients. You're going to lose business like that. Well, actually, no, what happens is they go to the GP, GP is lovely, reads my letter and says, I agree with you.

I refer you go to an endocrine and say, you don't need that. You're fine. Now, this is my issue. Okay. And I use this to patients. Is aging acceptable? Of course it is, because you're going to get old. [00:33:00] And as a consequence, as you get older, let's take one particular aspect of aging. Joint degeneration. So wear and tear of the joints, what we call arthritis or arthrosis.

Maybe that's a better term. Arthritis is the inflammatory process. But the point is we're all going to get arthritic. We have to accept that. And that's acceptable. But do we accept the dysfunction and pain as a consequence of of arthritic joints? No, we don't. What do we do? We give them painkillers, we get them physio, we do joint injections, we do acupuncture, acupressure, cupping, and eventually. Guess what? We even replaced the joint with a, with a prosthetic joint. 

Munir Adam: Yeah. 

Amir Eslami: So the same way you're allowed to age as a man, testosterone will deplete. But that doesn't mean don't do anything about it. Exactly. However, don't break it if it's not fixed. I've had patients who come to me, testosterone is really low. It looks to me like I'm talking phenomenally low. Okay. But they're not symptomatic. And I say, well, why do you want to fix this for? This, your body's happy. with this particular amount of testosterone. 

Munir Adam: Maybe 

Amir Eslami: if I give it a bit more, it could cause a lot more [00:34:00] poorer outcomes. So it's best that we don't do anything.

Symptom-Based Treatment Approach

Amir Eslami: When you become symptomatic, you see now, look, I'm using symptomology to guide me rather than a blood test. 

Munir Adam: Yes, yeah. And that, so that is one of the disadvantages, and why not just test? Everyone and perhaps that's one of the reasons because you're going to end up picking some where they have genuinely low testosterone, but clinically they're fine. And you've got to treat the patient, not the result 

Amir Eslami: result. And but you see now, likewise, if the patient is symptomatic, but their testicles are not that they're okay, but they're not great. Why are we not treating their symptoms?

Because it is a element of the, if you could call it the unknown, unknown. So then you, you study the subject, you look at that feedback, you understand it, you look at the side effects and the mitigation of risk.

And the more you get into it, actually like, A lot more men need testosterone, you know, and just like you said, with subacute hypothyroidism, TSH might be okay, but your thyroid levels are dipping a little bit. And in that situation, you go, well, should we, we say, well, how do you feel? I feel fine. Okay, fine.

Exactly. When they become symptomatic, we [00:35:00] start 

Munir Adam: putting thyroxine in the equation. Don't we? So I think what you're saying is do it as a case by case basis. 

Amir Eslami: Absolutely. 100%. And. Now, the patient would also enjoy the experience and we'll see that you're actually taking a one to one, you know, journey of them.

And also they do build relationships much more slowly when it comes to health. Oh, yeah, I don't present early. We noticed that if you look at the studies, especially look at the primary care to social and active group, the PCTAG done a study on this and they said most of presentations were women and children

 and a sparse amount as men and women do come.

It's literally about routine stuff rather than, Oh, talk about yourself. Maybe we had that years ago. Time to talk. And that never, never found me, we kind of lost it. 

Munir Adam: So we, we need to be more proactive in encouraging them and making them feel comfortable and actually to talk about, and, and, and especially given that these topics that we said earlier on are embarrassing, 

I want to move on to the actual, the, the treatment you mentioned you [00:36:00] alluded to this earlier about injections. 

Testosterone Therapy: Forms and Monitoring

Munir Adam: Just summarize, what are the forms that testosterone takes? They, they see you, or they see an endocrinologist, they're discharged back to us sometimes, and then we're told to continue this. Sometimes it's things like testogel, sometimes it's sustenon, do we have to monitor them and are there pros and cons of this treatment? 

Amir Eslami: Okay. So , before we can talk about the forms, we have to talk about the patient's needs. And when you look at patient needs, you have to remember, does the patient want to desire fertility still, or they're not too fussed about fertility?

And that's really important because we, we might think, Oh, an older man doesn't want children. Well, actually he still might want children. And one of the contraindications using testosterone itself is if a person still wants to procreate. 

