Questions on TRT
What is testosterone replacement therapy (TRT)? What are the symptoms of low testosterone? Do I have “low t”? How do I find a doctor to put me on testosterone replacement therapy? What are the downsides or side effects of TRT? Is TRT dangerous? How do I know if I have low testosterone?
Normal Ranges of Testosterone
Total Testosterone (TT) usually peaks in men around age 30. The normal range for TT in men is about 350-1200 ng/dl. But that includes sick 80 year olds, healthy 25 year olds and so on. The average TT for a healthy 30 year old is about 600. After age 30, TT typically decreases 1% every year as you age. By the time one reaches about age 60, the average TT is somewhere around 450.
Low Testosterone (Hypogonadism)
According to the Cleveland Clinic, Hypogonadism is usually clearly medically defined as TT that is below 250 ng/dl. TT that is between 250-350 is often considered borderline low medically and things like Free Testosterone should be evaluated. It is estimated that 40% of all males are hypogonadal in this day and age. This percentage increases or decreases due to other factors such as obesity, diabetes and other comorbidities.
Potential Symptoms of Hypogonadism
Included in no particular order, symptoms are: fatigue, feeling weak, low libido, erectile dysfunction (weakened or lack of erections), poor sleep (i.e. insomnia), “brain fog”, difficulty concentrating, loss of body hair (i.e. reduced shaving), depressed mood, increase in body fat, decreased muscle mass, decreased bone strength, lower sperm production, congestive heart failure, less endurance, loss of height, grumpiness, depression, deterioration in ability to play sports, falling asleep after dinner, and deterioration in work performance.
Types of Hypogonadism
There are two types of Hypogonadism: Primary and Secondary. Primary means your testicles are not functioning properly. Secondary often means your pituitary is not functioning properly. It can also be due to problems with your thyroid, hypothalamus, and/or adrenals. Now that you have your blood work indicating Hypogonadism, you need to see what your Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH) are. LH is produced in the pituitary gland and acts as a signal to the Leydig Cells in your testicles that tells them to produce testosterone. FSH is also produced in the pituitary gland and acts as a signal (along with testosterone) to the Sertoli Cells in your testicles that tells them to produce sperm. LH and FSH work together synergistically.
If you have high LH and FSH in combination with low testosterone you have Primary Hypogonadism. This means your pituitary is “yelling” at your testicles to produce more testosterone but they are not responding. If you have low or normal LH and FSH in combination with low testosterone you have Secondary Hypogonadism. This means that your pituitary is not recognizing that your body is deficient in testosterone so it is not sending a “loud” signal to your testicles to produce more testosterone. You will often hear this system referred to as the Hypothalamic-Pituitary-Testicular Axis or HPTA and I encourage you to spend more time learning about it.
Causes of Hypogonadism
Possible causes of Primary Hypogonadism include: physical trauma to the testicles, aging, toxins (e.g. alcohol or heavy metals), Klinefelter’s Syndrome, XYY Syndrome, anorchia, orhitis, varicocele, hemochromatosis, mumps, certain prescription drugs and radiation treatment or chemotherapy. There are other possibilities as well that you can discuss with your doctor. If you are Primary you should consult with an urologist to see if you can determine what is wrong with your testicles.
Possible causes of Secondary Hypogonadism include: physical trauma to the head, aging, pituitary and/or hypothalamus tumor (usually benign), Hyperprolactinemia, Kallman’s Syndrome, HIV, obesity. Again, there are other possibilities as well that you can discuss with your doctor. If you are secondary you should consult with an endocrinologist and probably have an MRI done. Sometimes it is possible to get your pituitary gland working again by attempting a “restart”. This option should be considered especially if you are in your 20’s or early 30’s. I won’t go into details here, but it often involves using Clomid or other similar medications. I would strongly encourage you to work with a doctor that is very knowledgeable in restart protocols.
Unfortunately, the truth is that many guys never determine what is causing their Hypogonadism. The good news is that means one of the serious illnesses listed above is not causing it. It likely comes down to getting old, being over-weight or being unlucky.
There are other health problems that can lower your testosterone and should be looked into with your doctor before starting treatment. These include: sleep apnea/hypopnea, thyroid problems, poor diet, and drug use including certain pain medication. I highly encourage you to have a sleep study done to rule this possibility out and have a full thyroid panel run. Take a look at your diet, drug use and lifestyle as well.
Testosterone Replacement Therapy (TRT)
If you have reached the point of determining that TRT is your best option, I want you to know that the good news is that it is a very effective treatment. The horrible symptoms that you have been experiencing should be alleviated in as soon as 3-6 weeks. It may take longer depending on the how long you have been hypogonadal and its severity. Fairly soon though, you will likely start feeling like you are 18 years old again. Your energy and libido will return. You will feel alive and strong again.
