Men's Sexual Health Compounded Treatments: A Review with Shaun Noorian from Empower Pharmacy

Podcast Transcript Summary: "Exploring Men's Health Solutions with Shaun Noorian"​

Host Introduction
Nelson Vergel:
Hello everyone, Nelson Vergel here with ExcelMale.com and DiscountedLabs.com. I’m excited to have my good friend Shaun Noorian join us today. Shaun is the CEO and founder of Empower Pharmacy, the largest compounding pharmacy in the world. I’ve known Shaun for over 15 years, and he’s here to share his expertise on medications for erectile dysfunction (ED), premature ejaculation, and more. Welcome, Shaun!

​

Shaun Noorian:
Thanks, Nelson. It’s great to be here. I’m excited to talk about these medications and how compounding pharmacies provide tailored solutions to improve health, performance, and quality of life.

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Shaun’s Journey into Compounding Pharmacy​

Nelson:
Shaun, tell us about your journey into this field. What led you to start Empower Pharmacy?
Shaun:
Sixteen years ago, I was diagnosed with low testosterone at age 25. My doctor sent me to a compounding pharmacy for treatment, and the experience changed my life. Inspired by that, I became a licensed pharmacy technician and started Empower Pharmacy to deliver high-quality, affordable medications with excellent service.
Using my engineering background, I introduced manufacturing efficiencies that helped Empower grow into one of the largest compounding pharmacies in the U.S. We’re now an FDA-registered outsourcing facility, supplying medications to patients, providers, and institutions.

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Exploring Men's Health Solutions​

Nelson:
Let’s dive into the treatments available for men’s health issues like ED and premature ejaculation.
Shaun:
Absolutely! Here’s an overview of the most common solutions:

1. Intracavernosal Injections (ICIs)​

• Bimix: Combines papaverine and phentolamine to relax muscles and increase blood flow. It’s effective but can cause priapism (erections lasting over 4 hours). Providers test dosages in-office to ensure safety.
• Trimix: Adds prostaglandin to Bimix for stronger effects. It’s the first-line injectable for ED.
• Quadmix: Includes atropine sulfate for patients who don’t respond to Trimix.

Note: Always follow medical guidance. Start with the lowest dose and escalate under supervision to avoid priapism.

2. Oral Medications​

• Sildenafil (Viagra): Available as traditional tablets or fast-dissolving oral disintegrating tablets (ODTs) for quicker absorption.
• Tadalafil (Cialis): Known for its longer half-life, offering up to 36 hours of effectiveness.
• Combination Therapies:
  • Sildenafil or tadalafil with apomorphine to boost libido.
  • Sildenafil with oxytocin to address psychological and physical barriers.
  • Tadalafil with tramadol to help with premature ejaculation.

3. Hormonal Therapies​

• Cabergoline: Lowers prolactin, a hormone that can cause ED and gynecomastia (breast tissue growth).
• Oxytocin: The "love hormone" improves bonding and arousal, especially for psychological ED. It’s available as sublingual tablets or nasal sprays for faster absorption.

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Practical Advice for Providers​

Nelson:
How can doctors unfamiliar with compounded medications learn to prescribe them?
Shaun:
Doctors can:

1. Contact Us: Our pharmacists provide guidance on prescribing.
2. Attend Conferences: Events like the Sexual Medicine Society of North America offer valuable insights.
3. Use Online Resources: Our website includes product details, mechanisms of action, and contraindications.

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Beyond ED: Comprehensive Men’s Health Solutions​

Nelson:
Let’s highlight other areas Empower Pharmacy covers.
Shaun:
Empower provides solutions for:

• Hair Loss and Acne: Managing androgenic effects of testosterone.
• Fertility: Combining testosterone replacement therapy (TRT) with HCG or FSH to maintain sperm production.
• Prostate Health: Medications for BPH and other concerns.
• Weight Management: Options for weight loss and long-term management.
• Wellness: Supplements like antioxidants, B vitamins, and amino acids to enhance energy and recovery.

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Closing Remarks​

Nelson:
Thanks, Shaun! This was an incredible overview. To our listeners:

• Subscribe to the Excel Male YouTube channel.
• Visit ExcelMale.com for resources like a free 20-page guide on ED treatments.
• Use DiscountedLabs.com for affordable blood tests.
• Check out my new book, Beyond Testosterone, now on Amazon.

And if your doctor isn’t familiar with Empower Pharmacy, let them know they can contact Shaun’s team for more information. Thanks again, Shaun!
Shaun:
Thank you, Nelson. Looking forward to our next discussion!

