Temecula, Calif. -- The Nevada State Athletic Commission in 2007 reviewed and approved Dan Henderson for a seemingly counterintuitive therapeutic use exemption that allowed him to inject testosterone and gain clearance to fight.
Henderson's approval marked the first time the commission signed off on testosterone replacement therapy as legitimate medical treatment, yet the two-time Olympic wrestler was "so nervous about it" that he initially preferred to maintain off-the-chart low testosterone blood levels, just in case.
"I was new to it," Henderson said. "I didn't have my levels quite right for a while."
Four years after cracking Wanderlei Silva's jaw in Las Vegas to win the Pride championship belt at 205 pounds, weekly testosterone supplements are now as much a part of Henderson's life as breathing -- and the way he describes it, almost as necessary.
Where he was once fatigued and "getting sick quite a bit" due to a diminished immune system, Henderson, now 40 years old, is healthy and about as good as he's ever been in the fighting arena. Absent a use exemption for TRT, which requires hormone levels to exist in a "normal" range, Henderson simply couldn't be the current Strikeforce light heavyweight champion or in a position to fight Fedor Emelianenko in Hoffman Estates, Ill., on Saturday (Showtime, 10 p.m. ET).
It raises philosophical questions about whether this type of prescription is appropriate for professional athletes. As far as Henderson is concerned, those issues are fodder for media, which, he said, is "making a big deal of it" because of the recent indiscretions of Chael Sonnen and Nate Marquardt.
"I don't know what the statistics are, but a lot of the general public are having to do the same thing," Henderson said. "A lot more people than you realize, because it's not a topic that guys like to talk about. But they're having to do that. I think there's some of those people that are in sports and in MMA that are going to need it as well. The fact that it's even a topic at all is because there have been a couple guys abusing the system."
On the same weekend Henderson fights Fedor, the Association of Boxing Commissions, an organization encompassing state and Native American agencies charged with overseeing the regulation of boxing and mixed martial arts, is scheduled to address the increasingly prevalent issue of therapeutic use exemptions for testosterone replacement therapy.
The topic has been a focus of regulators the past 12 months following incidents involving Sonnen in California and Marquardt in New Jersey and Pennsylvania.
Dr. Sheryl Wulkan, chair of the ABC medical committee and chief ringside physician in New Jersey, developed policies, procedures and forms related to TRT and use exemptions over the past year that she'll present to the membership during the association's annual convention in Washington, D.C.
"There are some states that have not had to deal with a problem such as this," said Tim Lueckenhoff, director of the Missouri Office of Athletics and the sitting president of the ABC. "Our association's goal is to educate our members, so they will be told how to handle a situation similar to this and, as always, Dr. Wulkan is available for advice."
While the Muhammad Ali Boxing Reform Act established unified rules for boxing and a registry that tracked boxers via national identification cards, it did little else to bring cohesion to the piecemeal commission process.
Virtually everything the ABC sets out to do serves as an advisory or informational role. While MMA is handled virtually identically to boxing by the regulators, the sport does not fall under the umbrella of federal law. And even if it were to, the Ali Act is so poorly enforced -- U.S. attorneys simply don't follow up on complaints put forward by the ABC, according to Lueckenhoff -- it seems little would be gained if MMA was folded into the legislation.
"At the end of the day it's up to each commission how they want to handle it," said Keith Kizer, executive director of the Nevada State Athletic Commission.
Starting with Henderson prior to his bout against Silva in Las Vegas, Nevada has granted three of four use exemption requests for testosterone over the past decade.
"As of right now it's definitely not an epidemic," he said.
Based on the unique structure of each regulatory agency, various funding scenarios and shortfalls playing out state by state, and the reality that some jurisdictions simply do not operate as diligently as others, the prospect of setting up a cohesive use exemption and TRT policy seems unlikely at this time.
"I know a lot of states would like it," said California State Athletic Commission executive officer George Dodd. "Some states aren't in favor because they'd like to make the determination on their own."
"You have to go with whatever state you go into," said Ohio Athletic Commission executive officer Bernie Profato. "But there are people that just do the job to get by and collect their paycheck."
Ohio followed Nevada's lead and awarded Henderson a use exemption in 2008. Five states -- Nevada, Ohio, Georgia, Tennessee and Missouri -- all operating on a "case by case" basis, allowed Henderson to compete while taking injections for testosterone. He also fought under UFC regulation while competing for the organization in England and Ireland.
The entire time, Henderson dealt with varying standards and operating procedures.
"It's been easy, mainly because I've already been cleared in Nevada," Henderson said. "I'll just give them a letter from my doctor. Typically during training camp I'll take one or two blood tests just to cover my own ass, to say, 'Hey, my levels never go up.' They can test me after the fights as well, but I don't think I've ever been blood tested since my first time."
While Wulkan's recommendations to the ABC membership should be helpful in pushing regulators to uniformity in their handling of the issue, they aren't compelled to adopt a standardized procedure, even if most agree it's for the best.
"I think there's a lot of value there," said Jeff Mullen, executive director of the Tennessee Athletic Commission. "I think we need to come up with a uniform procedure where all the commissions could hopefully follow it."
Said Profato: "I think whatever they come up with medically, I'm going to rely on it."
Tennessee handled Henderson after Ohio, and though a specific policy or procedure for dealing with therapeutic testosterone usage was not in place, it approved the treatments after considering medical documents and consulting with a prominent state in which Henderson was already cleared.
In Illinois, which has not established protocols to handle therapeutic use exemptions, either, Ron Puccillo, the director of boxing for the state's boxing commission, called Nevada last week with questions about Henderson's treatments. According to Susan Hofer, spokesperson for the Illinois Department of Financial and Professional Regulation, the final determination on whether to issue Henderson a use exemption was made by the director of the division, Jay Stewart, after consultation from Puccillo and a medical board.
Long considered among the country's most proactive commissions, Nevada's procedures have been refined over the years. To curb attempts of fighters looking to secure use exemptions for the purpose of a sort of sanctioned performance enhancement, Kizer said the NSAC has recently added procedures designed to determine whether an applicant's diminished testosterone production is a result of previous use. It will also test out of competition, including requiring costly blood work, which is the only way to determine that the amount of testosterone is within acceptable limits.
"I've heard people say you should just outlaw any kind of exemptions," Kizer said. "That's not fair. What's next -- outlawing rehabilitation after surgery? People have conditions. Just because you're an athlete doesn't mean you have less rights to live a healthy life."
However, he said, "I think it's fair to be suspicious."
California, where Sonnen tested positive for synthetic testosterone after failing to properly notify the state of his TRT treatments, is considering regulations that mandate fighters who request use exemptions to stand in front of the commission and explain why.
"It's something the commission wanted to address," said Dodd. "We've caught more people than anyone else, some big-name people as well. We wanted to have something in place because there's such a wide range of therapeutic use out there. But we want to make sure, still, that fighters aren't taking the easy road as far as when they request a therapeutic use. Instead of trying alternative drugs, the first thing they're going to do is jump into steroids."
As California addresses the proper application of use exemptions, Dodd agrees with Profato, Kizer, Mullen and a host of other regulators that a need exists "to make sure we're giving the fighters a fair chance all the way around."
Henderson, nonplussed by the process, said he's never felt burdened since becoming comfortable with the treatment.
Still, he said, "If I've been approved somewhere I'd like to know that it's approved everywhere."
Josh Gross covers MMA for ESPN.com. Follow him on Twitter at JoshGrossESPN.