Learn Quickly About Testosterone Deficiency and Its Treatments

I hope you enjoy this part 1. Yes, it is almost 2 hours long but I concentrated everything I know so that you do not have to read for hours.

What is low testosterone (hypogonadism) and how is it diagnosed?​

Low testosterone, or hypogonadism, refers to insufficient testosterone levels in men, which can impact various bodily functions. It's broadly defined by total testosterone levels ranging from 300-350 ng/dL (nanograms per deciliter) to 1100 ng/dL, with some experts considering levels below 400 ng/dL as low. Diagnosis typically involves two morning-time fasting blood tests for total and free testosterone, as levels can fluctuate. Beyond blood tests, a thorough diagnosis also considers the presence of symptoms associated with low testosterone, such as decreased libido, fatigue, loss of muscle mass, and mood changes.

There are two main types of hypogonadism:

• Primary hypogonadism: Originates from testicular dysfunction, often indicated by high luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels with low testosterone.
• Secondary hypogonadism: Stems from issues in the hypothalamus or pituitary gland, resulting in low LH and FSH alongside low testosterone. Pituitary adenomas (benign tumors) can be a cause and may require an MRI for diagnosis if testosterone levels are very low without other apparent reasons.

What are the main health risks and symptoms associated with low testosterone?​

Low testosterone can manifest in a range of symptoms, impacting both physical and psychological well-being. Common symptoms include:

• Sexual dysfunction: Decreased libido, erectile dysfunction, and reduced spontaneous or morning erections.
• Physical changes: Loss of muscle mass and strength, increased fat mass, decreased bone mineral density, loss of body hair, and sometimes gynecomastia (breast tissue enlargement).
• Mood and cognitive issues: Fatigue, decreased energy and motivation, increased irritability or moodiness, depression, poor concentration, and memory disturbances.
• Other symptoms: Hot flashes and sweats (in men), anemia, and reduced physical work performance.

Beyond symptoms, low testosterone is linked to several health risks, including:

• Increased risk of metabolic syndrome (e.g., increased fat mass, high triglycerides).
• Penile damage affecting erectile function (Venus leakage).
• Increased risk of all-cause mortality and anemia.
• Increased risk of diabetes, fractures, memory-related issues, and depression.
• Increased arterial plaque and decreased sleep quality.
• Hardening of the arteries and increased inflammation.

What are common treatment options for low testosterone and their administration methods?​

The most common prescribed forms of testosterone replacement therapy (TRT) include:

• Gels and Creams (Transdermal): These are applied to the skin (e.g., arms, shoulders, inner thighs, armpits) daily.
• Advantages: Provide relatively stable blood levels, easy self-administration, and a more physiological pattern of blood levels. Compounded creams can be alcohol-free and applied to specific areas like the scrotum for potentially increased DHT.
• Disadvantages: Risk of transference to others (partners, children), inconsistent absorption in some individuals, and potential skin irritation.
• Injections: Testosterone esters like cypionate and enanthate are commonly injected. Propionate is a shorter-acting ester. Long-acting injections (e.g., testosterone undecanoate, also known as Aveed or Nebido overseas) are also available.
• Advantages: Generally inexpensive, direct delivery. Newer injection techniques using smaller needles (e.g., 27-gauge insulin syringes for subcutaneous or shallow intramuscular injections) are less painful, require less product waste, and allow for easier self-administration.
• Disadvantages: Can cause "peaks and valleys" in blood levels, leading to fluctuations in mood and energy. Higher red blood cell production is a common side effect. Traditional deep intramuscular injections can be painful.
• Pellets: Small pellets (e.g., Testopel) are inserted under the skin (typically in the upper buttocks) every 3-4 months. Compounding pharmacies can also create more concentrated and cost-effective pellets.
• Advantages: Long duration of action, stable blood levels, and improved compliance due to infrequent administration.
• Disadvantages: Requires a minor surgical procedure for insertion, risk of pellet extrusion (pellets popping out), bruising, and infection at the insertion site.
• Oral/Buccal Testosterone (e.g., Striant): A system that adheres to the gums and delivers testosterone twice daily.
• Disadvantages: Less popular due to twice-daily administration, potential gum irritation, and altered taste.

It's important to note that many doctors are moving away from the traditional 200mg every two weeks injection schedule in favor of smaller, more frequent doses (e.g., 100mg weekly or 50mg twice weekly) to minimize peaks and valleys in blood levels and reduce side effects.

What are the potential side effects and contraindications of testosterone therapy?​

While TRT offers significant benefits, it also carries potential risks and is not suitable for everyone.

Common Side Effects:

• Increased Red Blood Cells (Hematocrit): This is the most common side effect and can increase blood viscosity, raising blood pressure and potentially cardiovascular risks. Regular blood donation (phlebotomy) is often required to manage this.
• Acne and Oily Skin: Especially in younger men, higher doses can lead to increased sebum production and breakouts.
• Reduced Sperm Production and Fertility: TRT often shuts down the body's natural testosterone production, leading to decreased FSH and LH, which are essential for sperm production. This can impair fertility, though strategies like HCG can help preserve it.
• Gynecomastia: While rare with normal testosterone levels, it can occur if the testosterone-to-estrogen ratio is unfavorable, or due to genetic factors and high IGF-1 levels.
• Male Pattern Balding: DHT, a metabolite of testosterone, is linked to hair loss, especially in genetically predisposed individuals.
• Sleep Apnea: TRT can induce or worsen sleep apnea, particularly in overweight individuals.

Less Common/Controversial Side Effects:

• Decreased HDL Cholesterol: Good cholesterol levels may decrease.
• Cardiovascular Disease: The link between TRT and increased cardiovascular risk has been heavily debated, with many studies showing that normalizing testosterone actually improves cardiovascular health, while a few older, less rigorous studies suggested increased risk. Proper monitoring and management are crucial.
• Benign Prostatic Hypertrophy (BPH) and Urinary Tract Symptoms: Recent studies suggest TRT may improve, rather than worsen, urinary tract symptoms in many men. The idea that TRT causes prostate cancer is largely refuted by current data, with a "saturation model" suggesting a limited accelerative effect only in existing cancers at certain levels.
• Anxiety and Water Retention: Some men report initial anxiety or water retention, which often normalize with continued therapy or dose adjustments.

Contraindications (Who should NOT be given testosterone):

• Men with severe, untreated sleep apnea.
• Individuals with a hematocrit over 50% at baseline.
• Men with a Prostatic Specific Antigen (PSA) of 4 or higher without a urological workup.
• Men with a prior history of prostate cancer that has not been successfully treated with complete removal of the prostate and whose PSA is not normal or low.
• Men with a history of clotting disorders (e.g., DVT), as TRT may potentially increase risk in a small percentage of genetically predisposed individuals, though this is controversial.
• It is generally not contraindicated for obese patients or those with a history of cardiovascular disease, despite some doctor's perceptions.

How does testosterone replacement therapy affect other hormones and body systems?​

Testosterone replacement therapy has a significant impact on various hormones and body systems, primarily by influencing the Hypothalamic-Pituitary-Testicular Axis (HPTA). When external testosterone is introduced, the body senses sufficient levels and sends feedback to the hypothalamus and pituitary gland to decrease the production of Gonadotropin-Releasing Hormone (GnRH), Luteinizing Hormone (LH), and Follicle-Stimulating Hormone (FSH). This feedback loop effectively shuts down the body's natural testosterone production and sperm production by the testicles.

Beyond direct suppression, testosterone also influences other hormones:

• Estrogen (Estradiol): Testosterone is a precursor to estradiol (a type of estrogen) through a process called aromatization, which occurs in the liver and fat cells. Estradiol is crucial for men's bone density, libido, cognitive function, and cardiovascular health. While essential, managing estradiol levels is important, as both excessively high or low levels can cause issues.
• DHT (Dihydrotestosterone): Testosterone is converted into DHT by the 5-alpha reductase enzyme. DHT is linked to libido, but also to potential negative side effects like acne and, controversially, prostate enlargement.
• Sex Hormone-Binding Globulin (SHBG): SHBG is a protein that binds to testosterone, making it unavailable for immediate use by the body. As men age, SHBG tends to increase, leading to lower free (unbound and active) testosterone levels. TRT can sometimes influence SHBG levels.

Systemically, TRT aims to reverse the symptoms of low testosterone, leading to:

• Improved body composition: Increased lean body mass and decreased fat mass.
• Increased muscle strength and stamina.
• Enhanced bone mineral density.
• Better mood and cognitive function.
• Improved glucose control.
• Potential cardiovascular benefits: Normalizing testosterone has been increasingly associated with improved cardiovascular health.
• Increased red blood cell production: As mentioned, this can be a side effect requiring monitoring.

What are "normal" testosterone ranges, and why is there controversy surrounding them?​

Defining "normal" testosterone levels is a point of significant controversy among medical groups, lab companies, and even experienced practitioners.

