What do I get for my monthly patient support fee?
Good question. Access to renowned specialist Testosterone Doctors who have worked for many years in this field and who regularly attend British, European and World meetings, ensuring you get the best medical advice with up to the minute information and care from a Doctor who can immediately implement new treatments, thinking and medication.
What about blood tests are they included in the monthly patient support fee?
This is a slightly more complex area. As a part of this fee, the Doctor will write to your GP and ask them if they will support you in doing the appropriate blood tests and even ask them if they will consider prescribing. Most GP’s will support these blood test. However, you need to be aware that if they will not assist you will need to get blood tests done privately with a company such as Medichecks. The Leger Clinic Ltd has negotiated with Medichecks, the country’s leading private blood testing laboratory for a 10% discount for all Leger Clinic patients requiring a blood test for checking their testosterone levels along with other relevant tests such as Thyroid function.
To access this discount all you need to do is follow this link:
medichecks and enter the code LEGER10 when prompted.
What does my first Consultation cost?
Effective from 1st July 2022 the initial consultation is £220 and this would be a video consultation over Teams, Zoom or WhatsApp and for reviews a telephone appointment
What does my first Consultation involve?
You will have a consultation with one of the Clinic’s specialist Doctors. The initial consultation generally lasts about 45 minutes and includes a detailed history, taking an AMS questionnaire and together we will review the blood tests that you have sent to us prior to your consultation. There will be plenty of time for you to ask questions on this consultation. We will also explain and discuss the various treatment options. For this reason, we do not require detailed emails prior to your consultation. In the first year you would need to email your blood results after 1 month on treatment, then 3 months, then 6 months and also importantly inform us how your symptoms are and (if any) side effects. One of the clinical team will respond to these emails. If during that period, you have a change of medication or dose, the clinical team may suggest more frequent blood tests than those detailed. We find that patients do not really need to be in touch with us apart from at these review periods.
Do you just offer Gels?
No, the Leger Clinic offers a full range of appropriate treatments including: Chlomiphene, Gels and injections including the use of HCG when appropriate. These will all be discussed in detail at your Consultation.
Do you offer Aromatase Inhibitors?
Yes, as and when appropriate.
How do I get my repeat prescriptions?
Please email firstname.lastname@example.org at least 2 weeks before you are due to run out of medication and one of our clinical team will arrange a prescription for you. This will generally be via one of the specialist online pharmacies we use and they have been chosen based on good pricing and excellent customer service.
Is there an increased risk of prostate cancer with taking testosterone replacement therapy?
A. Should you have a PSA test? And when? Dr Benjamin Davis discusses whether an increased risk of prostate cancer is one of the risks of taking testosterone replacement therapy.
Some basic facts about prostate cancer:
It’s the most common cancer in men. Over 50,000 men are diagnosed with prostate cancer in the UK each year, and 12,000 die from it.1 However, a lot of men live with prostate cancer for a long time and it never causes them any problem. In fact, over 78% of men in the UK diagnosed with prostate cancer survive over 10 years. Some men, particularly those with a family history or those of Black ethnicity are at higher risk. The risk of prostate cancer changes with age. The graph below shows that there are virtually no cases of prostate cancer in men under 45, but the risk of prostate cancer increases as men get older.2 This means in men under 45 we don’t need to be worried about prostate cancer, but once over 45 or 50 years old we need to be more aware of the possibility.
Should I have a PSA test?
A PSA or Prostate Specific Antigen test is a blood test that can help diagnose prostate cancer. However, it’s not a perfect test. 75% of men with a raised PSA (a level over 3) will not have prostate cancer, and equally a small proportion of men with a low PSA will later be found to have prostate cancer. A PSA can be raised for lots of different reasons as the image below shows:
Having a PSA done is an individual decision. It is included in the Advanced TRT blood tests we recommend from Medichecks. If you are having a PSA blood test, it is best to avoid vigorous exercise including cycling and sex for 2 days before the test as this can affect the level.
The risk of having a raised PSA is that you might need further investigation including an ultrasound scan or MRI and then possibly a prostate biopsy to look for cancer cells even when no cancer is present. The use of more advanced MRI techniques has reduced the need for prostate biopsy by about 25% and so the risk of a raised PSA leading to invasive prostate biopsy has decreased in recent years.
Is an increased risk of prostate cancer one of the risks of taking testosterone replacement therapy?
There is an understandable concern that increasing your testosterone level might increase your risk of prostate cancer. After all, men who have prostate cancer are treated with drugs that block or reduce testosterone levels in the body. So surely increasing your testosterone must increase your risk of prostate cancer?
The evidence from multiple studies seems to be that testosterone replacement doesn’t increase the risk of prostate cancer.4 Guidance from the European association of urology, the British Society of Sexual Medicine conclude there is no compelling evidence that testosterone therapy is associated with an increased risk of prostate cancer.5 Multiple studies have shown that testosterone levels do not correlate with risk of prostate cancer.
