Hey, any guys out there want to talk about their declining sex drive, bouts of fatigue, constant brain fog, decreasing muscle mass and increasing belly fat? Anyone, anyone? Bueller, Bueller?
*crickets*
Wow, tough crowd. Yet, your silence is completely understandable. No one wants to discuss these symptoms, especially when one knows or suspects such indicators are attributable to low testosterone. You don’t know how to talk about it, much less want to, and it doesn’t get any easier trying to discuss with a doctor. Sadly, there are many physicians out there who either think Low T is overblown, or they simply aren’t trained to guide you on balancing your hormone levels.
Like it or not, though, you need to talk with someone, and thankfully, Peak is listening. The company’s focus is to help you rediscover your best self through at-home testing, testosterone therapy replacement (TRT) and telemedical consultations with a network of board-certified physicians specializing in fields like endocrinology, urology and internal medicine. This includes Dr. Danielle McDevitt, an internal medicine physician based in Annapolis, MD, who for more than 10 years has specialized in hormone consultation, treatment and optimization. The good doctor was kind enough to sit with Peak (virtually, of course) and weigh in on an essential list of things to know before, during and after a consultation. (You can also check out exclusive clips from this interview on Peak's YouTube channel.)
1. Find a physician that’s experienced in treating hormones.
According to the late theoretical physicist Albert Einstein, “The only source of knowledge is experience.” Pretty smart guy, if you ask us, and a great mindset to have while searching for a provider that can assess and treat clinically significant hormone deficiencies.
“It’s really important to know the type of provider you’re going to talk to about [hormones],” says Dr. McDevitt. “Some primary care doctors understand them, some don’t. If you really think there’s something wrong with your hormones, I would recommend doing a little research and finding someone who’s like, ‘I understand balancing hormones. I work with different hormones, from what Big Pharma has to compounding.’”
It isn’t surprising when a male patient looking for an assessment of their hormones experiences resistance from his PCP (primary care physician). It’s also not a complete shock if said doctor chooses to refer the patient out if they uncover below-normal testosterone levels. As Dr. McDevitt sees it, not all physicians are schooled in-depth in the ways of testosterone therapy; instead, many are trained to say, “If this is within range, there shouldn't be an issue.”
McDevitt herself was initially trained in a similar fashion, though her thinking changed following her residency, when she began working in a practice focused on “integrative medicine,” a union of Eastern and Western healing-oriented medicine focused on the person as a whole.
“A big part of it was hormone balancing, both in women and in men. That’s where I learned [about] hormones,” she says. “I continued my education with the A4M [American Academy of Anti-Aging Medicine], and they do a big endocrinology…I guess module, you would call it…with the Fellowship. It talks about really understanding hormones, how they’re important for us and how to balance them, and their role in preventative health [services].”
2. Go easy on yourself when discussing your hormones.
Say you’ve done the research and found a physician with extensive knowhow in balancing hormone levels. Now you have to talk with them about your Low T, and the personal issues accompanying it – weight gain, muscle loss, no energy, mood swings galore and a sex drive that’s grounded on the Monopoly game board spot “Go Directly to Jail.”
It seems like a pretty heavy conversation to have with a doctor you’re meeting for the first time. However, should it be? Think about your consultation like a blind date: If you and the doctor hit off, great. You’ll agree to see each other again. If you don’t…hey, there are other fish in the sea. And, much like a blind date, don’t put all the pressure on yourself to engage in conversation. Just ease into the discussion, treat it like a no-judgements zone and see how the consultation plays out.
Also remember: If you’re signing up for a Peak consultation, you’re doing so with physicians who are laser-focused on optimization. There’s no mystery as to what you’ll discuss with them, which better enables you to focus on what you want to discuss. In short, you likely ain’t tellin’ them anything they haven’t heard before, so open up.
Dr. McDevitt notices that men in general seem a little more comfortable with her in a Peak consultation versus a wellness visit to her office, where the patient isn’t necessarily aware of their Low T issues and has difficulty understanding – and therefore discussing – the symptoms associated.
“A lot of men [using Peak’s service] do research about their hormones,” she says. “They also come to us knowing we’re going to talk about sex hormones…. It’s a little different, but that’s one of the beauties about Peak. A patient already knows what they’re going into with the appointment.”
