About to Start a New Protocol

[Astro]

I am new to this forum.

I’m an active 69 y/o male in generally good health. I’m not overweight, I exercise regularly, my resting pulse is 55, I eat fairly healthy, don’t smoke and only drink one or two beers per week. I have been diagnosed with secondary-hypogonadism. My LH and FSH were “inappropriately normal” according to my endo (both should have been higher). An MRI showed a very small tumor (adenoma) on the pituitary gland, which may be responsible—but this is an unknown and will be monitored each year going forward, to see if the tumor changes shape or size. I qualified for TRT because of low Free Testosterone and typical low-T symptoms. I have been on TRT for 6 months and currently taking 75mg Test-enanthate weekly.

I’m seeking some advice on a proposed new protocol—suggested by a new doctor.

Baseline Before TRT:
Total-T: 333 (129-767)
Free-T (dialysis/MS): 42.4 (44-244)
SHBG: 67 (10-57)
Estradiol (not sensitive): 17.7 (11.3-43.2)
DHT: 300 (106 - 719)
DHEA-S: 24 (42-290)
TSH: 3.14
T3: 3.0

My goals for TRT are (in order of priority)

Productivity: restore my energy, motivation, quick decision-making, sociability, mood.

Sexual Function: rescue my libido (now at zero), improve erections, restore penile sensitivity and orgasm intensity.

Physical: At my age, I fight muscle-loss and even just maintaining muscle is difficult. Gaining a little would be nice—but not essential.

I’ve been with an endo for 6 months. We tried daily gel (50mg then 75mg). Then switched to T-enanthate injections sub-q at 50mg weekly and then 75mg, injected weekly—which is where I am today.

Her sole focus throughout this process was on getting my Free-T to a “normal” level. She recently declared victory when my FT reached 137 pg/ml (47-244 ARUP labs). She achieved this by switching to blood labs taken at mid-point (day 3.5), instead of at trough-level (day 7, pre-injection). Through six months of treatment she has been thoroughly uninterested in whether any of my symptoms had diminished. So I've recently changed doctors.

Here are some current lab numbers:

Total-T: 1129 (250-1100) tested at mid-point
Total-T: 1102 (250 - 1100) tested at trough
Free-T (dialysis/MS): 170.4 (30-135) Quest/tested at mid-point
Free-T (dialysis/MS): 80.6 (6-73) Quest/tested at trough
SHBG: 74 (22-77)
Estradiol (sensitive): 40 (< 30) Quest/tested at mid-point
Estradiol (sensitive): 29 (< 30) Quest/tested at trough
DHEA-S: 12 (20-217)

My symptoms have improved somewhat.
My mood is a bit better and I no longer feel depressed.
I have some improvement in energy/productivity for about 3 days per week as I move through the weekly roller-coaster.
These improvements are short-lived and not as strong as I was hoping for. My endo is not interested in any of this.

My new doctor is recommending the following:

160mg Test-cyp per week, split into 80mg every 3.5 days.
500 mg HCG twice weekly
20mg DHEA daily

I have not started this yet. I can sort of understand the reasoning for this. I'm getting some benefit from 75mg but it doesn't last the whole week. The new protocol takes care of this by (1) switching to Cyprionate, and (2) adding another dose of approximately the same size each week. However, this more than doubles the amount of testosterone and adds 2 new factors (HCG and DHEA).

I’m somewhat worried that this amount of Test could push my estradiol too high and require AI to control it—I’m really not eager to go there. My current Test:E-2 ratios suggest that I could actually use more E-2 so perhaps I'm worrying over nothing.

I'm also curious about the dose of HCG. I may not need that much. Is it easier to titrate upward or downward? Would it be better to start low and move up? After 6 months of TRT my testes are already atrophied. I'm not concerned about that. I''ve no intention of having children and I'm not upset with the cosmetic effect of a smaller scrotum. I've gathered from reading other posts that HCG has other benefits (like making you generally feel better), but I wouldn't want to take more than necessary.

Sorry if this post is a bit scattered. I'm just a bit nervous about making such a big change all at once.
Any comments, suggestions or advice would be welcome. Thanks to all of you. This is a great site.

 

[madman]

I am new to this forum.

I’m an active 69 y/o male in generally good health. I’m not overweight, I exercise regularly, my resting pulse is 55, I eat fairly healthy, don’t smoke and only drink one or two beers per week. I have been diagnosed with secondary-hypogonadism. My LH and FSH were “inappropriately normal” according to my endo (both should have been higher). An MRI showed a very small tumor (adenoma) on the pituitary gland, which may be responsible—but this is an unknown and will be monitored each year going forward, to see if the tumor changes shape or size. I qualified for TRT because of low Free Testosterone and typical low-T symptoms. I have been on TRT for 6 months and currently taking 75mg Test-enanthate weekly.

I’m seeking some advice on a proposed new protocol—suggested by a new doctor.

Baseline Before TRT:
Total-T: 333 (129-767)
Free-T (dialysis/MS): 42.4 (44-244)
SHBG: 67 (10-57)
Estradiol (not sensitive): 17.7 (11.3-43.2)
DHT: 300 (106 - 719)
DHEA-S: 24 (42-290)
TSH: 3.14
T3: 3.0

My goals for TRT are (in order of priority)

Productivity: restore my energy, motivation, quick decision-making, sociability, mood.

Sexual Function: rescue my libido (now at zero), improve erections, restore penile sensitivity and orgasm intensity.

Physical: At my age, I fight muscle-loss and even just maintaining muscle is difficult. Gaining a little would be nice—but not essential.

I’ve been with an endo for 6 months. We tried daily gel (50mg then 75mg). Then switched to T-enanthate injections sub-q at 50mg weekly and then 75mg, injected weekly—which is where I am today.

Her sole focus throughout this process was on getting my Free-T to a “normal” level. She recently declared victory when my FT reached 137 pg/ml (47-244 ARUP labs). She achieved this by switching to blood labs taken at mid-point (day 3.5), instead of at trough-level (day 7, pre-injection). Through six months of treatment she has been thoroughly uninterested in whether any of my symptoms had diminished. So I've recently changed doctors.

Here are some current lab numbers:

Total-T: 1129 (250-1100) tested at mid-point
Total-T: 1102 (250 - 1100) tested at trough
Free-T (dialysis/MS): 170.4 (30-135) Quest/tested at mid-point
Free-T (dialysis/MS): 80.6 (6-73) Quest/tested at trough
SHBG: 74 (22-77)
Estradiol (sensitive): 40 (< 30) Quest/tested at mid-point
Estradiol (sensitive): 29 (< 30) Quest/tested at trough
DHEA-S: 12 (20-217)

My symptoms have improved somewhat.
My mood is a bit better and I no longer feel depressed.
I have some improvement in energy/productivity for about 3 days per week as I move through the weekly roller-coaster.
These improvements are short-lived and not as strong as I was hoping for. My endo is not interested in any of this.

My new doctor is recommending the following:

160mg Test-cyp per week, split into 80mg every 3.5 days.
500 mg HCG twice weekly
20mg DHEA daily

I have not started this yet. I can sort of understand the reasoning for this. I'm getting some benefit from 75mg but it doesn't last the whole week. The new protocol takes care of this by (1) switching to Cyprionate, and (2) adding another dose of approximately the same size each week. However, this more than doubles the amount of testosterone and adds 2 new factors (HCG and DHEA).

I’m somewhat worried that this amount of Test could push my estradiol too high and require AI to control it—I’m really not eager to go there. My current Test:E-2 ratios suggest that I could actually use more E-2 so perhaps I'm worrying over nothing.