Why might this be? Decreasing your testosterone treats prostate cancer, but increasing it through testosterone replacement therapy doesn’t increase prostate cancer risk? Studies have shown that the prostate gets saturated with testosterone at around 8-8.5nmol/L, so increasing your testosterone above this level, doesn’t lead to higher levels of testosterone in the prostate.6
It is therefore possible that if your total testosterone is less than 8.5nmol/L, you may be more likely to see a rise in your PSA when you start testosterone therapy; and possibly have a higher risk of prostate cancer which has stayed quiet when your testosterone level is low, growing when you start testosterone therapy and your level goes over 8.5nmol/L.
The Testosterone Trials were a trial of testosterone therapy done in the USA. One study from this trial compared men over the age of 65 taking testosterone with a placebo (non-active drug) group. 7 4.4% of men taking testosterone had a rise in the PSA by 1 year which necessitated referral to a urologist vs 1.7% in the placebo group. Twenty-two out of 743 men in total between the two arms were seen by a Urologist and 6 of these ended up having prostate biopsies – 4 men in the testosterone arm, and two in the placebo arm. Of the four men taking testosterone who had a prostate biopsy, three had prostate cancer, two of which were high grade (more high risk). Of the two men who had a biopsy in the placebo group, one had cancer. These were men aged over 65 and so had a higher risk of prostate cancer. You can see that the risk of needing a biopsy from PSA monitoring is low, and those who did have a biopsy were highly likely to have prostate cancer, particularly in the men taking testosterone replacement therapy
It can all seem a bit confusing but the take aways are:
- There is no convincing evidence that an increased risk of prostate cancer is one of the risks of taking testosterone replacement therapy. However, an absence of evidence doesn’t totally rule out the risk of prostate cancer after starting testosterone. To be on the safe side, for men over the age of 50, checking your prostate through examination and monitoring of your PSA is recommended before starting testosterone replacement therapy and with a repeat PSA test at 3 – 6 and 12 months, and yearly after that.
All of the clinical team at the Leger Clinic are experienced in discussing these issues and are more than happy to talk through PSA monitoring at any point.
- Cancer Research UK. Prostate cancer statistics. Published 2022. Accessed December 8, 2022. https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer
- Cancer Research UK. Prostate cancer incidence statistics . Published December 2022. Accessed December 8, 2022. https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer/incidence
- GOV.UK. PSA testing: advice for men without symptoms aged 50 and over – GOV.UK. Published March 2022. Accessed December 8, 2022. https://www.gov.uk/government/publications/prostate-specific-antigen-testing-description-in-brief
- Cui Y, Zong H, Yan H, Zhang Y. The effect of testosterone replacement therapy on prostate cancer: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis. 2014;17(2):132-143. doi:10.1038/PCAN.2013.60
- Hackett G, Kirby M, Edwards D, et al. British Society for Sexual Medicine Guidelines on Adult Testosterone Deficiency, With Statements for UK Practice. Journal of Sexual Medicine. 2017;14(12):1504-1523. doi:10.1016/j.jsxm.2017.10.067
- Marks LS, Mazer NA, Mostaghel E, et al. Effect of Testosterone Replacement Therapy on Prostate Tissue in Men With Late-Onset HypogonadismA Randomized Controlled Trial. JAMA. 2006;296(19):2351-2361. doi:10.1001/jama.296.19.2351
- Cunningham GR, Ellenberg SS, Bhasin S, et al. Prostate-Specific Antigen Levels during Testosterone Treatment of Hypogonadal Older Men: Data from a Controlled Trial. Journal of Clinical Endocrinology and Metabolism. 2019;104(12):6238-6246. doi:10.1210/jc.2019-00806
Are there any fringe benefits to taking TRT apart from the sexual ones?
Yes, apart from improving you sexually there are a number of benefits which are now beginning to emerge from men who have been taking TRT long term. Among these are:
- Improvements to your cardiovascular system
- Improvements to your cognitive function and memory
- Increased mineral bone density to help prevent fractures.
- Increased muscle mass and decreased body fat
All that said it is a mistake to expect miracles. The benefits from TRT are often subtle and mild and TAKE TIME!
Not necessarily life transforming but rather life enhancing.
What is a “normal” level of testosterone?
Surprisingly, this is where there is such disagreement which leads generally to the diagnosis of TDS being missed. Traditionally, and, the level given out by many NHS laboratories, gives a level of under 8 as being abnormal.
There are now several guidelines European Society of Sexual Medicine, the International Society of Sexual Medicine, The European Society of Urologists and even our own British Society of Sexual Medicine which state that levels of testosterone under 12 warrant a trial of testosterone therapy if the Doctor seeing the patient has a high suspicion that the patient has the condition.
In 2015 a group of leading world Andrologists produced the following statement:
“1. Symptomatic men with total testosterone levels lower than 12 nmol/l should be treated with Testosterone therapy.
2. A trial of testosterone therapy in symptomatic men with total testosterone levels of higher than 12 nmol/l can be considered based upon clinical presentation”
i.e. if a Testosterone specialist such as myself feels that the clinical picture fits with testosterone deficiency, then a trial is justified
Most experts agree that a patient should also have a calculated free testosterone which is done by measuring the SHBG in addition to testosterone.