Basic TRT Overview

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Normal Ranges:
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. 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.

Unfortunately, the medical community often does not do a good job of recognizing what your TT should be for your age. In fact, I have seen countless guys come through this forum that cannot even get their doctor to treat them when their TT is below 200 – they simply chalk it up to “getting old”. It can often be an uphill battle to get treated. If you are used to having TT around 800 and it drops to 370 you likely will not be feeling like you used to. It is also unfortunate that very few men have their TT checked when they are young and healthy to establish their baseline. There are Clinics out there that specialize in TRT and they are often up to date in current TRT protocols. I would encourage you to consider them as a treatment option.

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:

 

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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.

If you read the instructions that come with your prescription Test Cyp, you will see that it recommends doing intramuscular injections once every two weeks – often 200mg as the starting point. Unfortunately, many doctors still follow these outdated instructions when prescribing Test Cyp. Due to the approximate 5 day half-life, injecting once every two weeks is a recipe for disaster. It puts you on what we often refer to as a hormonal roller coaster. You start out with really high TT levels – often supraphysiological (above normal) which poses problems that I will speak to later. And after two weeks, your TT levels will be so low that you will feel terrible. You will administer another injection and start this roller coaster ride again. This does not mimic your natural testosterone levels which remains much more stable. Therefore, it is better to inject smaller doses more frequently. Once a week is better; but a lot of guys have found that injecting every 3.5 days works best for stable TT levels (e.g. Tuesday night and Saturday morning). So if your doctor put you on 200mg of Test Cyp every two weeks, you would want to inject 100mg every week or 50mg every 3.5 days instead.

Let me share my personal experience with you. My doctor actually did prescribe 200mg every two weeks. I talked to him about the roller coaster ride and he had no problem letting me start injecting 100mg once a week. I had lab work done after about 10 weeks to see what my peak and trough TT levels were within a seven day period. My peak was 1,100ng/dl and my trough was 330ng/dl. I felt pretty good for a few days and pretty lousy by the end of the week. I talked to my doctor about switching to 50mg injections every 3.5 days which he again was fine with if I was ok with the additional pinning. This put my TT right around a stable 650ng/dl. I felt a lot better without the big swings.

Another 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.

 

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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.

You can find the testosterone dose that raises your TT levels without causing high amounts of aromatization. Generally there is a “tipping point”. Let me provide another example from my personal experience. When I was injecting 50mg every 3.5 days, my E2 was at 27pg/ml (TT was at 650ng/dl). I tried injecting 60mg every 3.5 days and this resulted in E2 of 97pg/ml and TT of 880ng/dl. That extra 20mg a week was more than my body could handle on its own and resulted in a lot of aromatization. For comparison, when I was doing the injections of 100mg once per week my E2 was at 115pg/ml. That’s higher than many women’s levels at certain stages of their monthly ovulatory cycle.

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).

This leaves you with two basic choices for an approach to TRT. Use the fewest medications possible and find the dose that doesn’t cause high levels of aromatization. Or use a dose the puts you in the upper part of the normal TT range and incorporate an AI into your protocol. Both are perfectly good approaches to TRT. Or if you are one of the lucky ones, get to the top end of the normal range without needing to use an AI.

There are some over-the-counter supplements that you can take to reduce E2. They will not counter high levels of E2, but they can be effective when your E2 is slightly elevated. These include: diindolylmethane (DIM), zinc and vitamin B-6. They work by helping you excrete the E2 faster as opposed to inhibiting aromatization.

If you do use an AI or supplements, you need to be very careful to not lower your Estradiol too much. Men need E2 as well. You want to keep your E2 in the 20-40pg/ml range. If you ever do “crash” your E2 too low you will quickly learn that it is one of the worst feelings in the world. You will likely experience: extreme fatigue, joint pain, “brain fog”, low libido, erectile dysfunction, anxiety and a general sense of feeling pretty lousy. Some guys are bedridden while they wait for their E2 to bounce back after crashing it. If you are going to be off one way or the other, you are better off letting your E2 be a little on the high side rather than on the low side. Everyone freaks out about gynecomastia and convinces themselves they need more AI, but having your E2 in the 40’s is generally a lot better than having it in the teens.