I'm also curious about the dose of HCG. I may not need that much. Is it easier to titrate upward or downward? Would it be better to start low and move up? After 6 months of TRT my testes are already atrophied. I'm not concerned about that. I''ve no intention of having children and I'm not upset with the cosmetic effect of a smaller scrotum. I've gathered from reading other posts that HCG has other benefits (like making you generally feel better), but I wouldn't want to take more than necessary.

Sorry if this post is a bit scattered. I'm just a bit nervous about making such a big change all at once.
Any comments, suggestions or advice would be welcome. Thanks to all of you. This is a great site.

Here are some current lab numbers:

Total-T: 1129 (250-1100) tested at mid-point
Total-T: 1102 (250 - 1100) tested at trough
Free-T (dialysis/MS): 170.4 (30-135) Quest/tested at mid-point
Free-T (dialysis/MS): 80.6 (6-73) Quest/tested at trough
SHBG: 74 (22-77)
Estradiol (sensitive): 40 (< 30) Quest/tested at mid-point
Estradiol (sensitive): 29 (< 30) Quest/tested at trough
DHEA-S: 12 (20-217)

My symptoms have improved somewhat.
My mood is a bit better and I no longer feel depressed.
I have some improvement in energy/productivity for about 3 days per week as I move through the weekly roller-coaster.
These improvements are short-lived and not as strong as I was hoping for. My endo is not interested in any of this.


Forget testing mid-point as the goal here is to achieve a healthy trough FT.

We always want to test at the true trough (lowest point) before your next injection.

Seeing as you are injecting once weekly your true trough is 7 days post-injection.

Downfall for many when following a once weekly protocol is that there will be a big swing in the peak--->trough and blood levels will not be as stable throughout the week which can have a negative effect on mood, energy, libido/erectile function and recovery due to the big swing in hormones especially when injecting strictly IM.

Top it off that many are aiming for too high a trough which means that peak TT and more importantly FT will be sky-high!

You would be far better off splitting up the weekly dose and atleast injecting twice-weekly (every 3.5 days) which will clip the peak--->trough and result iin more stable blood levels throughout the week.

As we always preach on here start low and go slow on a T only protocol as we want to see how your body reacts to T and where said protocol will have your trough TT and more importantly FT, estradiol let alone other critical blood markers RBCs, hemoglobin and hematocrit.

There will always be time to increase the dose if need be.

Much easier going up than coming down.

Most men on TTh are injecting 100-200 mg T/week whether once weekly or split into more frequent injections as in twice-weekly (every 3.5 days), M/W/F, EOD or daily.

The majority of men can easily hit a healthy let alone high trough FT injecting 100-150 mg T/week especially when split into more frequent injections.

Yes there will always be those outliers who may need the higher-end dose 200 mg/week but it is far from common as in rare.

Such dose would have the majority overmedicated!

Looking over your lab results as you can see you are hitting a high trough TT 1102 ng/dL but with a high SHBG 74 nmol/L your trough FT is still going to be decent and although your trough FT is on the high-end of the reference range supposedly tested using the most accurate assay (Equilibrium Dialysis) the reference range seems off compared to the reference range given for your mid-point FT.

Even whe looking at your pre-TTh baseline FT you listed dialysis but the reference range would be for the calculated method (modified Vermeulen).

We can easily calculate your FT using the linear law-of-mass action Vermeulen (cFTV) which will give a good approximation.

If we take your high trough TT 1102 ng/dL, high SHBG 74 nmol/L and Albumin 4.3 g/dL (default) then your trough cFTV 15.5 ng/dL would be healthy.

You are hitting a trough TT 1102 ng/dL and trough cFTV 15.5 ng/dL 7 days post-injection which means that your peak TT and more importantly FT will be much higher as in almost double!

Free & Bioavailable Testosterone calculator

FT <5 ng/dL would be considerd low.

FT 5-9 ng/dL would be considered the grey zone where some men may experience symptoms of low-T.

FT 10-15 ng/dL would be healthy.

FT 20-25 ng/dL would be high-end/high.

The majority of men will do well with a trough FT 15-25 ng/dL depending on the injection frequency.

Need to keep in mind that there is a big difference between one running a high-end/high trough FT 20-25 ng/dL injecting daily vs twice-weekly vs once weekly.

Also going to be a big difference in peak--->trough on said protocol!

Many tend to overlook this and gun for a high-end/high trough FT only to end up struggling with sides especilly in the long run.

Just to put this in perspective most healthy young males would be hitting a cFTV 13-15 ng/dL or 10-12 ng/dL tested using the most accurate assay the gold standard Equilibrium Dialysis and this is a short-lived daily peak to boot!

You are hitiing a trough cFTV 15.5 ng/dL 7 days post-injection so there is no way in hell anyone can say your trough FT is too low or subpar!

Even then you could easily split the dose and inject twice-weekly (every 3.5 days) which will clip the peak--->trough as in bring up your trough and soften the peak and your blood levels will be more stable throughout the week.




My new doctor is recommending the following:

160mg Test-cyp per week, split into 80mg every 3.5 days.
500 mg HCG twice weekly
20mg DHEA daily

I have not started this yet. I can sort of understand the reasoning for this. I'm getting some benefit from 75mg but it doesn't last the whole week. The new protocol takes care of this by (1) switching to Cyprionate, and (2) adding another dose of approximately the same size each week. However, this more than doubles the amount of testosterone and adds 2 new factors (HCG and DHEA).


This is overkill off the hop!

Will not make much of a difference whether one is injecting TE or TC when it comes to the PKs as they are basically interchangeable.

160 mg T/week split into twice-weekly injections will most likely have your trough FT too high let alone throwing in the hCG will drive up your TT/FT and estradiol further.

Top it off such dose is a surefire way to drive up your RBCs, hemoglobin and hematocrit.

Standard starting dose across the board is 100 mg T/week or better yet 50 mg T twice-weekly.

Yes some mey choose to start <100 mg T/week.

Again always best to start low and go slow preferably on a T only protocol so you can see how you react to said dose of T and where said protocol (dose of T/injection frequency) has your trough TT and more importantly FT, estradiol let alone critical blood markers RBCs, hemoglobin and hematocrit.

There will always be time to increase the dose if need be or add in hCG.

Starting dose 250iu hCG twice-weekly is sensible no need to jump in at 500iu.

If you start off on T + hCG and end up running into any issues you will be at a loss trying to tease things out.

All that should really matter here is the dose of T one needs to achieve a healthy trough FT which will result in relief/improvement of low-T symptoms and overall well-being.

Yes symptom relief is what truly matters but when it comes to what trough FT level is needed one needs to keep in mind the overall goal would be to use the least amount in order to feel well while at the same time minimizing/preventing sides and keeping blood markers healthy long-term.

Bottom line do what you feel is best for you!




Look over the threads in post #6

Thread 'Erythrocytosis: Diagnosis and investigation'

Dec 24, 2024

FIGURE 2 Management of erythrocytosis (Source: adapted from BSH guidelines 2019).6

Abstract

An absolute erythrocytosis is present when the red cell mass is greater than 125% of the predicted. This is suspected when the hemoglobin or hematocrit is above the normal range. An erythrocytosis can be classified as primary or secondary and congenital or acquired. The commonest primary acquired disorder is polycythemia vera. The diagnostic criteria for PV have evolved over time and this is the main diagnosis managed in hematology clinics. There...