• General Range: Broadly, total testosterone levels in men are considered to range anywhere from 350 to 1100 nanograms per deciliter (ng/dL).
• Medical Guidelines: Different medical organizations have varying cut-off points for defining low testosterone. For example, some European and International societies suggested anything under 350 ng/dL as low (as of 2009 guidelines). The Endocrine Society has cited 300 ng/dL. A group of experienced prescribers in 2014 even suggested anything under 400 ng/dL.
• Insurance vs. Cash-Based Clinics: Insurance companies often require levels below 300-350 ng/dL and the presence of symptoms for TRT approval. Cash-based clinics, having more flexibility, may consider levels up to 500 ng/dL if symptoms are present.
• Lab-Specific Ranges: Each lab company often sets its own "normal" ranges based on data collected from its patient population, further contributing to the variability.

The controversy stems from the fact that a single number doesn't fully capture an individual's health status or symptom profile. Many men with testosterone levels within the "lower normal" range may still experience significant symptoms of hypogonadism. Furthermore, studies have linked various health risks to testosterone levels well above these "official" low thresholds (e.g., increased metabolic syndrome risk below 450 ng/dL, increased all-cause death risk below 350 ng/dL). This suggests that "normal" on a lab report might not equate to "optimal" for an individual's well-being and long-term health.

What factors can naturally influence testosterone levels, and are there effective over-the-counter "boosters"?​

Several lifestyle factors can significantly influence natural testosterone levels, and addressing these can often lead to improvements:

• Sleep Quality and Hygiene: This is identified as one of the most crucial factors. Chronic sleep deprivation, especially from electronics exposure before bed, severely impacts the body's natural circadian rhythm, which promotes hormone production (including testosterone) at night. Aim for at least 7 hours of quality, dark sleep per night.
• Weight Loss: Being overweight can decrease testosterone by 100-250 ng/dL. Losing weight is a powerful way to naturally increase testosterone levels.
• Glucose Control: Poor glucose control and diabetes are linked to lower testosterone. Exercise can improve glucose regulation.
• Exercise: Regular physical activity can improve testosterone, but overtraining can paradoxically decrease it.
• Environmental Toxins and Endocrine Disruptors: Exposure to plastics, pesticides, hydrocarbons, and phytoestrogens (e.g., from soy products) can act as endocrine disruptors, potentially increasing estrogen and decreasing testosterone.
• Nutrient Deficiencies: Deficiencies in certain micronutrients like zinc, magnesium, vitamins E, K, D, B6, and folate can impact testosterone production. However, supplementing only helps if a deficiency exists; otherwise, it won't boost levels.
• Chronic Illnesses: Conditions like chronic liver disease, COPD, sleep apnea, renal disease, HIV, hypertension, high lipids, and arthritis can contribute to low testosterone.
• Medications: Certain drugs, including glucocorticoids, opiates, ketoconazole, and some antidepressants or blood pressure medications, can lower testosterone.
• Alcohol and Drug Use: Excessive use can negatively impact hormone levels.

Regarding over-the-counter "testosterone boosters," the consensus is that they are generally ineffective and a multi-million dollar industry built on false promises. Many have been found to contain unlisted pharmaceutical ingredients (like sildenafil, the active ingredient in Viagra) and are not regulated by the FDA. Consumers waste a lot of money on these products, and their perceived effects are often due to hidden ingredients or placebo. Focusing on lifestyle changes is a more effective and safer approach for natural testosterone optimization.

How is testosterone therapy monitored, and what are the "10 TRT Commandments"?​

Monitoring testosterone therapy is crucial for optimizing treatment and managing side effects. It involves regular blood tests and communication with a physician.

Standard Monitoring Practices:

• Baseline Tests: Before starting TRT, initial blood tests typically include total and free testosterone, PSA (prostate-specific antigen), LH, FSH, lipids, CBC (complete blood count), and sensitive estradiol. Prolactin may also be checked if testosterone levels are very low without a clear cause.
• Follow-up Tests:6-8 Weeks Post-Initiation: First follow-up to check testosterone levels and adjust dosing. Hematocrit (red blood cell volume) should also be checked.
• 6 Months Post-Initiation: Another follow-up to assess stability and long-term side effects.
• Annually (if stable): Regular annual monitoring of key blood markers (testosterone, hematocrit, PSA, lipids) and symptom assessment.
• Specific Monitoring for Side Effects:Hematocrit: If elevated, blood donation (phlebotomy) or dose reduction may be necessary.
• PSA: Monitored for increases, which may indicate prostate issues (though often benign or due to infection rather than cancer itself).
• Estradiol: Monitored, especially with the sensitive test, as both high and very low levels can cause issues.

"10 TRT Commandments" for Patients:

1. Have reasonable expectations: TRT is not a magic cure-all.
2. Do not fall prey to testosterone booster scams.
3. Do not obsess about estradiol without testing it with the right (sensitive) test.
4. Monitor your hematocrit to prevent complications from increased red blood cells.
5. Explore easier injection methods like subcutaneous or shallow intramuscular injections with smaller needles.
6. Never "cycle" testosterone replacement: TRT is generally a continuous therapy; stopping and restarting can do more harm than good.
7. Consistently measure and monitor your blood tests and trends: Utilize tracking tools like health apps or graphs.
8. Do not change more than one variable at a time: This helps identify what works and what doesn't.
9. Protect your fertility and testicular size/function with the use of HCG if fertility is a concern.
10. Stay informed and educated about TRT, as the field is constantly evolving.

What are compounding pharmacies, and how do they fit into testosterone therapy?​

Compounding pharmacies play a significant role in testosterone therapy, especially for patients whose needs aren't met by commercially available products or for those seeking more affordable options. They custom-prepare medications based on a doctor's prescription, often tailoring the dosage, form, and ingredients to an individual patient.

Key Aspects of Compounding Pharmacies in TRT:

• Customization: They can produce testosterone creams at higher concentrations than commercial gels, or in alcohol-free bases. They also make more potent and cost-effective testosterone pellets.
• Cost-Effectiveness: Compounded products are generally much cheaper than FDA-approved commercial products, especially out-of-pocket, and can often be delivered directly to the patient's home with all necessary supplies.
• Access for Women: Compounding pharmacies are crucial for women needing testosterone therapy, as there are no FDA-approved testosterone products specifically for women. They can prepare creams or other formulations combined with progesterone or estrogen.
• Specific Formulations: Beyond standard gels and injections, they can provide options like testosterone cypionate or propionate injections, or oral medications like clomiphene (to improve fertility in younger men) and HCG (to maintain testicular size and fertility).
• Regulatory Environment: The compounding pharmacy industry is undergoing rapid changes in regulations, particularly with the rise of "503B outsourcing facilities."
• 503A Compounding Pharmacies: These are traditional pharmacies that compound medications for individual patients based on a prescription.
• 503B Outsourcing Facilities: These operate under stricter FDA regulations, similar to pharmaceutical manufacturers, ensuring higher sterility and quality control, especially for injectable products. Many traditional 503A pharmacies can no longer produce injectables due to these new, stringent requirements.

Patients should seek out compounding pharmacies, particularly 503B facilities, that have high quality standards and are FDA-inspected and regulated to ensure the safety and efficacy of their products.

 

Men's Health Lecture Slides by Nelson Vergel

 

Great video

 

Short video: Causes of Low Testosterone and Benefits of Treatment

Low Testosterone - Causes, Benefits of Treatment, and Timelines​

This briefing summarizes key information from "Low Testosterone: Causes and Benefits of Treatment," focusing on the causes of low testosterone, the proven benefits of treatment, and the expected timelines for observing these benefits.

Main Themes:​

• Multifactorial Causes of Low Testosterone: Low testosterone is not attributed to a single cause but rather a complex interplay of chronic health conditions, lifestyle factors, medications, genetic predispositions, and nutrient deficiencies.
• Comprehensive Benefits of Testosterone Therapy: Treatment for low testosterone offers a wide range of benefits extending beyond sexual health, impacting cardiovascular health, mood, cognitive function, body composition, and overall quality of life.
• Varied Timelines for Treatment Efficacy: The time it takes to see benefits from testosterone therapy varies significantly depending on the specific benefit being observed, the individual's health status, and age. Some improvements are rapid, while others take many months.

Most Important Ideas/Facts & Supporting Quotes:​

1. Diverse Causes of Low Testosterone: Low testosterone can be triggered by a wide array of factors, indicating a need for comprehensive assessment when diagnosing the condition.

• Chronic Diseases: "the causes of her organization could be chronic liver disease COPD sleep apnea renal disease use of different drugs... HIV hypertension high lipids infertility obesity sleep apnea arthritis diabetes and PG teri at enormous"
• Medications: Specific drugs are implicated, including "glucocorticoids opiates ketoconazole which is an antifungal and anabolic steroids can actually shut down testosterone production."
• Genetic and Environmental Factors: The source mentions "genetic mutations and there is there are some genetic mutations that can affect development sexual development in boys as I said before you environmental factors metabolic syndrome."
• Aging and Other Hormonal Imbalances: "illnesses aging other hormone deficiencies thyroid is one of them very connected to or to whore testosterone production."
• Nutrient Deficiencies and Lifestyle: "nutrient deficiencies as I said before life style issues medications." While specific vitamins like "magnesium vitamin E vitamin K vitamin D vitamin b6 folate" are mentioned as potentially beneficial if a deficiency exists, the source clearly states, "if you do supplement and you have no deficiencies you you will not see improvements in testosterone that's as simple as that."

