TRT and Why it often Doesn't Work

Thread starter #1
My contention is that TRT as it is widely practiced is failing many patients, gives sub-optimal results to others and oftentimes, where it does "work", works almost by default.

If a guy is symptomatic and is diagnosed as low T he is often started on a regimen of an aromatisable Testosterone (say injectable T Cyp). At a sufficient dosage most patients will quickly reach adequate levels of TT and E2, however many don't have relief of symptoms: their lack of 5-ar conversion means DHT levels remain too low.

Here's where it often all goes wrong: In order to achieve relief of symptoms the dosage of T Cyp is usually increased, often repeatedly. As the dosages are increased the need for an AI to "balance" levels increases too. Some, fortunate, patients will find relief early enough in this process and before TT has become too elevated. Others won't until their TT levels cause side effects - blood pressure, HCT, lipids, prolactin.

This type of regimen I would describe as balancing hormones from the top down - elevating E2 to excessive levels and then rebalancing to DHT with the use of AIs.
This is fundamentally wrong. Whatever happened to that basic tenet of good medicine: using the minimum efficacious dose for the relief of symptoms?
What symptomatic guys need is a sufficiency and balance of DHT and E2 the 2 metabolites of T. Surely that balance is better achieved by increasing DHT disproportionately to E2. ie balancing from the bottom up.

Guys that are symptomatic are low in androgens, some may have lacked androgens their entire existence: in the womb, at puberty and throughput adulthood. They start therapy and what are they prescribed - large doses of aromatisable T (perhaps topped off with hCG). The prospects for many are a short lived, and possibly bewildering, "honeymoon period" (where androgens and dopamine predominate) followed by a crash where estrogens, prolactin and norepinephrine return with a vengeance.

We know that T Cream, particularly when applied to the scrotum, will raise DHT disproportionately to other modalities. (There was the good news this week that Dr Crisler is introducing this therapy - others will surely follow). We also know that many guys, particularly over time, have absorbency problems with transdermals. We know too that a relatively small amount of injectable T will give us adequate levels of TT and E2.
What I conclude from those 3 facts is that a correctly dosed protocol of T Cyp conjunctive with T Cream has good prospects as an efficacious therapy. That is a weekly dosage of T Cyp (in suitably divided doses) and a daily dosage of T Cream.

A great advantage of this mixed modality of administering T, is the potential to keep a sufficiency of the sex hormones at all times yet allow DHT, and thereby the associated motivation/pleasure/reward neurotransmitters, a degree of diurnal variation.
Potentially a "best of both worlds" situation.

My suggestion to any guy starting therapy, or struggling with their current protocol, would be to consider the following:

Give DHT equal importance to E2. (At least Consider that the DHT:E2 ratio, at adequate levels, is what counts).

Don't be persuaded by the virtual demonisation of DHT as the "stuff that makes you go bald". (Sure raising the level of androgens will exacerbate and accelerate the balding process in those that are predisposed so if you believe or know that you have androgenic alopetia you may have a choice to make).

At the start of therapy ensure DHT is included in your bloods panel. Many providers don't routinely test for DHT as serum levels are though to be a poor indication of activity at receptor/in tissue. Personally I have found serum levels to be instructive.

Don't think of injectables/transdermals as an either/or option but potentially as "what dose of each" to get effective relief of symptoms.
 
#3
My contention is that TRT as it is widely practiced is failing many patients, gives sub-optimal results to others and oftentimes, where it does "work", works almost by default.

If a guy is symptomatic and is diagnosed as low T he is often started on a regimen of an aromatisable Testosterone (say injectable T Cyp). At a sufficient dosage most patients will quickly reach adequate levels of TT and E2, however many don't have relief of symptoms: their lack of 5-ar conversion means DHT levels remain too low.

Here's where it often all goes wrong: In order to achieve relief of symptoms the dosage of T Cyp is usually increased, often repeatedly. As the dosages are increased the need for an AI to "balance" levels increases too. Some, fortunate, patients will find relief early enough in this process and before TT has become too elevated. Others won't until their TT levels cause side effects - blood pressure, HCT, lipids, prolactin.