• madman
• testosterone; t-therapy; erythrocytosis; h/h/rbcs
• Replies: 5
• Forum: Testosterone Side Effect Management

post #6

Thread 'Testosterone Therapy and Erythrocytosis - the most common dose-limiting effect of testosterone therapy'

Apr 21, 2024

Testosterone Therapy and Erythrocytosis • The Blood Project

Introduction Androgens play a crucial role in the development and maintenance of: Male reproductive and sexual functions Body composition Erythropoiesis

www.thebloodproject.com

Introduction

• Androgens play a crucial role in the development and maintenance of:
  
  • Male reproductive and sexual functions
  • Body composition
  • Erythropoiesis
  • Muscle and bone health
  • Cognitive function
• Testosterone falls progressively with age and a significant percentage of men over the age of 60 years have serum testosterone levels that are below the lower limits of young...

• madman
• hypogonadism; testosterone; hematocrit; cvd
• Replies: 12
• Forum: Testosterone Side Effect Management

• 

Thread 'Age-stratified reference ranges for directly measured (ED LC-MS/MS) serum free testosterone in healthy men'

May 11, 2024

Just to be clear up any confusion this is Fiers camps data for mFT reference ranges not the harmonized reference range being worked on by the CDC.


*Serum samples were analyzed from healthy men participating in the SIBLOS/SIBEX and EMAS studies, both population-based cohort studies

* mFT levels were measured in 867 men using ED LC-MS/MS as previously reported (1). Subsequently, 95% reference ranges were determined using the non-parametric method


Reference: 1. Fiers T, Wu F, Moghetti P, Vanderschueren D, Lapauw B, Kaufman JM. Reassessing Free-Testosterone...

• madman
• free testosterone; ed/refernce range; tth
• Replies: 4
• Forum: Testosterone and Men's Health Articles

 

[Phil Goodman]

Glad you went with another doc. Her being unconcerned with symptom resolution is a big red flag, and switching the testing day to midweek instead of trough and proclaiming victory due to increased levels on test is one of the dumbest things I’ve ever heard.


Off the top of my head with regard to your newly suggested protocol. Doubling your dose and adding HCG at the same time seems like overkill, as madman mentioned.I’d say start with 50 mg twice/week and go with IM over sub q. Since you’ve already noticed significant atrophy I’d say go with 250 ius of HCG 3 times/week. And your DHEA levels have been consistently low so adding that is probably a good idea. 25 mg/day is a good starting point, but you may end up wanting to dial that down to 12.5 mg/day. Actually that would put you on almost the exact same protocol I’m on, only difference being I’m at 120/week for test. I’ve been through a few different protocols over the years but this is one I’ve stuck with for a long time and is the best I’ve found. Obviously everyone is different, but based on numbers, symptoms, and response to your earlier protocol I think that would be a great next step for you. Then just adjust as needed if it leaves anything to be desired. Only other thing I would add is that it would likely be beneficial to coincide your heavy lifting days so that they fall on day of test injection or the day after, as that could help with recovery and muscle growth,

 

[Astro]

Thank you both for your advice and support! I agree that my first Endo's switch to mid-point testing was bogus and essentially cheating. She really didn't seem to know what she was doing and she made mistakes on nearly every Rx she wrote for me--these needed correction before the pharmacy would fill them.

I'm not in a hurry, so taking my time to find the right dose is fine with me. I certainly don't want to overshoot the proper dose and have to titrate downward. I think the doctor mentioned his intent to saturate my high SHBG. Not sure what benefit that would achieve--or even what that means.

Phil, I'm not clear on why you recommend IM injections. I've read as much medical literature as I could find on this topic and I got the impression that sub-Q injections were just as effective in delivering testosterone--plus they are less painful and produce less scar tissue over time. A good article from the JournaI of Clinical Endocrinology and Metabolism that I found in PubMed (PMC9006970) summarizes several other articles and provides context. Testosterone Therapy With Subcutaneous Injections: A Safe, Practical, and Reasonable Option - PMC

Madman correctly spotted an error in my listing of Free-T levels for one of the labs. Sorry about that. My Endo refused to order most of these labs. Once treatment started, she only ordered FT, hemoglobin and hematocrit. I wanted more data so I could track E-2 and other measures, so I paid out of pocket and got my own labs through Quest and LabCorp. Kind of pissed about that.

You've provided several links to articles and posts--I've not reviewed them yet, but I will...I want to educate myself and take more control of my treatment. I think I'm going to start with 50mg Test E3.5D. After 4 to 6 weeks I could make an assessment of my symptoms and get some labs. Then ramp up to 60mg twice weekly and try that. Going up step-wise this way should ensure that I won't skip over the proper dose. I'll wait until I have the proper T-dose figured out before starting HCG. I've already started taking some DHEA (currently 15mg/daily). I also test low on Pregnenolone: 12 ng/dl (22-237). Should I supplement that too? Its available OTC.

Question: Assuming I stick with HCG doses of roughly 700 to 1,000mg/week (split into 2 or 3 doses), how much extra endogenous testosterone would my testes likely produce? For example, if I find that my perfect Test-dose is 120mg/week, would subsequent activation of my testes with HCG cause my internal testosterone (injected + endogenous) to jump to, say, 140mg/week?

Thanks again for your help. It matters.

 

[Vince]

I am new to this forum.

I’m an active 69 y/o male in generally good health. I’m not overweight, I exercise regularly, my resting pulse is 55, I eat fairly healthy, don’t smoke and only drink one or two beers per week. I have been diagnosed with secondary-hypogonadism. My LH and FSH were “inappropriately normal” according to my endo (both should have been higher). An MRI showed a very small tumor (adenoma) on the pituitary gland, which may be responsible—but this is an unknown and will be monitored each year going forward, to see if the tumor changes shape or size. I qualified for TRT because of low Free Testosterone and typical low-T symptoms. I have been on TRT for 6 months and currently taking 75mg Test-enanthate weekly.

I’m seeking some advice on a proposed new protocol—suggested by a new doctor.

Baseline Before TRT:
Total-T: 333 (129-767)
Free-T (dialysis/MS): 42.4 (44-244)
SHBG: 67 (10-57)
Estradiol (not sensitive): 17.7 (11.3-43.2)
DHT: 300 (106 - 719)
DHEA-S: 24 (42-290)
TSH: 3.14
T3: 3.0

My goals for TRT are (in order of priority)

Productivity: restore my energy, motivation, quick decision-making, sociability, mood.

Sexual Function: rescue my libido (now at zero), improve erections, restore penile sensitivity and orgasm intensity.

Physical: At my age, I fight muscle-loss and even just maintaining muscle is difficult. Gaining a little would be nice—but not essential.

I’ve been with an endo for 6 months. We tried daily gel (50mg then 75mg). Then switched to T-enanthate injections sub-q at 50mg weekly and then 75mg, injected weekly—which is where I am today.

Her sole focus throughout this process was on getting my Free-T to a “normal” level. She recently declared victory when my FT reached 137 pg/ml (47-244 ARUP labs). She achieved this by switching to blood labs taken at mid-point (day 3.5), instead of at trough-level (day 7, pre-injection). Through six months of treatment she has been thoroughly uninterested in whether any of my symptoms had diminished. So I've recently changed doctors.

Here are some current lab numbers:

Total-T: 1129 (250-1100) tested at mid-point
Total-T: 1102 (250 - 1100) tested at trough
Free-T (dialysis/MS): 170.4 (30-135) Quest/tested at mid-point
Free-T (dialysis/MS): 80.6 (6-73) Quest/tested at trough
SHBG: 74 (22-77)
Estradiol (sensitive): 40 (< 30) Quest/tested at mid-point
Estradiol (sensitive): 29 (< 30) Quest/tested at trough
DHEA-S: 12 (20-217)

My symptoms have improved somewhat.
My mood is a bit better and I no longer feel depressed.
I have some improvement in energy/productivity for about 3 days per week as I move through the weekly roller-coaster.
These improvements are short-lived and not as strong as I was hoping for. My endo is not interested in any of this.

