Tired All The Time- What Could Be Wrong? (Part 1)


I would say that of all the complaints I hear at my clinic, this is by far the commonest. The scary thing is that it seems to transcend age and sex. This means that ‘tired all the time’ (tatt in dr’s world) can attack anyone at any age. So how can you avoid it?

Before we can answer that question, we need to understand what is normal and why tatt happens.

Do you remember looking at kids and their boundless energy levels? When they eat sugar, they get hyperactive and start running around. A totally normal response to excessive sugar in the blood that the body needs to get rid of as sugar is inflammatory and the body knows it. So parents, please let your kids run around- its a good thing. What about in adults? What happens when we consume too much alcohol or sugary drinks (liquid carbs)? How about snacks; including ‘healthy’ snacks? We hardly ever need to run around to burn it after. This is not the ideal response to that sugar excess. So what happens here?

Your body releases insulin. Insulin’s job is to make sure that the excess sugar is picked up and either used or stored. A lot of this happens in the liver. So the liver is now under stress to deal with all this. Cortisol the stress hormone is released. Cortisol and insulin work hand in hand (not quite so simple but good enough for the layperson). You’ll find that if you consume too much rubbish or are overly stressed, you put on weight in the middle- a classic tell tale sign of the start of insulin or cortisol issues. Unfortunately with age, this worsens as the body’s ability to adapt decreases. Now, a lot of nutrients are used up in this process. When we talk about nutrients, we talk about vitamins, minerals, amino acids, antioxidants etc. So someone with a poor diet or highly stressed life actually need more nutrient support as they probably do not get enough from their diet to make up for how quickly things get used up. These hormones also communicate with other hormones- thyroid being an important one. Thyroid controls your metabolism. Or how effectively your body consumes fuel (or sugar/fat). With age, this function goes down as well. Or perhaps you’ve accumulated ‘problems’ over the years that affect your body’s functionality.

What kind of problems are those? A whole host of potential issues. Let’s list some down:

  • Environmental issues such as toxic mold (in a old, damp house), or fumes from a brand new carpet or paintwork

  • Living and working in the city - exposure to exhaust fumes containing lead, arsenic and other heavy metals

  • Accumulation of toxins from food - e.g. mercury from seafood, sprayed chemicals (pesticides) in fruits and veg, chemical fertilisers

  • Accumulation of toxins or change in ionic charge in your body when you have e.g. metal fillings or 2 or more different types of metals in your body. This is really interesting. If you develop tatt after an orthopedic procedure or after getting dental work; including a simple brace- think about this. Its not well known enough so do your due diligence

  • Day to day stresses like SAD (seasonal affective disorder), lowered immunity due to antibiotic overuse or excessive exposure to bugs; overwork

  • Age related hormonal decline

  • Too much screen time

  • Excessive exposure to EMR (electromagnetic radiation)

  • Start or autoimmunity where the body starts attacking itself

This is merely a snapshot. The list goes on. On its own, there probably isn’t enough to knock the average person down but when a few factors are present, the cumulative effect can have a large effect.

This is mostly the reason why the average person will try various things to improve their tatt status and find that they may improve things for awhile but that they cannot shift it. It is also why in long standing cases, most people need help to get over it. It simply is not as easy as it seems to get to the bottom of.

So what can we do? We will investigate this in the second part of this blog series, so stay tuned….

“Anti – ageing” – Is there a cheap, quick treat to anti-ageing?


It isn’t a secret that in the world we live in seems we are more concerned by our body appearance more than our immune function. We are troubled by either shifting or decreasing than maintaining our body mass, we are worried by the risk of age related diseases such as cardiovascular, osteoporosis, cancer and neurodegenerative disorders and general frailty in our later years.

Social media encourages us to seek for the #gymbody, the #lookgoodfeelgood factor, which is not entirely possible. Of course, there are measures we can take such as cosmetic surgery, anti-ageing measures in the form of bioidentical hormone replacement, cocktails of vitamins, antioxidants, anti-inflammatory compounds and aesthetics, however, the point is, not everyone can afford or is favourable to these treatments.