Munir Adam: Oh, really? 

Amir Eslami: Okay. Yeah, you can't use testosterone therapy. Well, you can, but you shouldn't because that, I mean, there are relative pathways you can use, but in terms of absolutes, you can either say, I'm not too keen on fertility [00:37:00] or actually I want to maintain fertility. So in a younger cohort of patients, they might say, look, I'm going to maintain fertility. So in that group, you use particular treatments could be either oral or subcutaneous treatments and what they will do, they, they act synonymously with your own internal pathways. So. Good example is clomiphene, the oral tablet, which is the, the estrogen reuptake inhibitor or the SS or selective estrogen reuptake inhibitor modulator.

So basically it competes with estrogen in the hypothalamus to tell the brain there's no more estrogen. And by doing that. Indirectly telling the brain there's no testosterone. Ah. So then LH and equivocally FSH start rising and I've seen it go up quite considerably. LH can go up a lot but again the caveat to that is that will only really work if the LH is not responding.

So if the LH is more than 6 if it's a low LH, normal low, then [00:38:00] giving them chloramethane is really good because you can actually get their own test levels going up as well as maintaining their sperm sperm production. The other thing that is sometimes used again, I remember clomiphene and you have to be very clear on this.

Clomiphene, it is used for hypergonadic, hypergonadic trophic hypergonadicism. So low LH levels in response to having low testosterone is is a off license, off label preparation. And that's why a lot of doctors don't want to prescribe it. Even though we don't use, it can be indicated. As you know, there's lots of drugs that we prescribe that are off license label, and we have to have this clomiphene.

Henceforth, we have a discussion about side effects, benefits, risk mitigation and the like thereof. 

Munir Adam: But it's awareness raising partly that leads to a familiarity and then people feel more comfortable as well, isn't it? I think so. I think some years ago, Clomiphene is used for PCOS as well, isn't it? Yeah, absolutely.

Now this is something that we've all become much more familiar with. So I think awareness raising and this is what this is about. 

Amir Eslami: So an another drug that we sometimes use when it comes to mimicking the pathways is something known as interesting enough is the human [00:39:00] choon gran atropin hormone, or the H cg which is found in pregnant women.

Yeah, so you can use other recombinant or purified filtered hate CG from women who also been pregnant, the urine, and it's used to mimic LH. 

Munir Adam: Okay, and that will then work on the Leydig cells, right? 

Amir Eslami: Absolutely, to increase testosterone. So testosterone not only works on the body, but there's something known as intratesticular testosterone, which actually helps productivity of sperm and the sharpening of the sperm, obviously, in terms of the morphology and the production in terms of its ability to, if you want have a good outcome when it comes to procreation. So we need not only testosterone in the body, you need testosterone in the actual testes to help sperm productivity. So that, that would be your fertility sparing pathway. 

Now, most men would go on the fertility non sparing pathway, would I say, I'm not too keen on fertility, I'm okay. I'm technically a granddad now, so I'm not too fussed about having children.

And what we [00:40:00] tell them is that the reason why we mention this is because people who take exogenous, meaning outside testosterone of the body it will suppress the internal testosterone systems. And I'll tell you why that happens. We used again the boiler and thermostat principle. But before we get into that principle about one in 10 men who take testosterone, and this is why recreational users have to be very careful, can have complete azoospermia that's not that's not recoverable.

So it's irreparable. 

Munir Adam: Wow. 

Amir Eslami: So one in ten bodybuilders who are not careful could not only get azoospermia, but they'll never come back again. And they have to be really, really careful. And I think, I think that's what people don't realise and not take into consideration. I think That's what's really key.

But unfortunately, and this is the flip side of that statement, a lot of patients who get told that they actually think I'm telling them that testosterone is a type of contraception and a lot of men in their forties have actually had their spouses fall pregnant.

And I said, I didn't say to you, it was a contraceptive. I said at one in 10, everything. Your libido gets better, erections get better. You want to have more relations and as [00:41:00] a consequence, you're going to increase the risk of falling pregnant. So I've had that conversation. So I will make that very clear. I said, gentlemen, you are going to have a whole relation.