2. Broad-Ranging Benefits of Testosterone Therapy: The benefits of testosterone treatment extend far beyond improving libido, significantly impacting general health and well-being.

• Cognitive and Mood Improvement: "improve cognitive function mood libido stamina really bitter non"
• Cardiovascular Health: "improve cardiovascular health actually main with low testosterone tend to die of heart disease faster than men with normal testosterone." However, it's crucial to note the controversy: "there's obviously controversial data right now that has been discussed a lot in the past few years on the use of higher doses and and poorly managed testosterone therapy that can has been associated with increase cardiovascular risk."
• Body Composition and Metabolic Control: "improving improvements in body composition in Lukis control."
• Fertility (with caveats): "fertility when you improve testosterone you can improve fertility to a certain point and then you may have a decrease in fertility depending on different factors."
• Physical Capacity and Potential Longevity: "exercise functional capacity capacity improves and there's some studies not too many really small data set that may suggest improve longevity and survival."
• Inflammation Reduction: "inflammation decreases the social basement decreases inflammation very fast within 3 to 12 weeks."
• Quality of Life: "Oddie of life could be also you can see benefits within a few weeks and that's usually what happens men tend to feel really well really good the first month and then it tends to plateau... but in most men like me there have been usually forever we we wake up to the fact that is actually improving our quality of life."

3. Timelines for Observing Benefits (Variable and Individualized): Patients should be aware that the onset of benefits varies, and some improvements take considerable time. Individual factors like age and co-morbidities influence the speed of response.

• Rapid Improvements (Weeks):Sexual Interest: "sexual interests are probably is probably the factor that improves the fastest and the most obvious within three to six weeks there's more interest in sex or more attraction to potential sexual partners."
• Inflammation Decrease: "within 3 to 12 weeks."
• Depressive Mood: "as fast as three weeks to you know as low as thirty thirty weeks."
• Quality of Life: "within a few weeks."
• Medium-Term Improvements (Months):Blood Sugar Control: "anywhere from 12 weeks on the lower side to 52 weeks."
• Long-Term Improvements (Many Months to a Year):Bone Mineral Density: "takes a long time because obviously bone is a lot harder to build this is a very slow process."
• Body Composition: "up to 52 weeks."
• Erections/Ejaculations (Less Predictable): "erections and ejaculations that is difficult to assess some men do experience better directions especially morning morning time erections and so men don't so it also depends on age and different factors that would really don't know all the factors involved."
• Individual Variation: "it's hard to predict everybody's different and depends on your age depends on you know more abilities if you have diabetes you have high blood pressure you know if you're 29 this movement compared to a 65 year old obviously there are different different conditions and different factors that are involved in the efficacy of testosterone."

What are the main causes of low testosterone?​

Low testosterone can stem from a wide range of factors, including chronic illnesses such as liver disease, COPD, sleep apnea, renal disease, HIV, hypertension, high lipids, arthritis, and diabetes. Lifestyle issues like obesity and metabolic syndrome also contribute. Certain medications, including glucocorticoids, opiates, ketoconazole, and even anabolic steroids, can suppress testosterone production. Other causes include genetic mutations affecting sexual development, environmental factors, aging, other hormone deficiencies (like thyroid issues), and nutrient deficiencies.

Can supplementing with vitamins and minerals increase testosterone levels?​

Supplementing with vitamins and minerals such as magnesium, vitamin E, vitamin K, vitamin D, vitamin B6, and folate may only improve testosterone levels if an individual has a pre-existing deficiency in those specific nutrients. If there are no deficiencies, supplementation is unlikely to result in an improvement in testosterone blood levels.

What are the recognized benefits of testosterone replacement therapy?​

Testosterone replacement therapy offers a wide array of potential benefits. These include improved cognitive function, mood, libido, and stamina. It can also enhance cardiovascular health, with studies suggesting that men with low testosterone may face a higher risk of heart disease. Improvements in body composition, glucose control, and exercise functional capacity are also commonly observed. There's some limited data suggesting potential improvements in longevity and survival. For men with low testosterone and associated infertility, therapy can improve fertility to a certain extent, though it may also decrease fertility depending on various factors.

How quickly can one expect to see benefits from testosterone therapy?​

The timeframe for experiencing benefits from testosterone therapy varies significantly depending on individual factors like age, co-morbidities (e.g., diabetes, high blood pressure), and overall health. While some benefits can be noticed relatively quickly, others take much longer. For instance, decreased inflammation can be observed within 3 to 12 weeks, and sexual interest often improves within 3 to 6 weeks. Depressive mood may improve within 3 to 30 weeks. Quality of life often sees initial improvements within a few weeks, though it may plateau thereafter. Blood sugar control and body composition changes typically take longer, ranging from 12 to 52 weeks. Bone mineral density improvement is a very slow process, requiring a considerable amount of time.

Does testosterone therapy improve fertility?​

Testosterone therapy can improve fertility to a certain point when low testosterone is a contributing factor to infertility. However, it's also important to note that depending on various factors and potentially higher doses, testosterone therapy can sometimes lead to a decrease in fertility. The impact on fertility is complex and can be individualized.

Is there any controversy surrounding testosterone therapy and cardiovascular risk?​

Yes, there has been controversial data discussed regarding the use of higher doses of testosterone therapy and poorly managed treatment plans, which have been associated with an increased cardiovascular risk. This highlights the importance of proper management and monitoring by healthcare professionals to mitigate potential risks.

What are some of the earliest and most noticeable improvements from testosterone therapy?​

Among the earliest and most consistently observed improvements from testosterone therapy are increased sexual interest and libido, which can be noticeable within 3 to 6 weeks. Many men also report a general improvement in their quality of life within the first few weeks, often feeling significantly better during the initial month of treatment. Decreased inflammation is also a relatively quick benefit, typically seen within 3 to 12 weeks.

Why do some men feel a plateau in benefits after initial improvements from testosterone therapy?​

Many men experience a significant improvement in their quality of life during the first month of testosterone therapy, leading them to feel "really good." However, this initial feeling can sometimes plateau thereafter, which might lead to discouragement. Despite this plateau, many men who continue therapy realize over time that they have reached a "new normal" where their overall quality of life has genuinely improved compared to their pre-treatment state, often becoming more evident if they were to stop the therapy.

 

Wow Nelson. Thanks for keeping us educated!

 

Wow Nelson. Thanks for keeping us educated!

You are welcome!

 

Short video: Risks of Testosterone Therapy

Risks and Considerations of Testosterone Replacement Therapy (TRT)​

This briefing document summarizes the potential risks, side effects, and contraindications associated with Testosterone Replacement Therapy (TRT), drawing from excerpts of "Risks of Testosterone Replacement Therapy." It also highlights areas of ongoing debate and evolving medical understanding.

I. Common Side Effects and Management​

While TRT can offer benefits, it's crucial to be aware of potential side effects, especially if not properly managed:

• Skin Issues:Increased acne, oily skin, and folliculitis (immune response on hair follicles) are common, particularly in younger men and with higher doses.
• The speaker notes that "the same treatments work for at the end folliculitis."
• Cholesterol Levels:Higher TRT doses can lead to a decrease in "good cholesterol" (HDL cholesterol).
• Increased Red Blood Cells (Hematocrit):This is "probably...the most common" side effect and can increase blood viscosity.
• Many men require blood donations (phlebotomies) "every few months to decrease red blood cells."
• The speaker criticizes the lack of studies comparing outcomes in TRT patients who do and do not undergo phlebotomy, calling it "the main main factor involved in cardiovascular risk in my opinion."
• Gynecomastia (Breast Tissue Development):"Gynecomastia is really rare when you have normal levels of testosterone."
• It typically occurs when the "testosterone to australasia [estradiol] is slow" or due to genetics and high IGF-1 levels, making it a "very complex topic."
• Nipple sensitivity can be mistaken for gynecomastia, causing unnecessary alarm.
• Male Pattern Balding:Increased male pattern balding can occur, especially in younger men.
• Genetic factors are involved, and "DHT may be a factor involved here."
• Sleep Apnea:TRT can "induce or worse in sleep apnea," particularly in men who already have it or are overweight.
• Reduced Sperm Production/Fertility:TRT "definitely" reduces sperm production as the HPTA axis (Hypothalamic-Pituitary-Testicular Axis) is shut down.
• However, "that doesn't mean that some men on testosterone replacement may not father a child."
• Recent advancements allow for combining TRT with HCG or using clomiphene to "improve sperm count and not having to crash your testosterone."
• Water Retention:This "very annoying" side effect is experienced by "very few people talked about" and is characterized by increased water retention in the first month or so, typically normalizing after a few weeks.
• Anxiety:Some men report anxiety upon starting TRT, which "tends to normalize later or when they reduce doses." The speaker initially disbelieved this due to their own positive experience, but notes observing it in others.

