When to Start TRT?

Dr. Nagler,

My T has been going on for about a month now.

I'm getting a little used to it; not quite as depressed as I was the first two weeks; but it's still annoying although I don't "hear" it when I am busy, but it still is too bothersome. It fluctuates between a hissing sound for a cople of days before changing more into a buzzing sound for a day or two, then repeats. On a few occasions for maybe half a day when it was hissing, it reduced about 70-80% which was very nice! However, it hasn't reduced for several days.

I also suffer from hearing loss (kind of surprised me on the test) and have some TMJ issues.

Question: how much more time should I give it before pursing TRT - and would you know of someone in the Detroit, MI area? Thanks.

 

Hi @dh42 -

Once the (relatively few) causes of tinnitus that can be fixed and in-so-doing appreciably mitigate your tinnitus have been ruled out, and once the (even fewer) causes of tinnitus that represent a threat to your health have been ruled out, then what (if anything) you do and when you do it really depends on how much your tinnitus bothers you.

My bias is towards CBT and TRT, but those are not the only options. Indeed maybe just some "tincture of time" is in order.

Let me take the liberty of rephrasing your question and make your situation considerably more dire than you describe in your inquiry:

You have had tinnitus for a month. Your tinnitus bothers you a lot. On a scale on 1 to 10, where 1 is "I have tinnitus, but it does not affect me in the least" and 10 is "I have tinnitus and it has totally and irrevocably destroyed my life," you would call yourself a 7 or 8. You have completed an ENT and audiological evaluation. Whatever is causing your tinnitus, it is not among the causes of tinnitus that can be fixed and in-so-doing appreciably mitigate your tinnitus, and it is not among the causes of tinnitus that represent a threat to your health. Those two facts having been established as a result of your ENT and audiological evaluations, you have looked at a number of options and are seriously considering TRT. You understand that TRT is a protocol that facilitates the habituation of tinnitus. What are the pros and cons of starting now rather than holding off for a while?​

Well, the success rate of TRT (in the hands of a knowledgeable and experienced TRT clinician) is on the order of 85% within six to twelve months of beginning the protocol. But even if you do nothing, there is a good chance that you will habituate to your satisfaction within six to twelve months of the onset of your tinnitus. (Remember, the individuals who populate tinnitus support boards by and large are not representative of the tinnitus community as a whole. Those who populate tinnitus support boards typically are not doing well - they have not habituated in six to twelve months - or they would not be on support boards in the first place. More about that later.) So the real question is what do you lose if you start TRT now (one month into tinnitus), and within another six to twelve months you have habituated your tinnitus to your great satisfaction and relief? Say you have moved from a 7 or 8 on that scale to a 1 or a 2. What do you lose? Well, you lose the knowledge that it was TRT and not "tincture of time" that did the trick, and you lose the cost of TRT. So if you really need to know that it was the TRT, then wait a year or longer before starting! For me, I waited eight months or so ... but that was only because it was back in 1994, and TRT was so new that it took me quite a while to even learn of its existence. If I knew back then what I know now, I'd have started much much sooner - and the fact that I wouldn't ever know for sure that it was TRT that got me where I am today in terms of my tinnitus would not have bothered me in the least. But that's me, and you are you! This is your decision and your decision alone.

Now I am going to say something about the folks in the Internet tinnitus community who continue to truly suffer month in and month out ... year in and year out. They post on the boards all the time, and I feel bad for each and every one of them. We all do. We all share their pain. I only wish to point out that to the best of my knowledge not one of them has undergone TRT in the hands of a clinician who is knowledgeable and experienced in TRT. That is their choice, and each can give you a reason. I am not questioning their decision. I am not questioning their reasoning. It is what it is. I just say that it is something worth keeping in mind as you or those like you make your decisions. People with horrendous screaming tinnitus do TRT all the time. And the vast majority do very well - provided that they place themselves in the care of knowledgeable and experienced TRT clinicians.

The last part of your question is who would I recommend in the Detroit area. Well I only recommend TRT clinicians whom I know personally, whom I have actually seen work with patients, who are ethical beyond question, and who are extremely knowledgeable and experienced. In other words, when I recommend a TRT clinician, that recommendation must be absolutely unconditional - or I do not make it at all. The closest person to Detroit who fits that highly restrictive set of criteria is Dr. Paula Schwartz in Edina, Minnesota. You would need to make a single trip to her office for an in-person evaluation and to initiate TRT counseling (same visit). All follow-up could be done via phone and/or Skype. Perhaps for starters you might simply give her a call, explain your situation, and see what she thinks!! You lose nothing but the cost of a phone call. Seems like a reasonable next step to me. Or ... since your particular situation is not as dire as the scenario I described earlier, just give it a little more time - that's a reasonable next step as well. Maybe take a while to work on your own Obstacles to Habituation first!

Hope this helps.

Dr. Stephen Nagler