This leads me to how you can know if your E2 is too high or too low. While there are signs that tend to be the “canary in the coal mine” like acne (high E2) or joint pain (low E2), you must have blood work done to measure your E2. I can’t tell you how many guys have sworn their E2 was too high only to have blood work show that it was actually too low or vice-versa. It is very hard to tell the difference – especially when you are inexperienced. Get frequent blood work done. You should also note that there are different types of blood tests to check Estradiol. There is the Regular Assay and the Sensitive Assay. The regular assay is meant for women and it is not very accurate at the lower levels typically found in men. The sensitive assay is designed to be much more accurate at the lower levels found in men. Make sure you get the Estradiol Sensitive Assay performed.

There are a lot of doctors out there that prescribe TRT but know next to nothing about Estradiol management. If you read through the TRT forum you will find plenty of examples where guys have had their doctors tell them, “Men don’t have estradiol,” or “You don’t have to worry about estradiol.” This is incorrect and may indicate that they have outdated knowledge on the topic or they are still learning how to treat Hypogonadism effectively. It is an imperative that you monitor and manage E2 while on TRT. As I stated earlier, I believe E2 causes 90% of the problems encountered while on TRT.

Hematocrit:
The other primary negative side effect of TRT is elevated hematocrit (blood thickness). Exogenous testosterone causes your body to produce more red blood cells which in turn makes your blood thicker. This is nothing to be alarmed about as it is very easy to manage. Simply donate a pint of whole blood every 56 days (minimum frequency allowed). This will lower your hematocrit and help save lives at the same time. You can do this at the Red Cross and other similar organizations. If for some reason this donation frequency is not often enough to keep your hematocrit within normal levels there are other options available which you can learn about on the TRT forum. Please don’t wait for your hematocrit to become above normal before going in to donate blood. You will be turned away. An ounce of prevention is certainly worth a pound of cure here.

 

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Blood Work:
This would be a good time to talk about the Blood Work that needs to be done while on TRT. Before you start TRT, you will need to check your TT, LH and FSH. If these indicate Secondary Hypogonadism you should check your Prolactin as well to rule out Hyperprolactinemia. Also get a Thyroid panel to make sure it is functioning properly (TSH, T3, T4, Free T3, Free T4, FTI, THBR). If you have borderline Hypogonadism you should check your Free Testosterone and Sex Hormone Binding Globulin (SHBG). Finally, you will want to reconfirm the initial results by checking TT, LH and FSH again.

If Primary Hypogonadism is indicated you should simply reconfirm the results by checking TT, LH and FSH again. If you have borderline Hypogonadism you should check your Free Testosterone and Sex Hormone Binding Globulin (SHBG).

Once you are on TRT, you will need to do frequent blood work to see how you are doing – especially when you are beginning treatment and trying “dial in” your protocol. Here are the common labs that guys order on TRT.

Always Necessary:
• Total Testosterone (TT)
• Complete Blood Count (CBC) – this includes Hematocrit
• Metabolic Panel – this includes kidney and liver function
• Estradiol Sensitive

Sometimes Needed:
• Lipid Profile
• Prostate-Specific Antigen (PSA)
• Prolactin
• Iron
• Ferritin

Nice to Have Occasionally:
• Insulin Growth Factor (IGF-1)
• Thyroid Stimulating Hormone (TSH)
• Hemoglobin A1C (HbA1c)
• Vitamin B12
• Vitamin D
• Dehydroepiandrosterone (DHEA)
• Cortisol
• Cardiac Reactive Protein (CRP)
• Free Testosterone
• Sex Hormone Binding Globulin (SHBG)

Sometimes going through your doctor and insurance to get all of this blood work done can be inconvenient, expensive or even not permitted. A lot of guys on TRT use what are known as Private Labs. They are often much cheaper, convenient and as the name implies only you see the results. I share my results with my doctor, but that is up to you. A good company that you can use in most States is Private MD Labs (Private MD - Buy Lab Tests Online). I find that you get the best deals by purchasing one of their panels rather than getting labs al la carte. A very popular one is the Hormone Panel for Females. Despite its name, it is for men too. It includes: LH, FSH, TT, E2 (regular assay), CBC and Metabolic Panel. It costs about $50 if you use their 15% off coupon code. Sign up for their weekly newsletters to get the codes. The lab results will usually be available to you online in 24-48 hours. You can add on the Estradiol Sensitive Assay for about $58 more.