II. Controversies and Evolving Data​

Several areas surrounding TRT and its risks are subject to ongoing debate and evolving medical understanding:

• Cardiovascular Disease:
• The link between TRT and increased cardiovascular disease is "currently being debated."
• "A lot more studies showing the normalizing testosterone improves Carnivale cardiovascular health."
• Only "three studies showed there was an increased risk and when they were reviewed they were found to not be very good studies at all" due to inadequate monitoring and lack of phlebotomy.
• Benign Prostatic Hypertrophy (BPH) and Urinary Tract Symptoms:
• There is "controversy when it comes to data on worsening of annoying prostatic hypertrophy or or even urinary tract symptoms."
• However, "most studies published in the past two years show they're actually an improvement in urinary tract sentence."
• Prostate Cancer:
• The concern about TRT causing prostate cancer is being challenged by "more and more data."
• Dr. Kara's lecture showed "it was all the data that he has now proven that in general this time that's not really cause prostatic cancer."
• A "saturation model" suggests that there's a certain level of testosterone that can accelerate existing prostate cancer, but beyond that, "that no longer occurs."
• Men with a prior history of successfully treated prostate cancer (complete removal, normal/low PSA) "don't have to be excluded from treatment."
• However, those who received radiation or other therapies "may actually have some risks involved."
• Clotting Disorders (DVT - Deep Vein Thrombosis):
• The FDA has warned about potential relapse of clotting disorders in men with a prior history of DVT on TRT.
• This appears to affect only "2% of men we have genetic mutations are making more prone to having clotting disorders."
• This is a "very controversial topic," with many studies finding "no association between testosterone and clotting disorders."
• Genetic testing is available for predisposed individuals.

III. Contraindications and Pre-Treatment Considerations​

Certain conditions or existing health issues contraindicate TRT or require careful evaluation:

• Severe Sleep Apnea (Untreated):Men with severe sleep apnea "not currently treated with a CPAP machine" should not be given testosterone.
• Untreated sleep apnea can itself lead to low testosterone and increased red blood cells due to decreased nighttime oxygen levels.
• A sleep study is the only way to diagnose sleep apnea and is often covered by insurance.
• High Hematocrit (Red Blood Cells) > 50%:This is a contraindication.
• Some men already have high hematocrit before TRT due to anabolic steroid use, sleep apnea, smoking, COPD, or congenital polycythemia (family history).
• This must be "explored before starting somebody on testosterone because if somebody is already has already a high hematocrit at baseline it's only gonna get worse."
• Prostatic Specific Antigen (PSA) 4 or Higher:A PSA of 4 or higher generally requires referral to a urologist for workup before TRT initiation.
• A significant increase in PSA (more than 1 ng/mL) within the first six months of TRT, or if PSA does not decrease after 4 weeks of antibiotic treatment (for potential prostate infection), warrants urology referral and discussion of TRT cessation.
• Prostatitis (prostate infection), especially with increased sexual activity, can temporarily elevate PSA, and antibiotic treatment may resolve it.
• Prior History of Prostate Cancer (Post-Radiation/Other Therapies):While men with successfully removed prostates and normal PSA may be candidates, those who received radiation or other prostate cancer therapies "may actually have some risks involved" and require a urologist's assessment.

IV. Misconceptions and Special Considerations​

• Obesity and Cardiovascular Disease:TRT "is not contraindicated for obese patients and those with a history of cardiovascular disease at all."
• While overweight patients may aromatize more testosterone to estradiol, they may also lose fat on TRT, which could improve aromatization. However, sleep apnea and other co-morbidities must be considered.

This briefing underscores the importance of a thorough medical evaluation, careful patient monitoring, and an understanding of the evolving scientific landscape when considering Testosterone Replacement Therapy.

What are some common side effects of Testosterone Replacement Therapy (TRT)?​

Common side effects of TRT can include increased acne and oily skin, particularly in younger men, and potentially folliculitis. A frequent concern is an increase in red blood cell count (hematocrit), which can thicken the blood and may necessitate regular blood donations (phlebotomy) to manage. Some men might also experience a decrease in "good" cholesterol (HDL). Other potential, though often debated or less common, side effects include increased male pattern balding (especially with genetic predisposition and DHT involvement), and initial anxiety or water retention, which often normalizes over time.

How does TRT affect cardiovascular health and red blood cell count?​

The impact of TRT on cardiovascular health is debated. While some early studies suggested an increased risk, more recent research often indicates that normalizing testosterone levels can improve cardiovascular health. A critical factor in this discussion is the management of increased red blood cell count, which is a common side effect of TRT. Elevated red blood cell levels can increase blood viscosity and potentially pose a cardiovascular risk. Proper monitoring and management, often through blood donations, are crucial, yet many studies on TRT and cardiovascular risk have not adequately accounted for this intervention.

Can TRT impact male fertility?​

Yes, TRT can significantly reduce sperm production and fertility because it can shut down the Hypothalamic-Pituitary-Gonadal (HPG) axis, leading to zero levels of FSH (follicle-stimulating hormone), which is essential for sperm production. While some men on TRT may still be able to father children, the reduction in fertility is a known issue. However, recent advancements allow for strategies to mitigate this, such as combining TRT with Human Chorionic Gonadotropin (HCG) or using clomiphene, without necessarily requiring men to stop TRT entirely when trying to conceive.

What are the contraindications for TRT?​

Men with severe, untreated sleep apnea (those not using a CPAP machine) should not be given TRT, as it can worsen the condition. Individuals with significantly elevated red blood cell count (hematocrit above 50) at baseline, potentially due to undiagnosed sleep apnea, anabolic steroid use, smoking, COPD, or a family history of polycythemia, also require careful evaluation, as TRT will further increase these levels. Additionally, men with a prostatic specific antigen (PSA) level of 4 or higher generally need a urological workup before considering TRT. A prior history of clotting disorders like DVT is also a contraindication, especially for individuals with genetic predispositions, though the association between TRT and clotting disorders remains controversial.

What is the relationship between TRT, prostate health, and PSA levels?​

The relationship between TRT and prostate health, particularly prostate cancer, has been a significant concern. However, recent data increasingly suggests that TRT does not generally cause prostate cancer. There's a "saturation model" theory suggesting a certain level of testosterone can accelerate pre-existing prostate cancer, but beyond that, higher levels may not further increase risk. Men with a successfully treated history of prostate cancer (complete prostate removal and normal PSA) may not be excluded from TRT, though those who received radiation or other therapies require careful assessment by a urologist. Monitoring PSA velocity (increase of more than 1 ng/mL within the first six months) is important. It's worth noting that prostatitis (prostate infection) can also cause PSA increases, which may be treated with antibiotics before considering further diagnostic steps like biopsies.

How does TRT affect sleep apnea?​

TRT can induce or worsen sleep apnea, especially in men who already have the condition or are overweight. Untreated severe sleep apnea is a contraindication for TRT due to this risk. It's important to recognize that fatigue and low testosterone levels can both be symptoms of sleep apnea, and addressing sleep apnea is crucial before initiating TRT. Men with sleep apnea often have elevated red blood cell counts due to decreased oxygen levels at night, which the body compensates for by producing more red blood cells. A sleep study is the only definitive way to diagnose sleep apnea.

Are there any less common or temporary side effects of TRT?​

Some less common or temporary side effects include anxiety and water retention. While the source notes that some men on TRT might experience anxiety, this often normalizes over time or with dose adjustments. Similarly, water retention can occur during the first month or so of treatment but typically resolves within a few weeks. Gynecomastia (development of breast tissue) is considered rare with normal testosterone levels and is more often associated with an imbalance between testosterone and estradiol, genetic factors, or high IGF-1 levels. Nipple sensitivity can occur but does not necessarily indicate gynecomastia.

Can TRT be given to patients who are obese or have a history of cardiovascular disease?​

Contrary to some beliefs, TRT is generally not contraindicated for obese patients or those with a history of cardiovascular disease. While overweight patients may convert more testosterone to estradiol (aromatization), fat loss on TRT can actually improve this. However, it's crucial to consider that obese individuals are also more likely to have underlying conditions like sleep apnea, which must be addressed before or concurrently with TRT. The ongoing debate regarding TRT and cardiovascular disease continues, with a growing body of evidence suggesting that normalizing testosterone may be beneficial rather than harmful, especially when red blood cell levels are properly managed.

 

Testosterone Blood Level: How Low is Too Low?

This briefing document summarizes key information regarding testosterone, its role in the human body, the effects of low testosterone, and the complexities surrounding its measurement and treatment.

1. Testosterone: A Vital Hormone for Both Sexes​

Testosterone is an androgenic hormone often equated with males, but it is present in both men and women, albeit in significantly lower concentrations in women (about one-tenth that of men). It plays a crucial role in various bodily functions and affects numerous target organs.

Key Functions and Target Organs:

• Hair Growth: Influences hair growth and can contribute to balding.
• Skin: Affects sebum production, which can cause acne.
• Liver: Promotes protein synthesis.
• Male Sexual Organs: Essential for penile growth, spermatogenesis (sperm production), and prostate growth and function.
• Brain: Impacts libido and mood.
• Muscles: Increases strength and muscle volume.
• Kidneys: Stimulates red blood cell production.
• Bone Marrow: Stimulates stem cells and accelerates linear growth and closure in growing boys and girls, contributing to bone density.