There are various options for TRT administration including; self-injections, gels, creams, patches and pellets. I am going to steer you towards injections. By far, injecting testosterone is the most effective, cheapest, easiest and safest option.
Gels and creams are ineffective for most men. They are not absorbed evenly through the skin and stop absorbing well over time. They are messy. It can be difficult, if not impossible, to achieve optimal TT levels with this method. DHT levels can be raised much higher than experienced with alternatives. And most importantly, there is a risk of transfer to the women and children in your life. In my opinion, transfer is an unacceptable risk when there are other good treatment options available. Plus gels/creams are often very expensive.
Patches irritate the skin, fall off and don’t transmit testosterone well. I don’t know anyone using patches anymore.
Pellets are implanted under your skin usually in your hip/glute area. They are very expensive and painful. I would encourage you to watch a YouTube video of the procedure if you are considering this treatment method. That should scare you away from this option.
That leaves injections. I strongly encourage you to insist on doing self-injections. They sound scary, but the truth is they are very easy to do. Do not let fear stop you. Every single one of us was very nervous doing our first self-injection. With a little practice though, you will be able to safely and painlessly administer them in a few minutes. Have a nurse at your doctor’s office show you how to do them or watch videos on YouTube. If your doctor will not allow you to self-inject, it is time to look for a new doctor. That would be like not allowing a diabetic to self-inject insulin. Here are a couple of links to help you with self-injections:
Testosterone Injections
In the United States, Testosterone Cypionate (Test Cyp) is most commonly used for TRT and usually prescribed in doses of 100-200mg per week. The Cypionate refers to the ester that the testosterone is suspended in. It is the ester that allows the testosterone to be slowly released into your blood stream. Because of the ester, it takes time for testosterone levels to build up in you when you first start. That is why effects often don’t kick in for 3-6 weeks. During this time, what is left of your natural endogenous testosterone production is being shut down and the testosterone levels from what you are administering exogenously are building up. It typically can take about two months to reach desired TT levels. There are other esters available and all they do is change the speed at which the testosterone is released. In the end, they are all testosterone.
You will often hear the term Half-life come up. The half-life is the amount of time required for a quantity to fall to half its value as measured at the beginning of the time period. Testosterone Cypionate has a half-life of approximately 5 days when injected intramuscularly. So if you inject 100mg of Test Cyp, 5 days later about 50mg will be remaining. About 25mg after 10 days will be remaining. And so on. But please note that everyone metabolizes Test Cyp at a different rate.
Good option for injections is to perform subcutaneous (Sub-Q) injections rather than intramuscular. This slows down the rate at which the testosterone is absorbed into the blood stream. This can be beneficial in reducing Aromatization which I will speak to later. But Sub-Q injections are best left for small doses. If the doses become too large you can be left with uncomfortable nodules under your skin. Most guys seem to prefer intramuscular injections, but Sub-Q is gaining popularity.
Estradiol
One of the primary negative side effects that you must worry about while on TRT is Aromatization of testosterone into Estradiol (E2), a potent form of estrogen. In my estimation, elevated E2 is the cause of 90% of the problems one encounters on TRT. Your body has what are known as Aromatase Enzymes and it is more prevalent in fat cells. Unfortunately, many men who find themselves on TRT have accumulated unwanted fat. The higher your TT levels are, the more aromatization you are likely to experience. Ideally you want your E2 to be between 20-40pg/ml. When your E2 is elevated you can experience: acne, feeling bloated, elevated blood pressure, erectile dysfunction, edema, fatigue, “brain fog”, gynecomastia, and emotional disturbances. Estradiol is also being investigated as a cause of prostate problems whereas in the past testosterone was suspected to be a cause.
There are several things you can do to manage aromatization and the resulting E2. As I mentioned earlier, one of them is to administer more frequent smaller injections of Testosterone. If you avoid the spikes in your TT you will aromatize less. This is why a lot of guys inject every 3.5 days.
If you want to be at the higher end of the TT normal range (approximately 1,200ng/dl) then you will likely have to use another medication known as an Aromatase Inhibitor (AI). AI’s reduce the amount of testosterone that is converted into E2 via the Aromatase Enzyme. Two common AI’s used by TRT patients are Arimidex (Anastrozole) and Aromasin (Exemestane). Arimidex is generally dosed at .50mg to 1.00mg per week for TRT. If you are injecting Test Cyp every 3.5 days it would be good to take half your weekly AI dose with each injection. Arimidex has a half-life of around 48 hours. Aromasin is generally dosed at 6.25mg to 12.50mg per every other day for TRT. Its half-life is around 27 hours which is why it needs to be dosed more frequently (possibly even as low as 9 hours in males per one study).