The question raised here at the top in bold here warrants a brief explanation, and before reading on, the answer is yes – there is a quick treat anti-ageing treatment, which helps us feel and look good without anticipating needles prodding and pricking.

Most importantly, we should remember that the ageing process is simply characterised by the declining functional capacity, increasing vulnerability to disease, debility, and unfortunately, death. I would like to think, we all aim to live longer, try to reverse our ageing process and fight against all of these traits. We know that as we get old, some of us have a higher risk to disease than others and frailty is a consequence of natural ageing.

Clinically, beyond the obvious signs and symptoms, we want to analyse the  biomarkers of cellular ageing, inflammation and age associated immune deficiencies at tissue and cellular level, to identify these deficits.

Keeping these markers optimum, at least within normality there are things we can try to do without contemplating blood draws or swallowing a pill. Surprisingly, it is what we have all heard before.

  • Exercise (both resistance and aerobic) in combination with adequate protein and energy intake.

As we age it is natural that we lose muscle mass. Moreover, during chronic illness our body wastes plus muscle mass is wasted and weakened. Lean muscle mass has been reported to decrease at approximately 1% per year after 30 years of age and observed at the end of the fifth decade. In layman’s terms, we have to replace what we are losing and gain muscle to slow down this process.

Screen Shot 2018-02-28 at 12.43.25.png

Yes, it is the cheapest, safest and most reliable route to anti-ageing. I'll highlight the word protein purposefully as it deserves clarification. Studies in anti-ageing have shown that adequate protein intake, particularly, leucine-enriched balanced amino acids and possibly creatine enhancing muscle strength. Some studies have even recommended the amount protein ingested should be spread equally throughout the day, i.e, equivalent amounts at breakfast, lunch, and dinner. Also, if additional protein supplementation is given it should be administered between meals. Levels of protein intake as high as 1.6 g of protein/kg/day have been demonstrated to increase exercise-induced muscle hypertrophy in older persons. Without getting deeper into the protein debate which will be up for discussion in future blogs, the equation is so far simple. A  dose of aerobic exercise + increased protein intake + resistance/strength exercises to increase muscle mass =  (- ageing + feel good/look good).

The Male Ticking Biological Clock

Having seen so many patients for testosterone replacement therapy over the years, there is an interesting trend that I’m starting to notice. The issue of “biological clock ticking” now applies to both sexes.


Where previously this was seen to be a purely female problem, you now have a scenario where men in their late 30s and early 40s need to quickly make their minds up about finding the right girl and getting pregnant. A situation previously plaguing women in their 30s mostly. The reasons for this are a decrease in quality (poor swimmers, abnormal shapes) and quantity of men’s sperm. The causes of this decrease is multifold:


  • the rise in stress levels (despite your wonderful ability to manage your stress)

  • environmental toxins including that from frequent flying

  • depleted nutrients due to lifestyle and depleting resources

  • Cycling- yes that pressure on the testis for prolonged periods can be an issue

  • Anything that increases the temperature of things down there eg tight underpants/jeans

  • Radiation emission from laptops- this is low levels, continuous and prolonged. And becoming a huge issue of late for those who actually place it habitually on their laps

  • Radiation from mobile phones- the jury’s out on this. We don’t know the answer yet. Read this blog for a neutral take on phones and you can make your own mind up

  • age-related depleted hormonal profile  

  • Commencing testosterone replacement therapy


From my point of view, as a practitioner looking after them; I’m able to optimise them and make them feel great. But at the same time, I have to find a balance and be able to minimise any chances of reduced fertility with combining HCG or Clomid to their regimes, amongst other interventions. For some patients, they even consider freezing their sperm in the same way a woman would freeze her eggs.


Its a rather odd discussion to have in a culture where its not uncommon for a man of 70 to father a child (although we have no idea of the quality of that successful sperm). The point of this blog is to raise awareness that this is an increasingly common issue. Hidden as no one really talks about it. Not to be taken lightly. And not to be relegated to being only a “woman’s” problem.

