The National Health Service (NHS) was founded by Aneurin Bevan in 1946 with the aim of “providing care based on need and free at the point of delivery”. It was a piece of socialism that had altruistic intention, however over the years our helping fund the modern NHS through our National Insurance contributions has given us a sense of entitlement. The NHS is clearly underfunded and under-resourced, its used as a political pawn and abused by the entitled many. There is toxic over-crowding in Emergency Departments and GP surgeries up and down the length of the country. There are inequalities and perceived injustices as the model struggles to cope with demand and expectation.
The Men’s Health Clinic believe that a positive change can be affected to the collective, by affecting a change to the individual. Increased awareness and improved understanding through education and experience allows you to, not only make an informed choice, but also improves compliance. Taking responsibility for your own health provides you with autonomy and a sense of engagement necessary for you to affect a positive change to your well-being. Many people have a passive paternalistic relationship with the NHS, but sometimes ownership needs to be taken to put you back into the driver’s seat.
We have provided men with a helpful guide to accessing care and treatment for testosterone deficiency through the NHS – ‘https://themenshealthclinic.co.uk/trt-wars-get-trt-uk. If you qualify for Testosterone Replacement Therapy (TRT) according to the current British Society for Sexual Medicine (BSSM) guidelines http://www.bssm.org.uk/wp-content/uploads/2018/09/guidelines-on-adult-testosterone-deficiency-with-statements-for-uk-practice.pdf, it is likely that you will be initially referred to an NHS Endocrinologist who will review your blood work and look for an organic pathology. Some NHS Endocrinologists do not accept the BSSM guidelines and utilise local pathology reference ranges to determine if your testosterone levels are low enough for TRT to be considered. If investigations do not identify an organic pathology, its unlikely that you will be considered a candidate for TRT.
We have many patients who have been turned down for treatment by the NHS, despite qualifying according to the BSSM guidelines, and choose to pursue private treatment through our clinic. We still actively encourage these patients to seek support from their family GP, as GP’s are often willing to carry out the necessary blood tests, and sometimes even prescribe their testosterone medication for them, whilst remaining under the care and supervision of our clinic. We work with a growing doctors and have begun to receive referrals from both NHS GPs and a private Professor of Endocrinology, as they appreciate that they cannot deliver the standard of care and level of service the patient needs within the constraints of the NHS, or their experience.
So, if your doctor agrees to providing you with treatment for Testosterone Deficiency under the NHS, what TRT options are available?
Nebido (Testosterone Undeconate) is often prescribed by the NHS. When it was first licenced in the UK for TRT, the manufacturer promised stable testosterone levels with only twelve weekly injections, which was obviously an appealing prospect. In fact, when we first opened our clinic in January 2016, we also used Nebido, initially prescribing it as per the manufacturer’s guidelines. Unfortunately, our experience with it demonstrated that consistently stable levels could not be achieved. Testosterone Undecanoate is notorious for causing peaks and troughs and after twelve weeks, most of our patient’s testosterone levels had returned to baseline. Shortening the injection interval helped to a certain degree, but negative symptoms often persisted.
The other commonly prescribed TRT by the NHS is a testosterone gel, either in the form of Testogel or Tostran. However, inadequate dosing and variable absorption tend to make the gel an ineffective long term solution in a large majority of patients.
Can the above preparations work? Of course, but are they the BEST available options? No.
Sustanon and Testosterone Enanthate are used in both NHS and private practice. They can frequently be found on NHS prescribing formularies but are usually only prescribed on the recommendation of an NHS Endocrinologist. NHS Endocrinologists will often strictly adhere to the original prescribing guidelines, which are both outdated and ineffective. This is something we have previously written about in our blogs ‘The Sledgehammer Approach to TRT’ https://themenshealthclinic.co.uk/the-sledgehammer-approach-to-trt and ‘Gold Standard TRT’ https://themenshealthclinic.co.uk/gold-standard-trt. Private practice allows for more autonomy in the prescribing of these medications, which often results in improved efficacy and patient outcomes.
At The Men’s Health Clinic, our gold standard recommendation for TRT is daily subcutaneous injections of Testosterone Cypionate & Human Chorionic Gonadotropin (HCG). Testosterone Cypionate has been the ester of choice in the USA for a long time, it is well tolerated and effective. HCG is not routinely prescribed by the NHS, or even in private practice, with TRT. Despite this, we believe that benefits of using HCG alongside TRT cannot be over-emphasised. These benefits include improved testicular function, fertility and an improved sense of well-being. https://themenshealthclinic.co.uk/the-benefits-of-using-hcg-with-trt.
Our prescribing rationale for all TRT options available at our clinic is clearly explained in ‘TRT – Best Practice’ https://themenshealthclinic.co.uk/trt-best-practice. The premise behind TRT should not simply be stable levels, it should be Hormone Replacement Therapy. You cannot have a one size fits all model as we are all biologically unique.
So, which is best? Testosterone Replacement Therapy through the NHS or Private? In my professional opinion, if you want the best possible care, the answer is obvious.
Dr Robert Stevens MBChB MRCGP Dip.FIPT