This type of regimen I would describe as balancing hormones from the top down - elevating E2 to excessive levels and then rebalancing to DHT with the use of AIs.
This is fundamentally wrong. Whatever happened to that basic tenet of good medicine: using the minimum efficacious dose for the relief of symptoms?
What symptomatic guys need is a sufficiency and balance of DHT and E2 the 2 metabolites of T. Surely that balance is better achieved by increasing DHT disproportionately to E2. ie balancing from the bottom up.

Guys that are symptomatic are low in androgens, some may have lacked androgens their entire existence: in the womb, at puberty and throughput adulthood. They start therapy and what are they prescribed - large doses of aromatisable T (perhaps topped off with hCG). The prospects for many are a short lived, and possibly bewildering, "honeymoon period" (where androgens and dopamine predominate) followed by a crash where estrogens, prolactin and norepinephrine return with a vengeance.

We know that T Cream, particularly when applied to the scrotum, will raise DHT disproportionately to other modalities. (There was the good news this week that Dr Crisler is introducing this therapy - others will surely follow). We also know that many guys, particularly over time, have absorbency problems with transdermals. We know too that a relatively small amount of injectable T will give us adequate levels of TT and E2.
What I conclude from those 3 facts is that a correctly dosed protocol of T Cyp conjunctive with T Cream has good prospects as an efficacious therapy. That is a weekly dosage of T Cyp (in suitably divided doses) and a daily dosage of T Cream.

A great advantage of this mixed modality of administering T, is the potential to keep a sufficiency of the sex hormones at all times yet allow DHT, and thereby the associated motivation/pleasure/reward neurotransmitters, a degree of diurnal variation.
Potentially a "best of both worlds" situation.

My suggestion to any guy starting therapy, or struggling with their current protocol, would be to consider the following:

Give DHT equal importance to E2. (At least Consider that the DHT:E2 ratio, at adequate levels, is what counts).

Don't be persuaded by the virtual demonisation of DHT as the "stuff that makes you go bald". (Sure raising the level of androgens will exacerbate and accelerate the balding process in those that are predisposed so if you believe or know that you have androgenic alopetia you may have a choice to make).

At the start of therapy ensure DHT is included in your bloods panel. Many providers don't routinely test for DHT as serum levels are though to be a poor indication of activity at receptor/in tissue. Personally I have found serum levels to be instructive.

Don't think of injectables/transdermals as an either/or option but potentially as "what dose of each" to get effective relief of symptoms.
Very well thought out. I’m intrigued enough to have my dht tested next time. Are there other ways to raise dht other than scrotal creams? I’m concerned about my wife coming in contact with the T cream.
 
#4
YBWV
What were your dht levels prior to starting T and what are your DHT levels now that you are on T??
What is your T dosage?
 
#5
Very well thought out. I’m intrigued enough to have my dht tested next time. Are there other ways to raise dht other than scrotal creams? I’m concerned about my wife coming in contact with the T cream.
If you slather it on in the AM and go to work you should be fine later in the day. Transference I think is a bit exaggerated and would have to be some direct, extensive contact.
 

S1W

Active Member
#7
The current norm in patients who use both seems to be lead with Cypionate, etc, and supplement with cream. I'm curious what it might feel like to reverse those roles - lead with cream, supplement with Cypionate.

For example, apply 100mg 20% cream every morning, while injecting a low weekly dose of cypionate to provide a higher/more stable baseline?
 
#8
what about taking Masteeron or Proviron instead of rubbing cream on your balls? You could dose it more exact and directly add DHT without effecting your T level.
 
Thread starter #9
Post of the day. Well done. @YBWV

It used to be said in years past that you could have a better result treating a mans DHT as opposed to giving Testosterone.
I believe the reason DHT has often been disregarded as TRT has evolved owes much to the background of many of the leading practitioners.