Testosterone Series 4- Let’s talk about Nebido, Sustanon and Enantate

This series has been a long time coming as my time gets limited and other interests drive my focus elsewhere but TRT is still one of the things I most enjoy doing. The idea of this blog is to give a more medically based opinion on the 3 commonest injectables used in the UK; my experience with it and my patients’ experience with it including labs.


Firstly, I’d like to touch upon the fact that this blog is not referring to testosterone cycles- what you normally see in forums- that focus more on body building. The focus is on sub-optimal testosterone levels being brought back up to optimal levels.


The 3 commonest injectables that I use at my practice and their various quirks are summarised below:


Sustanon 250

  • commonest due to price.

  • Comes in ampoule only. If you are getting it online in a vial, its not from a UK pharmacy.

  • Claims to be sustained release- hence called susta-non due to having 4 different esters (or carrier molecules). Each ester releases the testosterone at a different time and hence you get a more staggered release pattern where the peaks and troughs are more stable.

  • Single 1ml shot lasts 2.5 to 3 weeks. It can be given in divided doses.

  • Main disadvantage- carrier oil is peanut oil and benzyl alcohol. This is becoming a problem I’m seeing more and more of as its giving rise to side effects which I don’t get with other injectables. Most people with mild intolerances generally don’t even know they cannot handle peanut oil. When given in such large doses (1ml into the muscle), it can cause pain and local inflammation that lasts much longer than expected. As part of my practice is gut dysbiosis where I see a lot of food intolerances, I recognised this very early on. If this is your experience too, try changing to the other injectables or use creams.

  • The average response I get when I ask about peanuts is that my patients love it! Do keep an open mind about intolerances- just because you love it does not mean that you can handle it. Look out for other symptoms of intolerances like joint pains, rashes, headaches, flu-like symptoms etc. You may get none, or all of them.


Testosterone Enantate 250mg

  • This is the most similar to Cypionate that many people read about in forums. Cypionate is available in the US and some other countries but not in the UK. Its what I would put my patients on who need continuity of care from the US.

  • Its quite a bit more expensive that sustanon- stupidly more in fact. I don’t know why!

  • Comes in ampoule only. If you are getting it online in a vial, its not from a UK pharmacy. The ones in vials are considerably cheaper- according to google and from what some of my patients tell me- but we practitioners will never advocate it. Its just not worth it to me.

  • Is given in the same way as Sustanon- either single shot that last 2-3 weeks or in divided doses.

  • Carrier oil here is castor oil which is less allergenic (apparently) and benzyl benzoate.

  • I personally have never had a complaint with this so suspect that it probably is less allergenic.

  • If the price point of this and sustanon were the same, I would prefer using this.

Taken at our clinic

Taken at our clinic


Nebido 250mg (4ml)

  • This can hurt but its usually due to the volume of product injected into a small area. I occasionally inject it either in both buttock cheeks especially in very slim patients, or change directions still with the same entry point to spread things out a little.

  • This comes in a vial.

  • Carrier oil here is refined castor oil which is less allergenic (apparently) and benzyl benzoate.

  • I’m not a huge fan of Nebido but it has its place. I personally prefer it for patients who have completed their family (for potential fertility implications), travel a lot, have compliance issues or similar reasons.

  • This always suppresses your pituitary hormones which means that the negative feedback generated will block your own production of testosterone.

  • On a practical level, a lot of people don’t mind it and are happy to put up with some testicular shrinkage- as long as everything is being monitored regularly.

  • Others freak out a little when their pituitary levels of LH comes back as close to nonexistent. They can either opt for a different option or start on a HCG protocol (Human Chorionic Gonadotropin) to stimulate their own production of testosterone alongside testosterone. Its a protocol used a lot in the US and quite many of my American patients request the same continuity of care as it works well for them.

  • There are also a small number who really feel the peak- not in a good way. Optimal levels of testosterone usually makes you calmer and less anxious but too much or too little can give rise to similar symptoms paradoxically when it comes to moods and aggression.