3. Show your vulnerable side. Talk about the tough stuff.
No matter how much advance research patients do about a provider or their symptoms, some just can’t bring themselves to mention the more sensitive problems surrounding Low T – chief among them, to put in Star Wars terms, how to re-energize the ol’ lightsaber. Talk about fatigue? You bet. Lack of energy? Sure, let’s discuss. But a sagging erection or a libido on the lam? “Sorry, doc, I just remembered that I have an appointment to be anywhere but here at this moment in time…”
Look, no man wants to admit that something that functioned so well in their twenties isn’t performing like it used to. Be that as it may, holding back such pertinent details can be detrimental to your wellbeing. A doctor can’t help you if you don’t tell them all of your symptoms, which makes it imperative for you to address the elephant in your virtual consultation room.
Dr. McDevitt prides herself on being “a very casual physician” who won’t start off a consultation with point-blank questions like “What’s wrong? What are your symptoms?” Instead, she’ll ask the patients questions about where he lives and what the weather there is like. “We start off a conversation like you would with a friend or someone you’re meeting for the first time in a way that’s [like,] ‘Okay, I’m getting to know you,’” she explains. “[Then] we get into the work.”
Sometimes it’s just the ice-breaker that’s needed to let a patient know they can talk freely with her. Sometimes, but not always. And when McDevitt thinks the patient still seems uncomfortable, she puts it upon herself to further chip away at that ice and get into the nitty-gritty of their “Low T tête-à-tête.”
“it’s important for not only the patient, but definitely for the provider to bring up those awkward subjects,” she says. “I explain to them, ‘Look, sex drive…I get it. The dropping [of levels]…we all experience it.’ It’s both sexes. Talking about the strength of an erection…not many men want to admit that it’s not as strong. [It’s the] same thing with women and vaginal dryness; that’s not the first thing a female’s going to tell me. I usually bring those kinds of things up and say, ‘I know it’s awkward, but let’s just talk about it.’”
4. Think about what you can bring to the conversation.
When you’re going into a consultation with your physician, provide as much information about yourself as possible. We’re not talking about the patient intake that’s documented beforehand, collecting important demographic, social and clinical data, consent forms, insurance, payments and other key information. A hormone optimization specialist worth their salt is looking for the history and details that can be easily overlooked or missing altogether from an intake – the ones that best capture how your life is being impacted at work, at home and in the bedroom.
“Really tell your symptoms,” Dr. McDevitt urges. “If you say, ‘I’m just tired’ and the levels are so-so…that’s not a strong clinical picture... All those symptoms that we ask about…sex drive, strength of erection…just be honest so we can understand what’s going on.
“I always ask patients about their mojo – like, how they’re feeling,” she adds. “‘Do you want to sit on the couch or do you want to go out with your friends?’ ‘Do you want to have that relationship with your partner or are you rather like, “I just want to go to bed”?’ I want to know those things, and about supplements and family history.”
It’s also important to share the medications and vitamins you’re taking, as well as your dosages. You may not see an obvious connection between them and your hormones, but then, you’re not the one with medical degrees hanging on your wall. Besides the fact that certain prescription medications can decrease your testosterone levels, a doctor will want to make sure that whatever treatment they prescribe is safe and compatible with anything else you’re taking.
Last, if you’ve seen a PCP over the past year and have the results of blood work from that visit, share it with the physician who’s evaluating your hormone deficiencies. It allows the doctor to compare your past and present levels, plus it gives them a better idea as to how the rest of your levels – including your Vitamin D and thyroid – are functioning. Your body’s a well-oiled machine; get the full inspection, okay?
5. Questions, questions and more questions: Know the ones to ask.
Hey, we understand. There’s a lot of information being thrown your way – so much that it can be a bit daunting to process all of it, especially in the thick of a consultation. Just remember, the consultation is a two-way communication between you and your doctor. The best way you can hold up your end of the conversation is to engage with your physician and be inquisitive. To quote Krishna Saagar: “The worst question ever asked, is the one that is never asked.”
It is absolutely, 100 percent more than fine to ask questions – as many as you feel is necessary to help you make informed decisions about TRT and rediscovering your best self, physically, mentally and emotionally. So, let’s think about the questions that are most beneficial for you to ask.
First, it’s extremely important that you understand just how the pathways of hormones work. Essentially, hormones travel throughout the body either via your bloodstream or inside fluid around your cells. Upon finding a target cell, they bind with specific protein receptors inside or on the cell, thereby altering cell activity.
