FAQ: How do I find a *good* doctor for TRT? How do I find a *good* TRT clinic?

Here's my attempted masterwork on picking a clinic. I'll probably edit this a few times.

Is this clinic shitty?

The first thing you should be thinking about when choosing a clinic is do they know what they are doing in terms of managing patients on TRT. Price, convenience, etc., are all secondary concerns. If your doctor and his/her staff are shitty, your experience on TRT will be shitty.

Questions you should be asking:

1. When they're prescribing testosterone, is that testosterone compounded with anything else (e.g., anastrozle or DHEA)? If the answer is yes, you should immediately hang up the phone and never speak with this clinic again. Any provider who does this has no idea what they are doing and are cutting corners in order to increase their profit margin. This is the most obvious way to tell if a clinic is horrible.
2. What is their practice with regard to aromatase inhibitors? I will admit upfront that I don't believe that AIs are ever appropriate in the context of TRT. The best clinics out there do not prescribe AIs for any of their patients, and that is (in my opinion) the easiest way to tell if a clinic is following the medical literature in their practice. But even if you don't agree with that:
   1. You should find out if the clinic is prescribing an AI upfront and having their patients take them without ever knowing what their estrogen is like on TRT. You should never begin taking an AI at the same time as testosterone, and any doctor who is telling you to should not be managing TRT patients.
   2. Find out what the clinic's position is on when an AI should or must be taken. If your e2 is sitting at 80, and you feel amazing, is this clinic going to insist that you pop a few milligrams of anastrozle per week to get it down? Or are they just going to prescribe it and tell you to take it if you get certain symptoms? If the clinic is only concerned with the numbers on the labwork, and not how you feel, stay away from them.
3. This is related to 2.2 - Good clinics are seeking to treat your symptoms, not your numbers on labwork. If after 8 weeks on whatever protocol you start on, you aren't feeling well, the goal should be to modify your protocol so that you do feel well. If your levels come back at 800 ng/dL and you still have symptoms, your doctor's response should not be "well, but your numbers are in range, so I don't know what to tell you." If your levels are at 1,200 ng/dL and you feel perfect, your doctor should not be saying "well, we need to lower your dose because your testosterone levels are too high." This is a difficult thing to tease out when choosing a clinic. To the extent that the clinic will tell you what their goal is in terms of blood levels, stay away from any that say they just want to get you into the "normal range." Some will say "high-normal," and that is better, but can be hit or miss. If a clinic responds to this kind of inquiry that their goal is to treat your symptoms, whatever the levels you have to get in order to relieve those symptoms, that is a clinic you should consider. Another metric is whether the clinic has a certain blood level of testosterone a prospective patient must be below in order to qualify for treatment. The best clinics treat symptoms, not numbers.
4. You should find out what medications the clinic typically starts people out on. If they give you a huge list of medications that they prescribe all of their patients (e.g., 200mg test cyp per week, 1mg anastrozle per week, 1000iu HCG/gonadorelin per week, plus DHEA and whatever else), stay away from them. Ideally, you should be starting with only testosterone (or, if fertility is super important to you and you can't wait a few months to get your testosterone in order before taking HCG, then you should only be starting on test and HCG). Any clinic that starts patients out on three or more medications doesn't know what they're doing. When you start throwing that many variables into a human body, there is no possible way you can tell what's causing a patient not to feel optimal and what needs to be changed so that they do.
5. Ask how many of their patients have to donate blood regularly. Many doctors are under the mistaken impression that elevated hematocrit levels are, by themselves, harmful in men on TRT. This is not true. See, for example, Dr. Scott Howell's work on this, or other videos available on YouTube. The vast majority of men on TRT will have some amount of elevated hematocrit and do not need to be donating blood. If you're donating blood several times a year, you are likely doing it for no reason and will probably feel like shit eventually.
6. Look at the labwork they're requesting. Providers should be checking, at a minimum, your health markers (CBC with differential, kidney and liver values, lipid panel), total testosterone, free testosterone and/or SHBG (both is fine, but you need at least one of those). If all your clinic is looking at is total testosterone, they're not monitoring your health. And if they don't have either SHGB or free testosterone, they don't know enough about TRT to test for what you actually need to know in order to push a patient toward symptom relief.

Is this clinic going to overcharge me?

Price is probably the next important thing. That said, if you followed the above criteria and picked a clinic that actually knows what they're doing, it's unlikely that you're going to be charged more than they are worth. The clinics I am familiar with that I recommend to people are less expensive than some of the shitty ones people go with.

The first thing to keep in mind is that these clinics must make money to stay in business. In the United States, people are desensitized to how much medical care costs because they typically pay insurance premiums and are only responsible for a portion of the costs billed by their providers. But you are paying for them nonetheless. Medical care is not free. In the TRT context, you will typically be paying entirely out of pocket. How exactly you pay for the clinics services can vary wildly.