Other Options

  • Bioidentical topical creams from Compounding Pharmacies- I use these a lot and my patients love them (mostly). They are much easier to use compared to the gels available on the NHS (messy, too large a volume and sometimes does not give the blood picture expected which may point to user inconsistency in application).

  • My topicals come in 3 forms- creams, gels or liposomal gel. I have so far only ever ordered the liposomal gel as its absorbability is far superior at no extra cost.

  • As these are bespoke, there is a period of trial and error until you find the right dose after which, we simply make the cream in said dose for each patient.

  • Its more physiological with everyday application and so mimics the body’s own production more closely. This also translate into less pituitary suppression.

  • Disadvantage- some people perceive creams to be less effective (not true). Some don’t like having to apply a cream everyday.

  • Transdermal Implants- not a commonly available option and I do not have much experience in it for testosterone. This is something I’m hoping to explore as I believe that there is a place for it seeing as it has a 4-5 month life cycle. My experience in implants is in contraceptive implants which I did not like. Similar to Nebido, my personal feeling is that in order to achieve such longevity, it needs to be quite powerful which can give rise to side effects initially. However, do watch this space as I’m hoping to explore this further and may find myself changing my mind about it.


I hope that this article will help you gain an idea of what is available legally via a pharmacy in this country and to be able to tell the difference between what may or may not suit you. Or why you may be reacting to something others don’t have a problem with. As with most things medical, its not quite that simple but getting the right balance is possible and certainly achievable.


10 Lesser Known Benefits of TRT

Most people think of Testosterone replacement therapy as a “Libido and Muscle” therapy. I have however, started noticing a trend of more and more people coming in asking for the lesser known benefits of TRT. These are usually people with normal jobs, family and life, just wanting a better quality of life. So here a little peep into what people are telling me:


  1. My hands and feet are warmer.

  2. I’m much calmer and not so anxious anymore.

  3. I’m able to handle stress better and hence, I feel that I perform better at work.

  4. I have the will and energy to play with my kids again.

  5. I’ve stopped yelling at my kids (as much) and the noise they make does not irritate me the way it used to.

  6. I’m more assertive and stand up for myself a lot more (to the detriment of some partners and co-workers!).

  7. I wake up more refreshed. My sleep has improved.

  8. I’ve put on weight but I’m trimmer (muscle weighs more than fat)

  9. I’ve better hair growth on my face (good for the current facial hair trend but not for all)

  10. Brain function is much better. Everything seems clearer and there is no brain fog anymore.


I decided to write this in the first person as its literally a snippet from different people’s stories. As a practitioner, its very gratifying to hear. It also means that after a while, they forget about harpal clinic- a wonderful thing- as life feels right again. These are on top of the well known benefits of libido enhancement and erectile issues; also the muscle building capacity which is dose dependent. Incidentally, this also applies to women on TRT.

There probably are other contributing factors as well as I tend to manage stress where relevant, at the same time. This is hugely important as both stress hormone and testosterone share similar building blocks. Therefore a ‘steal’ happens whenever more stress hormones need to be built, as they are the more important in hormonal hierarchy. In any case, these snippets are from my 3 month reviews post commencing therapy and its likely to stay the same or improve. Pretty exciting I’d say!



Testosterone Series 3- Libido and Sexual Dysfunction

Testosterone and libido.jpg

Sexual dysfunction is possibly the commonest reason men visit their doctors for those who think beyond the viagras and cialis; and are keen on understanding their testosterone levels.


Some common manifestations of low T sexually in men:

  • decrease in frequency of morning erections

  • decrease in strength of morning erections

  • takes more concentration to get an erection

  • takes more concentration to then keep it going

  • decrease in the volume of ejaculate

  • losing an erection halfway or not able to maintain an erection

  • decrease interest in sex and low libido

  • little to no erection ie sexual dysfunction

  • secondary premature ejaculation (as concerned that one may lose erection)

  • a sense that the penis feels smaller when fully erect than before


In women, it mostly manifests as a decrease in libido and loss of interest in sex. Some women will find it harder to orgasm or that it takes longer to stimulate than they used to remember.