____________________________________________



By Nelson Vergel | B.S. Chemical Engineering, MBA | Founder, ExcelMale.com | 34+ years on TRT | NIH and FDA advisory panel service | Author: Testosterone: A Man's Guide, Beyond Testosterone, The Peptide Consensus

Curated By Nelson Vergel | ExcelMale.com | Updated July 2026

ExcelMale Consensus: Standard Viagra and Cialis fail or become intolerable for a large share of men over time, and that is not the end of the road. Compounding pharmacies make oral dissolving tablets, troches, drug combinations, and penile injections (Trimix, Bimix, Quadmix) that work when off-the-shelf pills do not. The practical rule from two decades in this community: step up in order (oral PDE5, then combination orals, then injections), start injections at a tiny test dose under a trained provider, and never re-dose an injection the same night.

Key Takeaways

• Compounded ED options give you a ladder to climb when standard sildenafil or tadalafil stops working or causes side effects like headache, back pain, or nasal congestion.
• Oral dissolving tablets (ODTs) and troches absorb through the mouth lining and can act faster than a swallowed pill.
• Penile injections (Trimix, Bimix, Quadmix) are the most effective non-surgical treatment and also the ones that demand the most training. Priapism is the main risk.
• About 4% of men develop priapism after an in-office injection, and it recurs in roughly a third of them within a year, so dosing discipline matters.
• Some ED is driven by high prolactin, and one cabergoline tablet a week can correct it. Most doctors never check.

Roughly a third of men stop responding to Viagra or Cialis within a few years, and plenty more quit because of side effects they never signed up for. If that is you, compounded ED medications are the reason you have a next move instead of a dead end. A compounding pharmacy can make the same active ingredients in faster-absorbing forms, blend two or three drugs into one dose, and produce penile injections that work when nothing swallowed does. This is the menu Shawn Nurian, founder of Empower Pharmacy, walked through on the ExcelMale podcast, and it is wider than most men (and most doctors) realize.

What Compounded Oral ED Options Exist Beyond Standard Viagra and Cialis?​

The four PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) all work the same way. They relax smooth muscle and let blood fill the two chambers inside the penis. What differs is timing and tolerability. Sildenafil has a half-life near 4 hours. Vardenafil sits around 4 to 6 hours with a side-effect profile some men tolerate better than sildenafil. Tadalafil runs about 17.5 hours, which is why it earned the "weekend" reputation.

A compounding pharmacy changes the delivery, not the molecule. The most common request Empower sees is the oral dissolving tablet (ODT), a tablet that breaks down in under a minute. Placed under the tongue, some of the drug absorbs through the mouth lining straight into the bloodstream instead of waiting on your stomach. A troche does something similar. It is a wax-like lozenge you park between cheek and gum for slow buccal absorption. Men who dislike swallowing pills, or who want a quicker onset, tend to prefer these.

What About Combining Sildenafil or Tadalafil With Other Drugs?​

This is where compounding earns its keep. A pharmacy can put a PDE5 inhibitor in the same dose as a second agent that targets arousal rather than blood flow.

Sildenafil or tadalafil with oxytocin pairs blood-flow help with the brain side of arousal. Oxytocin is the pituitary hormone tied to bonding and connection, and it shows up as a compounded option for men whose ED has a psychological component. For a man whose block to getting an erection is emotional rather than vascular, oxytocin adds a central arousal effect that a blood-flow drug alone does not provide.

Sildenafil or tadalafil with apomorphine, a dopaminergic drug, aims at the same problem from a different direction by nudging dopamine to raise arousal. Tadalafil with phentolamine (the vasodilator also found in the injections below) stacks two blood-flow mechanisms for men who do not respond well to a PDE5 inhibitor alone.

Sildenafil with testosterone in a troche is used about 30 minutes before sex so both have time to take effect, with testosterone supporting libido while sildenafil supports the erection. A 2021 meta-analysis in JAMA Network Open found combination approaches often outperform a single agent, which is the clinical logic behind these formulas.

What Are Trimix, Bimix, and Quadmix, and When Do You Step Up to Injections?​

When PDE5 pills stop working, or the side effects (headache, nausea, the rare blue-tinted vision) become intolerable, the next rung is intracavernosal injection therapy, or ICI. You inject a tiny volume into the side of the penis, into the corpora cavernosa, the two blood-holding chambers. The drug relaxes that tissue directly, so it works even in men who no longer respond to oral medication.

