Nate Marquardt, Chael Sonnen, Dan Henderson and God knows who else – it seems like Testosterone Replacement Therapy (TRT) is all the rage today.  But what is it exactly?  Some new fad, akin to the Rubix Cube and disco music?  Or is it a legitimate medical treatment for a legitimate condition?  Hey, my student loans are all from law school, not medical school, so I’m not qualified to answer those questions.  However, Dr. Sherry Wulkan most certainly is.

Board certified in internal medicine and wielding the kind of sports medicine experience that makes her the New Jersey State Athletic Control Board’s resident TRT ace (to paraphrase Nick Lembo), Dr. Wulkan has examined more MMA fighters than you can shake a stick at.  Consequently, MMA Convert reached out to her for the skinny on this week’s hot topic.

First, a brief endocrinology lesson, courtesy of Dr. Wulkan:

There seems to be a lot of confusion about what testosterone replacement is, and how this hormone affects the body, so here’s some background information: Testosterone is made in the testes, but the signal that determines how much of the hormone needs to be made comes from the brain.  When enough of the hormone is made, a signal is sent back to the brain to tell it to turn off the signal that stimulates more production.  Under normal circumstances, this feedback loop ensures that men produce sufficient quantities of testosterone, but no more than is required.  When a man who has a normal ability to produce adequate hormone levels decides to supplement with external sources of this hormone for performance enhancement, he shuts down his natural ability to make his own testosterone.  In the early stages, his own body’s ability to produce this product is merely suppressed (it can return to normal over several months). Eventually, however, the cells that make testosterone are destroyed, and the athlete then becomes dependent on testosterone replacement for normal male function and health. This phenomenon is believed to be related to dosage, duration of usage, and preparation type.

What is testosterone replacement therapy?

Testosterone replacement therapy is the use of hormone replacement for men incapable of producing sufficient amounts of this hormone themselves. This is a medical condition, and the medicine used to treat this ailment is testosterone and similar androgenic compounds. Levels are monitored to maintain patients in the mid-range used by the reference laboratory available to their physician. Injectable formulations are available as are gel forms.  Oral androgen replacement is rarely used, since there has been a strong association of its use with liver cancer (hepatocellular carcinoma).

Testosterone replacement therapy is not synonymous with the use of this hormone for performance enhancement; that is a form of abuse, not necessity. Males in their twenties and thirties rarely experience this disorder. End stage liver disease, end stage kidney disease and alcoholism can cause low testosterone.

How prevalent is it in the sports you oversee?

The request for testosterone replacement therapy is more common now than even five years ago.

To what would you attribute that to?

There are several reasons for the increase in requests for testosterone replacement therapy. Easier access to performance enhancing drugs by internet, and products advertised on television networks, have likely increased the number of  athletes using these medicines. Perhaps of greater importance, more and more athletes are openly admitting prior use of performance enhancing drugs (steroids), and a greater number of these men are requesting assistance with the health issues caused by chronic prior use. We are beginning to see a secondary wave of consequences of long term use of these drugs, that is, permanent or partial suppression of a young male athlete’s ability to make his own hormone(s).

What precipitates the need for TRT/What would cause the need for it?

The most common reason to require TRT in a young male is prior use of high doses of performance enhancing androgens (ie steroids). They are used to make levels of the hormone supra-normal, so that muscles become larger, strength increases, aggressiveness increases; post work-out recovery is also anecdotally reported as faster.  However, there are consequences to using too much of a “good thing”; you can destroy your own ability to make testosterone. When that happens, levels fall below normal range, and supplementation is required to alleviate the symptoms caused by inadequate hormone production.

Can someone’s ability to produce testosterone eventually be rehabilitated or is TRT a permanent treatment regimen?

Not in all cases.

Is it possible for someone to abuse TRT during training by exceeding the prescribed dosage, gain an advantage in better training recovery, and ease back on the TRT to get their testosterone down to acceptable levels by fight time?

That is the theory.

There is a cost-benefit ratio that needs to be looked at.  A competitor’s cardiac abilities (cardio) may actually be hindered by using performance enhancing androgens, because the skeletal muscle mass (biceps, quadriceps etc) becomes so great that it requires more of the blood pumped by the heart.. This puts a strain on the heart and other vital organs, since excess androgens do not cause specialized tissues to enlarge proportionate to skeletal muscle growth. High blood pressure is also a complication of steroid abuse, and can contribute to diminished cardio. In addition, there is also an increased risk of tendon tears.

Preparations used vary, but in general, athletes who use performance enhancing androgens also have a psychological addiction; it provides a mental edge; they like the way they look and feel at higher levels.  Athletes may feel the decline in levels, and this may affect the way they PERCEIVE their ability to perform. In addition, mood swings are associated with steroid withdrawal.

Can any doctor prescribe TRT?

Any doctor can prescribe TRT.  As with all medical issues, it is probably best to seek a physician who has a great deal of familiarity, and who with this issue, such as a Board Certified endocrinologist.

The ABC medical committee will present its recommendations at the annual conference for the monitoring of combat sports athletes on TRT and for elaboration on the policy for granting TUE (therapeutic exemptions). The guidelines will follow those of WADA (World Anti Doping Association) and the USADA (United States Anti Doping Association).  A board certified endocrinologist will need to submit the work-up as outlined.