by TC Luoma T-Nation
Testosterone Replacement Therapy 101
Here’s what you need to know…
- Testosterone replacement therapy is as much an art as it is a science. Sadly, many doctors are crappy artists.
- A “normal” testosterone reading means almost nothing. You need to have total testosterone, free testosterone, and bioavailable testosterone measured to get a reasonably accurate hormonal picture.
- Testosterone replacement therapy (TRT) should be given based on symptoms instead of blood values. If you have no energy, gain fat easily, have trouble putting on muscle, have a low libido, and suffer from depression, you may need TRT.
- You have the choice of injections, gels, creams, pellets, or supplements in treating low T. However, testosterone injections give you the most bang for your buck.
- TRT causes very few negative side effects. TRT however, is contraindicated in men with existing prostate cancer. It can also cause an easily treatable condition where your blood thickens.
- Some benefits of TRT happen quickly, while others take years. Libido can improve within weeks, as can depression, but loss of body fat and an increase in muscle takes months to plateau while continuing on at a lesser pace for years.
Are Your Balls Doing Their Job?
So you just got the results of your blood test and your testosterone charts out at 600 nanograms per deciliter (ng/dl) of blood. You know that “normal” is somewhere between the range of 200 and 1100 ng/dl. So you breathe a sigh of relief and mentally give your balls a slap on their backs for a job well done in kicking out a reading of 600. But what does that number really mean?
“Normal” Testosterone Means Zilch
Unfortunately, that reading of 600 ng/dl means almost nothing. Testing for testosterone is rife with inconsistencies. Blood values of testosterone vary by the minute and the day. The only way to get a reasonably accurate reading would be to collect urine over a 24-hour period and have the lab use it to measure testosterone and its metabolites. Alternately, you could donate at least three blood samples from different times during the day. The lab would then pool the samples together and test that sample.
But nobody does it that way. It’s more expensive, more time consuming, and more inconvenient. Besides, the doctor would think you were nuts for even suggesting it because, really, who are you to question him, you hapless mortal, and why are you worried so much about your T levels? You should be content with vague blood readings, average testosterone levels, and at least quasi-functional balls like the rest of the sheep on the planet.
And even if you did pool multiple blood samples, it still wouldn’t tell you much. For one thing, even though the results might indicate that you have a normal level of testosterone, it might not be normal for YOU.
Maybe you would’ve measured a high octane 1100 when you were in your twenties, but now you’re sputtering along at a comparatively low octane 600 and spend your days Facebooking, or it’s offline equivalent, scrap booking. The only way you’d know what was normal for you is if you’d established a testosterone baseline reading before you turned 30. But again, nobody does that.
The Other Players: SHBG and Estradiol
Then there’s the issue of steroid hormone binding globulin, or SHBG. It’s a glycoprotein that literally binds up the sex hormones, including, on average, about 60% of your testosterone, and that percentage keeps climbing as you grow older.
The more SHBG you have, the more of your testosterone is bound up, leaving less of it free to do all the good stuff. So while your testosterone level may be 600, a good portion of it is locked up. It can be maddening. It’s like having a genie in a bottle that you can’t uncork.
That’s why, at the very least, when trying to determine your T levels, doctors should ask the lab for your total testosterone levels, your “free” testosterone levels, and your “bioavailable” testosterone levels so you can get a little bit better of an idea of what your situation is. But, you guessed it, nobody does that, at least very few conventionally trained doctors.
And we can’t forget about estrogen, or more specifically, estradiol levels in men. Your testosterone levels may read normal, but if estradiol levels are high, it could thwart testosterone in its efforts to make you the man you’re supposed to be.
As you can see, determining normal testosterone levels is a tricky beast. So, regardless of what your lab values are, and given the problematical nature of the lab tests, you have to instead rely on symptoms and the simple desire to be more than you are, hormonally speaking.
The Symptoms of Low T
Do you have less energy? Have you experienced an inexplicable increase in body fat and have trouble losing it? How about a loss of muscle tone and an inability to make progress in your workouts? Does your erection sometimes falter and wane? Do you think more about your lawn than lady parts?
How about premature aging? Difficulty in concentration or memory? Depression? Or maybe a lack of “appropriate aggressiveness” where you don’t take the initiative in matters of business or the heart?
Maybe you’re nervous, or always pissed off, ready to tear the head off the pudknocker in line in front of you who bought the last damn cinnamon roll? Any of these things could be indicative of low T, including, seemingly paradoxically, that last item on the list about undue anger levels.
Historically, low testosterone, or hypogonadism, has largely been a problem of middle age and beyond. A 2006 study reported that 39% of men over 45 suffer from it. Another study said that while 13 million men in the U.S. may be deficient in testosterone, fewer than 10% get treatment for it.
That’s quite a chunk of human change, but consider that these statistics reflect only those men that were clinically deficient, i.e., their lab tests indicated they were low. It leaves out the millions – many who are young or relatively young – whose lab tests say they may be fine but based on their symptoms, are probably deficient.