2. The Impact of Aging on Hormone Levels​

Most hormones, including testosterone, decline with age. This age-related decline in testosterone typically begins between 30 and 40 years of age, with approximately 1.2% lost each year. While the average total testosterone level in a 75-year-old man is about 35% lower than a 25-year-old, and bioavailable testosterone is 50% lower, it's important to note that "many men in the seventh or eighth decade have normal testosterone levels," indicating individual variability.

Exceptions to the Decline:

• Insulin: Increases with age due to increasing insulin resistance.
• Cortisol: Also increases with age, acting as an inflammatory and stress hormone.

The rise in insulin and cortisol with age contributes to "weight more fat, get more inflammation, and more chronic illnesses that are related to aging."

Circadian Rhythm: Testosterone production peaks early in the morning, typically between 4 to 6 a.m., in both younger and older men. However, in older men, "the effects are blunted by age," resulting in a less pronounced peak and a more constant blood level throughout the day.

3. Symptoms and Effects of Low Testosterone​

Low testosterone, often referred to as "low T," can manifest in a variety of symptoms and lead to significant health issues. Many of these effects can be "reversed" by normalizing testosterone blood levels.

Common Symptoms:

• Sexual dysfunction or lack of interest in sex
• Erectile dysfunction
• Decreased sense of well-being
• Increased irritation or moodiness
• Fatigue
• Poor appetite
• Loss of muscle mass and strength
• Depression

Health Issues Associated with Low Testosterone:

The source highlights various studies linking specific testosterone levels to increased risks of different pathologies:

• Less than 450 ng/dL: Increased risk of metabolic syndrome (increased fat mass, waist circumference, high triglycerides, etc.).
• Less than 400 ng/dL: Linked to Venus leakage (internal penile damage affecting erectile function).
• Less than 350 ng/dL: Linked to all-cause death risk and anemia risk.
• Less than 300 ng/dL: Associated with lower libido, weight gain, increased diabetes risk, increased risk of fractures, memory-related issues, and increased depression risk.
• Less than 250 ng/dL: Increased arterial plaque and decreased sleep quality.
• Less than 235 ng/dL: Hardening of the arteries.
• Less than 200 ng/dL: Decreased morning erections.
• Less than 150 ng/dL: Increased inflammation.

The speaker notes that "300 or so 350 300 it's kind of a midpoint and all these data in so it actually makes sense so far what the guidelines have been saying it's not far off from what studies are showing when it comes to increased risks of different health health issues."

4. Defining "Low Testosterone": A Point of Controversy​

Defining what constitutes "normal" or "low" testosterone levels remains a significant area of debate and controversy within the medical community. There is "no agreement" across various medical groups, and even different lab companies have their own ranges based on their internal databases.

Normal Ranges (General):

• Men: Broadly considered to be anywhere from 350 to 1100 nanograms per deciliter (ng/dL) for total testosterone and 10 to 50 ng/dL for free testosterone.
• Women: About one-tenth of the concentration in men.

Varying Guidelines from Medical Groups:

• European Academy of Urology, European Association of Urology, International Society of Andrology, International Society for the Study of the Aging Male (2009 Guidelines): Anything under 350 ng/dL (or 12.1 nanomolar/liter) and free testosterone less than 65 picograms per milliliter is considered low.
• Endocrine Society (TES): Defines low as under 300 ng/dL.
• Group of Experts (2014): A group of high-prescribers and experienced doctors agreed that anything under 400 ng/dL is considered low.

Implications for Treatment and Insurance:

• Insurance Companies: Most insurance companies currently approve testosterone therapies for levels between 300 to 350 ng/dL, provided the patient also exhibits symptoms of low testosterone and has a corroborating blood test.
• Cash-Based Clinics: These clinics tend to be "a little bit more flexible when it comes to testosterone levels up to 500 nanograms if you have symptoms of low testosterone."

This variability highlights the ongoing challenge in standardizing the diagnosis and treatment of low testosterone, with both scientific evidence and practical considerations influencing clinical decisions.

 

How to Inject Testosterone

Testosterone Injection Methods and Best Practices​

This briefing reviews current and historical approaches to testosterone injection, highlighting key changes in dosing, administration methods, and monitoring, with a focus on optimizing efficacy and minimizing side effects.

Main Themes & Most Important Ideas:​

1. Evolution of Dosing Regimens: From "Old School" to Optimized Frequency

• Old School Dosing (Past 30-40 years): "200 to 250 milligrams intramuscular deep injections every two weeks." This method, often recommended by commercial product package inserts, leads to significant "peaks and valleys" in testosterone (and estradiol) levels, with a peak in the first few days and a decline by day 14.
• New School/Popular Approach: "100 milligrams every week or 50 milligrams twice a week." This more frequent administration with lower doses is gaining popularity, especially in cash-based clinics.
• Benefits of Frequent, Lower Doses: This approach results in "not only better efficacy but lower hematocrit, lower production of red blood cells and side effects." It effectively minimizes the undesirable "peaks and valleys blood levels."
• Extreme Frequency: Some highly adherent individuals even "inject everyday propionate clinicals," reporting feeling better, though this requires "a lot of commitment and a personality type."

2. The Role of Esters in Testosterone Pharmacokinetics

• Purpose of Esters: Testosterone itself has a very short half-life (10 minutes in the liver). Chemists in the 1930s and 40s attached "little like molecules" (esters) to the testosterone molecule to "modify the molecule [to make] the body not dispose of or metabolize testosterone as fast." This modification "keeps the body the product more chance to work."
• Common Esters and Their Durationropionate: "definitely shorter acting," requires more frequent injection.
• Cypionate & Enanthate: "longer than the OH" of testosterone. No significant data suggests one lasts longer than the other.
• Undecanoate (Nebido/Aveed): The "longer acting one that can last anywhere from 8 to 12 weeks max." In the US, Aveed is approved at "750 milligrams at week 0, 4 and then every ten weeks 750 milligrams."

3. Advancements in Injection Techniques: Moving Beyond Deep IM

• Old School Injection (Deep IM): Traditionally, testosterone was administered via "intramuscular deep injections I am deep I am," often using a "one and a half needle 23 gauge to inject in in the glutes." This required two needles (an 18-gauge to load, a 23-gauge to inject) and often necessitated "aspiration to make sure you didn't hit a vein or an artery." This method was described as not "looking forward to it every every two weeks."
• Subcutaneous (SQ) Injections: In the past 4-5 years, SQ injections have "been shown... to work really well as well or better than intramuscular." Data supporting this comes from studies, including "transgender female to males using the subcutaneous method and the study showed really good blood levels with that method." Common SQ sites include the "abdominal area."
• Shallow Intramuscular (Shallow IM): A term coined by the speaker, this involves injecting "shallow I am" using an insulin syringe, often in the "delts." The speaker prefers this over deep SQ due to "redness on my abdominal area."
• Advantages of Insulin Syringes (27-gauge, half-inch):"less pain"
• "no aspiration" needed (due to low risk of hitting a vein/artery)
• "waste less product" (compared to larger needles where product can be lost in the needle tip)
• "fewer supplies"
• "one only one hand needed" for injection, promoting independence.
• "make things a lot easier for many of us that I really don't you don't feel pain at all."
• Injection Sites: "deltoids, quads, and glutes" for shallow IM. "Subcutaneous abdominal area" for SQ.
• Caution: Injecting "more than 0.5 ccs with that insulin syringe tends to create a large volume under the skin or or shallow am that may create some scar tissue if you abuse it."

4. Importance of Monitoring and Adjusting Dosage

• Optimal Monitoring Time: The speaker recommends checking "testosterone 24 to 48 hours after injections" to capture the peak level.
• Common (Less Optimal) Monitoring: "Most doctors don't do that they actually have you checked your testosterone right before the next injection for the lowest possible level."
• Dose Adjustment Criteria: "dose needs to be increased if your blood testosterone at week six or eight has not reached levels above 600 or so." Conversely, "if you decrease the dose I need checked more frequently you decrease the chances for peaks and valleys."

In summary, the field of testosterone injection has evolved considerably, moving towards more frequent, lower-dose administrations to achieve more stable blood levels, and adopting less invasive, more convenient injection techniques, primarily driven by patient comfort and improved outcomes.

 

Testosterone Metabolites

Testosterone Metabolism and its Broader Hormonal Context​

This briefing summarizes key information regarding testosterone, its metabolism, the broader endocrine system, and the roles of its various forms and metabolites.

1. The Endocrine Cascade: Cholesterol as the "Mother of All Hormones"​

All steroid hormones, including sex hormones and cortisol, originate from cholesterol. This highlights the foundational role of cholesterol in the body's hormonal system. The excerpt states, "the mother of all hormones is cholesterol cholesterol without cholesterol we would not be able to make sex hormones or even even cortisol."

The production of these hormones follows a cascade, with testosterone being an androgenic hormone that can further metabolize into other forms like estradiol.