These come in three strengths. Trimix is the workhorse and makes up roughly 90% of what Empower dispenses. It combines papaverine and phentolamine (both vasodilators and smooth-muscle relaxers) with prostaglandin. Bimix drops the prostaglandin, leaving papaverine and phentolamine. Providers usually move a man from Trimix to Bimix when the prostaglandin causes injection pain, since some men feel that burn and some never do. Quadmix is Trimix plus atropine sulfate, reserved for men who have become less responsive to Trimix and need extra effect.

ICI is the most effective non-surgical ED treatment there is. It has also saved marriages, and I mean that literally. I have watched men who had written off their sex lives get erections like they were 20 again. The trade-off is that injections demand the most education of anything in this field. Like all ED, the underlying problem is progressive, so a man may eventually stop responding to injections too. When that happens, the last option is a penile prosthesis.

Why Does the Starting Dose Matter So Much?​

Because too much causes priapism. The starting dose for a man without advanced ED is genuinely tiny, around 0.05 cc, roughly a drop, and the provider titrates up slowly from there toward a ceiling near half a cc. Most men never need more than about 0.12 cc drawn in an insulin syringe. Papaverine is the ingredient most responsible for a prolonged erection, so dosing it correctly is the whole game.

This is why borrowing your buddy's Trimix is a bad idea that usually ends in the ER. His dose is not your dose. A trained urologist or provider gives a test dose in the office first, often checks for venous leakage with ultrasound, and teaches you to titrate. Follow that instruction and ICI is very safe. One firm rule from this community: never inject a second time the same night if the first dose underdelivers. The drug accumulates, and a second shot is how a soft response turns into a four-hour emergency.

What Is Priapism and How Do You Treat an Erection That Lasts Too Long?​

Priapism is an erection lasting longer than 4 hours, and it is the reason all the dosing caution above exists. It happens in a minority of ICI users, and a 2024 analysis in the International Journal of Impotence Research put the rate near 4% after an in-office injection, with recurrence around 32% within the first year. Younger men and those with mood or behavioral conditions were at higher risk.

The danger is oxygen. In ischemic priapism, blood gets trapped in the penis and stops flowing. Once it loses oxygen it starts to coagulate, and trapped, clotting blood is hard for the body to clear. If the tissue goes without oxygen long enough it begins to die, and that can cause permanent ED. This is why 4 hours is the line where you act.

Treatment goes in order. First-line at home is often pseudoephedrine, an oral decongestant that can help reduce a stubborn erection. If a provider has given you a vial of compounded phenylephrine, that is next. Phenylephrine is a vasoconstrictor, the opposite of the drugs that caused the erection, and it is injected into the same chambers to bring the erection down (detumescence). Commercial phenylephrine only comes in a 10 mg/mL strength, which is too strong for this use, so pharmacies compound a diluted version near one-tenth that concentration. If neither works, go to the hospital fast, where the erection can be drained or treated surgically. Do exactly what your provider tells you and do not wait it out.

Can High Prolactin Cause ED, and Does Cabergoline Fix It?​

Yes, and this one gets missed constantly. Prolactin is the hormone behind breast-milk production in women, and men carry a little of it too. When it runs high in a man it can cause erectile dysfunction, nipple tenderness, and breast tissue growth that can be mistaken for gynecomastia.

High prolactin is not common, which is why it is not a routine first check. But there is a specific situation where it earns a look: a man on testosterone who is not responding the way he should within 3 to 4 months, especially if his baseline testosterone was very low. That is when a sharp doctor checks prolactin. You can also order it yourself through DiscountedLabs.com without a doctor visit. If it comes back high, one cabergoline tablet a week is usually enough to bring it down. A randomized, placebo-controlled study in the International Journal of Impotence Research found cabergoline improved erectile function, desire, and satisfaction in men with psychogenic ED while normalizing hormone levels. Correct the prolactin and the ED driven by it often resolves.

What Treats ED and Premature Ejaculation at the Same Time?​

Plenty of men have both a soft erection and a short fuse, and there is a compounded answer for that pairing: tadalafil with tramadol. Tramadol is a pain medication, but at a low dose it delays ejaculation. Combine it with tadalafil and you address the erection and the timing in one dose.

The evidence supports the concept. A 2023 randomized, placebo-controlled trial found on-demand sildenafil plus tramadol lengthened time to ejaculation more than either drug alone. Two points to know. The tramadol dose here is much lower than what is used for pain, so most men will not feel pain relief, only the ejaculation delay. And tramadol is a controlled substance, so it needs a prescription and is limited to about a 90-day supply. For a man juggling ED and rapid ejaculation, this combination can be a strong single solution.