So please be careful. 

Munir Adam: Glad you said that. I think, because I think some of the female listeners out there might have a, may have been planning to speak to their male partners and you know, go on, go and get some testosterone. You know, it's about time you did some contraception. 

Amir Eslami: Yeah, so it's actually it's a case of what actually it doesn't work like that.

But yeah, and they find that it's interesting. It's an inverse situation was a lot of the patients say to me that my I've had so many patients say to me that my spouse, that the female counterpart really wants to have more relations. And they say, I don't want more relations. So I'm not keen on it as a man.

And that puts pressure on the relationship on the inverse. When, when they were younger, they wanted more relations and their spouse didn't want as much. So it's, we, we, and that's why I said to patients that 

Munir Adam: human being is complicated, aren't we? 

Amir Eslami: Absolutely. And I think managing men's hormones and women's hormones, simultaneously is really helpful when it comes to relations.

Now, now, obviously when you got on the pathway of exogenous testosterone being, now [00:42:00] you have another two algorithms. Are you needle phobic or are you not needle phobic? 

Munir Adam: Okay. 

Amir Eslami: So if you're not needle phobic, we talk about that. But if you feel like, no, no, no, if I see a needle, I'm going to pass out. Please do not talk to him about injectables.

So fair enough for them, things like either Testogel which is a very simple application. Now you might say, well, why don't you just give everyone test the jar? It's nice and easy. Compliance. You've got to put it on every single day. 

Whereas the injection is every ...7 to 10 to 14 days. And if it's Nebido, which is the long acting up to eight to 12 weeks sometimes.

So it depends, you know, you're, you're, you know, what you, what you like. And I think this is why you have that combination of the pros and cons of therapy. And then finally injectables. You've got testosterone, Sustenon, enanthate, cypionate, Nebido, the long acting nandrolone, and they have all of their own pros and cons.

Now and in terms of monitoring, it's usually you monitor their blood profile and their symptoms from zero to two to three months. And then at the two to three months point you do four to six [00:43:00] months and then six monthly for the first two years and Then usually yearly thereafter. 

Munir Adam: What what do you measure? What do you monitor?

Amir Eslami: Apart from seeing them about asymptomology? You measure their full blood count to look for the hematocrit because we said it can get thicker Yeah, and how do you mitigate that? I'm I will tell patients the best way to mitigate there's either increased duration of therapy or reduced dose or actually You One of the best ways is blood donations, and there was a, yeah, you can donate every three months, you can donate blood.

So the benefit there is you're done. And I've had letters from the blood donation services where there were issue in the past about having patients who want testosterone therapy because they fought looking at a lot of recreational users, but they brought back saying, no, actually we accept anyone as long as there's a letter or formulation saying that he's on this kind of therapy.

Because the you know, venesection is great because you get to give blood away. It's wholesome blood. It's blood packed full of red cells because your erythropoietic levels have gone up. So I do advocate patient every 3 to 4 months okay. Everybody's a winner.

[00:44:00] Everyone's a winner if you get benefit in that way. And then you've got then you've got Looking at the renal function because we said already I look at renal function because I find patients generally don't drink enough water So I always keep an eye on that. 

Okay, 

Amir Eslami: but again, there is a small cohort that you can get segmental Blemishitis, but that really really happens.

Liver function specifically if they're taking orals like clomiphene We know clomiphene can actually cause ASD to transiently raise Okay But we look at that in totality Then obviously you're looking at the PSA really important because that can go up at any point and remember testosterone doesn't, doesn't cause testosterone.

Testosterone does not cause prostate cancer, but you don't want to have prostate cancer and be on testosterone therapy because it will exponentially make that that cancer worse. It's very important to understand there is no evidence whatsoever that that can cause cancer. If anything, what we find is as test levels fall, prostate cancer levels go up.

And that's the, that's the correlation. You can't call it a causation. But again, PSA can go up with prostatitis, UTIs, sexual relations, any of the above.