A clinic gets paid in some combination of fixed monthly fees, markups on medication and labwork, and fee-for-service consultations. Common business models include:

• 100% monthly fee. A clinic will bill you a set amount per month, which includes any consultations, labwork, and medications. It is common for a clinic using this model to have different tiers of pricing. For example, someone taking testosterone only might be charged $X per month, while someone who is also taking HCG will be paying more. Predictability is the main benefit of this pricing model.
• 100% a la carte. These clinics will charge you for every item individually, with no fixed monthly charges. That means you'll pay for each consult with a physician, labwork, and each medication. Generally, there will be a markup on labwork and medication. Meaning, the clinic gets a volume discount from LabCorp and pays a certain amount for labwork, and will pay a compounding pharmacy a set amount for testosterone and other prescriptions. The clinic charges patients a higher amount for each, keeping the difference as profit. With this model, it may be easier to get a physician consult when you want, as well as different ancillary medications, because you're paying for it.
• Mixed monthly fee and a la carte. This is usually the worst model. You're paying these clinics a monthly fee that covers something less than (1) any consults you need; (2) bloodwork; and (3) medications. If a clinic is charging you a fee that doesn't cover all three of those things, you're probably being overcharged. By "medications" I mean the things you need for your TRT protocol, i.e., testosterone, HCG, etc. This model is usually bad because you don't get the predictability of a fixed monthly fee, and you're still being forced to pay for certain items. The exception: Some clinics will charge a flat "management" fee per month that includes all provider consults and bloodwork, and the patient pays for medications at the cost the pharmacy charges, meaning the clinic isn't marking those up. That is generally okay. Just pay attention to the medication cost. If you're being charged $150 per 10mL vial of testosterone cypionate, you're not paying the pharmacy-direct cost.

Ask a prospective clinic if they can give you a typical breakdown of the yearly costs (both for the first year and every year after) of a patient who is taking only testosterone at whatever dosage they typically start patients on. If a clinic is not confident about letting you know what you'll be paying, it's probably because they're charging you too much.

Other considerations

Quality and price are the most important things, but there are a few others things you might want to consider:

1. If you want HCG to be an option, ask your clinic if they have it. HCG is still available from many telemedicine clinics, including any clinics that use Empower Pharmacy. Clinics may offer you gonadorelin as a substitute (or, god forbid, Clomid), but it isn't the same.
2. Other medications - some clinics have a pretty limited offering, while others have a full slate of peptides, sexual health medicine such as Tadalafil, other anabolic compounds such as Nandrolone, and other hormone treatments such as Thyroid medications.

Where to find a clinic

I don't really want to get into recommending or bashing specific clinics. But here's a few ways not to find a clinic:

1. Facebook advertisements - I have yet to see a really good clinic use a skeevy-looking Facebook ad.
2. Clinics whose webpages look like they were made yesterday.
3. Solely based on a recommendation from someone who has been with a given clinic for less than six months.

Ask the clinic you’re interested in for what they include in routine bloodwork. They should include Total testosterone, free testosterone, SHBG, estradiol (preferably ultra sensitive estradiol), comprehensive metabolic panel, lipid panel, CBC, PSA (initial labs), and LH & FSH (initial labs). If they are missing a substantial portion of this, it’s probably best to bring your business elsewhere.

Call Defy medical. They are great.

The super short answer is educate yourself as much as you can. Period. You are your own advocate, and you know how you feel. I don't care how reputable the clinic is, they work with you, not the other way around.

The long answer is what PreftigeWhore wrote. His is great advice.

[deleted]

why do you say gonadorelin is not the same as hcg? I just read a study where size and sperm was higher with the gonadorelin patients than the hcg. Although, who knows the reliability of that. whats your reasoning, if you don't mind me asking?

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thanks

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https://journals.lww.com/md-journal/fulltext/2019/08020/optimal_treatment_for_spermatogenesis_in_male.25.aspx

Hello,

I am in TRT for about 1.5 years now. I was happy with my guy, but when pharmacy lost the ability to compound HCG my doc just switched me to Clomid, gave me little info, and did not explain to me that commercial HCG was still available. When I learned it was, he referred me to his partner pharmacies and they can’t obtain commercial HCG.

He also started me on anastrazole automatically.

I was doing great on HCG and want it back so am prepared to switch clinics. I’m in the Bay Area. Any advice? Should I just switch to Defy? Does anyone know if they can still access HCG? Money isn’t really an issue.

Thanks

They’re all scammers

Any good online clinics ??

I would add one thing to the list of what is a good clinic.

Will they issue a prescription that can be filled at a pharmacy of your choice, and what do they charge for this service?

IM experience, an out of state clinic will not issue a script for Testosterone, but they will fax a script for most anything else. Like thyroid meds, metformin, etc. I have used Defy medical in the past, and they will issue a script for testosterone in their home state of Florida.

I am guessing the main reason clinics don't want to issue out of state testosterone scripts because that is either illegal or opens them up to too much government oversite. Side issue, clinic likely have a higher profit margin if you use their affiliated pharmacy.

The reason you might want a local script is because then you can use your own health care drug plan to pay for things like thyroid meds, which is likely pretty cheap.

Any providers in the Baltimore or DC area??

Any reputable clinics in Richmond Virginia?