It also ignores the younger men who don’t typically get their T levels tested. Millions of them are likely deficient, too. Not because of old age, but because of environmental estrogens, pituitary and testicle stifling chemicals in general, and probably even a soft, cushy, modern, convenience-filled low-testosterone lifestyle.
In fact, it’s speculated that the testosterone levels of today’s average man are roughly half of what his grandfather’s were, at a comparative point in life.
Get the Right Lab Work Done
Your first task is to find a progressive doctor, or at least one who isn’t threatened by a patient who knows what he wants. Luckily, there are now plenty of low-testosterone treatment centers around the country. Unfortunately, many of them are in it for quick dough and they aren’t likely to be as informed on the topic as you’d like them to be. All the more reason for you to take charge.
Once you find the right doc, describe your symptoms, confess your desire to get testosterone replacement therapy, and ask for lab work. But make sure you get tests done in exactly the way specified below. (For instance, if you don’t ask for a “sensitive assay” estradiol test for males, they’re going to measure your estradiol the same as if you were a ballerina from the Bolshoi ballet suffering from menstruation problems.)
Ask for this lab work:
- Testosterone, total
- Testosterone, bioavailable
- Testosterone, free
- Estradiol (sensitive assay)
- Steroid Hormone Binding Globulin
- Follicle Stimulating Hormone (FSH)
- Luteinizing Hormone (LH)
- Dihydrotestosterone (DHT)
- Complete Blood Count (CBC)
- Prostate Specific Antigen (PSA)
- Blood Chemistry Panel
- Metabolic Panel
These tests will give a fairly good baseline reading of where you stand so that when you have follow-up blood testing done three to six months later, you can see if you’re on the right dosage and whether you’re suffering any insidious negative side effects.
What Are Your Choices For T Replacement?
If you test out as deficient in testosterone, or if you have symptoms of low testosterone, you likely want to do something about it. There are definitely over-the-counter supplements designed for this very purpose. (Alpha Male® and Tribex® are the most potent.) And while effective, they’re best used by healthy younger men who want a boost in T levels for bodybuilding purposes. They probably aren’t the best choice for men who are clinically low and who’ve made the choice to undergo what’s usually a lifetime commitment to testosterone replacement therapy, or TRT.
1. Testosterone Injections
Testosterone injections are the creme de la creme of TRT. While it’s true that testosterone gels (see below) create a more natural ebb and flow of testosterone, injections, provided they’re administered properly, give you the most muscle-building, libido boosting, rock-your-world bang for the buck.
You essentially have two injectable choices in America, testosterone enanthate and testosterone cypionate. The half lives of these esters differ slightly, but it’s not that big a deal, especially if your dosing is adequate and you’ve chosen a suitable injection method and schedule.
For most men, 100 mg. a week of either ester is enough for effective TRT. However, some men need less and some men need more, possibly up to 200 mg. a week. Beyond that amount and you’re pretty much on a mild bodybuilding steroid cycle instead of testosterone replacement.
Even if you’re injecting weekly (always on the same day), you still might suffer a bit of a low-testosterone lull as you get further away from injection day. To remedy this, many men split their dosage in half and inject twice a week instead of once a week. Doing so keeps your blood levels of testosterone fairly stable.
And while many men micromanage their hardest workouts to coincide with the peaks and troughs of their TRT, it’s largely an unnecessary battle, especially when you’re giving yourself two injections a week. Injections given that close together ensure that you’re pretty much always riding a peak.
Additionally, you might want to consider subcutaneous injections rather than intramuscular injections. Dr. John Crisler, noted testosterone guru, insists that sub-q is much more effective, so much so that 80 mg. of testosterone injected under the skin is equal to 100 mg. injected intramuscularly. Plus, he adds, you don’t poke your muscle bellies full of thousands of holes over the course of a lifetime of TRT.
All you do is take a pinch of skin on your glute, thigh, or even belly, and inject a tiny needle into the fold at either a 45-degree or 90-degree angle. Fully depress the plunger, release the skin, and you’re good to go. Whether Crisler is right about the potency of sub-q injections isn’t known for sure, but it has the ring of truth and it’s worth a try.
2. Testosterone Gels
As mentioned above, testosterone gels provide a much more natural androgen rhythm and there’s probably some argument to be made that mimicking the body’s natural rhythms is the way to go. However, many believe it doesn’t have the same bang for the testosterone buck as injectable esters.
Besides, gels have their drawbacks. You should only apply gels to freshly showered skin. You should refrain from swimming or working up a sweat for at least an hour. Furthermore, you can’t, under any circumstances, let a child or female (especially a pregnant one) come into contact with the treated area until it’s absolutely dry.
If you do decide to use gels, you must apply them once (or in some cases, twice) a day. Don’t use your hands to apply the gel, though. Any gel on the hands doesn’t soak in to the bloodstream. It’s like applying gel onto an old catcher’s mitt, which isn’t very permeable. Instead, squeeze the gel onto your forearms and rub them together. That way you won’t waste any.