Frequently Asked Questions​

Are compounded ED medications FDA approved?​

Compounded medications are not FDA-approved products, because compounding tailors a formula to an individual prescription rather than mass-producing a fixed drug. The active ingredients (sildenafil, tadalafil, papaverine, phentolamine) are the same ones in approved drugs. Empower also runs an FDA-registered outsourcing facility that makes medications for clinics and hospitals under stricter oversight. Use a licensed pharmacy and a prescribing provider.

How do I get a doctor to prescribe Trimix or a compounded formula?​

Many providers learn these options from patient forums like ExcelMale, from conferences such as the Sexual Medicine Society of North America, or from continuing-education courses. A provider can also call a compounding pharmacy directly and speak with a medical affairs pharmacist about formulas, dosing, contraindications, and interactions. If your doctor is unfamiliar with compounding, that phone call is often the fastest path.

Which PDE5 inhibitor has the fewest side effects?​

It is individual. Some men get every side effect on tadalafil (back pain, heartburn, sinus congestion, headache) and tolerate vardenafil cleanly. Others do the reverse. Vardenafil is chemically close to sildenafil but causes fewer side effects for some men. The takeaway: if one pill does not agree with you, do not quit on the whole category. Try another.

Is Trimix safe to use at home?​

It is safe when a trained provider sets your starting dose and teaches you to titrate, and dangerous when you guess. Start at the tiny test dose your provider gives you, escalate slowly, and never inject twice in one session. Keep a priapism plan ready before your first shot.

Do these medications treat the cause of ED or just the symptom?​

Most treat the symptom so you can have sex now, which for a man with vascular or age-related ED is the practical goal. The exception is prolactin-driven ED, where cabergoline addresses the actual cause. This is why testing (testosterone, prolactin, and a workup with your provider) matters alongside treatment.

Conclusion​

One thing the podcast made obvious that most men never hear: the reason you have options today is that a compounding pharmacy can build around your specific failure point. Ten or fifteen years ago, if Viagra gave you a splitting headache, you were mostly out of luck. Now vardenafil, an ODT, a troche, a combination formula, or an injection is a prescription away. If a pill stopped working or made you miserable, that is a signal to climb the ladder, not to give up. Start by reading the real-world dosing experience in our two-decade Trimix guide, and if your erections are fine but desire is the problem, what to do about erectile dysfunction is the next thing to read.

Key References​

1. Ziegelmann M, et al. Evaluating the management trends for priapism and assessing the risk of priapism after in-office intracavernosal injections: a cross-sectional analysis. International Journal of Impotence Research. 2024. Evaluating the management trends for priapism and assessing the risk of priapism after in-office intracavernosal injections: a cross-sectional analysis - International Journal of Impotence Research
2. Nickel M, Moleda D, Loew T, Rother W, Pedrosa Gil F. Cabergoline treatment in men with psychogenic erectile dysfunction: a randomized, double-blind, placebo-controlled study. International Journal of Impotence Research. 2007. Cabergoline treatment in men with psychogenic erectile dysfunction: a randomized, double-blind, placebo-controlled study - International Journal of Impotence Research
3. Combined on-demand sildenafil citrate and tramadol hydrochloride is an effective and safe treatment for premature ejaculation: a randomized placebo-controlled double-blind clinical trial. Journal of International Medical Research. 2023. https://doi.org/10.1080/20905998.2023.2287869
4. Prospective comparison of tadalafil 5 mg, dapoxetine 30 mg, and the combination of both in the treatment of premature ejaculation. Arab Journal of Urology. 2023. https://doi.org/10.1080/20905998.2023.2277081
5. Zhao C, et al. Assessment of Combination Therapies vs Monotherapy for Erectile Dysfunction: A Systematic Review and Meta-analysis. JAMA Network Open. 2021. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2776549
6. Which PDE5 inhibitor is the most effective in the treatment of erectile dysfunction: a network meta-analysis. Andrology. 2024. https://doi.org/10.1111/andr.13642
7. Burnett AL, et al. Erectile Dysfunction: AUA Guideline. Journal of Urology. 2018. https://doi.org/10.1016/j.juro.2018.05.004
8. De Rosa M, et al. Six Months of Treatment with Cabergoline Restores Sexual Potency in Hyperprolactinemic Males. Journal of Clinical Endocrinology & Metabolism. 2004;89(2):621. https://academic.oup.com/jcem/article/89/2/621/2840576

Related ExcelMale Forum Discussions​

• Trimix for Erectile Dysfunction: A Real-World Guide From Two Decades of Experience walks through titration and dosing from long-term community use.
• How To Inject Trimix for Erectile Dysfunction covers injection technique step by step.
• 27 Questions and Answers About Trimix Penile Injection Therapy is a practical FAQ built from real user questions.
• Trimix vs Bimix Question discusses when men switch off prostaglandin for injection pain.
• Trimix Antidote for Priapism: Phenylephrine HCl Injection explains the rescue protocol for a prolonged erection.