At BobyBuiding levels of exogenous T there will never be a deficit of DHT and when it does become an issue its probably because it "caused" problems, notably MPB.

Like most things in life it's about balance.
And adequate, physiological levels.
 
#10
what about taking Masteeron or Proviron instead of rubbing cream on your balls? You could dose it more exact and directly add DHT without effecting your T level.
Good point though it's crucial to explain the things that you can legally obtain and things that are basically illegal as no Dr worth anything is going to prescribe Mast/Pro to you. We're talking here about what is legal and can be prescribed. You are not.
 
#11
YBWV if a person injects 2x50mg/W or 100mg/W how would a mixed protocol (T gel and Cyp) look like more or less considering all levels are fine, DHT, TT, FT etc...
Just curious!
 
#12
Good point though it's crucial to explain the things that you can legally obtain and things that are basically illegal as no Dr worth anything is going to prescribe Mast/Pro to you. We're talking here about what is legal and can be prescribed. You are not.
Bingo. We’ve discussed the pros and cons of compounds like mast. Problem is it’s not legal in the US so the point is moot.
 
Thread starter #13
Bingo. We’ve discussed the pros and cons of compounds like mast. Problem is it’s not legal in the US so the point is moot.
That's essentially what brought me to Excelmale - the fact that in the US Proviron etc are not licenced and therefore there is the workaround of significantly raising DHT by applying T Cream direct to the scrotum.

The question I was raising, and you responded to my previous post, was is there an effect locally in the testes in addition to the overall (mostly beneficial) systemic effect. Is it possible that there is an effect on intratesticular aromatisation?

The main reason I am interested in that is because of the difficulty with the local aromatisation in hCG therapy. In such therapy a patient is shut down already so adding an Androgen wouldn't be a problem.
I assume the answer must be "No" otherwise hCG + T Cream might offer potential as an efficacious regimen.
If anyone does have any answers/pointers I'd be grateful.
 
Thread starter #17
Good post, although blocking estradiol is as bad as blocking DHT. I think combing injections with scrotal T creams will become more popular.

And DHT is not as bad as guys think. Here is a review.

Effect of DHT on Prostate and Sexual Function: Review of Studies - ExcelMale
Thanks for commenting Nelson. I appreciate all you do for men's Health and the opportunity to participate on your Forum.
I've recommended Excelmale to several contacts - particularly my doctor.

I have to say that "blocking" E2 is the very last thing on my mind - keeping it at an adequate level and in balance with DHT is what I strive to achieve. So my question on the prospect that the T Cream might have a local effect at the testes wasn't in hope that it could block aromatisation but more that it could perhaps improve the balance of androgen to estrogens.
As I understand it excessive intratesticular aromatisation is what often undermines hCG monotherapy.
 

Nelson Vergel

Founder, ExcelMale.com
#19
Thanks for commenting Nelson. I appreciate all you do for men's Health and the opportunity to participate on your Forum.
I've recommended Excelmale to several contacts - particularly my doctor.

I have to say that "blocking" E2 is the very last thing on my mind - keeping it at an adequate level and in balance with DHT is what I strive to achieve. So my question on the prospect that the T Cream might have a local effect at the testes wasn't in hope that it could block aromatisation but more that it could perhaps improve the balance of androgen to estrogens.
As I understand it excessive intratesticular aromatisation is what often undermines hCG monotherapy.
Increased DHT will decrease estradiol. DHT occupies estrogen receptors.

There is not a single study that shows that increased aromatization caused by HCG use is a bad thing. I actually think its a good thing and probably related to the improved sex drive and penile sensitivity we feel on TRT + HCG. Also, increased E2 with HCG levels off.

hcg 300 qd 3 days estradiol.jpg

HCG men estradiol.PNG

You may want to read the latest review on aromatization:

The Top 18 Things You Did Not Know About Estradiol's Role in Men's Health | Discounted Labs
 
#20
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