Its one of those situations that generally creeps up on people with daily life stresses playing a big part. As more and more raw materials are required to keep our stress hormones (that are necessary to survival, unlike testosterone) in good supply, a ‘steal’ situation occurs that reroutes materials so that less is available to make up hormones at the bottom of the hormonal cascade.


In many cases, it becomes a situation where the the couple simply prefer the TV to doing anything more physical and slowly start avoiding ‘sexy’ situations without even realising it. Or one partner may perceive a sense of decrease in attention from their partner, occasionally even leading to accusations of cheating.


Dealing with these situations can be fairly complex with no easy one size fits all formula. The longer it is left, the worse it can become as it may come to a point where there is psychological impact (much harder to deal with!). Also, a more holistic approach is generally required to prevent so much ‘stealing’ and to balance the other hormones at the same time for optimum performance.


On the whole, it is still manageable, preventable and treatable in majority of people. It also adds tremendously to the release of ‘feel good’ neurotransmitters, which then decreases the stress hormones, and gives rise to deeper sleep. So quite frequently a win-win situation!


Testosterone Series 2 - Testosterone, Muscle Mass and Fat

This is a well known use of testosterone (T)- the ‘muscle’ hormone. Not only does it increase the size of muscle mass, it also increases the strength and power of the muscle fibres. (1) There is also some benefit from the other well-known ‘side effect’ of raised T, which is increased oxygen carrying capacity of the blood (due to increase in the number of red blood cell). This leads to better tissue reperfusion after exercise and so one is able to exercise longer and/or more efficiently.

In the young, it is sometimes taken to ‘bulk’ alongside anabolic steroids- this is usually ‘underground’ usage and not what we will be discussing here although I have been hearing a lot from people suffering the repercussions of self-administration.

What happens in someone with normal T?

  • Firstly, everyone has a different normal and it might be a good idea to do a blood test when you feel like you’re at your peak physically just to know what’s your normal. It will come in handy 10 years down the line. For some, low normal may feel great but for others it may seem deficient. Normal blood ranges are there as a guide and should be used as just that- a guide.

  • If you feel symptoms of low T but your blood range is within normal, it may mean that you function better at higher levels. So your normal is NOT another person’s.

  • Within normal ranges, increasing T (by supplementation etc) will not change muscle mass much.

  • Increase in resistance training leads to increase in testosterone production acutely.

  • Supplementation to levels at least 20-30% of top of normal range (supraphysiologic levels) is necessary to make a statistical difference to muscle mass.

What happens in age-related decline?

  • A man first notices a drop in T when exercise does not produce the same results it used to. Diet and activity levels being stable, you will notice the invariable creep of middle or belly fat- the hard to shift love handles. Initially, you may be able to shift it with a change in exercise routine or changes in the diet. After a while, you’ll find that it does not work as well anymore.

  • All over body fat versus muscle mass ratio will see a shift as well. There will be softer bits all over. The tendency will be toward building more fat depots rather than muscle.

  • Again increase in resistance training leads to increase in testosterone production acutely.

  • Over time, a vicious circle develops where increased fat and decreased muscle mass leads to lower energy levels to lower activity levels to increased fat, so on and so forth. This leads to the change in body shape very characteristic of low T.

  • Ageing beyond 35-40 years is associated with a 1-3% decline per year of testosterone according to one study. (2)

  • In women, the most noticeable changes occur after menopause, again with a similar distribution of fat. This is alongside oestrogen and progesterone drop and hence usually missed or brushed off as not being relevant.

So in summary:

  • Low T causes increase in fat mass and is associated with obesity. The mechanism is not well known. One study succeeded in demonstrating that androgens inhibit the creation of fat. (3) There is still a lot of research required in this area but observational studies certainly seems to support this.

  • TRT increases muscle mass, strength and power.

  • The leaner a person is, the higher the testosterone levels. Lean here refers to the lack to fatty tissue as opposed to lean/bulky muscle mass.