Medical Disclaimer
This article is for educational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider before starting or modifying any hormone therapy or medical treatment.

About ExcelMale​

ExcelMale.com is a men's health community with more than 24,000 members and over 20 years of archives, founded by Nelson Vergel. Nelson is a chemical engineer with 34+ years on TRT and has served on NIH and FDA advisory panels. He is the author of Testosterone: A Man's Guide and Beyond Testosterone.[/HEADING]

 

Beyond Standard Testosterone Therapy: A Practical Guide to Compounded Hormone Options for Men

Men starting hormone therapy often hear about only one option: testosterone injections.

In reality, hormone treatment includes several medications, delivery systems, strengths, and combinations. Some are commercially manufactured. Others are prepared by compounding pharmacies for patients who need a dose, ingredient, or delivery method unavailable through a standard retail pharmacy.

I recently spoke with Shaun Noorian, CEO of Empower Pharmacy, about the range of compounded hormone treatments prescribed for men. Our discussion covered testosterone, fertility support, estrogen management, thyroid therapy, growth hormone treatments, anabolic medications, and the role of personalized compounding.

This article summarizes the main points from our conversation while adding important clinical context.

Why Men Use Compounding Pharmacies

Commercial medications are manufactured in fixed strengths and dosage forms. This works for many patients, but hormone therapy often requires more individualized dosing.

A compounding pharmacy prepares a medication based on a prescription for a specific patient. A doctor might prescribe a compounded medication when a patient needs:

• A lower dose than the commercial product provides
• A different carrier oil
• An alcohol-free cream
• A capsule without certain fillers or dyes
• A combination of two prescribed ingredients
• A formulation unavailable from a commercial manufacturer
• A different delivery system, such as a troche, nasal gel, cream, or sustained-release capsule

Compounding does not mean every customized treatment is proven superior. It means the prescriber has more options when a standard product does not meet the patient's needs.

The quality and regulatory status of the pharmacy matter. Patients should use a properly licensed pharmacy and work with a clinician who understands hormone monitoring.

Testosterone Is Only One Part of Hormone Therapy

Testosterone replacement therapy affects more than the testosterone number on a laboratory report.

Treatment also influences:

• Estradiol
• Luteinizing hormone, or LH
• Follicle-stimulating hormone, or FSH
• Sperm production
• Testicular size
• Red blood cell production
• Lipids
• Prostate markers
• Sexual function
• Mood and energy
• Fertility goals

This explains why two men taking the same testosterone dose might experience different results.

One man might feel excellent. Another might develop nipple tenderness, acne, fluid retention, elevated hematocrit, fertility concerns, or fluctuations between injections.

The goal should not be to force every man onto the same protocol. The goal should be to find the lowest effective treatment plan based on symptoms, laboratory results, medical history, and personal priorities.

Anastrozole and Other Aromatase Inhibitors

Testosterone converts into estradiol through the aromatase enzyme. Some men experience a greater rise in estradiol than others during testosterone therapy.

Anastrozole, letrozole, and exemestane reduce aromatase activity. These medications were developed for estrogen-sensitive breast cancer, but some clinicians prescribe them off-label in men.

Possible reasons include:

• Persistent nipple tenderness
• Documented gynecomastia
• High estradiol with compatible symptoms
• Excessive fluid retention after other causes have been considered

Commercial anastrozole often comes as a 1 mg tablet. For many men, 1 mg is a large dose. A compounded capsule might provide a smaller amount, such as 0.1 mg or 0.25 mg.

This matters because men need estradiol.

Estradiol supports:

• Bone density
• Sexual function
• Joint health
• Brain function
• Cardiovascular physiology

Lowering estradiol too far might cause low libido, erectile problems, fatigue, depressed mood, joint discomfort, and loss of bone density.

An aromatase inhibitor should not be prescribed automatically because estradiol rises during TRT. The first step often involves reviewing the testosterone dose, injection frequency, body composition, symptoms, and accuracy of the estradiol assay.

Clomiphene Citrate

Clomiphene is a selective estrogen receptor modulator. It blocks estrogen signaling in parts of the hypothalamus and pituitary, which often increases LH and FSH.