What is testosterone replacement therapy (TRT)? What are the symptoms of low testosterone? Do I have “low t”? How do I find a doctor to put me on testosterone replacement therapy? What are the downsides or side effects of TRT? Is TRT dangerous? How do I know if I have low testosterone?
Normal Ranges of Testosterone
Total Testosterone (TT) usually peaks in men around age 30. The normal range for TT in men is about 350-1200 ng/dl. But that includes sick 80 year olds, healthy 25 year olds and so on. The average TT for a healthy 30 year old is about 600. After age 30, TT typically decreases 1% every year as you age. By the time one reaches about age 60, the average TT is somewhere around 450.
Low Testosterone (Hypogonadism)
According to the Cleveland Clinic, Hypogonadism is usually clearly medically defined as TT that is below 250 ng/dl. TT that is between 250-350 is often considered borderline low medically and things like Free Testosterone should be evaluated. It is estimated that 40% of all males are hypogonadal in this day and age. This percentage increases or decreases due to other factors such as obesity, diabetes and other comorbidities.
Potential Symptoms of Hypogonadism
Included in no particular order, symptoms are: fatigue, feeling weak, low libido, erectile dysfunction (weakened or lack of erections), poor sleep (i.e. insomnia), “brain fog”, difficulty concentrating, loss of body hair (i.e. reduced shaving), depressed mood, increase in body fat, decreased muscle mass, decreased bone strength, lower sperm production, congestive heart failure, less endurance, loss of height, grumpiness, depression, deterioration in ability to play sports, falling asleep after dinner, and deterioration in work performance.
Types of Hypogonadism
There are two types of Hypogonadism: Primary and Secondary. Primary means your testicles are not functioning properly. Secondary often means your pituitary is not functioning properly. It can also be due to problems with your thyroid, hypothalamus, and/or adrenals. Now that you have your blood work indicating Hypogonadism, you need to see what your Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH) are. LH is produced in the pituitary gland and acts as a signal to the Leydig Cells in your testicles that tells them to produce testosterone. FSH is also produced in the pituitary gland and acts as a signal (along with testosterone) to the Sertoli Cells in your testicles that tells them to produce sperm. LH and FSH work together synergistically.
If you have high LH and FSH in combination with low testosterone you have Primary Hypogonadism. This means your pituitary is “yelling” at your testicles to produce more testosterone but they are not responding. If you have low or normal LH and FSH in combination with low testosterone you have Secondary Hypogonadism. This means that your pituitary is not recognizing that your body is deficient in testosterone so it is not sending a “loud” signal to your testicles to produce more testosterone. You will often hear this system referred to as the Hypothalamic-Pituitary-Testicular Axis or HPTA and I encourage you to spend more time learning about it.
Causes of Hypogonadism
Possible causes of Primary Hypogonadism include: physical trauma to the testicles, aging, toxins (e.g. alcohol or heavy metals), Klinefelter’s Syndrome, XYY Syndrome, anorchia, orhitis, varicocele, hemochromatosis, mumps, certain prescription drugs and radiation treatment or chemotherapy. There are other possibilities as well that you can discuss with your doctor. If you are Primary you should consult with an urologist to see if you can determine what is wrong with your testicles.
Possible causes of Secondary Hypogonadism include: physical trauma to the head, aging, pituitary and/or hypothalamus tumor (usually benign), Hyperprolactinemia, Kallman’s Syndrome, HIV, obesity. Again, there are other possibilities as well that you can discuss with your doctor. If you are secondary you should consult with an endocrinologist and probably have an MRI done. Sometimes it is possible to get your pituitary gland working again by attempting a “restart”. This option should be considered especially if you are in your 20’s or early 30’s. I won’t go into details here, but it often involves using Clomid or other similar medications. I would strongly encourage you to work with a doctor that is very knowledgeable in restart protocols.
Unfortunately, the truth is that many guys never determine what is causing their Hypogonadism. The good news is that means one of the serious illnesses listed above is not causing it. It likely comes down to getting old, being over-weight or being unlucky.
There are other health problems that can lower your testosterone and should be looked into with your doctor before starting treatment. These include: sleep apnea/hypopnea, thyroid problems, poor diet, and drug use including certain pain medication. I highly encourage you to have a sleep study done to rule this possibility out and have a full thyroid panel run. Take a look at your diet, drug use and lifestyle as well.
Testosterone Replacement Therapy (TRT)
If you have reached the point of determining that TRT is your best option, I want you to know that the good news is that it is a very effective treatment. The horrible symptoms that you have been experiencing should be alleviated in as soon as 3-6 weeks. It may take longer depending on the how long you have been hypogonadal and its severity. Fairly soon though, you will likely start feeling like you are 18 years old again. Your energy and libido will return. You will feel alive and strong again.