Easy to understand, right? No, we don’t quite get it, either.
Thankfully, that’s where someone like Dr. McDevitt steps in. She knows a lot of this information is likely to go over your head, so she breaks down how the pathways work with regards to your hormones. This provides you with ample opportunity to ask about the available forms of testosterone replacement and the possible side effects associated with each treatment.
“How to use a medication is really important to ask about, what possible side effects…knowing when side effects are not good and [how soon] to reach out,” she says. “I have some patients who are like, ‘Don’t worry about it. Just tell me the end product and what’s going to happen.’ But I like to tell patients how the pathways work, because it’s important to understand…you need to really monitor safely while optimizing hormones.”
Asking questions about monitoring your optimization is especially crucial if you and your significant other intend to start or add to your family. McDevitt warns that some optimization methods can potentially decrease your sperm count and, therefore, your ability to produce offspring. She recommends that if you’re going to pursue hormone replacement, be sure to ask which forms of treatment are less likely a risk of compromising your fertility. (E.g., clomid.)
The physician notes that the majority of her Peak consultations are with males who want to improve themselves and “get back to who they were.” However, in recent years, she has noticed one sizable difference in her patients.
“We’re seeing such broad ages now,” she says. “Most of my men were 40 to 70 [years old]. Now I’m seeing men in their twenties and thirties. So, there is something going on, and a lot of us are having kids older now. They’re not coming to us for infertility issues; they’re coming to us because of the symptoms they’re having. But because they’re so young, not a lot of them are done with their family planning.”
6. Understand how a Peak consultation works.
Let’s quickly explain that your appointment with a Peak physician, made after you receive the results of your lab work, is a video consultation through Peak’s telehealth platform.
With regards to scheduling, it’s really very simple: Log in to app.getpeaktoday.com, click on the top left hamburger menu, then click on “Consultations.” The names of providers that appear on-screen are the ones that are available in your location. Their time slot availabilities also appear, allowing you to choose the time that’s best for you. If you don’t see any available time slots or any that work for your schedule, email support@getpeaktoday and ask for assistance. Most patients are seen within a week of notifying the Peak team.
How does a typical Peak consultation with Dr. McDevitt go? First things first: Have your I.D. card on you. “We always make sure we check I.D., just so we have the right patient,” she laughs.
Next, McDevitt reviews the patient intake and talks with you to develop a firm understanding of your medical history and, as she calls it, your “mojo.” After that, she shares her computer screen to review your blood work with you. That includes these biomarkers measured by Peak’s at-home hormone testing kit:
• Free testosterone
• Total Testosterone
• Luteinizing Hormone (LH)
• Estradiol
• Sex Hormone Binding Globulin (SHBG)
• Albumin
• Alanine Aminotransferase (ALT)
• Aspartate Transaminase (AST)
“I give the patient a little medical degree background…explain what each lab means for them and how they’re affecting their body,” McDevitt says. “This also gives them an opportunity to ask questions and understand there’s not just one number we’re looking at. There’s more to it than the hormonal symphony.”
The doctor firmly believes that Peak’s telemedicine platform has made doctor-patient consultations easier and more effective. “There’s this little bit of a barrier between you. You’re not right in front of someone physically,” she notes, motioning her hand like a buffer. “You’re in the comfort of your house, some people do it in their car or some do it on their lunch break while working.”
Of course, certain aspects of a wellness visit must be conducted in-person – most notably, in instances when a doctor is required to physically touch a patient to diagnose. Yet, there’s no denying the monumental significance of telemedicine in a society that must currently restrict direct contact with one another due to COVID-19.
“What we’re able to do via telemedicine is monitor patients and not just leave them hanging in a world where they’re like, ‘I don’t know what to do if I have some kind of symptoms…I need to talk to someone!’” McDevitt laughs. “Even when I go in to see a doctor, that ‘doctor environment’…it’s usually cold, sterile, everything’s a certain way, white walls-type of thing. [On a screen,] patients are definitely less anxious. When people are more comfortable, they’ll tell you more.”
7. Numbers don’t lie, but they don’t always tell the complete story.
Once your labs are completed, your Peak physician will assess if your hormone levels fall within certain reference ranges. Just bear in mind that even though it’s important to determine what a patient’s ideal levels should be, there’s more to it than going strictly by the numbers.
“The labs are just a guidance,” insists Dr. McDevitt. “You really have to look at the clinical picture and the person individually.”