LH stimulates the Leydig cells in the testes to produce testosterone. FSH supports sperm production.

For selected men with secondary hypogonadism, clomiphene might increase their natural testosterone production while preserving fertility.

This differs from standard TRT. Exogenous testosterone usually suppresses LH and FSH, which reduces intratesticular testosterone and sperm production.

Clomiphene is often considered for men who:

• Want to preserve fertility
• Have functioning testicles
• Have low or inappropriately normal LH and FSH
• Prefer an oral treatment
• Want to avoid testicular shrinkage associated with testosterone suppression

Commercial clomiphene has traditionally been sold as a 50 mg tablet. Some clinicians prefer smaller doses due to side effects and the long half-life of one of its isomers.

Potential side effects include:

• Mood changes
• Visual symptoms
• Headaches
• Increased estradiol
• Reduced libido despite improved laboratory values
• Breast tenderness
• Unpredictable symptom response

More testosterone on paper does not always translate into feeling better.

Enclomiphene

Clomiphene contains two isomers: enclomiphene and zuclomiphene.

Enclomiphene is generally considered the more anti-estrogenic component responsible for stimulating LH and testosterone production. Zuclomiphene stays in the body longer and has more estrogen-like activity.

This difference has led some clinicians to prescribe compounded enclomiphene rather than standard clomiphene.

Supporters believe enclomiphene might raise testosterone with fewer estrogenic effects. Clinical response still varies, and long-term outcome data remain limited compared with established testosterone products.

Men using enclomiphene still require monitoring of:

• Total and free testosterone
• Estradiol
• LH and FSH
• Hematocrit
• Lipids
• PSA when appropriate
• Symptoms and sexual function

A laboratory increase alone should not define success.

Human Chorionic Gonadotropin, or hCG

hCG is produced during pregnancy, but its structure and activity closely resemble LH.

When a man injects hCG, it stimulates the LH receptor in the testes. This supports intratesticular testosterone production.

Clinicians prescribe hCG in several situations:

• As monotherapy for selected cases of secondary hypogonadism
• Alongside testosterone to support testicular function
• To reduce testicular shrinkage
• As part of a fertility treatment plan
• To help maintain intratesticular testosterone during TRT

Testosterone suppresses the hormonal signals coming from the brain. hCG bypasses part of this pathway by stimulating the testes directly.

hCG does not guarantee preserved fertility. Some men need additional treatment, such as FSH or human menopausal gonadotropin, especially when sperm production remains low.

Possible hCG side effects include:

• Increased estradiol
• Breast tenderness
• Acne
• Fluid retention
• Mood changes
• Higher testosterone than intended

Dosing should match the treatment goal. A fertility protocol differs from a protocol intended only to maintain testicular size.

Gonadorelin Is Not the Same as hCG

Gonadorelin is a form of gonadotropin-releasing hormone, or GnRH.

GnRH signals the pituitary gland to release LH and FSH. hCG acts farther downstream by stimulating the LH receptor directly.

This distinction matters.

Gonadorelin depends on a functioning pituitary gland and proper pulsatile stimulation. Its short half-life makes standard intermittent injections a poor replacement for hCG in many TRT protocols.

hCG has a longer biological effect and directly stimulates the testes.

The two medications should not be treated as interchangeable based only on the claim that both influence LH-related pathways.

DHEA

DHEA is produced mainly by the adrenal glands. It serves as a precursor for several sex hormones.

DHEA supplements are widely available without a prescription in the United States, though access and regulation differ by country.

DHEA does not reliably raise testosterone enough to correct meaningful male hypogonadism. It might be considered when a patient has low DHEA sulfate levels, adrenal concerns, or a specific clinical reason for supplementation.

Potential effects include:

• Increased acne
• Oily skin
• Hair loss in susceptible patients
• Changes in estradiol or androgen levels
• Sleep or mood changes

Women often experience a greater androgenic response to DHEA than men. For this reason, DHEA has also been used in selected women with low libido, though evidence varies.

A compounded product provides a verified prescription strength and offers options such as capsules, creams, or troches. This does not mean every patient needs pharmaceutical-grade DHEA.

Pregnenolone

Pregnenolone sits near the beginning of the steroid hormone synthesis pathway. This has led to its popular description as the "mother hormone."

The phrase often creates the impression that taking pregnenolone automatically restores all downstream hormones. Human endocrine physiology is more regulated than this description suggests.