There are various options for TRT administration including; self-injections, gels, creams, patches and pellets. I am going to steer you towards injections. By far, injecting testosterone is the most effective, cheapest, easiest and safest option.
Gels and creams are ineffective for most men. They are not absorbed evenly through the skin and stop absorbing well over time. They are messy. It can be difficult, if not impossible, to achieve optimal TT levels with this method. DHT levels can be raised much higher than experienced with alternatives. And most importantly, there is a risk of transfer to the women and children in your life. In my opinion, transfer is an unacceptable risk when there are other good treatment options available. Plus gels/creams are often very expensive.
Patches irritate the skin, fall off and don’t transmit testosterone well. I don’t know anyone using patches anymore.
Pellets are implanted under your skin usually in your hip/glute area. They are very expensive and painful. I would encourage you to watch a YouTube video of the procedure if you are considering this treatment method. That should scare you away from this option.
That leaves injections. I strongly encourage you to insist on doing self-injections. They sound scary, but the truth is they are very easy to do. Do not let fear stop you. Every single one of us was very nervous doing our first self-injection. With a little practice though, you will be able to safely and painlessly administer them in a few minutes. Have a nurse at your doctor’s office show you how to do them or watch videos on YouTube. If your doctor will not allow you to self-inject, it is time to look for a new doctor. That would be like not allowing a diabetic to self-inject insulin. Here are a couple of links to help you with self-injections:
 |
| Testosterone Cypionate |
Testosterone Injections
In the United States, Testosterone Cypionate (Test Cyp) is most commonly used for TRT and usually prescribed in doses of 100-200mg per week. The Cypionate refers to the ester that the testosterone is suspended in. It is the ester that allows the testosterone to be slowly released into your blood stream. Because of the ester, it takes time for testosterone levels to build up in you when you first start. That is why effects often don’t kick in for 3-6 weeks. During this time, what is left of your natural endogenous testosterone production is being shut down and the testosterone levels from what you are administering exogenously are building up. It typically can take about two months to reach desired TT levels. There are other esters available and all they do is change the speed at which the testosterone is released. In the end, they are all testosterone.
You will often hear the term Half-life come up. The half-life is the amount of time required for a quantity to fall to half its value as measured at the beginning of the time period. Testosterone Cypionate has a half-life of approximately 5 days when injected intramuscularly. So if you inject 100mg of Test Cyp, 5 days later about 50mg will be remaining. About 25mg after 10 days will be remaining. And so on. But please note that everyone metabolizes Test Cyp at a different rate.
Good option for injections is to perform subcutaneous (Sub-Q) injections rather than intramuscular. This slows down the rate at which the testosterone is absorbed into the blood stream. This can be beneficial in reducing Aromatization which I will speak to later. But Sub-Q injections are best left for small doses. If the doses become too large you can be left with uncomfortable nodules under your skin. Most guys seem to prefer intramuscular injections, but Sub-Q is gaining popularity.
Estradiol
One of the primary negative side effects that you must worry about while on TRT is Aromatization of testosterone into Estradiol (E2), a potent form of estrogen. In my estimation, elevated E2 is the cause of 90% of the problems one encounters on TRT. Your body has what are known as Aromatase Enzymes and it is more prevalent in fat cells. Unfortunately, many men who find themselves on TRT have accumulated unwanted fat. The higher your TT levels are, the more aromatization you are likely to experience. Ideally you want your E2 to be between 20-40pg/ml. When your E2 is elevated you can experience: acne, feeling bloated, elevated blood pressure, erectile dysfunction, edema, fatigue, “brain fog”, gynecomastia, and emotional disturbances. Estradiol is also being investigated as a cause of prostate problems whereas in the past testosterone was suspected to be a cause.
There are several things you can do to manage aromatization and the resulting E2. As I mentioned earlier, one of them is to administer more frequent smaller injections of Testosterone. If you avoid the spikes in your TT you will aromatize less. This is why a lot of guys inject every 3.5 days.
If you want to be at the higher end of the TT normal range (approximately 1,200ng/dl) then you will likely have to use another medication known as an Aromatase Inhibitor (AI). AI’s reduce the amount of testosterone that is converted into E2 via the Aromatase Enzyme. Two common AI’s used by TRT patients are Arimidex (Anastrozole) and Aromasin (Exemestane). Arimidex is generally dosed at .50mg to 1.00mg per week for TRT. If you are injecting Test Cyp every 3.5 days it would be good to take half your weekly AI dose with each injection. Arimidex has a half-life of around 48 hours. Aromasin is generally dosed at 6.25mg to 12.50mg per every other day for TRT. Its half-life is around 27 hours which is why it needs to be dosed more frequently (possibly even as low as 9 hours in males per one study).
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