  • The fatter a person is, the lower the testosterone levels.

  • Benefits of more muscle mass: leaner, more energy/metabolic efficiency, increase insulin sensitivity and blood sugar control, improve balance and mobility, improve strength, stability and endurance, reduce risk of injury, create metabolic reserve amongst a host of other benefits. 


  1. http://www.ncbi.nlm.nih.gov/pubmed/11701431

  2. http://www.ncbi.nlm.nih.gov/pubmed/21058750

  3. http://www.ncbi.nlm.nih.gov/pubmed/16210377


Testosterone Series 1 - an Overview (Relevant to Both Men and Women)

In this series, I'd like to discuss the role of testosterone as part of a health management plan and go into some detail regarding the different questions/issues people may have regarding testosterone. In this first series, we will go over the basics of what testosterone is and can do. Over the coming few days/weeks/months, I will go into more detail regarding different aspects of testosterone replacement therapy, its potential problems including aromatisation, different forms available and the bioavailability, exercise and so on.

I intend to continue these series on different hormones and nutrition. Do keep your comments coming in (person/fb/blog) and let me know if you would like me to research and cover other topics.

Testosterone-vintage diagramme.jpg

Testosterone has a mixed reputation and with some thinking of it as the all singing and dancing “sex and muscle” hormone but others thinking of it as the “aggressive” hormone. Most images depicting testosterone usage tend to focus on these aspects (think “Hulk”).


So what is testosterone and what does it do in your body?

  • Testosterone is the male sex hormone that is at the bottom of the steroid hormonal synthesis pathway, starting with cholesterol at the top. This is significant, as will be made clear in future blog posts.

  • Testosterone is present, and hugely important in both men and women- remember it when libido levels dip in both men and women.

  • It declines with age, with a significant jump noted beyond the age of 40 for most men. Some will start the notice the effects of low testosterone much sooner, in their early 30s and some lucky men, will only notice it closer to their 50s.

  • It is usually first noticed when there’s a decline in libido- a classic case of “I like the idea of sex but the TV/computer/book seems more inviting”. This is for both men and women.

  • Others may have noticed it first when their exercise routine stops delivering the same results anymore. They now have a ‘roll’ around the middle that is hard to shift.

  • Others still may notice that their ability to party has declined (again preferring a quiet night in or out), their ability to cope at work decreases, home life feels like a drag.

  • Some find that their fuse is shorter; they get more anxious and worry more, have more frequent bouts of feeling down or even depression and most importantly, their “aggression” or more accurately the “go-getter” in them starts to flail.

Specifically testosterone:

  • increases the libido and sexual function in men and women

  • is responsible for male sexual characteristics including functions of the male sexual organs

  • increases muscle mass while decreasing fat mass

  • increase in strength and volume of muscle mass

  • increases production of red blood cells, which is the carrier of oxygen to all cells of the body

  • increases bone density alongside oestrogen (men have oestrogen too)

  • improves mood, anxiety, depression, and in normal physiological doses, improves aggression (despite its bad reputation for causing aggression)- an overall improved sense of well being.

  • sharper mind

  • thicker skin, increased sebum/oil production in skin, male-pattern of hair distribution

Low testosterone levels is debilitating and happens to all men and women with increase in age. Occasionally, it happens in younger men too, either due to various genetic or environmental factors or in post anabolic steroid therapy (to increase muscle mass in gyms) where their levels refuse to normalise after stopping the anabolic steroids. 

Optimised levels offers a lot of benefit to both sexes. This will be discussed in more detail over the coming series of blogs.



Sex and testosterone - how I got there...


I had the opportunity to watch “Hope Springs” with Meryl Streep and Tommy Lee Jones as part of inflight entertainment last year- a movie with a subject matter that is strangely close to my heart as they seemed to be like a lot of my patients. For those who have not seen this movie, its about a 50 something seemingly contented couple with underlying currents of discontent. The wife (Streep) is increasingly bothered by this and decides to seek ‘intensive’ therapy which the husband (Jones) has no choice but to go to. And so ensues multiple cringe worthy exercises they have to do under direction of the therapist (Steve Carrell). One exercise in particular led them to rip each others clothes off (ok, not quite rip!) and have intercouse. While thrusting, Jones is on top and looks away, Streep looks at him and wants him to connect with her and so turns his head towards her and wham! The erection is gone. What ensues is quite typical, she gets mad and takes it personally that he has indeed lost interest in having sex.