2. The Hypothalamic-Pituitary-Testicular Axis (HPTA): Regulation and Feedback Loops​

Testosterone production in males is controlled by the HPTA. The hypothalamus signals the pituitary gland, which in turn releases Luteinizing Hormone (LH) and Follicle-Stimulating Hormone (FSH) to the testicles, stimulating testosterone and sperm production.

A crucial aspect of the HPTA is its negative feedback loop:

• "As testosterone goes up there's a feedback loop that slows down the upstream signals."
• This means that when external testosterone (e.g., through injections or gels) is introduced, the body senses it and "sends the feedback to the big hairy hypothalamus to stop testosterone production."

Consequently, exogenous testosterone therapy can lead to the shutdown of the body's natural testosterone production. Recovering baseline production after stopping therapy can take "weeks or months," making it a significant consideration for individuals undergoing such treatments.

3. Testosterone Fractions: Free vs. Bound and the Role of SHBG​

Testosterone in the blood exists in different forms:

• Free Testosterone (Free T): Accounts for only about 2% of total testosterone. This is the bioavailable form that can readily act on receptors.
• Albumin-Bound Testosterone: A portion of testosterone is loosely bound to albumin and can be released for use by the body as needed.
• Sex Hormone-Binding Globulin (SHBG)-Bound Testosterone: This constitutes the majority of testosterone and is "bound very strongly" and generally "not really allowed to be used in the body as a control mechanism."

While historically seen as primarily a binding protein, emerging studies suggest SHBG might have roles in transporting and acting on receptors throughout the body, implying it's "not really an evil hormone."

SHBG and Aging: SHBG levels tend to increase with age, leading to a decrease in free and total testosterone. This is a significant factor in age-related declines in bioavailable testosterone.

Factors Affecting SHBG Levels:

• Increased SHBG: Associated with conditions like aging, liver cirrhosis, hyperthyroidism, use of anticonvulsants, estrogens, and HIV.
• Decreased SHBG: Associated with obesity, kidney disorders, low thyroid, use of glucocorticoids, progestins, anabolic steroids, acromegaly, and diabetes.
• The speaker notes that "leaner people that eat healthy tend to have higher sex hormone-binding globulin that people with diabetes," challenging common assumptions about decreasing SHBG for increased free testosterone.

4. Testosterone Metabolism: DHT and Estradiol​

Once produced (average male production is 5-7 mg/day), testosterone is metabolized into two key forms:

• Dihydrotestosterone (DHT):
• Produced by the enzyme 5-alpha reductase.
• Linked to libido and negative side effects like acne.
• Controversial data regarding its role in prostate hyperplasia, with some data suggesting it's "not the case."
• Works directly on the androgen receptor.
• Drugs like finasteride (Propecia/Proscar) block DHT production and are associated with a "finasteride syndrome" characterized by dramatically decreased libido in some men.
• Estradiol (E2):
• Produced by the aromatization of testosterone in the liver and fat cells. Testosterone is a "precursor of estradiol."
• Often misunderstood, estradiol is "not an evil hormone" for men and is "a very important hormone for not only women but men."
• Associated with numerous benefits in men: "increased bone density, increased libido, believe it or not decreased fat mass and even cognitive function and improved lipids."
• Men with very low estradiol often experience "low libido, hair issues like brittle hair, cognitive issues and and bone loss."
• Drugs like anastrozole and tamoxifen modulate estradiol but are, in the speaker's opinion, "overused" leading to "crushed estradiol levels that actually have implications in their health."

5. Actions of Testosterone: Androgenic and Neurogenic​

Testosterone exerts its effects through two main pathways:

• Androgenic Actions: These are mediated by testosterone binding directly to androgen receptors, affecting muscle growth, cognitive function, and other male characteristics.
• Neurogenic Actions: These are "mediated through the aromatization of testosterone to estradiol." Estradiol is crucial for "libido and body composition and cardiovascular health," and it also serves as a "feedback signal to in hppa to reduce testosterone levels when estradiol is is high."

In summary, the briefing highlights the intricate nature of the male endocrine system, emphasizing that testosterone is not an isolated hormone but part of a complex network of production, regulation, and metabolism. The importance of cholesterol, the delicate balance of the HPTA, the different forms of testosterone, and the often-overlooked benefits of its metabolites like estradiol are key takeaways.

 

Blood Tests Used to Monitor Testosterone Therapy

Monitoring Testosterone Replacement Therapy (TRT)​

I. Introduction to TRT Monitoring and Guidelines​

The provided source, "Blood Tests Used to Monitor TRT," emphasizes the critical role of systematic blood testing and follow-up in managing Testosterone Replacement Therapy. While clinical and medical groups offer guidelines for TRT monitoring, the presenter notes that "they don't agree on everything there," particularly regarding the exact timing of testosterone level measurements. However, there's more consensus on hematocrit measurements (proportion of red blood cells in the blood), generally recommending checks every three to six months.

Despite official guidelines, the presenter observes that "cash clinics and even insurance [clinics] are more aggressive than this," often conducting more frequent follow-ups.

II. Standard Blood Tests and Monitoring Schedule​

A. Initial (Baseline) Blood Tests: Before starting TRT, a comprehensive set of blood tests is recommended:

• Total and Free Testosterone: Essential for diagnosing low testosterone.
• PSA (Prostate-Specific Antigen): Crucial for prostate health monitoring.
• HS-TSH (High-Sensitivity Thyroid-Stimulating Hormone): To assess thyroid function.
• Lipids: To evaluate cardiovascular risk factors.
• CMP (Comprehensive Metabolic Panel): Checks kidney and liver function, electrolytes, and blood sugar.
• CBC (Complete Blood Count): Measures blood components, including red and white blood cells.
• Sensitive Estradiol: This is explicitly highlighted as a crucial test that "has to be done using the sensitive tests."
• Prolactin: Recommended if baseline testosterone is "very low."

B. Follow-Up Monitoring Schedule: While guidelines vary, a common aggressive follow-up schedule observed in practice includes:

• Baseline
• Week 8
• Week 12 or 16
• Six months
• Annually (if stable and dosage optimized)

III. Key Monitoring Variables and Side Effect Management​

The presenter stresses the importance of monitoring various factors to manage potential side effects of TRT. While not detailing all management strategies in this particular lecture, he highlights specific variables that require close attention:

• Hematocrit: This is identified as a top priority because "really ripple cells increases are the number one side effect and that can increase blood pressure and headaches in cardiovascular risks."
• Estradiol: Patients are cautioned against obsessing about estradiol levels "without testing it and testing it with the right test." This reinforces the need for the sensitive estradiol test.
• Fertility and Testicles: The use of HCG (Human Chorionic Gonadotropin) is recommended to "protect your fertility and testicles and upstream hormones."

IV. "Ten TRT Commandments" and Best Practices​

The presenter outlines a set of "Ten TRT Commandments" offering practical advice for patients undergoing TRT:

1. Have reasonable expectations: Set realistic goals for TRT outcomes.
2. Do not fall prey to testosterone booster scams: Avoid unproven and potentially harmful products.
3. Do not obsess about estradiol without testing it and testing it with the right test: Emphasizes proper testing and avoiding unnecessary anxiety.
4. Monitor your hematocrit: Due to its significant side effect potential.
5. Explore easier ways to inject: Such as subcutaneous or shallow intramuscular (IM) injections.
6. Never cycle testosterone: "There's no such a thing as cycling testosterone replacement you actually doing more harm than good." Stopping TRT can lead to weeks of low testosterone.
7. Measures or monitor your blood tests: Understand your trends using tools like "my health graphs and your t analyzer app."
8. Does not change more than one variable at a time: To accurately identify what interventions are effective. "You will lose track of what works and what doesn't."
9. Protect your fertility and testicles and upstream hormones with a use of HCG: As mentioned previously.
10. Don't stay behind: Encourage continuous learning and staying informed about new information, rather than solely relying on a doctor who may not be fully up-to-date.

V. Medications Prescribed with Testosterone​

Beyond testosterone itself, doctors may prescribe other therapies in conjunction with TRT:

• Anastrozole: An aromatase inhibitor to manage estrogen levels.
• HCG: To preserve fertility and testicular function.
• Injectable vitamins and nutrients: (e.g., Vitamin D, B12).
• Growth hormone releasing hormones (GHRH): For growth hormone optimization.
• ED drugs: Such as Cialis (tadalafil) or Viagra (sildenafil), noting they "can be also obtained cheaply from compounding pharmacies."
• Anabolic steroids: Specifically mentioning Oxandrolone and Anadrol, which are "two anabolic steroids approved in the United States for different conditions."
• Metformin: An anti-diabetic drug gaining popularity for "potential life extension benefits and also even weight loss."
• Blood pressure medications.

TRT Monitoring & Management: An FAQ​

What are the key blood tests required for monitoring TRT?​

Initial blood tests for Testosterone Replacement Therapy (TRT) should include total and free testosterone, Prostate-Specific Antigen (PSA), Luteinizing Hormone (LH), Follicle-Stimulating Hormone (FSH), lipids, Complete Metabolic Panel (CMP), Complete Blood Count (CBC), and sensitive estradiol. If baseline testosterone levels are very low, prolactin should also be checked. These tests help establish a baseline and identify any underlying issues.