Right. So we keep an eye on that and also the hormones. So FSH, LH, because [00:45:00] they will be suppressed if you use exogenous testosterone. Oestrogen because oestrogen can climb and you have to mitigate that by using AI blockers, aromatase inhibitors. Right. Or again, looking at treatment and managing their treatment protocols as well as a testosterone free testosterone and any of the other hormones related including the SHBG.

So that's the kind of general, if you want a very general brief look at it over time. 

Munir Adam: So essentially, these are similar to the tests that you mentioned initially when you're investigating for testosterone deficiency prior to referral. They get started on treatment. This might be injection, might be a gel, might be some other forms.

They might not go on testosterone directly, but they might go on the different treatment like clomiphene. And then when they're with us in primary care, we can support their monitoring by doing blood tests. Initially, I think you said two to three months, up to six months, and then four to six months, for a couple of years and then maybe... 

Amir Eslami: yearly thereafter, but I find I find patients. They usually say see me every six months doc I don't want to be left alone like this 

Munir Adam: Yeah, I think a lot of these patients might end up being more [00:46:00] continually monitored in secondary cares But it's nice for somebody like me in primary care to know Essentially what sort of monitoring because sometimes patient miss their appointments or they get cancelled and pushed back and all sorts of things happen So that's incredibly helpful.

One thing you mentioned is potentially be careful in terms of making sure that this particular man is not planning to procreate, to have children. 

Risks and Contraindications of TRT

Munir Adam: Are there any other risks, any disadvantages? 

Amir Eslami: Absolutely. So that if you look at in terms of contraindications, the absolute contraindication would be prostate cancer.

Munir Adam: Okay. 

Amir Eslami: So, other relative, but I wouldn't say absolute, but relative contradications is things like sleep, untreated sleep apnea.

So as long as they've got treated sleep apnea, it's fine because what they find is that it can contribute to the thickening of the adenoids and as a consequence can interrupt breathing during sleep. So people talk about that. 

Munir Adam: But, but didn't you say earlier that testosterone deficiency can cause sleep apnea?

Amir Eslami: It can worsen sleep apnoea. 

It can worsen it. Okay. Yeah. So if, if, [00:47:00] if it's treated, you can be autistic from therapy. That's fine. So that, that, that's the caveat treated, treated. So CPAP or what have you obviously we're talking about infertility.

Another interesting one is New York, New York heart classification grade three or four heart failure, and it's not because it makes heart failure worse.

It's because they've really got heart failure. Yeah. And now you give them testosterone, they feel amazing. And suddenly, they start running around and their libido goes up. Okay. And that can have consequences on their heart function. Okay. I'll leave, I'll leave that there. Yeah. So the point is we have to be very careful.

So if someone's got any type, so if you've got type 1 heart failure, it's fine. Ejection fraction less than I think it's 20 percent grade three or grade four. 

Munir Adam: So a lot of what you're saying is actually cautions, aren't they? They're, they're things to be mindful of. 

Amir Eslami: It doesn't, it doesn't induce the problem. It can actually, it can exacerbate the problem because that person is now feeling really good. 

Polycythemia. increased red cell count. [00:48:00] Again, we know that testosterone induces that process for the red blood cells through the bone marrow. So again, you need to be, there is a hypothetical risk. I've never seen it, and it's only spoken about, of things like clots.

Now there is no study that says if you have a DVT or PVT in the past, you shouldn't be on it. But I read one study from Tel Aviv that says that we Caution patients who've had maybe a DVT in the past, but again, the British Society of Sexual Medicine guidelines, the European Association of Urology and the American Association of Andrology. None of them say that you can't be on it for that reason, but if the levels are high, you tell them to venisect. So you give your blood away and it's fine. 

Oh, I forgot to mention one more point. Regarding bloods, you should check the iron levels as well. And there is a particular phenomenon known as haemochromatosis.

They get iron overload syndrome and that can cause problems in the liver, the pancreas, the spleen, as well as the testes because iron overload can actually desecrate the testes and consequences. So, so you do things like iron, you take the ferritin [00:49:00] and if it's really high, then you've got to check iron.

Now, does that mean they can't be in testosterone? No. It means that you found the cause for why test levels are low and treating the cause. doesn't necessarily reduce the, the, the chance of reducing testosterone. Obviously, what's due for haemochromatosis, if it's really high, you put it through venous section anyway, you know, bloodlet on a regular basis.