Now, I bring this up because I realise that my view of some of the scenes are actually quite contrary to common perception (including Streep’s in the movie) and possibly even the man in this particular instance mostly because its something that’s hard to admit.

I believe that what actually happened is this: Its been a while since they had had sex and he’s probably really relieved its even up, not to mention super thrilled. He is probably able to get it up most of the time but has trouble maintaining his erection and usually really needs to concentrate really hard so that it doesn’t go soft halfway- the slightest distraction is usually enough to derail things. Hence the eyes closing (yes, it possibly might mean plunging into the deepest depths of memory archives to dig up whatever it takes to keep it up- but not necessarily). Because he knows that if he loses it halfway- the partner may take it personally; the partner may think he’s a lesser man; the partner may think he’s cheating; most importantly, he may himself think that he’s a lesser man, that he’s losing it for good.


What usually happens in this instance is that the man, like all normal human beings, tries to avoid these situations- one tends to choose the path of least resistance. However much he tries not to think about it, its there in his subconscious- and stays there. The kinder the partner is to him in regards to intimacy- the worse he feels that he’s letting her down. So he pulls away. If the partner then treats him badly for being a ‘lesser’ man, at least he is allowed to be angry (somewhat soothing to be able to be angry legitimately). Some may even decide to stray to see if its different with other women- it could very well be for the first couple times (novelty does make a difference) but it invariably raises it ugly head eventually. They then either ignore the situation and hope it goes away or go online for cialis or viagra or see their GP.


This is just one example of the people who come to see me during my time in Harley Street and my advice helped a good number of them but not all. Naturally it is not realistic to expect treatment to help everyone but I felt that there was something missing. It didn’t feel right to treat only the one symptom (when it had multiple causes) and I felt powerless to help in other ways where their main carers, their family GP, was supposed to help but couldn’t due to NHS time constraints and targets. This was a holistic problem which required a holistic approach which couldn’t realistically be dealt with in the half hour I had with my patients (I was employed then and had to go by the employer’s rules which by all accounts was a fair amount of time compared to a GP’s 10 mins). I felt like I needed much more time to educate them, to talk to them, to find out the gist of the problem, to speak to their partners, to examine them, to get a feel for my patients, to really help them.

In my search for answers, I stumbled upon age management medicine. A logical, completely evidence based form of medical practice, which prevents problems before they happen. A movement that puts the responsibility in the patient’s hands- not a bad thing- empowers a patient with knowledge and know how- keeps the patient vital with a little help from me. I signed on to learn more in the USA (where else) where the movement is gathering momentum, met more inspiring people in a week than I have in years- all people who believe in change for the better and were not afraid to put themselves out there. Passion times infinity! What a wonderful way to start the journey!


Bioidentical hormones are the mainstay of vitality management and my average patient will be 40-70. Occasionally I see younger people who may be depleted for any number of reasons, one of the commonest being Androgen Induced Hypogonadism (post anabolic steroids for building muscle mass). Most hormonal levels go down with age and contribute to the ‘growing old’ feel we all get. The good news is that it doesn’t really need to happen. I also have developed a special interest post pregnancy blues and menopause alongside my main interest of sexual dysfunction. However, the most important category of people that should come to me does not need to have a ‘problem’. You should just want to feel like the way you did when you were younger- vital, full of energy and life! I will equip you with the know how to do your part and I will do my part.


Vigor Quest – NY Times

A few years old now, but a classic in my book and the article that first got me interested in the promise of medical age management.  It was the start of my journey into understanding what can be achieved with a combination or the right lifestyle and medical treatment where needed to do what the body can no longer do for itself.