My new doctor is recommending the following:

160mg Test-cyp per week, split into 80mg every 3.5 days.
500 mg HCG twice weekly
20mg DHEA daily

I have not started this yet. I can sort of understand the reasoning for this. I'm getting some benefit from 75mg but it doesn't last the whole week. The new protocol takes care of this by (1) switching to Cyprionate, and (2) adding another dose of approximately the same size each week. However, this more than doubles the amount of testosterone and adds 2 new factors (HCG and DHEA).

I’m somewhat worried that this amount of Test could push my estradiol too high and require AI to control it—I’m really not eager to go there. My current Test:E-2 ratios suggest that I could actually use more E-2 so perhaps I'm worrying over nothing.

I'm also curious about the dose of HCG. I may not need that much. Is it easier to titrate upward or downward? Would it be better to start low and move up? After 6 months of TRT my testes are already atrophied. I'm not concerned about that. I''ve no intention of having children and I'm not upset with the cosmetic effect of a smaller scrotum. I've gathered from reading other posts that HCG has other benefits (like making you generally feel better), but I wouldn't want to take more than necessary.

Sorry if this post is a bit scattered. I'm just a bit nervous about making such a big change all at once.
Any comments, suggestions or advice would be welcome. Thanks to all of you. This is a great site.

I'm close to your age and I have been on TRT for over 10 years. Here's my protocol.

Thread 'Vince's Labs from October 14, 2024'

Oct 23, 2024

Same protocol, 16 mg of testosterone cypionate daily, 500 iu of hcg every third day and no AI.

Pregnenolone 10 mg and 10 mg of DHEA.

My last injection before labs, about 27 1/2 hrs.

Labs are from LabCorp.

I did "not" get the Equilibrium Ultrafiltration for testing free testosterone. I didn't want to spend the extra money.

Testosterone, Serum 1482 ng/dL range 264-916
Free Testosterone 24.5 ng/dL range 6.6 -18.1
DHT 61 ng/dL (no range on results)
DHEA-Sulfate 260.0 H ug/dL range 30.9-295.6 (age adjusted)
Estradiol, Sensitive 26.7 pg/mL range 8.0-35.0
Sex Horm Binding Glob, Serum 57.5...

• Vince
• Replies: 7
• Forum: Blood Test Discussion

 

[Phil Goodman]

@Astro the reason I suggested IM is because based on the numerous accounts I’ve heard from people who have tried both delivery methods, IM is preferred by a significant majority. Some people seem to do just fine with sub q though so if it’s working for you then don’t switch up based on my suggestion alone. One of the key benefits of IM is that you’re delivering to tissue with blood flow, so absorption is faster and I’d say more consistent. But there are pros and cons to both methods so just find what works for you.

Since you are a case of secondary hypogonadism, I’d say you’re more likely to respond well to HCG. The issue, as far as we know, wasn’t with your testicles, but rather with your pituitary not signaling them to produce. No way to know until you start it, but you have a better chance of significant increase from HCG. That being said, yes, it could cause you to overshoot your sweet spot if you find that on test alone then add HCG to the mix. That’s one reason I recommended just going ahead and adding both. Normally I recommend going with one at a time, but since you’re already on test and have a lot of atrophy then it’s not quite the same as someone starting both right out the gate. But dialing in on test alone could still be a good option though. But like you said, you’ll need to factor that in when adding HCG. When I did it I went from 120/week to 100 and added HCG and my levels stayed about the same. Over time I ended up back at 120/week though, but I’ve felt good throughout the entire journey for the most part.

 

[Astro]

That sounds awesome. How much HCG do you use, and did you ever adjust it?

 

[Phil Goodman]

That sounds awesome. How much HCG do you use, and did you ever adjust it?

When I first added it I was at 120 mg/test per week and 1,000 ius of HCG(500 ius twice/week). That resulted in some weird Sundays consistently and over time I considered perhaps it was my HCG protocol playing a role. Though I will say I was going through things in my personal life that played a role, but the HCG did as well I’m almost certain. I had also dropped my test dose down to 100/week at some point along the way. Then I changed my HCG to 750 ius/week(250 3 times/week). That made a noticeable difference and I’ve been with that HCG protocol ever since. I did end up bumping my test dose back up to 120/week by adding 20 mgs on Sat. in addition to my normal MWF regimen. I don’t always do Sat. but most of the time I do, and it’s my heaviest gym day so I think that actually helps.

As far as timeline, within about 3 weeks of adding HCG there was a noticeable difference in size, and between weeks 4-5 my balls were as full as ever. That was in 1,000 ius per week though, so that may have been a little different if I’d gone with 750/week right out of the gate.

 

[Astro]

If I'm, potentially, a high responder to HCG, it might make sense to stay at 75mg Test/week (but switched to half that twice weekly) and then add HCG twice weekly. That would get me on-board with HCG and allow me to see its effects.

 

[madman]

Thank you both for your advice and support! I agree that my first Endo's switch to mid-point testing was bogus and essentially cheating. She really didn't seem to know what she was doing and she made mistakes on nearly every Rx she wrote for me--these needed correction before the pharmacy would fill them.

I'm not in a hurry, so taking my time to find the right dose is fine with me. I certainly don't want to overshoot the proper dose and have to titrate downward. I think the doctor mentioned his intent to saturate my high SHBG. Not sure what benefit that would achieve--or even what that means.

Phil, I'm not clear on why you recommend IM injections. I've read as much medical literature as I could find on this topic and I got the impression that sub-Q injections were just as effective in delivering testosterone--plus they are less painful and produce less scar tissue over time. A good article from the JournaI of Clinical Endocrinology and Metabolism that I found in PubMed (PMC9006970) summarizes several other articles and provides context. Testosterone Therapy With Subcutaneous Injections: A Safe, Practical, and Reasonable Option - PMC

Madman correctly spotted an error in my listing of Free-T levels for one of the labs. Sorry about that. My Endo refused to order most of these labs. Once treatment started, she only ordered FT, hemoglobin and hematocrit. I wanted more data so I could track E-2 and other measures, so I paid out of pocket and got my own labs through Quest and LabCorp. Kind of pissed about that.

You've provided several links to articles and posts--I've not reviewed them yet, but I will...I want to educate myself and take more control of my treatment. I think I'm going to start with 50mg Test E3.5D. After 4 to 6 weeks I could make an assessment of my symptoms and get some labs. Then ramp up to 60mg twice weekly and try that. Going up step-wise this way should ensure that I won't skip over the proper dose. I'll wait until I have the proper T-dose figured out before starting HCG. I've already started taking some DHEA (currently 15mg/daily). I also test low on Pregnenolone: 12 ng/dl (22-237). Should I supplement that too? Its available OTC.

Question: Assuming I stick with HCG doses of roughly 700 to 1,000mg/week (split into 2 or 3 doses), how much extra endogenous testosterone would my testes likely produce? For example, if I find that my perfect Test-dose is 120mg/week, would subsequent activation of my testes with HCG cause my internal testosterone (injected + endogenous) to jump to, say, 140mg/week?

Thanks again for your help. It matters.

Phil, I'm not clear on why you recommend IM injections. I've read as much medical literature as I could find on this topic and I got the impression that sub-Q injections were just as effective in delivering testosterone--plus they are less painful and produce less scar tissue over time. A good article from the JournaI of Clinical Endocrinology and Metabolism that I found in PubMed (PMC9006970) summarizes several other articles and provides context. Testosterone Therapy With Subcutaneous Injections: A Safe, Practical, and Reasonable Option - PMC


I posted that study on here back in 2021 (link below)

IM was always considered the go to in the past but sub-q is much more commonplace now as it is just as effective for most men.