Munir Adam: Well, I'm glad you said that because it is an important point and the risk there, although I'm not too worried because we, we test for ferritin all the time, don't we? 

Amir Eslami: Yeah, it's part and parcel of what, yeah, it's like you take it straight away. 

Other things to look out for, again, interesting enough, people don't think about this, breast cancer in men.

Ah. Absolutely. You shouldn't be using testosterone in these patients because testosterone converts to oestrogen. 

Munir Adam: And then you've got oestrogen, breast cancers. 

Amir Eslami: ER positive breast cancer. So I know only 1 percent of breast cancer is in men, but we have to take the consideration. So, you know, telling a man, do you have any kind of gynecomastia changes in the tissue area?

And also, I mean, , very seldomly again, and I just want to reiterate this and I want to make this clear. Testosterone levels are best [00:50:00] between say 21 and say 28, right? Around about that age, maybe 18 to 28, say, and as a clinician, would you take, okay, I'm trying to say in the most appropriate fashion, it is that age group, age group known to have hypertension, diabetes, heart disease, prostate cancer, cerebrovascular events, they're probably the best age group, isn't it?

Munir Adam: Yeah. 

Misuse and illegal activity

Amir Eslami: So I'm going to say something quite generalized. If testosterone really was a villain, wouldn't it be at that age group you get all of the problems, 

Munir Adam: yeah. . I see your point. 

Amir Eslami: We're talking about replacing what is lost. Optimizing what is insufficient. So as long as we keep our testosterone within a reasonable physiological domain, unlike there is that I took, we spoke about a small cohort that might have polymorphism that's different.

But as long as you keep it within that kind of 20 to 30 range, why would you induce all of these negative outcomes? Well, you could [00:51:00] possibly, but the reality is it shouldn't really happen. So we're talking about when we mentioned food retention, that's usually with bodybuilders, unfortunately, 'cause they use such high dosages on such a high level, so long that they induce these really, even with certain levels, you can actually induce dyslipidemia. So you can actually cause your cholesterol to go up to I've seen it go up to bodybuilders. 

Munir Adam: Is there, when you treat them on testosterone, is there a black market for it? 

Amir Eslami: Unfortunately there is, yeah. And unfortunately, Dr. Munir, I've heard a lot of people, and this is the problem with social media, a lot of people, a lot. are talking about TRT when actually they're talking about PEDs performance enhancement drugs. They're not talking about scheduled drugs that are prescribed from a GHPC regulated pharmacy from a CQC validated clinician.

 I had one patient who came to me from Scotland and he said, Oh, I had a trainer in Qatar who was prescribing me this drug because they're not in the UK, I don't know how it works. They've got some kind of loophole. [00:52:00] Where they're not regulated by anyone, but they're claiming to be TRT clinicians.

And I was like, I said to him, so if something happens, I'm honest to God. Who's going to be accountable? Because this patient just switched off his website and turned off his phone number, so I'm not talking to him anymore. I said, that's the benefit of treatment in the UK because we are bound by policies, procedures, by checks and balances.

Not because we're scared of litigation, it's because we have to take accountability. There's a trust between us and the patient that we have to respect and we have to admire. Now someone who's doing, and I said to him, listen, I'm just telling you, I don't think this is what he, and then when he showed me the particular testosterone brand, I I know this is definitely 100 percent black market, because I've seen it with everybody.

I was like, and he's charging you a certain rate because that testosterone is made like in someone's, someone's back garden. 

Munir Adam: It's not classified as a control drug, is it? 

Amir Eslami: It is. It is. Oh, it's a schedule four drug. Testosterone is scheduled for drugs. So that, that's why they that's why prescribing it. So you don't, by the way, Mr.

Schedule four, it means that you don't have to lock it away. You can leave it on [00:53:00] the shelf, right? But because it's scheduled for. And it's schedule four because it was a drug of abuse. 

Munir Adam: Okay, last few minutes. So I clearly need to find out more about this. I didn't know it was a control drug. Where can people find out more?

Will you be able to provide some resources? 