The fact is, everyone has a different reference range based off their lab work. For example, Peak doctors use a total testosterone reference range of 300 to 830 ng/dL, or nanograms per deciliter. Patients falling in the 300 or 400 ng/dL range aren’t optimized and are likely to display clear indications of low testosterone. However, Dr. McDevitt notes that when a patient’s levels fall in the “sweet spot” of 650 to 700 ng/dL despite exhibiting Low T symptoms, there are other underlying issues at hand.
“There could be different proteins that are chewing up their hormones,” she cites, “or they’re converting their hormones over to other hormones. It’s not just saying, ‘Okay, we have to replace that testosterone.’ We actually have to figure out other things.”
Among those “other things” McDevitt wants to figure out is when – or if – she should recommend TRT. The doctor doesn’t want to go that route if you’re successfully producing your own testosterone. However, if your levels are sub-optimal and you show symptoms of Low T, she wants to cover the optimization gamut, including lifestyle changes, supplements, medications and, if necessary, replacement.
“You’ve got to look at the clinical picture and the labs,” she explains, “then put it together and say, ‘Okay, what is that showing me? What’s the true story behind this patient?’”
8. Assess to address with a doctor sooner rather than later.
One reason why low testosterone is such a potent dilemma for males is its “slow burn” effect. Many won’t even notice a problem until it already strikes. As you age, symptoms slowly increase to a point where you suddenly realize that you don’t look or feel “right.” You don’t have the stamina to get through a routine workout, or the energy to get off the couch and play with your kids. And the bedroom? It has become your worst enemy. You can’t get enough sleep in it, nor do you have the desire or giddy-up to expel your amorous energies with a loved one.
Look at it this way: As soon as you feel some aches, pains or fever, you don’t really wait very long to go see a doctor, right? Two or three days, maybe a week? That’s nowhere near as long as men take to decide scheduling a consultation with Dr. McDevitt, or another physician, about their faltering hormones.
Says McDevitt, “I’ll always ask, ‘How long have you been noticing these symptoms?’ No one’s like, ‘Oh, it’s only been a month.’ Most of the time, it’s been six months to five years.”
Six months? Oof. But five years? It took that much time for Earth’s Mightiest Heroes to defeat Thanos and restore half a universe in Avengers: Endgame. To that point, it took about half that time to shoot Endgame back-to-back with its filmic predecessor, Infinity War.
What’s the holdup? According to McDevitt, a lot of her patients explore pretty much every option to alleviate their symptoms – from having their prostate and thyroid checked, to altering their lifestyle and diet – before they even consider a hormone imbalance to be “the last piece of the puzzle.” She also attributes long and inaccurately attached stigmas about men and hormones to her patients’ delayed conclusions that low testosterone may be the root of their biological evils.
“We talk about women’s hormones. Everyone knows about menopause; it’s a common thing. But with men…we don’t talk about andropause,” she says. “At the age of 45 to 55, there are the common questions you’re going to ask women: ‘Are you starting to have those symptoms?’ It’s not something we talk about in men, but it should be. It should be something primary care doctors address in all men going 50-on, because it’s happening to them, too. They’re having symptoms that we don’t see as much [by] looking at them, but yeah, it’s happening internally.”
9. Look at the bigger picture with hormone optimization.
Testosterone replacement therapy could very well be the answer to your problems. But before you take the plunge, go full steam ahead or indulge any other applicable idioms here, take a step back and really think about what TRT means – by that, we mean the process, the potential pros and cons, and the commitment that’s required on your part.
Your physician and you need to align as a team when devising a treatment plan that’s right for you. Dr. McDevitt says that she leaves no stone unturned in presenting all of the alternatives that are available, but at the end of the day, the final decision rests in your hands.
“I give them options,” she says, “even ones where I let them know, ‘I don’t think this is going to work, but this is an option.’ You have the right to know what all the possibilities are.”
With that, let’s just say you and your doctor agree that TRT is your best course of action. Peak offers the treatment via several options, including:
• Subcutaneous injection, in which you inject your testosterone dosage into the fat layer of your belly
• Topical application, which you administer cream to your scrotal skin
All three options offer distinct advantages and disadvantages, which your Peak doctor will review with you. That includes Dr. McDevitt, though she admits to having a particular preference among the three.