Pregnenolone supplementation does not reliably increase testosterone, cortisol, progesterone, or other hormones in a predictable way.

Some clinicians prescribe pregnenolone alone or with DHEA when laboratory values and symptoms support a trial. Evidence for broad anti-aging benefits remains limited.

Patients should monitor for:

• Irritability
• Sleep disruption
• Headaches
• Acne
• Mood changes
• Unexpected changes in downstream hormones

Danazol

Danazol is a synthetic steroid with complex androgenic and antigonadotropic effects. It suppresses pituitary gonadotropins and has been used for conditions such as hereditary angioedema and endometriosis.

Its role in routine male hormone management is limited.

Potential risks include:

• Liver injury
• Adverse lipid changes
• Acne
• Hair loss
• Mood changes
• Suppression of natural testosterone and sperm production

Danazol is not a routine treatment for nipple tenderness or gynecomastia. Better-studied options usually exist, depending on the cause and stage of breast tissue development.

Testosterone Delivery Options

No single testosterone delivery method works best for every man.

The main options include:

• Injections
• Creams and gels
• Pellets
• Nasal testosterone
• Oral testosterone undecanoate
• Buccal or troche formulations

Each method produces a different pharmacokinetic pattern and requires different precautions.

Testosterone Cypionate and Enanthate

Testosterone cypionate and testosterone enanthate are long-acting injectable esters.

Their clinical effects are similar. Cypionate is more common in the United States. Enanthate is widely used in other countries.

Commercial products often use carrier oils such as cottonseed or sesame oil. Compounding pharmacies might prepare testosterone in grapeseed oil or another suitable vehicle when prescribed.

A different carrier might help a patient who develops:

• Local irritation
• Swelling
• Persistent injection-site pain
• A suspected sensitivity to an oil or preservative

True allergies are uncommon. Injection technique, needle size, injection volume, contamination, and inflammation should also be considered.

Subcutaneous Versus Intramuscular Testosterone

Testosterone injections were traditionally given into muscle. Many men now inject smaller doses into subcutaneous tissue.

Subcutaneous injections often use smaller insulin syringes and might feel easier for long-term self-administration.

Potential advantages include:

• Smaller needles
• Less deep-tissue trauma
• Easier self-injection
• Lower injection volume when concentrated testosterone is used
• More frequent dosing with smaller amounts

Some men develop small lumps, redness, or irritation with subcutaneous injections. Others prefer intramuscular injections.

The best route depends on patient comfort, medication concentration, dosing schedule, and clinical response.

Mixed Testosterone Esters

Some compounded preparations combine a longer-acting ester, such as cypionate, with a shorter-acting ester, such as propionate.

The theory is simple. Propionate produces an earlier rise, while cypionate provides a longer effect.

This approach does not automatically produce better symptoms or more stable levels. Faster peaks might increase fluctuations, estradiol conversion, acne, or mood changes in sensitive patients.

Most men do well with one established ester and an appropriate dosing schedule.

Testosterone Cream

Compounded testosterone cream offers an alternative for men who dislike injections.

Application sites might include:

• Shoulders
• Upper arms
• Torso
• Inner thighs
• Scrotal skin, when prescribed

Scrotal skin absorbs testosterone efficiently. Scrotal application also tends to increase dihydrotestosterone, or DHT, more than application to other sites.

Some men report strong libido and symptom response with scrotal cream. Others experience acne, hair loss, prostate-related symptoms, or excessively high DHT.

Commercial alcohol-based gels should not be applied to the scrotum. The alcohol might cause severe burning and irritation. Compounded scrotal products usually use a cream base without alcohol.

Transference is a major concern with all topical testosterone. Medication left on the skin might expose a partner, child, or pet.

Patients should follow instructions regarding:

• Hand washing
• Application-site coverage
• Drying time
• Shower timing
• Skin-to-skin contact

Testosterone Pellets

Testosterone pellets are inserted under the skin through a small incision, usually near the hip or buttock.

The pellets release testosterone over several months.

Advantages include:

• No weekly injections
• No daily cream
• Reduced risk of topical transfer
• Convenience for men who travel

Limitations include:

• A minor surgical procedure
• Bruising or infection risk
• Pellet extrusion
• Difficulty adjusting the dose after insertion
• High early levels or low late-cycle levels
• Variable duration between patients
• Cost

Pellets work well for some men, but they offer less flexibility than injections or creams.

Nasal Testosterone

Nasal testosterone is applied inside the nostrils several times per day.

It produces brief increases in testosterone rather than maintaining a high level throughout the entire day. Some research suggests this short exposure might cause less suppression of LH, FSH, and sperm production than longer-acting TRT.

