You replied in two threads, so I’ll answer all your questions in this one.
My current protocol is 135 mg per week, split over 3 injections. My RBC is 5.37 (range 4.5–6.5), hemoglobin is 160 g/L, and hematocrit is 49.4. I’ve been on this protocol for 3 months.
I originally started with a cream applied to the balls twice daily. That was the only time I’ve felt good over the year of trying different protocols. The improvement only lasted about a week, and I believe it was around week five. At the time, I thought this was because my estrogen had risen too high, as it was 174 pmol/L compared to a TT of 32 nmol/L, and I was also experiencing sore nipples. After more research though I believe I could be related too DHEA as apparently DHEA raises for the first 6 weeks you start and then goes back down, would explain why after I hit stability on week 5 I felt amazing but then after the DHEA went back down I stated to feel bad again.
Because I didn’t want to inject much at the time, I then tried Sustanon, which was the worst protocol for me, so I quickly switched to cypionate. I started cypionate at 120 mg per week and am now on 135 mg per week.
Another commenter said it probably wasn’t hormonal, but I have to disagree. I was 23 when I started TRT, and until that point I had never once had morning wood. I got it for the first time when I started using the cream. I also had a major baby face and never shaved; my face was smooth, even with a magnifying glass you might have seen only a white hair or two. My blood test at the time showed a total testosterone of 15.2 nmol/L, taken first thing in the morning.
I would be down to lower my dose again but I am kind of praying it just has to do with having low DHEA and being a big responder to estrogen and having to take an AI.
Because I didn’t want to inject much at the time, I then tried Sustanon, which was the worst protocol for me, so I quickly switched to cypionate. I started cypionate at 120 mg per week and am now on 135 mg per week.
Still doubtful the low DHEA is the main culprit here.
Unfortunately when it comes to exogenous T many lack the understanding of how things work.
Highly doubtful you tried a lower dose first as the standard starting dose across the board by those in the know is 100 mg T/week and slim chance that you even even gave the protocols enough time as in 3 months to truly gauge the effectiveness.
When you switched over from Sustanon to TC you jumped on 120 mg T/week which is higher than the standard starting dose 100 mg T/week or better yet 50 mg T twice-weekly.
At least this time around you stuck with it for 12 weeks.
You are currently injecting 135 mg T/week which has you hitting a very high trough TT and more importantly your trough FT would be very high mind you seeing as you are injecting 3X weekly your peak--->trough would not be as extreme as someone injecting once weekly but you are still hitting a very high trough FT.
Not sure what testing method was used to test your FT but chances are seeing as you live outside of the US it was calculated.
Keep in mind the only way to know where your FT truly sits would be testing it using the most accurate assay the gold standard Equilibrium Dialysis especially in cases of altered SHBG.
If you live outside of the US then you would need to use/rely on the next best testing method which would be the go to calculated linear law-of-mass action Vermeulen (cFTV) which will give a good approximation.
No one should be using/relying on the known to be inaccurate direct IA (RIA/CLIA).
If we calculate your FT using Vermeulen method then with a very high trough TT 1182.5 ng/dL (41 nmol/L), normal SHBG 32.5 nmol/L and Albumin 4.3 g/dL (default) then your trough cFTV 30.3 ng/dL would be very high.
It is a given that with a very high trough TT 1182.5 ng/dL and normal SHBG that your trough FT would be very high.
Your peak TT and more importantly FT and estradiol will be higher.
Peak will be achieved within 24 hrs post-injection whether injecting TC or TE.
I see no issue with where your trough sits if you feel great overall, minus any sides and blood markers are healthy but unfortunately this is not the case.
Is it really due to the low DHEA?
You would easily have room to lower your weekly dose and bring down your trough FT if need be.
Reference range 6.5-25 ng/dL
When it comes to any protocol the body needs time to adapt to its new set-point.
If you jump the gun too soon you will end up chasing your tail until the cows come home.
The majority of men on therapy are using injectable T and the most commonly used esters are the medium acting esterified TC or TE.
Some men do use the short acting esterified TP but it is not as common especially seeing as most men do not want to be jabbing themselves daily or EOD.
Standard starting dose is 100 mg T/week or 50 mg twice-weekly.
Most men on TTh are injecting 100-200 mg/week whether once weekly or split into more frequent injections.
The majority of men can easily hit a healthy/high trough FT on 100-150 mg T/week especially when split into more frequent injections (twice-weekly, M/W/F, EOD or daily).
Some can achieve stellar levels injecting <100 mg/week especially when injecting more frequently.
Yes there will always be this outliers who may need the higher-end dose 200 mg/week but its far from common as in rare.
Those run of the mill T-clinics littered in the US, clueless doctors and so called GURU specialists pushing that more T is better mentality and its all about optimal bulls**t are the half-wits to blame for this!
Always best to start low and go slow on a T-only protocol so you can. see how your. body reacts and where said protocol (dose of T/injection frequency) has your trough TT and more importantly FT, estradiol and critical blood markers RBCs, hemoglobin and hematocrit.
Your RBCs, H/H are in range but have you ever donated and where does your ferritin/iron sit?
There will always be time to increase the dose of T or throw in hCG if need be.
Downfall of starting therapy on T + hCG is if you run into any sides it will be hard to pinpoint the culprit.
Even then no matter which ester is used the first 6 weeks of starting therapy means nothing when looking at the big picture here.
When first starting therapy keep in mind that hormones will be in FLUX during the weeks leading up until blood levels have stabilized (4-6 weeks TC/TE) as the body is trying to and it is common for one to experience what we call the honeymoon period due to T levels rising, increased dopamine and lighting up ARs (androgen receptors), euphoria, increased energy and a strong increase in libido and erections (morning/spontaneous).
Unfortunately for the majority this is temporary and short-lived as the body is trying to ADJUST to the elevated T/dopamine boost and eventually the body will ADAPT to its new-set point and for many the increased libido/erections and euphoric like state will tend to wane over time back to what we call the norm.
Even if you are one of the lucky ones that maintains the honeymoon feeling longer it will eventually wane more in the norm.
The first 6 weeks means nothing when looking at the bigger picture because once blood levels have stabilized (4-6 weeks Tc/TE) it will still take time for the body to ADAPT to its new set-point over the next few months and 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 fighting chance (12 weeks) before claiming it was as success or failure.
I you are not willing to put in the time needed to truly gauge the effectiveness of a protocol as in 12 weeks then you are going to be left chasing your tale endlessly!
Seeing as you are already 3 months in stick with it until you see if the addition of DHEA has any positive impact otherwise you will need to take a step back and assess your protocol.
Key point 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.76,77
Canadian Urological Association clinical practice guideline on testosterone deficiency in men: Evidence-based Q&A (2021)
Ethan D. Grober, MD; Yonah Krakowsky, MD; Mohit Khera, MD; Daniel T. Holmes, MD; Jay C. Lee, MD; John E. Grantmyre, MD; Premal Patel, MD; Richard A. Bebb, MD; Ryan Fitzpatrick, MD; Jeffrey D. Campbell, MD; Serge Carrier, MD; Abraham Morgentaler, MD
Introduction
As part of their ongoing commitment to education and best practice standards, the Canadian Urological Association (CUA) solicited the creation of a clinical practice guideline dedicated to...
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.
