If you haven’t done so already, have a read of Dr Amir Eslami’s blog, “Can you get TRT on the NHS?”. It explains the current hurdles a GP has to overcome to initiate TRT.
In the UK the treatment of the menopause can be generally managed by GPs. However, the same cannot be said when men experience symptoms of low testosterone due to the andropause or late-onset hypogonadism. Both involve reductions in essential hormones as we age, the difference is that one hormone is oestrogen (good) while the other is the dreaded testosterone (bad…..according to some).
Unfortunately, testosterone has the disadvantage in that it comes with so much additional negative baggage. The media has stockpiled many clichés as a substitute for real journalism for example, “testosterone-poisoned dictator”, “testosterone-fuelled anger” and “roid rage”. The mere mention of the word “testosterone” sends a shiver down the spine of the chattering classes.
In this day and age in the era of toxic masculinity, the vilification of testosterone has been made easier. Everything from wars to corporate greed has been blamed on the humble hormone testosterone. This may seem like reductionism in the extreme but if the fault lies with the patriarchal society then the fault must also lie with what makes a man a man, testosterone. However, leaving the current zeitgeist aside, the actual scientific data tells a different story. Numerous studies have demonstrated that the association of testosterone with violence and aggression as unwarranted.
So why is there a difference in the treatment of hormonal imbalances between men and women? Is there some form of gender discrimination at play here? The current logic of the NHS is to allow GPs to initiate HRT for women suffering from menopausal symptoms while TRT can only be prescribed on the NHS only if it is initiated in secondary or tertiary care settings. This is because TRT is classed as an “amber” drug.
Before we go on, I will just briefly explain some terminology to help understand all that NHS jargon.
When we talk about primary care what do we mean?
Primary care refers to services that a person usually first sees when they have a health problem. For many people, this is often a GP or practice nurse.
Primary care is based on caring for the person rather than specific conditions, so professionals who work in primary care are generalists rather than specialists in any particular disease area.
Secondary care services are usually based in a hospital or a clinic and include planned operations, specialist clinics such as cardiology or renal clinics.
Tertiary care is healthcare provided in more specialist centres.
Traffic Lights in the NHS
Now, what do we mean when we say that TRT is classed as “amber drugs”?
The Red Amber Green (RAG) classification offers guidance on the prescribing of drugs initiated in secondary care and reinforces the basic premise that:
“When clinical and/or prescribing responsibility for a patient is transferred from secondary to primary care, the primary care prescriber should have the appropriate competence to prescribe the necessary medicines. Therefore, it is essential that a transfer of care involving medicines that a primary care prescriber would not normally be familiar with, should not take place without the sharing of information
with the primary care prescriber and their mutual agreement to the transfer of care.”
The aim of this traffic light system is to define where responsibility for prescribing between primary and secondary care should lie through categorising individual drugs as red, amber or green.
Red – for secondary or tertiary care initiation and long-term maintenance of prescribing
Amber– drugs which are appropriate to be initiated and stabilised by a specialist in secondary or tertiary care, once stabilised the drug may be appropriate for responsibility to be transferred from secondary to primary care with the agreement of a GP and a formal ‘shared care’ agreement.
Green (following specialist initiation) – for drugs that must be initiated in secondary care but can then be safely prescribed in primary care with very little or no monitoring required.
Green (following specialist recommendation) – for drugs that can be initiated by primary care following written or verbal advice from a specialist and can then be safely prescribed in primary care with little or no monitoring.
Green – drugs which may be initiated, stabilised and maintained in a primary, secondary or tertiary care.
So now that the definitions are out of the way so let’s get back to the demonisation of men.
Gender Discrimination in the NHS?
What has led to this strange gender discrimination? Late-onset hypogonadism or the “andropause” is not a new phenomenon and whilst in the past men have been suffering in silence, more and more men are now making their voice heard. Usually, the man will have to have done his own research before approaching their GP. However, after the clearing the first hurdle of getting past the receptionist the obstacles to TRT only increase until they find themselves gridlocked by the above-mentioned traffic light system.
Once the GP has been convinced that the symptoms are due to low testosterone, a referral needs to be made to a specialist clinic. Letters and emails are sent and after much toing and froing, the Holy Grail of TRT may be obtained. But the time it takes to obtain TRT on the NHS will probably test the patience of a saint.
Despite the fact that late-onset hypogonadism is relatively common it is often undiagnosed and untreated. This can be caused by many factors one of which is that the symptoms of low testosterone mirror those from other comorbidities (such as obesity, hypertension, hyperlipidaemia, diabetes, erectile dysfunction, depression). In fact, the above-mentioned comorbidities are more common in hypogonadal men than in eugonadal ( normal testosterone levels) men.
Time is another factor. Erectile dysfunction can quickly be addressed with the phosphodiesterase 5 inhibitors or Viagra to you and me. It’s a quick fix that does little to solve the underlying issue. Similarly, depression can also involve a quick prescription for an SSRI. The doctors working in the NHS are not at fault. They are working within a “reactive” healthcare system that only responds when you get ill. This coupled to the ten-minute consultation really doesn’t give the GP much opportunity to really get to the heart of the issue.
The familiarity of many GPs to the subtle nuances of TRT is lacking. As mentioned above many of the symptoms of hypogonadism match those for other conditions. This lack of specialist knowledge is another reason GPs may be reluctant to initiate TRT since they would leave themselves exposed if they are unable to manage a patient effectively and deal with any adverse effects.
The concerns regarding prostate cancer are another reason that many doctors are hesitant to begin TRT. However, the science behind the link between testosterone and prostate cancer is extremely weak and based on a case study in a single individual in 1941! However, recent research has revealed that high testosterone levels do not increase prostate cancer risk
It is not that there are no guidelines to follow. Current BSSM guidelines provide clear information that would enable primary care doctors to help meet the needs of those men suffering from late-onset hypogonadism but unfortunately despite this, the treatment protocols are still mired in the dark ages with very few, in any, GPs willing to stick their heads over the parapet. It will require a paradigm shift and the willingness of the “reactive” healthcare system to transform into a “proactive” healthcare system to enable more men to access TRT on the NHS.
The solution for TRT
If your quest for the mythical NHS TRT has failed, do not despair. In the UK TRT can also be obtained privately from specialist TRT clinics. To start your TRT journey today book your FREE initial TRT consultation with Nebula Health.
 O’Connor DB, Archer J, Hair WM, Wu FC,” Exogenous testosterone, aggression, and mood in eugonadal and hypogonadal men” Physiol Behav, 2002Apr1, 75(4):557-66
 Hull University Teaching Hospitals NHS Trust. Amber list of Drugs (www.hey.nhs.uk/herpc/amber)  EL(91)127 “Responsibility for Prescribing between Hospitals and GPs.”, DH  Basil N. Late-onset hypogonadism. Med Clin North Am 2011; 95(3):507-523  Mulligan T, Frick MF, Zuraw QC, et al. Prevalence of hypogonadism in males aged at least 45 years. The HIM study. Intl J Clin Pract 2000,(7);762-9  Studies on Prostatic Cancer. I. The Effect of Castration, of Estrogen and of Androgen Injection on Serum Phosphatases in Metastatic Carcinoma of the Prostate Charles Huggins and Clarence V. Hodges
 Cancer Res Kaplan, Alan & Hu, Jim & Morgentaler, Abraham & Mulhall, John & Schulman, Claude & Montorsi, Francesco. (2015). Testosterone Therapy in Men With Prostate Cancer. European Urology. 69. 10.1016/j.eururo.2015.12.005. April 1 1941 (1) (4) 293-297;