Association of Ringside Physicians calls for phasing out of TRT

by Kirik Jenness
January 28, 2014

Association of Ringside Physicians has released a consensus statement on Therapeutic Use Exemptions for Testosterone Replacement Therapy.

The Association of Ringside Physicians (ARP), an international, non-profit organization dedicated to the health and safety of the boxer and mixed martial arts athlete, has released a consensus statement on therapeutic use exemptions for testosterone replace therapy in professional combat sport athletes, as follows:

The incidence of hypogonadism requiring the use of testoster one replacement therapy (TRT) in professional athletes is extraordinarily rare. Accordingly, the use of an anabolic steroid such as testosterone in a professional boxer or mixed martial artist is rarely justified. Steroid use of any type, including unmerited testosterone, significantly increases the safety and health risk to combat sports athletes and their opponents. TRT in a combat sports athlete may also create an unfair advantage contradictory to the integrity of sport. Consequently, the Association of Ringside Physicians supports the general elimination of therapeutic use exemptions (TUE) for testosterone replacement therapy.

Dr. Ray Monsell
Chairman, ARP

The cynical story about a TUE for TRT goes like this:
•MMA fighter takes illegal PEDs.
•PEDs inhibit your body's natural generation of testosterone (sometimes permanently, yikes)
•Fighter stops at the end of the cycle, and natural levels of testosterone lower.
•Fighter goes to a sympathetic MD and complains of fatigue, poor sleep, etc.
•Doctor diagnoses low testosterone, and prescribes Testosterone Replacement Therapy (TRT).
•Fighter goes to AC and gets Therapuetic Use Exemption (TUE).
•Vitor Belfort kicks everyone in the head and knocks them out.

The cynical story is that lots of fighters are doing it, and that AC TUEs in MMA are irresponsible.

"That’s a joke. Forget it. It’s a joke," said Dr. Don Catlin, a member of the International Olympic Committee's medical commission responsible for reviewing TUE applications. "I think in all the years I’ve done it, we’ve given two."

However, several factors are casting this narrative in doubt.

First, TUE in MMA is rare. as determined by a survey of the leading Athletic Commissions in the US.

"We've given out three in 12 years," says Nevada's Keith Kizer in 2102 (they were to Dan Henderson, Todd Duffee, and Shane Roller). New Jersey's Nick Lembo put the number at "less than five." The busiest commissioner in the world, Ohio's Bernie Profato has given only two, to Henderson and Strikeforce fighter Bristol Marundo.

So out of 15,000 regulated fighters, only a handful of TUEs have ever been granted. That is not an epidemic.

"It’s very rare, but there are some legitimate needs," Lembo explains. "My biggest concern is that most commissions don’t even test for these things in the first place so we’re over-penalizing the people that are coming forward and saying, ‘Hey, do whatever you want to me. Test me before and after the fight. Test me randomly. I need this, I’m on it and I’m going to be within normal limits.’ There are a lot of commissions who don’t believe in TUEs for any reason, but why be hard on the ones coming forward?"

A second factor - one that until now was largely unknown - is that head trauma can lead to low levels of testosterone. In a truly important piece, Mike Chiappetta explains.

In 2007, a paper published in the Journal of Athletic Training reported the first known connection between mild concussions and hypopituitarism, a deficiency that can lead to low testosterone.

That research, along with how traumatic brain injuries impact the pituitary gland, is being continued by Dr. Daniel F. Kelly, the director of the Brain Center and Pituitary Disorders Program in Santa Monica, California.

Kelly is currently in the midst of a study of 75 former NFL players. In an interview with MMA Fighting, Kelly said that preliminary data from the study suggests that pituitary damage is occurring in a subset of the retirees.

That study seems to corroborate a 2006 finding in Turkey that found that head injuries incurred by pro kickboxers have resulted in damage to the pituitary gland.

Dr. Fahrettin Kelestimur, a professor of endocrinology at Erciyes University in Turkey who authored the 2006 study, told MMA Fighting that the most common damage has caused growth hormone deficiency and hypogonadism, respectively.

Only a handful of state commissions require an MRI in order to grant a fighter’s license, but MRIs don’t always show the problem. A blood draw is more likely to determine if an issue exists, according to Kelly. Tests for luteinizing hormone (LH), follicle stimulating hormone (FSH), testosterone, growth hormone (GH) and IGF-1 (insulin-like growth factor 1) could serve as an effective screening tool to determine any pituitary damage.

Dr. Kelly, who has been working on issues pertaining to the pituitary gland for nearly 20 years, in 2008 co-authored a study that concluded chronic hypopituitarism occurred in approximately 20 percent of patients who had suffered mild, moderate or traumatic brain injury.

"(MMA) fighters are getting repeated insults to the head, sometimes more than concussive events," Kelly said. "And if you did a careful analysis of those people, I'm sure you'd see a significant rate of pituitary gland dysfunction. That's my prediction."

"I guess what’s really amazing, if you look at it another way, is how infrequently it occurs, and how sturdy the system is, how much damage it can take. The pituitary gland is this tiny little thing that’s less than a centimeter cubed. It’s sitting in a little, bony depression in the skull base and it’s getting banged around, and the connection is getting banged around repeatedly, yet it keeps it on ticking in most people. It’s a pretty resilient system, but only up to a point."

A third consideration is that TRT is not a magic bullet.

The number of fighters on TRT is not known with complete precision, nor is it known precisely how long they have been doing so. However, last year Bloody Elbow did an admirable survey of fighters known to be on TRT, and how the did. The fighters went a combined 15-17:
Chael Sonnen (5-4)
Vitor Belfort (2-0)
Dan Henderson (4-4)
Quinton Jackson (0-2)
Forrest Griffin (1-0)
Frank Mir (0-2)
Todd Duffee (1-1)
Nate Marquardt (2-1)
Shane Roller (0-3)

The great exception of course is Vitor Belfort, who is on one of the hottest streaks in the sport's history, and has become the poster child for those opposed to TRT. However, one fighter is just anecdotal evidence, and does not necessarily represent the issue as a whole.