The Case

Eric G. was a 39-year-old married man and father of two who worked rotating shifts. He found himself gaining weight; losing muscle; and struggling with decreased drive, stamina, and energy. When he entered a hormone replacement therapy (HRT) program, his body fat was 32 percent, his lean muscle mass was 61,339 grams, and he was in the 99th percentile for his age. Within six months, his body fat was 15 percent, his lean muscle mass increased to 72,679 grams, and he was in the 10th percentile for his age. He said, “Now that my transformation is complete, I’m able to work without limitations, have boundless energy and stamina, and approach all aspects of my life with newfound confidence.”

A successful HRT program must be in the hands of a skilled physician who acknowledges patients’ symptoms and utilizes evidence-based objective measurements to develop a treatment plan that will minimize risk while providing benefit.

Is HRT a Danger or a Miracle Cure?

HRT, like all medical treatments, has benefits and risks. The endocrine system is complex, and hormones are powerful. In the hands of an unskilled practitioner, HRT can be disastrous and should absolutely be avoided. However, under the careful supervision of an experienced physician, HRT is extremely safe and effective, with benefits far outweighing any risks.

Eric G. before and after his HRT program.

Scientific studies have shown that by age 40, most adults have significantly altered levels of several essential hormones. Patients complain of fatigue, decreased motivation, decreased sex drive, decreased energy, and changes in body composition with decreased muscle mass and increased body fat. These symptoms often lead to high cholesterol and high blood pressure and become more noticeable as time marches on. Patients often chalk them up to simple aging or depression or, worse, attribute them to career burnout or even a failing relationship.

Unfortunately, the medical community reinforces these interpretations and, in fact, erroneously publishes information warning against HRT entirely. Most physicians are familiar with the problems associated with the National Institutes of Health study warning women against HRT and know that the pendulum has already begun to swing back in favor of prudent HRT for menopause.

A study recently published in JAMA warned that testosterone replacement was associated with increased risk of stroke and heart attack. However, the men in this study were not prescribed an aromatase inhibitor along with their testosterone. When testosterone therapy does not include an aromatase inhibitor, estrogen will also rise, often to harmful levels. High estrogen is definitely associated with increased risk of blood clotting. Furthermore, testosterone can increase Hg and should be monitored. However, high testosterone alone is not a risk factor for stroke or heart attack. If it were, then these conditions would be more common in men between the ages of 18 and 25 rather than older men. Furthermore, the Kaplan-Meier methodology utilized in this study was less than ideal, skewing the data even more.

Another study recently concluded that low IGF-1 (the active metabolite of human growth hormone) was better than high IGF-1 and projected that death rates were more favorable for those with low IGF-1. However, this study was conducted with a small “N” of women in their 90s, a group in whom death projections are questionable, and again, the statistical methodology was not ideal. Another study evaluated a group of veterans and warned against human growth hormone therapy. However, the authors’ conclusions were directly contradictory to what the statistics demonstrated. Informed individuals understand that studies can be crafted and statistics manipulated to prove either side of an argument and that caution should be used prior to accepting anyone’s conclusions.

How to Approach HRT Discussions

Inaccurate information can lead doctors to minimize patients’ complaints of age-related symptoms and discourage them from considering HRT. Patients often present with the following complaints: “Doc, I just don’t feel as good as I used to. It’s becoming harder and harder to maintain my weight, and I’m losing fitness no matter how hard I work out. I just don’t have the energy or drive that I used to.” They are usually met with: “Why don’t you eat less and exercise more? If that doesn’t work, we can try an antidepressant,” or “You can’t expect to feel like you did when you were 25! Accept the fact you’re getting older; it’s better than the alternative.”

Physicians who respond in this manner are actually harming their patients by withholding an appropriate referral to an HRT specialist. Most physicians are familiar with menopause. They are less familiar with male-associated andropause and adult-onset human growth hormone deficiency, or somatopause. However, all three are recognized syndromes associated with hormonal shifts. These shifts contribute to a slow but steady decline in energy, loss of muscle mass, increased body fat, weaker bones, loss of skin tone, lapses in memory, and diminished sex drive and activity.

Like diabetes, these syndromes can be successfully treated using appropriate nutrition, exercise, and HRT. Insulin is a hormone that can be lethal when dosed improperly, but no physician would deny a hyperglycemic diabetic insulin because giving insulin is “risky.” Physicians are experts at managing the risk-benefit ratio and administering beneficial treatments to patients in need while managing their associated risks.

Careful Planning Is Key

As with any successful medical treatment, a successful HRT program must be in the hands of a skilled physician who acknowledges patients’ symptoms and utilizes evidence-based objective measurements to develop a treatment plan that will minimize risk while providing benefit. Objective baseline measurements should include body composition, bone density, digital strength, cardiac fitness testing, and comprehensive metabolic and hormone laboratory testing. These results must be interpreted based on optimal levels rather than disease-based reference ranges published by the lab. It is common for patients to have labs interpreted by their doctor and be told everything is fine. When interpreting the same exact data from a health perspective, key tests may be missing or deficiencies overlooked. These measures are the basis for a personalized, safe, and effective treatment plan.

Eric G.’s DXA scan, demonstrating a dramatic decrease in body fat and increase in muscle mass with a short course of HRT.

Like most endeavors in life, the key to executing a successful plan is in the follow-through. Patients must be monitored closely, especially in the first few months. Follow-up laboratory testing is essential within the first eight to 12 weeks. Doses must be adjusted to ensure that replacement is in the appropriate range and not creeping into supraphysiological levels where risks increase. Once dosing has been established, periodic monitoring must be continued. Due to a variety of variables, patients’ needs fluctuate over time. Therefore, doses that are appropriate today may not be appropriate in the future.

HRT has moved from the fringe into mainstream medical practice for two primary reasons. First, it works! But equally important is that HRT focuses on maximizing quality of life rather than the number of days of life.

Dr. Andrew has practiced medicine for more than 20 years and is the cofounder of the age management and aesthetic practice Elan Medical in Fairfield, Calif.