My uro is considered one of the pioneers in Canada when it comes to subcutaneous T injections.

Been doing this since the early 2000s and has treated 1000s of men that have done well (symptom relief/improvement) let alone achieving high/very high TT/FT levels.

I have been injecting strictly sub-q for 8.5 years and could easily achieve a healthy, high or absurdly high FT on such!

With all that being said you also need to keep in mind that when it comes to injecting oil-based esterified T subcutaneously some individuals do not fare well.

Comes down to the individual and how you react as there are some men who may experience lumps/nodules, pain/swelling, itchiness at the injection site injecting strictly sub-q even when injecting lower volumes of the oily solution.

Can be due to an allergic reaction to the excipients/carrier oil, ester use, or poor injection technique.

The volume of the oily solution and injection technique can play a big role.

Also need to keep in mind that some men will have issues with absorption/effectiveness hitting lower T levels sub-q vs IM although it is not commonplace.

Need to experiment over time and do what you feel is best for you!

Thread 'TRT with Subcutaneous Testosterone Injections: A Safe, Practical and Reasonable Option'

Oct 26, 2021

Abstract Context: Injections with intramuscular testosterone esters have been available for almost 8 decades and not only result in predictable serum testosterone levels but are also the most inexpensive modality. However, they are difficult to self-administer and associated with some discomfort. Recently, subcutaneous administration of testosterone esters has gained popularity, as self-administration is easier with this route. Available data, though limited, support the feasibility of this route. Here we review the pharmacokinetics and safety of subcutaneous testosterone therapy...

• madman
• subcutaneous testosterone injections
• Replies: 18
• Forum: Testosterone Basics & Questions

• 

Look over the numerous links to older threads in my reply post #24

Post in thread 'Can you help me calculate testosterone dose in 0.5 cc syringe?'

May 17, 2025

I know its ben awhile since posted but u will never get test into that small of a syringe. Plus Test is an IM (in the muscle inj) & those tiny insulin syringes dont reach muscle. U need a 1-3 CC syringe w/ a 1 inch needle. Prob 20-23 gauge

Such advice is old and outdated!

This is not the forum for such.

Where have you been hiding?

Oil based esterified T can be injected subcutaneously!

Most in the know are using LDS insulin syringes fixed needle 27-31G various needle lengths to draw'inject the oil based esterified T solution whether injecting shallow IM or strictly sub-q...

• madman

I think I'm going to start with 50mg Test E3.5D. After 4 to 6 weeks I could make an assessment of my symptoms and get some labs. Then ramp up to 60mg twice weekly and try that. Going up step-wise this way should ensure that I won't skip over the proper dose. I'll wait until I have the proper T-dose figured out before starting HCG.


Sensible dose (100 mg T split twice-weekly) and labs will be done 4-6 weeks in once steady-state is reached.

Just so you understand no one should be increasing their dose 4-6 weeks in after getting blood work unless your trough FT came back too low which is highly unlikely for the majority of men starting therapy.

More importantly here is you need to understand how exogenous T works.

The first 6 weeks means nothing when looking at the bigger picture here especially when it comes to gauging relief/improvenment of low-T symptoms and overall well-being!

You will be in a world of hurt if you keep bumping up your dose every 6 weeks because you do not feel well or are stuck on that more T is better mentality bulls**t.

Many still lack the understanding of how exogenous T works.

As I have stated numerous times on the forum over the years when starting TTh or tweaking a protocol (increasing/decreasing dose of T) hormones will be in FLUX during the weeks leading up until blood levels have stabilized (4-6 weeks TC/TE) and it is common for one to experience ups (increasing T dose) or downs (decreasing T dose) along the way as the body is trying to ADJUST.

Common when first starting TTh or tweaking a protocol (increasing dose of T) to experience what we call the honeymoon period increased energy, euphoric like state, increased libido and erections due to rising hormones, dopamine boost and lighting up of the ARs.

Addictive but unfortunately this is short-lived/temporary as the body will eventually ADAPT to its NEW SET-POINT!

Unfortunately many will keep chasing this to no avail, jack up your dose further!

Dead end road here!

The first 6 weeks is misleading when looking at the bigger picture.

Even then once blood levels have stabilized it will still take time (a few more months) for the body to ADAPT to its NEW SET-POINTand this is the critical time period when one needs to gauge how they truly feel overall regarding relief/improvement of low-t symptoms and overall well-being.

Every protocol needs to be given a fair shake/fighting chance 12 WEEKS before claiming whether it was truly a success or failure.

The uniformed ones tend to bailout 6 weeks in because they do not feel good and end up bailing out early.

The ones starting out on TTh end up increasing their dose thinking that higher levels are needed.

The ones that were jacked upon T from the get-go end up going back on the higher dose claiming they do not feel good on lower doses.

Put money on it if you put one on T for a 6 month trial and started them off low and slow on a T-only protocol and never let them see labs 6 weeks in let alone the 3 and 6 month mark and went by symptom relief slowly increasing the dose at 6 weeks if needed then 3 month mark if needed and 6 month mark if needed many would end up running much lower levels than they think would have been needed!

To many caught up on these so called HRT/men's health forums loaded with all those blast n cruisers let alone so called gurus polluting the net have already been brainwashed by the more T is better sheep mentality bulls**t!




Look over this thread!

Post in thread 'Surprising blood results . . . so is this it?'

May 24, 2024

Just because it's common doesn't mean it's a good idea. Such dosing came about because of infrequent injections, once every week or even every two weeks. The larger doses keep serum-level troughs close to physiological. But ignored are the excessive peaks, which are responsible for many of the side effects.

@Melody68: There is further evidence that lower dosing is preferred in the relatively new XYOSTED product. This is testosterone enanthate without any additives. As a result it has a half-life that is about double that of typical formulations of TE/TC. This in turn...

• madman

Critical point that needs to be stressed here!

*Following the initiation of testosterone therapy, serum concentrations of testosterone are known to correct earlier than the symptomatic, structural, and metabolic signs associated with TD





26. What is a reasonable timeline to begin to observe improvements in the signs and symptoms of testosterone deficiency?


*Following the initiation of testosterone therapy, serum concentrations of testosterone are known to correct earlier than the symptomatic, structural, and metabolic signs associated with TD.76,77 As such, patients should be counseled that symptom response will not be immediate. Expectations for treatment response should be established with each patient. Patients can anticipate improvements in many of the common symptoms of TD (libido, energy levels, sexual function) after 3 months of treatment or longer. Metabolic and structural (body composition, muscle mass, bone density) changes may take upwards of 6 months. 77 In addition, patients should be counseled that diet and exercise in combination with testosterone therapy are recommended for body composition changes.

*Appreciating this pattern of response to testosterone therapy is fundamental when determining the impact of treatment and the appropriate timing of follow-up evaluations while on therapy. For example, if patients undergo a symptom review and measurement of testosterone levels too early (< 3 months), it may lead both physicians and patients to conclude that the treatment has not been impactful (i.e. normal levels of testosterone without symptomatic/structural/metabolic benefit). However, if the same assessment was scheduled 3-6 months after the initiation of therapy, the clinical response tends to be more reflective of normalized levels of serum testosterone.

 

[Seagal]

I am new to this forum.

I’m an active 69 y/o male in generally good health. I’m not overweight, I exercise regularly, my resting pulse is 55, I eat fairly healthy, don’t smoke and only drink one or two beers per week. I have been diagnosed with secondary-hypogonadism. My LH and FSH were “inappropriately normal” according to my endo (both should have been higher). An MRI showed a very small tumor (adenoma) on the pituitary gland, which may be responsible—but this is an unknown and will be monitored each year going forward, to see if the tumor changes shape or size. I qualified for TRT because of low Free Testosterone and typical low-T symptoms. I have been on TRT for 6 months and currently taking 75mg Test-enanthate weekly.