Amir Eslami: Absolutely. So I 

think the best thing is if you go to the British Society of Sexual Medicine, BSSM. Got it. Or you go to the what is the primary care testosterone advisory group?

That's the one. They're really good. They have to go online free of charge module that you can add to this as your CPD get points on it. I might do that. It teaches you about testosterone deficiency and how it affects the numbers and how to manage it and what to look out for. It's a really brilliant module. module actually and it's really interactive. 

Munir Adam: We'll include it those links.

I like what you mentioned about that resource. I need something like this. I think listeners might want to do this module as well. Actually, it's free. .

Testosterone Therapy in Women

Munir Adam: Amir, last thing you promised, you say something about the role of testosterone for women.

Amir Eslami: Okay. So the, the, the role of testosterone in women is [00:54:00] becoming more and more understood and, and, and easily issued, especially in their, their postmenopausal patients. So we know that women who have got low when they go for the menopause, we speak about using things like, you know, biological hormones to just stand ever all.

And there's a new one come by by by juvie. I think it's called. There's loads of them that have come out. What they're saying now is that you should actually treat the testosterone deficiency because not women. If you look at the testicles is phenomenally low. in, in, in, in when they go through the menopause and you should actually supplement them.

I think it's about one 10th or one 20th of the dose you give to an adult male daily. And there are more and more analogs coming out. I think there's Androfen for women that are using now. 

Munir Adam: Some endocrinologists are doing that, I think. Yeah, they're actually issuing a few letters. 

Amir Eslami: So there's a study I saw actually said, interesting, really interesting using testosterone in women in the postmenopausal phase is nearly as a monotherapy.

As a monophobe and I couldn't believe this is nearly as good as treating their estrogen progesterone deficiency. Honestly, because there is an element [00:55:00] of conversion. Yeah. So they talk about that and say, if you treat that, I had one patient said, thank God for testosterone. She goes, I'm bouncing off the walls after my menopause.

And she's really keen. She was a journalist actually for the BBC. So 

Munir Adam: it's like the estrogen. I mean, the testosterone is what to do in women when you, you know, it just no, no, again, you have to have that whole conversation about the benefits and side effects. Oh yeah. I'm not starting it. But it's nice to know. It's nice to know that it exists. 

Amir Eslami: was going to add to that. There is one more cohort, which I wrote about, and there is a cohort of women who we still have to wait. There's a lot of studies behind it. Who've got female sexual dysfunctional disorder. Who actually they have libido issues. And as long as you can show that their social levels are awfully low, you can look at supplementation, again, that's got to go for a specialist, subspecialty of endocrinology, and that's what my particular paper was on when I done my MS here, I actually looked at that cohort and there was benefits, but again, there's a massive thing about, risk mitigation and side effects and stuff like that.

So there is benefits in that way. [00:56:00] 

Munir Adam: Amazing, Amir , take on message, please. 

Amir Eslami: Testosterone deficiency is a missed opportunity. So if you think it could be there, if you think it, test it.

Munir Adam: Fantastic.

 Well, well, well, such an important area, affecting such a large proportion of people, accounting for so many symptoms, and such an unmet need, right? 

Conclusion and Personal Motivation

Munir Adam: Very grateful to Amir. I finally asked him, what was it that got him into this? Why did he do it?

Amir Eslami: Basically why I got into it, I think the main reason was because I just saw a lot of men who were coming in with depression, anxiety, um, you know, libido problems, erectile dysfunction, and not being, firstly, looked into from a testosterone point of view, and secondly, when the testosterone levels were being looked into, were being told, well, actually, your levels aren't that bad, or, you know, weren't given, I believe, about, a fair crack at all the [00:57:00] different types of management protocols you can implement, which I've actually studied and gone into.

And so I wanted to make sure that I felt confident, not only about the subject matter of testosterone, but also from a general point of view, henceforth, why I've done my diploma in endocrinology, and then I've done my master's in endocrinology, and then I've done my paper in my master's about testosterone treatment, specifically in women, but also looking at in men. And I think, I just felt like there was this gaping hole, uh, that was left to the hands of subspecialties, who didn't actually do justice I felt really, on a topic that was, not really given much support,