How often should blood tests be done for TRT monitoring?​

Initial follow-up blood tests are typically done at week 6-8, with another at week 12 or 16, and then at 6 months. Once a patient is stable and their dosage is optimized, annual blood tests are usually sufficient. However, some doctors in cash clinics and even insurance-based practices may be more aggressive with follow-ups than official guidelines suggest.

What is hematocrit and why is it important to monitor during TRT?​

Hematocrit is the proportion of red blood cells in the blood. Monitoring hematocrit is crucial because an increase in red blood cells is a common side effect of TRT. Elevated hematocrit can lead to increased blood pressure, headaches, and higher cardiovascular risks. Regular monitoring, typically every three to six months, helps manage this potential side effect.

What are some common mistakes or pitfalls to avoid when undergoing TRT?​

Several common pitfalls to avoid include: obsessing about estradiol without testing it with the correct sensitive test; not monitoring hematocrit; cycling testosterone (as there's no such thing as "cycling" TRT, and it can be harmful); not consistently monitoring blood tests and trends; and changing more than one variable at a time when adjusting treatment, which makes it difficult to determine what's effective.

Why is it important to protect fertility and testicles during TRT?​

Testosterone Replacement Therapy can suppress natural testosterone production, which can impact fertility and testicular size. The use of Human Chorionic Gonadotropin (HCG) is often prescribed alongside testosterone to help protect fertility and maintain testicular function by stimulating the testes to produce their own testosterone and sperm.

Besides testosterone, what other therapies might doctors prescribe alongside TRT?​

Beyond testosterone, doctors may prescribe other therapies such as anastrozole (an aromatase inhibitor to manage estrogen levels), HCG (for fertility and testicular function), injectable vitamins and nutrients, growth hormone-releasing hormones, ED drugs (like sildenafil), certain anabolic steroids (like oxandrolone, approved for specific conditions), metformin (for its potential life extension and metabolic benefits), and blood pressure medications.

What are some reliable resources for information on TRT?​

Reliable resources for TRT information include websites like PeakTestosterone.com and ExcelMale.com, which offer articles, forums, and educational content. Books such as "Natural vs. Testosterone Treatments" by Lee Meyer and "The Testosterone Romance Guide" (available for free) are also valuable resources. Additionally, tools like My Health Graphs and the T Analyzer app can help individuals track and understand their blood test trends.

Why is it important to use a "sensitive" test for estradiol when on TRT?​

Using a "sensitive" estradiol test is crucial because standard estradiol tests may not be accurate enough for men on TRT. Testosterone can convert into estrogen, and imbalances in estradiol levels can lead to side effects such as water retention, gynecomastia, or emotional changes. A sensitive test provides a more precise measurement, allowing for better management of estrogen levels and prevention of these side effects.

 

How to Increase Testosterone Naturally

Natural Testosterone Enhancement​

This briefing summarizes key strategies for naturally increasing testosterone levels, drawing from Nelson Vergel's insights. It emphasizes lifestyle modifications and cautions against ineffective over-the-counter (OTC) supplements.

Main Themes & Key Ideas:​

1. Sleep Quality and Hygiene as the Foremost Factor: Vergel repeatedly stresses that sleep is the most crucial element in natural testosterone production. He states, "the first important factor or the most important one is the sleep quality and hygiene." Poor sleep disrupts the body's circadian rhythm and hormone production, including melatonin and testosterone. Young men are particularly susceptible due to "using a lot of electronics playing games or watching TV from bed and exposure of that light late at night."

• Actionable Advice:Aim for "at least seven hours a night."
• Prioritize "darkness" in the sleep environment.
• Avoid electronics ("do not bring electronics to bed and do not expose your eyes to light before 11:00 after 11:00 10:30 to 11:00 p.m.").
• Establish a consistent sleep schedule ("try to go to bed at the same time everyday" and "get up at the same time").
• Engage in relaxing activities before bed (e.g., "read a book" – a physical one, not from a screen).
• Get daylight exposure in the morning ("spend time in the daylight when you wake up in the morning try to get some Sun release in your face").
• Have a "light dinner not too late."

2. Weight Management and Glucose Control: Being overweight is directly linked to lower testosterone. "If you're overweight your testosterone may be down by 100 to 150 points nano grams." Additionally, problems with glucose control, such as "diabetes or high glucose," also tend to result in "lower testosterone."

• Actionable Advice: Weight loss for overweight individuals. Exercise can improve both glucose control and body composition.

3. Exercise, but Avoid Overtraining: Exercise is beneficial for testosterone, improving both glucose control and body composition. However, moderation is key. "Over training or over exercising may actually decrease this dosterone so you have to be careful about that too."

4. Avoiding Environmental Toxins and Endocrine Disruptors: The modern world presents significant challenges with pervasive environmental toxins that negatively impact hormone levels. These "endocrine disruptors pollutants and toxins... are affecting hormone levels increasing estrogens and decreasing testosterone in males in particular."

• Examples of Toxins: Plastics (especially when heated), flame retardants, emissions from refineries, phytoestrogens (e.g., in soy products), hydrocarbons, and pesticides.
• Actionable Advice: While difficult to completely avoid, efforts should be made to minimize exposure, such as "avoiding exposure food to plastics actually heating plastics."

5. The Ineffectiveness and Dangers of Over-the-Counter Testosterone Boosters: Vergel strongly warns against the "multi-million dollar industry" of OTC testosterone boosters, emphasizing that "there is not an effective over-the-counter testosterone booster."

• Reasons for Caution:Lack of Regulation: Supplement companies are "not regulated by the FDA and they do not have to submit quality control or ingredient testing to the FDA."
• Adulteration: Some boosters "have been found to have by agra or silas," leading men to mistakenly believe the product is working due to improved erectile function.
• FDA Action: The FDA frequently "catches companies every week" for shutting down these supplements when testing reveals unlisted or harmful ingredients.
• Consequence: Wasting money on ineffective products.

In summary, the most impactful natural strategies for increasing testosterone revolve around consistent, high-quality sleep, maintaining a healthy weight, strategic exercise, and minimizing exposure to environmental endocrine disruptors. OTC testosterone boosters are not recommended and can be harmful.

What are the most important natural ways to increase testosterone levels?​

The most crucial natural factor for increasing testosterone is sleep quality and hygiene. Aim for at least seven hours of darkness during sleep. Weight loss is also significant, as being overweight can lower testosterone by 100-150 nanograms. Additionally, avoiding environmental toxins like plastics and endocrine disruptors (e.g., flame retardants, pesticides) can help. Regular exercise that improves glucose control, without overtraining, is also beneficial.

Why is sleep so critical for testosterone production?​

Sleep is paramount because it directly impacts the production of melatonin and other hormones essential for your circadian rhythm and overall endocrine function. Exposure to electronics and light late at night significantly disrupts these processes, affecting growth hormone, thyroid function, and ultimately, testosterone. Consistent sleep schedules and minimizing screen time before bed are highly recommended.

How does body weight affect testosterone levels?​

Being overweight or obese can significantly decrease testosterone levels, potentially by 100 to 150 nanograms. Losing weight is an effective natural strategy to help increase testosterone back to healthier levels.

What role do environmental toxins play in testosterone levels?​

Environmental toxins and endocrine disruptors, such as plastics (especially when heated), flame retardants, industrial emissions, certain phytoestrogens (like those in soy products), hydrocarbons, and pesticides, can negatively impact hormone levels. These substances can increase estrogen and decrease testosterone in males, making it important to minimize exposure where possible.

Can exercise help improve testosterone, and are there any caveats?​

Yes, exercise can help improve testosterone levels by enhancing body composition and glucose control. However, it's important to be mindful of overtraining or over-exercising, as this can actually lead to a decrease in testosterone. A balanced approach is key.

Are over-the-counter testosterone boosters effective?​

No, over-the-counter testosterone boosters are generally not effective. This is a multi-million dollar industry, but many of these supplements have been found to contain unlisted ingredients, such as Viagra or Cialis, which may give the user a false sense of efficacy due to improved erectile function. The FDA frequently shuts down companies selling these supplements due to lack of regulation and quality control. It's advisable to avoid wasting money on them.

What are some practical tips for improving sleep hygiene to boost testosterone?​

To improve sleep hygiene, aim to go to bed and wake up at the same time every day. Avoid watching TV or using electronics before bed, especially after 10:30-11:00 p.m., as the light exposure significantly affects hormones. Stay hydrated, try to relax before sleep (avoid arguments or stressful phone calls), and spend time in daylight upon waking to help regulate your circadian rhythm. Have a light dinner not too late in the evening.

Why should one consider natural approaches before starting testosterone treatment?​

It's important to consider natural approaches before starting testosterone treatment because treatment is a significant commitment. It shuts down your body's natural testosterone production, and if you decide to stop, it can take a considerable amount of time for your body to resume its baseline production. Natural methods offer a way to optimize your body's own hormone production without external intervention.