I’m seeking some advice on a proposed new protocol—suggested by a new doctor.

Baseline Before TRT:
Total-T: 333 (129-767)
Free-T (dialysis/MS): 42.4 (44-244)
SHBG: 67 (10-57)
Estradiol (not sensitive): 17.7 (11.3-43.2)
DHT: 300 (106 - 719)
DHEA-S: 24 (42-290)
TSH: 3.14
T3: 3.0

My goals for TRT are (in order of priority)

Productivity: restore my energy, motivation, quick decision-making, sociability, mood.

Sexual Function: rescue my libido (now at zero), improve erections, restore penile sensitivity and orgasm intensity.

Physical: At my age, I fight muscle-loss and even just maintaining muscle is difficult. Gaining a little would be nice—but not essential.

I’ve been with an endo for 6 months. We tried daily gel (50mg then 75mg). Then switched to T-enanthate injections sub-q at 50mg weekly and then 75mg, injected weekly—which is where I am today.

Her sole focus throughout this process was on getting my Free-T to a “normal” level. She recently declared victory when my FT reached 137 pg/ml (47-244 ARUP labs). She achieved this by switching to blood labs taken at mid-point (day 3.5), instead of at trough-level (day 7, pre-injection). Through six months of treatment she has been thoroughly uninterested in whether any of my symptoms had diminished. So I've recently changed doctors.

Here are some current lab numbers:

Total-T: 1129 (250-1100) tested at mid-point
Total-T: 1102 (250 - 1100) tested at trough
Free-T (dialysis/MS): 170.4 (30-135) Quest/tested at mid-point
Free-T (dialysis/MS): 80.6 (6-73) Quest/tested at trough
SHBG: 74 (22-77)
Estradiol (sensitive): 40 (< 30) Quest/tested at mid-point
Estradiol (sensitive): 29 (< 30) Quest/tested at trough
DHEA-S: 12 (20-217)

My symptoms have improved somewhat.
My mood is a bit better and I no longer feel depressed.
I have some improvement in energy/productivity for about 3 days per week as I move through the weekly roller-coaster.
These improvements are short-lived and not as strong as I was hoping for. My endo is not interested in any of this.

My new doctor is recommending the following:

160mg Test-cyp per week, split into 80mg every 3.5 days.
500 mg HCG twice weekly
20mg DHEA daily

I have not started this yet. I can sort of understand the reasoning for this. I'm getting some benefit from 75mg but it doesn't last the whole week. The new protocol takes care of this by (1) switching to Cyprionate, and (2) adding another dose of approximately the same size each week. However, this more than doubles the amount of testosterone and adds 2 new factors (HCG and DHEA).

I’m somewhat worried that this amount of Test could push my estradiol too high and require AI to control it—I’m really not eager to go there. My current Test:E-2 ratios suggest that I could actually use more E-2 so perhaps I'm worrying over nothing.

I'm also curious about the dose of HCG. I may not need that much. Is it easier to titrate upward or downward? Would it be better to start low and move up? After 6 months of TRT my testes are already atrophied. I'm not concerned about that. I''ve no intention of having children and I'm not upset with the cosmetic effect of a smaller scrotum. I've gathered from reading other posts that HCG has other benefits (like making you generally feel better), but I wouldn't want to take more than necessary.

Sorry if this post is a bit scattered. I'm just a bit nervous about making such a big change all at once.
Any comments, suggestions or advice would be welcome. Thanks to all of you. This is a great site.

I would only add the dhea and observe if there is an improvement in symptoms. Imho this is reasonable because your dhea-s tested deficient twice.

 

[madman]

That sounds awesome. How much HCG do you use, and did you ever adjust it?

Your doing a 360 here going from 75 mg T/week to 100 mg T/week split (50 mg every 3.5 days) and have absolutely no clue where said dose is going to have your trough FT let alone how you are going to respond!

You were already hittting a healthy trough cFTV 15.5 ng/dL 7 days post-injection which also means your peak TT/ FT ( 8-24 hrs ) post-injection and TT/FT levels during the first 2-3 days would be very high.

You could have easily stayed on 75 mg/week and split the dose 37.5 mg every 3.5 days which would have easily brought up your trough FT and softened the peak.

Now you are increasing your weekly dose to 100 mg T/week split (50 mg every 3.5 days) which should easily have you hitting a healthy/high trough.

Throwing in the hCG off the hop is going to drive up your TT and more importantly FT and estradiol further!

Again if you run into any issues you will have a hard time teasing it out.

You would be far better going with T only until blood work is done so you can see where said dose has your trough levels.

You have already went without hCG for 6 month and another 6 weeks is not going to set you back here!

Either way do what you feel is best for you!

 

[Astro]

I'm trying to keep up with you, Madman!

I read that other thread. Learned a lot.

If I understand correctly: T-cyp blood levels will stabilize after about 6 weeks and a trough-blood-test could show where FT sits at that dose. If FT was not at an appropriate level, it might make sense to adjust the dose (up or down) but it would be much too early to adjust the dose based on symptoms alone. Symptoms can't assessed for at least 3 to 6 months.

Currently, my trough FT (80.6 pg/ml) appears OK, although its way below the target set by my new doctor. (He wants to see 200-250). I've been on my current dose (75mg/week) for 11 weeks. I can wait a while before making a change, although I think I'd like to make the switch to E3.5D just to even out the peaks/troughs--while keeping the total weekly dose constant. Would that be OK? Or is that going to restart the clock and prevent another adjustment for another 3-6 months?

 

[madman]

I'm trying to keep up with you, Madman!

I read that other thread. Learned a lot.

If I understand correctly: T-cyp blood levels will stabilize after about 6 weeks and a trough-blood-test could show where FT sits at that dose. If FT was not at an appropriate level, it might make sense to adjust the dose (up or down) but it would be much too early to adjust the dose based on symptoms alone. Symptoms can't assessed for at least 3 to 6 months.

Currently, my trough FT (80.6 pg/ml) appears OK, although its way below the target set by my new doctor. (He wants to see 200-250). I've been on my current dose (75mg/week) for 11 weeks. I can wait a while before making a change, although I think I'd like to make the switch to E3.5D just to even out the peaks/troughs--while keeping the total weekly dose constant. Would that be OK? Or is that going to restart the clock and prevent another adjustment for another 3-6 months?

Free-T (dialysis/MS): 80.6 (6-73) Quest/tested at trough

That is not the reference range for Quests Equilibrium Dialysis which is 35-155 pg/mL (3.5-15.5 ng/dL) it is most likely a modified form of the calculated Vermeulen (cFTV).

Looking over the refernce ranges you posted for mid/trough FT they are different so you never used the most accurate assay ED everytime you tested!

You would need to retest your trough FT to verify this and your best bet would be using Nelsons discounted labs as testing is done through Quest Diagnostics using the most accurate assays for TT (LC-MS/MS) and FT (Equilibrium Dialysis).

Testosterone, Free (Equilibrium Dialysis) and Total, MS - Most Affordable and Accurate Test

Get an affordable and accurate testosterone test results with our Total Testosterone, M and Free (Equilibrium Dialysis) test. Visit DiscountedLabs.com for more information.

www.discountedlabs.com

That is why I used the linear law of-mass-action Vermeulen which is the go to method for FT if it was not tested using the gold standard ED.