Another popular option is to get the Hormone Panel for Males. It costs about $143 after the 15% off coupon code and includes: TT, Free T, Estradiol Sensitive, CBC, Metabolic Panel, Lipid Profile, IGF-1, PSA and a Thyroid Profile.

If funds are really tight, just get the Hormone Panel for Females for $50. Although the Regular E2 assay is less accurate, the general rule of thumb is to subtract 10-20 points from the value. It tends to come in higher; but not always.

Lastly, let me strongly urge you to learn how to read your labs. You are your own best advocate for your health. Don’t rely on your doctor for everything if he or she does not specialize in TRT. As I have mentioned a few times already, many doctors know very little about TRT. The sad truth is that by reading this post, joining this forum and taking your time to do homework that you will very likely know much more about TRT than your doctor. This will save you from having a bad experience.

hCG
Human Chorionic Gonadotropin (hCG) is often used in TRT; but not always. It mimics the LH that is released by the pituitary gland. You generally take hCG by administering Sub-Q injections, although intramuscular works as well. hCG has certain benefits to men on TRT. Of interest to many men is that it helps keep the testicles from shrinking which often happens when they are shut down due to using exogenous testosterone. It can also help “back fill” your HPTA pathways as your testicles do more than simply produce Testosterone. hCG will help keep your DHEA, Cortisol and Pregnenolone levels in balance. It can also help even out your TT levels so that you are on less of a hormonal roller coaster ride.

There are entire posts dedicated to hCG, so I will not try to replicate them here. I do encourage you to seek them out when doing your homework. A few things to consider though are: many men express having a “sense of well-being” while taking hCG, taking too much and taking it too frequently can be harmful, it is expensive, and it can cause high estradiol levels that cannot be controlled by taking an Aromatase Inhibitor. Many regular doctors are not very familiar with hCG in TRT protocols and will be reluctant to prescribe it. If you want to use hCG your best bet may be to go through a TRT clinic that specializes in this area of medicine.

DHEA and Pregnenolone:
If you are not going to use hCG while on TRT, it is recommended that you supplement with DHEA and Pregnenolone as your testicles are shut down and may not be producing these adequately. Both can be found at drug stores over-the-counter. Micronized or transdermal forms are generally preferred.

Talking to Your Significant Other:
Telling your spouse or significant other that you are hypogonadal can be embarrassing and difficult. But I really want to encourage you to talk with them. They will most likely already know that something is wrong with you. For example, when I talked to my wife she told me that she didn’t think I found her attractive anymore. This was the farthest thing from the truth. I explained that I was just too tired to want to have sex. You also need to talk about the changes that are about to happen to you. I am not kidding when I say you will probably have the energy and libido of an 18 year old again. Make sure your significant other is prepared to help you put that increased libido and energy to good use. They can help you deal with the changes you are about to go through. Maybe they can even help you with injections.

There often exists a lot of negative bias around using Anabolic-Androgenic Steroids in our culture. Unfortunately, it has gotten a bad reputation. Make sure that your significant other understands that you are deficient in testosterone and you will only be replacing what should normally be there. And don’t forget, estrogen is a steroid too. Help them understand that there are serious health risks associated with Hypogonadism as described earlier. In fact, print this off and let them read it. I think once they see the new you that they will agree TRT is a good thing when you suffer from Hypogonadism.

Frequently Asked Questions:

Can I run TRT for 3 months and then stop?
No. TRT is meant to be for life. You go on TRT because you are hypogonadal. Taking testosterone for a short period of time will not fix that. Once you stop TRT you will slowly return to your previous TT levels or even lower.

Can I go on TRT without a doctor?
Self-administered TRT is not advised. Hopefully after reading this overview you have a greater appreciation for the complexity of the HPTA. It is a very complicated system. One that is best left in the hand of physicians that have trained many years to understand it. You need a doctor monitoring you. And having a prescription for you medications and getting them from a licensed pharmacy is without a doubt the best way to do TRT.

Will I get scar tissue from the injections?
This is a risk of TRT over many years. Rotating injection spots is the best way to mitigate this risk. I recommend having at least 4 spots. I rotate between my deltoids and quadriceps.

Differences between Testosterone Cypionate and Enanthate?
As far as TRT is concerned, these two esters are interchangeable. You should not notice any differences between them.

Will I get muscle “gains” on TRT?
TRT will restore your natural testosterone levels. You will be able to achieve muscle gains just like any other normal and healthy male.