3. Everything Else
Just about everything else, including creams, pellets, and sublingual drops, isn’t much worth discussing. Granted, creams can be effective, but they’re messy and they don’t penetrate the skin as well as gels. Pellets and drops, however, are either ineffective or impractical and make accurate dosing all but impossible.
There are, however, other protocols that have proven to be effective in treating secondary hypogonadism (where the hypothalamus, for whatever reason, isn’t telling the pituitary to produce LH and FSH, which in turn cause the testicles to produce T), like selective estrogen receptor modulators, or SERMs.
Two of the most commonly known ones are Clomid (clomiphene) and Nolvadex (tamoxifen). They simply trick the pituitary into producing LH, which then tells the testicles to get to work. Exact protocols are beyond the scope of this article, though.
TRT, Your Testicles, and HCG
One of the big fears about undertaking TRT is infertility and shrinking balls. While TRT does reduce the number of sperm that a man produces, it’d be foolish to think that your replacement dosage has rendered you safe from becoming a daddy. In many cases, though, the testicles will shrink and sperm count will drop, but these effects are easily prevented by concurrently administering human chorionic gonadotropin, or HCG.
The drug mimics LH so that your testicles don’t shut down. They’ll still produce sperm and they’ll still produce testosterone, so shrinkage won’t occur. Additionally, there are LH receptors throughout the body, and HCG attaches to these system-wide receptors. Anecdotally, at least, this causes men on TRT and HCG therapy to report feeling pretty damn good.
HCG is administered subcutaneously via an insulin needle and it’s easily available to your doctor through various compounding pharmacies around the country. The generally recommended starting dose is about 100 iu a day, working up to higher daily doses or, alternately, 250 or 500 administered twice a week.
The Potential Negative Side Effects of TRT
There are a small number of bad things that can happen when on TRT. One is only an issue if you have prostate cancer before starting TRT therapy.
Note that there’s absolutely no evidence – even after researchers have compiled thousands of studies and patient histories – that TRT can cause prostate cancer. However, for some reasons that we don’t totally understand yet, TRT can make prostate cancer worse. That’s why it’s important to have digital rectal exams (DREs) every year while continuing to monitor prostate specific antigens (PSA).
TRT can also cause a condition called polycythemia, which simply means that the testosterone therapy has caused your body to produce too many red blood cells. Instead of freely flowing through your veins, your blood gets thick and spurts along like the stuff that comes out of the Dairy Queen soft serve machine and it can understandably cause heart attacks and strokes when it clogs up your plumbing.
That’s why it’s important to monitor both hemoglobin and hematocrit. If hemoglobin exceeds 18.0, or hematocrit exceeds approximately 50.0, you either need to adjust your dosage of testosterone, donate some blood to the Red Cross, or submit yourself for what’s called therapeutic phlebotomy (a simple blood draw in a doctor’s office).
What About Gyno and Heart Attacks?
The much-dreaded gynecomastia is almost unheard of in males receiving TRT. Gynecomastia, or the growth of male breast tissue, is seen almost exclusively in men taking pro-bodybuilder levels of testosterone (1,000 to 3,000 mg. a week) or testosterone analogs. Hair loss is a possibility, but it seems to stabilize in your 30’s. If you’ve made it that far without losing your hair, it’s highly doubtful that TRT will make things any worse.
All of the rest of the stuff you may have heard about testosterone causing heart attacks or anything else bad is horribly, horribly wrong. If anything, men with low testosterone levels are much more prone to a host of maladies, including heart disease, diabetes, dementia, and pretty much everything else usually associated with old age, death, or decrepitude in males.
What to Expect from Testosterone Replacement Therapy
Testosterone does cool stuff to the body, but it usually doesn’t happen overnight. While you might start feeling pretty good, almost elated, after starting therapy, the various physiological benefits take varying amounts of time.
- Sexual benefits. These kick in fully at about week 3 and plateau between weeks 19 and 21.
- Depression. If it’s a factor, depression often starts to lift by about week 6, but maximum benefits take longer.
- Anxiety, sociability, and stimulation of the cerebral cortex (the part that controls attention and even creativity). These start to improve at about week 3, plateauing about 3 months after beginning therapy.
- Insulin sensitivity. Starts to increase in just a few days, with effects becoming evident (less body fat) in 3 to 12 months, but often continuing for years.
- Increased muscularity. This is highly dependent not only on having adequate testosterone levels, but genetics, diet, lifestyle, and training. However, generally speaking, testosterone therapy can positively affect muscularity in as little as a month, peak at about a year, and then continue at a slower pace for some time.
- The good life. And then there’s the intangible benefit known as life enjoyment. It’s what you often get when you combine all of testosterone’s benefits, the physiological and the psychological, into one. It can’t really be measured, but it’s oh-so valuable. Just make sure you find a doctor that understands that.