 

Testosterone Resources

Testosterone Resources and Support Ecosystem​

This briefing reviews the key themes, resources, and factual information presented in the "Testosterone Resources" source. The speaker, a creator of multiple platforms, emphasizes providing accessible and affordable information and tools for individuals interested in testosterone replacement therapy (TRT) and overall health management.

Main Themes:​

1. Empowerment through Information and Community: A central theme is empowering individuals to take charge of their health by providing extensive, free resources and fostering a supportive online community. The speaker repeatedly highlights the educational nature of their platforms and the ability for users to engage with experts and peers.
2. Accessibility and Affordability: The speaker stresses the importance of making blood testing and information affordable and easily accessible, circumventing traditional gatekeepers where possible (e.g., direct-to-consumer lab testing).
3. Comprehensive Support Beyond Testosterone: While "testosterone" is in the name of many resources, the scope extends to general health, wellness, nutrition, fitness, and even other hormone-related topics, including HRT for women and peptides. This suggests a holistic approach to well-being.
4. Data Tracking and Personal Monitoring: A strong emphasis is placed on tools that allow individuals to track their progress, symptoms, and blood test results over time, facilitating better communication with healthcare providers and personal understanding of treatment efficacy.

Most Important Ideas/Facts and Key Resources:​

• Free Book: "Testosterone: A Man's Guide"
• Description: A foundational resource providing detailed information on testosterone.
• Access: Downloadable for free at first.testosteronewisdom.com.
• Quote: "you can download my book testosterone a man's guide which basically has all the details I speak about today."
• Additional Benefit: Includes a discount code for compounded medications in the United States.
• ExcelMale.com - Online Forum and Resource Hub
• Description: A comprehensive online forum with almost 18,000 members, including doctors and educated men, providing a vast array of information and community support related to testosterone and male health.
• Content Highlights:Basic Information: "testosterone basic basics and questions"
• Side Effect Management: "how to prevent and reverse side effects"
• Specific Uses: "how to use for instance climbing for fertility," "when the Stas room is not enough" (addressing cases where TRT isn't a magic cure).
• Blood Test Discussions: "people post blood test results on the blood test discussion folder is actually pretty useful because it's a great way to get input from other people and even doctor stone the site."
• Research & Studies: "we post different studies that almost every day on the miscellaneous studies resources and suppliers."
• Direct Expert Q&A: "you can actually ask directly doctors and experts that we have on the site."
• Interviews: "expert interviews which are videos and written interviews."
• Broader Health Topics: Workout routines, health/wellness, nutrition, supplements, peptides (including growth hormone releasing hormones), androgens for chronic illnesses, anabolic agents for wasting disease, and HRT in women.
• Referrals & Reviews: Referral to clinics, reviews of doctors, clinics, compounding pharmacies, supplements, blood testing companies, and books.
• Quote on Community Control: "great moderator so nobody gets abused and everything is pretty much in control of any potential misbehaviors that you see a lot online nowadays."
• Discounted Lab Testing: DiscountedLabs.com
• Description: A company offering affordable blood testing in most US states (except some in the Northeast).
• Key Feature: Allows individuals to order their own tests and visit a lab location without needing a doctor's referral.
• Results Delivery: Email results within 5-7 business days.
• Quote: "I probably provide one of the best prices out there you can actually order if you go to this country and lapse comma you can order your own tests and go to the closest lab for location without having to see a doctor."
• TRT Analyzer App
• Description: A free mobile application available on App Store and Google Play, with over 8,000 downloads.
• Functionality: Enables users to track daily metrics like energy levels, libido, erectile function, and mood.
• Data Visualization: Allows plotting of variables, which can be printed or emailed to doctors.
• Tracking Features: Records changes in testosterone dosage or other products and daily self-reported feelings.
• Quote: "this is a really interesting app that you can use to to really track how well you're doing every day with this you know when it comes to energy levels libido erectile function mood etc."
• MyHealthGraphs.com
• Description: A website designed to plot blood test results graphically.
• Current Status: Manual input, but future upgrades aim for automatic PDF reading and data input.
• Purpose: To provide a visual representation of health trends from blood work.
• ExcelMale YouTube Channel
• Description: Hosts videos of lectures and educational content related to testosterone and health.
• Access: "this video the video of this lecture will be posted on the Excel Mail YouTube channel."

 

You are welcome!

Nelson,
Thank you so much for the informational YouTube videos. I was curious if you have any advice for mitigating vision bluriness and tightness in chest in the first 72 hours after a 40mg test cyp injection? The blood tests that Dr. Glueck recommended were all taken and it came back that there are no clotting risks. Is there any other items you might be able to suggest to counter the vision bluriness and tightness in chest and throat area?

 

Get checked for this when your blurriness is happening

Can Testosterone Cause Retinopathy?

Not sure I know what to do about your chest and throat tightening 72 hours later.

 

nelson,
Thank you for your quick response. I went to an opthomologist and they said my eyes were fine, they said that testosterone can cause bluriness due to hormone changes or something like that. But they didn't have a resolution other than taking drops and those don't do much.

 

Here are several things that your doctor may fail to tell you when you start testosterone replacement therapy (TRT):

1- TRT decreases your sperm count. It decreases LH and FSH responsible for sperm production. If you want to remain fertile, talk to your doctor about clomiphene or adding hCG to TRT.

HCG plus TRT to Prevent / Reverse Testicular Shrinkage and Decreased Fertility - Excel Male TRT Forum​

Human Chorionic Gonadotropin (From the book Testosterone: A Mans Guide, amazon.com) Short podcast: hCG: What Every Man Should Know Good summary : Why Use hCG With TRT?- A Clinical Review Human chorionic gonadotropin (HCG) (not to be confused with human growth hormone, or HGH) is a...


2- TRT may increase your blood viscosity due to increased hematocrit, the amount of red blood cells in the blood. Some doctors may want to stop your TRT when this happens, but this side effect can be managed easily with blood donations or therapeutic phlebotomy. Just be careful: frequent blood donations can deplete iron and cause fatigue. More details here: High Hematocrit Caused by TRT: How to Lower and Manage it

3- TRT shuts down your own testosterone production. It may recover after a few weeks and up to 6 months after you stop.

4- TRT improves sex drive, muscle mass, and fat burning in most men. But it does not work for everyone, and dose and frequency are important along with other factors like side effect management. It is not a magic bullet. Average time to see benefits: How long does TRT take to show effects?

5- Testosterone can be injected under the skin with an 1/2 inch 27-29 gauge insulin syringe (Most doctors think you should inject deeply into muscle) or shallow IM (1/2 inch syringe, 90 degrees). More information about benefits : Where to Inject Testosterone: Intramuscular vs. Subcutaneous Injections

6- Many doctors still prescribe testosterone injections at 200 mg every two weeks. Many are moving towards 100 mg/week or 50 mg twice per week with an insulin syringe (27 to 29 gauge, 1/2 inch).

7- TRT improves erectile function in some men, but not all. It improves libido in most men, regardless of age, though. Some men take low-dose daily Cialis along with TRT. Daily low-dose Cialis can have cardiovascular benefits and also help with BPH. More information is here : The benefits of long term use of Cialis

8- You can monitor your own blood tests via companies like DiscountedLabs.com without a doctor visit. Order Discounted Lab Tests Online Without a Doctor Visit

9- You can access a testosterone doctor via telemedicine no matter where you live in the U.S. if you don’t have one close by. However, most of them do not take insurance. Looking for Hormone Doctors?

10- TRT does not cause prostate cancer or heart attacks (cardiovascular outcomes depend on proper monitoring of hematocrit, HDL, and blood pressure, though). However, recent data shows that AFIB or heart palpitations can increase in some older men. This issue is under investigation.

11- Many men do not know that you can ask questions to other men who have used TRT for a few years by visiting Forum list

12- Many doctors only measure blood levels of total testosterone but forget to include free testosterone, DHT (metabolite), and thyroid function tests. Men with very low T levels should also get their prolactin tested to rule out a pituitary adenoma.

13- Most insurance companies only pay for certain TRT products but not others. And most refuse to pay if your testosterone level is over 350 ng/dL. You can bypass insurance by having your doctor fax the prescription to a compounding pharmacy.

14- Urologists are quickly becoming the most knowledgeable doctors of TRT management. Urology conferences now have full days devoted to TRT studies. Looking for a doctor in the US?:

Looking for Hormone Doctors?​

15- Some men fail to achieve benefits from TRT. Comorbidities and other issues can be to blame. Metabolic issues can increase the risk of water retention and high blood pressure in some men. Those men should consult a cardiologist for a full checkup. Water Retention While on TRT May Only Occur to Certain Men

16- TRT does not cause prostate cancer or heart attacks (cardiovascular outcomes depend on proper monitoring of hematocrit, HDL, and blood pressure, though). However, recent data shows that AFIB or heart palpitations, can increase in some older men. This issue is under investigation.

17- Emerging data shows that aromatase inhibition may not needed in TRT management. There is no data on what “high estradiol” is for men on TRT with higher testosterone blood levels, however. More details on estradiol are here:

estradiol lab test​

estradiol sensitive test description

www.discountedlabs.com