With a high trough TT 1102 ng/dL, high SHBG 74 nmol/L and Albumin 4.3 g/dL (default) your trough FT 7 days post-injection would have been 155 pg/mL (15.5 ng/dL) which is healthy.

Yes I already stated that a more sensible move would be splitting your weekly dose and injecting twice-weekly.

You could stay on your current protocol 75 mg T/week and split the dose which would clip your peak--->trough meaning bring up your trough and soften the peak which means that your trough FT would end up being higher as in 200-250 pg/mL (20-25 ng/dL).

Even then I stated that the standard starting dose is 100 mg T/week or better yet 50 mg T every 3.5 days.

So yes you can increase your current dose 75 mg T/week by 25 mg and it should easily have your trough FT much higher than your current trough 155 pg/mL (15.5 ng/dL).

Again as I stated you are going to be better off splitting your weekly dose so go ahead just decide on whether you want to stick with your current dose 75 mg T or bump it up to 100 mg T.

 

[madman]

I'm trying to keep up with you, Madman!

I read that other thread. Learned a lot.

If I understand correctly: T-cyp blood levels will stabilize after about 6 weeks and a trough-blood-test could show where FT sits at that dose. If FT was not at an appropriate level, it might make sense to adjust the dose (up or down) but it would be much too early to adjust the dose based on symptoms alone. Symptoms can't assessed for at least 3 to 6 months.

Currently, my trough FT (80.6 pg/ml) appears OK, although its way below the target set by my new doctor. (He wants to see 200-250). I've been on my current dose (75mg/week) for 11 weeks. I can wait a while before making a change, although I think I'd like to make the switch to E3.5D just to even out the peaks/troughs--while keeping the total weekly dose constant. Would that be OK? Or is that going to restart the clock and prevent another adjustment for another 3-6 months?

Baseline Before TRT:
Total-T: 333 (129-767)
Free-T (dialysis/MS): 42.4 (44-244)
SHBG: 67 (10-57)
Estradiol (not sensitive): 17.7 (11.3-43.2)
DHT: 300 (106 - 719)
DHEA-S: 24 (42-290)
TSH: 3.14
T3: 3.0

Your FT was tested using a modified calculated method as I can tell from the reference range used.




Here are some current lab numbers:

Total-T: 1129 (250-1100) tested at mid-point
Total-T: 1102 (250 - 1100) tested at trough
Free-T (dialysis/MS): 170.4 (30-135) Quest/tested at mid-point
Free-T (dialysis/MS): 80.6 (6-73) Quest/tested at trough
SHBG: 74 (22-77)
Estradiol (sensitive): 40 (< 30) Quest/tested at mid-point
Estradiol (sensitive): 29 (< 30) Quest/tested at trough
DHEA-S: 12 (20-217)


Your mid-point FT look as though it may have been testedby ED but ther refernce range should be 35-155 pg/mL unless it was adjusted for your age bracket!

Your trough FT which is what truly matters here was not tested using the most accurate assay the gold standard Equilibrium Dialysis based on the reference range so I would not rely on such that is why I calculated your trough FT using the go to linear law-of-mass action Vermeulen (cFTV) which will give a good approximation.

The gold standard Equilibrium Dialysis would be considered the most accurate assay when it come to free testosterone but if you live in a country which does not have access to such highly doubtful if you reside in the US then you would need to use/rely upon the calculated linear law-of-mass action Vermeulen (cFTV).

The only way to know where FT truly sits is to have it tested using the most accurate methods/assays (ED/UF) especially in cases of altered SHBG.

The gold standard would be Equilibrium Dialysis.

If you do not have access (highly doubtful if you reside in the US) to such then you would need to use/rely upon the go to calculated linear law-of-mass action cFTV which will give a good approximation but keep in mind it tends to overestimate FT.

As I have stated numerous times on the forum you always have the option of using/relying upon calculated FT which would be the linear law-of-mass action cFTV as it has already been validated twice (1st time was done using TT/SHBG assays no longer available) and was then eventually re-validated using current state-of-the-art ED method (higher order reference method) let alone more recently against CDCs standardized Equilibrium Dialysis assay.

Yes it tends to overestimate slightly but it is nothing to fret over!


*Calculated free T using high-quality T and SHBG assays has been considered the most useful for clinical purposes [99]. All algorithms suffer from some inaccuracies, including the variable quality of SHBG IAs [100], not replicating the non-linear nature of T-SHBG binding, different and inaccurate association constants for SHBG and albumin binding [101], and variable agreement with equilibrium dialysis results [99,100]. However, until further developments in the field materialize, the linear model algorithms [in particular, the most used Vermeulen equation [102]] appear to give, despite a small systematic positive bias, acceptable data for the clinical management and research[37,103]

Thread 'Use of calculated FT in men: advantages and limitations'

Nov 6, 2024

Use of calculated free testosterone in men: advantages and... : Current Opinion in Endocrinology, Diabetes and Obesity

hting its relevance in preventing misdiagnosis and overtreatment of male hypogonadism. Recent findings While there is consensus on measuring total T – comprising sex hormone-binding globulin (SHBG)-bound, albumin-bound, and free T – as a first step in diagnosing male hypogonadism, evidence...

journals.lww.com

INTRODUCTION

Clinical practice guidelines on the diagnosis of male hypogonadism focus on clinical signs and symptoms of androgen deficiency, as well as biochemical assessment of low circulating testosterone (T). However, there is a longstanding debate, as well as a persisting controversy concerning biochemical assessment of serum T and in particular the use (and misuse) of free T. Free T, as advocated by the free hormone hypothesis, represents...

• madman
• hypogonadism; free testosterone; cft/ed
• Replies: 10
• Forum: Testosterone and Men's Health Articles

 

[Astro]

Thanks!
My FT labs at mid-point was done by Quest and was 170.7 pg/ml (30-135) and used Dialysis. I only got the mid-point labs because I knew that my endo was going to make a decision using her Utah based lab (ARUP) for Free-T at mid-point. The ARUP lab uses Eq-Dialysis/MS but it also uses a completely different range so its not comparable with Quest or LabCorp.

My FT labs at trough used Quest's cheaper service which included:
Total T: 1102
SHBG: 74
BioAvailable: 169.3 (15-150)
Free-T (calculated): 80.6 (6-73)
Albumin: 4.6

Using the on-line calculator (and correcting for the slightly different Albumin level) gives me a Free-T of 15.1 ng/dl which lands in the "healthy" range.

Why my new doctor set such high levels as targets really baffles me:
Free-T: 200-250
E-2: 30-60
DHEA-s: 200-300

Looks like I need to have a conversation with him so I understand what is driving his protocol. I want to move A LOT slower than he does, apparently. I would hate to have to switch doctors, yet again. But I will if he is not willing to work with me on this.

 

[madman]

Thanks!
My FT labs at mid-point was done by Quest and was 170.7 pg/ml (30-135) and used Dialysis. I only got the mid-point labs because I knew that my endo was going to make a decision using her Utah based lab (ARUP) for Free-T at mid-point. The ARUP lab uses Eq-Dialysis/MS but it also uses a completely different range so its not comparable with Quest or LabCorp.

My FT labs at trough used Quest's cheaper service which included:
Total T: 1102
SHBG: 74
BioAvailable: 169.3 (15-150)
Free-T (calculated): 80.6 (6-73)
Albumin: 4.6

Using the on-line calculator (and correcting for the slightly different Albumin level) gives me a Free-T of 15.1 ng/dl which lands in the "healthy" range.

Why my new doctor set such high levels as targets really baffles me:
Free-T: 200-250
E-2: 30-60
DHEA-s: 200-300

Looks like I need to have a conversation with him so I understand what is driving his protocol. I want to move A LOT slower than he does, apparently. I would hate to have to switch doctors, yet again. But I will if he is not willing to work with me on this.

