Dr Jonny Coxon BM BCh MA MD MRCS MRCGP FECSM - INTERVIEW

Description

One of the big problems we’re having with diagnosis of testosterone deficiency is the difficulty that we see with laboratories giving reference ranges which vary hugely across the country. Often they’re just based on normal distributions according to that particular analysis, and of course they don't very often line up with the guidance in all sorts of testosterone deficiency guidelines which will tell you that there are cutoffs that we should be treating testosterone deficiency at in the presence of symptoms as well, and that can be a massive difficulty especially in primary care where most of my practice is done. A GP will get a result back, perhaps they’ve been taught about looking for testosterone deficiency and they duly do the tests, and then the laboratory tells them that that test is normal, and the GP will be having a flood of results to go through that day and they will quickly file that result as normal, and the opportunity is gone to diagnose testosterone deficiency, so we are really trying to get that message out. For example in the British Society for Sexual Medicine, another of the members is a biochemist and he is having a big program he’s written to laboratories across the country asking them questions, probing questions about what they do, seeing that some give comments, some don't. Some on the basis of that have changed so that they now are giving comments so they can give guidelines, in the same way that we would be for HbA1c, cholesterols. We don't quote reference ranges there, or we may do but we say “these are the action levels,” so it’s the action levels that are really important and that we’re trying to promote, so we’re trying to win that battle.

It can be difficult to bring out for men their sexual symptoms if they haven't presented with them themselves, if they haven't told you about them, so sometimes it can be looking for those men who are more likely to. So we may say, for example in reviewing a man with diabetes, “It is well known that men with diabetes are more likely to have troubles with their erections. Is that you have?” Or perhaps you may also see that with men with urinary symptoms, similarly, “It’s well known there’s a very strong link between men and urinary symptoms and those with erection problems. Is that something you suffer from?” It may be they tell you straight away or maybe there’s instant denial, but hey presto, a few weeks or months later, they come back, “That thing you said about erection problems, I’d like to talk about that.” So it may need coaxing out of men and they’re often very grateful for it.

I would always screen for hypogonadism in men with erectile dysfunction and those who – perhaps with some interesting experience in the area, I’ve started to spot the symptoms that otherwise, especially in primary care and general practice, may be dismissed as very common symptoms that men present with – so those who have tiredness, depression, anemia even, it may not be the first thing that comes to mind. So it’s trying to get a message across so that we can start looking for testosterone deficiency in a larger group of men, but I suppose really the battle is to try and find those that are low-hanging fruit, so the diabetic men, the higher the BMI, the more likely we are to find it, and at least start to probe and ask about the symptoms for testosterone deficiency and start to find the cases that are we know out there.

In terms of treating obesity, absolutely I would always say that lifestyle interventions are hugely important. I don't think anybody in this area would deny that. The point is that how successful those lifestyle interventions are, I think we’ve all seen in our everyday practice I was going to say there are variable results, but really they are often very disappointing results, so to try and get something to boost those lifestyle interventions can be hugely important. In the context of testosterone deficiency, giving a man some more motivation, allowing him to see around their body in time some conversion from fat mass to muscle mass can really help and does give some results, and that’s just not give anecdotal. There have been studies comparing lifestyle intervention alone with lifestyle intervention and testosterone replacement in those with deficiency, and there have been real differences. So that's why certainly in the British Society, and indeed other guidelines, we would always say that weight loss should be recommended, but in the context of a man who is obese with testosterone deficiency, that should be boosted by testosterone therapy.

Weight alone, purely in and of itself, can definitely help sexual dysfunction. That has been proven and it makes sense to a degree I think. I always tell my patients not to think of this fat around their body as an inactive thing beneath their skin that's growing. It’s an active organ, pumping out hormones, and I stay basic with them but I try and tell them that those hormones may not be helping their testosterone levels and may be driving up their estrogen levels. That often gets ears pricked up and they realize that various other things are happening with that fat tissues that's unhealthy for their general health and certainly for their sexual function as well. It can be difficult to motivate someone to lose their weight, and that's an extra thing in the armamentarium to remind them that it can genuinely help their sexual function. The loss of weight and the exercise that comes with that to increase cardiovascular health will definitely help their sexual dysfunction to a degree.

I’m certainly looking for testosterone deficiency in those men with type 2 diabetes now. It’s become part of the blood test that I will ask my nurses in practice to check, perhaps not every year. We’re trying to get them to do it every two or three years. Let’s check the testosterone levels in our diabetic men, and because of that, I’m finding a lot more cases. That's been something to deal with as it’s been an increased workload but I’m happy with because I’m finding real cases, and I’m seeing some men who over the last two or three years that I’ve been doing it more and more, have been coming back incredibly happy. I mean we always think of the cases that come to mind with amazing results, but there have been plenty across the board and some really happy men who have found their general health and their relationships, their sexual function, their confidence in themselves to be hugely boosted, so it’s been a very powerful thing.

Adherence with testosterone therapy is always going to be a potential problem. I am very upfront with my patients at the beginning, and I work through their nervousness about starting something that I say may have to be lifelong. In general practice, we’re quite used to that. There are lots of medication that we will advise patients to start that may be lifelong, when we treat hypertension, hypercholesterolemia, hypothyroidism, diabetes usually with some exceptions, and I tell patients that if they want the full benefits from their testosterone therapy, of which there are many, they will have to be patient. Hopefully they will be encouraged by some reasonably early changes. They may see their libido and general motivation increase quite early. They may have to wait longer for their erections to become better, but they may have to wait even longer still to see body shape changes, to see their muscle mass increasing, to become stronger, and I can tell them that inside their body their bones are getting stronger and that can take even longer. So I remind them that there’s lots of studies and data that show the longer they’re on it, the better their general health will be, and we’re replacing something natural. We’re getting them back to something which they would have had in their bodies beforehand. We’re not doing anything unnatural. We just want them to be back where they used to be and to reap the benefits from that.


 

Speakers

Prof. Dr. med. Marija Pfeifer

Dr Jonny Coxon BM BCh MA MD MRCS MRCGP FECSM

Dr Jonny Coxon BM BCh MA MD MRCS MRCGP FECSM

GP Partner
Specialty Doctor: Urology & Gender Identity

Brighton, UK

 

Dr Jonny Coxon BM BCh MA MD MRCS MRCGP FECSM

GP Partner
Specialty Doctor: Urology & Gender Identity

Brighton, UK

 

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