“My preferred method is the injectable form,” she reveals. “I like it because of compliance – most patients only have to do it one to two times a week, so it’s easy to remember. Also, the bioavailability’s really good, and I usually feel there are less side effects.”
By “bioavailability,” the doctor means the quantity of testosterone that’s absorbed into your system. McDevitt also finds topical TRT to be “very bioavailable, the levels do get up there, but I just don’t see a change in the clinical picture as I do with the injections.” She describes troches as “a nice, really cool alternative,” provided you can adhere to the routine. “You have to do it twice a day. I mean, half of us don’t even remember to take our Vitamin D, and you’re asking someone to all of a sudden [take testosterone] twice a day.”
10. The consultation isn’t the end, but rather, a beginning…so long as you follow up.
Okay, let’s recap: You’ve done your homework ahead of time, had a great consultation with a Peak physician and received a breakdown of your TRT options. All that’s left is to have Peak deliver your monthly shipment of medication to your door and wham-bam-thank-you-ma’am, cue the “Happily Ever After” music. We’re done here.
Not so fast. This movie doesn’t end quite that clean. That’s because this movie really doesn’t have an ending. No, sir. Men need to navigate the world of hormones very carefully. The number of studies has, thankfully, grown in recent years. However, some of those studies differ or contradict each other so greatly that they can push you to go one way or another. Or worse, they can overwhelm you to the point that you throw up your hands and don’t do anything to resolve your problem.
As we said, the consultation doesn’t just end with you receiving a recommended treatment. This is only the beginning, and it’s important that you understand this. There needs to be follow-through post-consultation, both on the doctor’s part and yours.
“A lot of times, I’ll see that things may not be as well monitored as it should be,” says Dr. McDevitt. “In order to protect your patient, and yourself as a provider, you need to have the right follow-ups. It’s very important.”
The doctor fully appreciates that follow-up consultations won’t always produce the answers a patient’s looking for. Yet, to paraphrase Gary Oldman in The Dark Knight, sometimes the results aren’t the ones a patient deserves, but the ones a patient needs.
“The thing that can get frustrating with hormones,” she explains, “is that there’s a lot of adjustment. It’s not ‘one algorithm fits everyone.’ There are things that you can start with, but someone might not respond really well to that. So, you need to adjust the dosing or the different routes, or add in some nutraceuticals.”
Let’s take this down to brass tacks: Optimizing one’s hormones is a balancing act and, more often than not, a lifelong one. If a doctor tells you they’re diagnosing and treating your Low T “the same way I treat all of my patients,” then that physician is performing a disservice to you and to your fellow man. Can the constant adjustment of dosage and frequency become frustrating? Sure. Is it really necessary? Absolutely.
Does the adage “Rome wasn’t built in a day” ring a bell? Well, what’s often overlooked is the other half of that axiom: “…but they laid bricks every hour.” Self-help author James Clear points out that Rome – or in your case, your body – is the goal. However, the bricks are the system. Focusing on this particular system of “bricklaying” – follow-up consultations, retesting and adjustments on treatment – is what ultimately achieves your goals: To feel stronger and more energetic. To resharpen your mental focus. To rekindle that pilot light in the rumpus room and go full-on en fuego. To rediscover your best self.
Look, you may not appreciate the beat of a lifelong dance with TRT and balancing your hormones. I don’t know many who would. But there’s no argument that treatment, if it works the way your physician has intended, will fine-tune your body in little to no time.
Then there’s the fact that with treatment firms like Peak, you’re required to do hormone retesting every three months and have follow-up consultations with Peak physicians like Dr. McDevitt. That means your levels are constantly monitored, and your treatment is adjusted the moment something isn’t working the way it’s supposed to. And as a bonus, you as the patient become more comfortable expressing yourself, your concerns and, yes, even your frustrations in follow-up conversations with your provider.
“[Patients are] definitely more relaxed in follow-ups,” notes Dr. McDevitt. “Half of them will just call me by my first name. They’re like, ‘Hey, Danielle, I’ve been wanting to talk to you. I have these questions.’ And some, we’re [virtually] high-fiving each other [because] we’ve nailed it – ‘Things are great, levels look great, I feel great.’ I’m like, ‘All right, you’re safe, you’re doing well, we’ve taken that symptom score and brought it down. I’ll see you in three months.’” she laughs. “It’s very rewarding.”
Watch exclusive clips from this interview, and more, on Peak's YouTube channel.
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