Just to be clear here based off cFTV correcting for Albumin you are hitting a trough FTV 15.1 ng/dL which would be healthy and far from low.

This is 7 days post-injection to boot.

As I stated earlier most healthy young males would be hitting a cFT 13-15 ng/dL or 10-12 ng/dl tested using the most accurate assay ED and this is a short-lived daily peak to boot!

Just to be clear if your trough FT had been tested using the most accurate assay ED than it would have come back lower as cFTV tends to overestimate slightly.

You might end up around 12-13 ng/dL which would still be considered healthy although it is well under where many would aim for on T-therapy which would be high-end/high (20-25 ng/dL).

Again most men will do well with a trough FT 15-25 ng/dL.

Yes many would tend to aim for a higher trough 20-25 ng/dL but again you need to put this in persective.

There is a huge difference in one hitiing a high-end/high trough FT injecting daily vs twice-weekly vs once weekly.

Big difference in peak--->.trough here.

Yes many may fare better running a higher-end trough but again you need to pay attention to your trough/injection frequency.

Many tend to overlook this.

Running too high a trough/steady-state FT can be just as bad in many ways as running too low a FT especially when it comes to libido and erectile function.

You will be hammering the s**t out of your dopamine 24/7 let alone in many cases may have very well blown way beyond your natty genetic set-point!

T has a tonc effect in the CNS which can easily make one feel amped up.

T levels were never meant to be jacked up 24/7!

There is a fine balance here.

The only sensible way you will ever know is to start low and go slow and work your way up until you find what trough FT level you can handle/feel good on overall while at the same time preventing/minimizing any sides and keeping blood markers healthy long-term.

Downfall here is way too many men are jacked up on T from the get-go let alone fall into the trap of that more T is better sheep mentality bulls**t.

 

[Systemlord]

Things got overly complicated too quickly, splitting your dose up twice weekly would’ve been more reasonable. It never ceases to amaze me how many times endo’s fail at something as simple as treating a man with low testosterone.

 

[madman]

Thanks!
My FT labs at mid-point was done by Quest and was 170.7 pg/ml (30-135) and used Dialysis. I only got the mid-point labs because I knew that my endo was going to make a decision using her Utah based lab (ARUP) for Free-T at mid-point. The ARUP lab uses Eq-Dialysis/MS but it also uses a completely different range so its not comparable with Quest or LabCorp.

My FT labs at trough used Quest's cheaper service which included:
Total T: 1102
SHBG: 74
BioAvailable: 169.3 (15-150)
Free-T (calculated): 80.6 (6-73)
Albumin: 4.6

Using the on-line calculator (and correcting for the slightly different Albumin level) gives me a Free-T of 15.1 ng/dl which lands in the "healthy" range.

Why my new doctor set such high levels as targets really baffles me:
Free-T: 200-250
E-2: 30-60
DHEA-s: 200-300

Looks like I need to have a conversation with him so I understand what is driving his protocol. I want to move A LOT slower than he does, apparently. I would hate to have to switch doctors, yet again. But I will if he is not willing to work with me on this.

What percentile of healthy young men would even be hitting a peak not trough FT 20-25 ng/dL?

Even if you took the outlier nattys (healthy young men) hitting a high FT 20-25 ng/dL again this is a short-lived daily peak to boot!

Sure as hell not a trough - depending on injection frequency - 2 days later (EOD), 3 days later (M/W/F), 3.5 days later (twice-weekly), let alone 7 days later (once weekly)!

Again just to put this in perspective most healthy young males would be hitting a FT 10-12 ng/dL tested using the gold standard Equilibrium Dialysis assay (most accurate) or a cFTV 13-15 ng/dL and this is a short-lived peak to boot!

Very few nattys are running around with a peak FT 20-25 ng/dL, 25 ng/dL being the 95th percentile!

These would be outliers here!

Better yet show me a healthy young natty male walking around with a high-end peak TT let alone 1000+ ng/dL with FT through the roof that has low/lowish SHBG.

Such does not exist!

Thread 'Age-stratified reference ranges for directly measured (ED LC-MS/MS) serum free testosterone in healthy men'

May 11, 2024

Just to be clear up any confusion this is Fiers camps data for mFT reference ranges not the harmonized reference range being worked on by the CDC.


*Serum samples were analyzed from healthy men participating in the SIBLOS/SIBEX and EMAS studies, both population-based cohort studies

* mFT levels were measured in 867 men using ED LC-MS/MS as previously reported (1). Subsequently, 95% reference ranges were determined using the non-parametric method


Reference: 1. Fiers T, Wu F, Moghetti P, Vanderschueren D, Lapauw B, Kaufman JM. Reassessing Free-Testosterone...

• madman
• free testosterone; ed/refernce range; tth
• Replies: 4
• Forum: Testosterone and Men's Health Articles

*We established mFT reference ranges for healthy men aged 18 to 69 years




We present 95% mFT age-stratified reference ranges

Age category (years)	Median mFT (ng/dl)	95% mFT reference range (ng/dl)
18-29 (n=140) 30-39 (n=252)	12.0 9.8	6.7-25.3 4.9-18.5
40-49 (n=207)	8.1	4.3.14.2
50-59 (n=146)	7.1	3.8-12.8
60-69 (n=126)	6.4	3.4-11.7
70-79 (n=125)	5.6	2.7-8.7

*The gold-standard for the determination of FT levels is considered to be directly measured free testosterone (mFT) using equilibrium dialysis followed by mass spectrometry (ED LC-MS/MS). However, no widely accepted reference ranges are available for this clinical parameter. We established mFT reference ranges for healthy men aged 18 to 69 years






*Serum samples were analyzed from healthy men participating in the SIBLOS/SIBEX and EMAS studies, both population-based cohort studies


* mFT levels were measured in 867 men using ED LC-MS/MS as previously reported (1).


Reference: 1. Fiers T, Wu F, Moghetti P, Vanderschueren D, Lapauw B, Kaufman JM. Reassessing Free-Testosterone Calculation by Liquid Chromatography–Tandem Mass Spectrometry Direct Equilibrium Dialysis. J Clin Endocrinol Metab. 2018;103(6). doi:10.1210/jc.2017-02360

In the current study, we used a state-of-the-art direct ED method to reassess FT in sets of representative serum samples. This method takes advantage of the ability of a highly sensitive and accurate measurement of T by liquid chromatography–tandem mass spectrometry (LC-MS/MS) to reliably measure the low FT concentration directly in the dialysate after ED. This more straightforward method avoids potential sources of inaccuracy in indirect ED, such as those resulting from tracer impurities or from measures to limit their impact (e.g., sample dilution). We then used the measured FT results to re-evaluate some characteristics of two more established and a more recently proposed calculations for estimation of FT.








Look over post # 19/21/23

Post in thread 'Feedback on lab results'

Oct 13, 2024

I think that’s a good point about people going from injections to oral, and it would take some time to adjust to daily rollercoasters while also not being elevated more throughout the week. However, I also think that the term “absurdly high” is pretty subjective, and sitting at or slightly above the top of the reference range isn’t necessarily a bad thing. If a person takes care of themselves with diet, exercise, and sleep.. then I’d say being on the higher end is probably a better thing. It’s definitely preferential for building muscle and bone density, which is very...

• madman

• 

 

[Astro]

Thanks again to all who posted. I never expected to get so much support from strangers.

The whole hormone thing is still very new to me and I have a lot to learn. If I've learned anything today, its that I need to slow down. It might take a year or more to find my appropriate doses, but in the end I'll have a better understanding of what my body needs.