Potential advantages include:

• No needles
• Low transfer risk
• Short exposure
• Possible fertility advantages for selected men

Limitations include:

• Multiple daily doses
• Nasal irritation
• Congestion
• Variable absorption
• Less convenient dosing

Nasal testosterone should not be presented as guaranteed fertility-preserving therapy. Men seeking fertility should have semen analysis and appropriate follow-up.

Testosterone Troches

A troche dissolves between the cheek and gum or under the tongue.

Testosterone troches produce relatively rapid absorption and short-lived levels. They often require frequent dosing and might produce inconsistent blood concentrations.

They are less common for male TRT than injections, creams, pellets, or approved oral testosterone undecanoate products.

Claims that a troche taken before sex or exercise reliably improves immediate performance lack strong clinical evidence. Testosterone is not an on-demand erectile medication.

Sexual function depends on vascular health, nerve function, psychological factors, relationship factors, medication use, sleep, and baseline hormone status.

Nandrolone Decanoate

Nandrolone is an anabolic androgenic steroid with approved and historical medical uses. Some clinicians prescribe compounded nandrolone off-label for men with severe muscle loss, chronic wasting, low bone density, or persistent joint complaints.

Nandrolone has a higher anabolic-to-androgenic ratio than testosterone, though this does not make it free from androgenic or cardiovascular risks.

Potential concerns include:

• Suppression of LH and FSH
• Reduced sperm production
• Lower natural testosterone production
• Erectile dysfunction
• Reduced libido
• Adverse lipid changes
• Increased hematocrit
• Acne
• Fluid retention
• Mood changes
• Cardiovascular risk

Nandrolone is often prescribed with testosterone because nandrolone alone might produce sexual dysfunction in some men.

Reports of improved joint comfort do not prove that nandrolone repairs cartilage, tendons, or ligaments. Reduced pain might lead a patient to overload an injured joint.

Oxandrolone

Oxandrolone is an oral anabolic steroid developed for conditions involving weight loss, catabolism, burns, surgery, and other serious medical problems.

Some clinicians use it for muscle wasting or recovery when the expected benefit outweighs the risks.

Potential risks include:

• Suppression of natural testosterone
• Reduced fertility
• Lower HDL cholesterol
• Higher LDL cholesterol
• Liver enzyme elevations
• Liver injury
• Acne
• Hair loss
• Mood changes

Oxandrolone is often described as mild. This description understates its effects on lipids and natural hormone production.

Buccal or sublingual delivery does not eliminate liver exposure or prove protection from hepatotoxicity. Patients still need medical monitoring.

Oxymetholone and Stanozolol

Oxymetholone and stanozolol are potent oral anabolic steroids.

Their medical uses have included anemia, hereditary angioedema, and severe wasting conditions. They are not routine hormone replacement drugs.

Risks include:

• Liver toxicity
• Severe HDL reduction
• Increased LDL cholesterol
• Blood pressure changes
• Fluid retention
• Suppression of natural testosterone
• Fertility impairment
• Acne and hair loss
• Cardiovascular stress

These medications require a clear medical indication, conservative duration, and careful monitoring.

Growth Hormone

Somatropin is recombinant human growth hormone.

Approved uses include documented growth hormone deficiency and several specific medical disorders. Adult growth hormone deficiency should be diagnosed through clinical evaluation and appropriate testing.

Growth hormone is sometimes promoted for muscle gain, fat loss, sleep, skin quality, or general anti-aging. These uses remain controversial and often lack a valid deficiency diagnosis.

Potential side effects include:

• Fluid retention
• Joint pain
• Carpal tunnel symptoms
• Insulin resistance
• Higher blood glucose
• Sleep apnea worsening
• Headaches
• Enlargement of certain tissues
• Increased IGF-1

Growth hormone should not be prescribed based only on aging, fatigue, or one low random growth hormone measurement.

Sermorelin

Sermorelin is a growth hormone-releasing hormone analogue. It stimulates the pituitary gland to release growth hormone.

Its effect depends on functioning pituitary cells.

Sermorelin differs from somatropin because it stimulates endogenous secretion rather than replacing growth hormone directly.

Potential benefits and risks depend on the patient's diagnosis, dose, pituitary function, and IGF-1 response.

Many peptide products are marketed with claims that exceed available evidence. Patients should confirm the legal status, source, sterility, and clinical rationale before treatment.

Thyroid Hormone Treatment

Thyroid problems might produce symptoms resembling low testosterone, including:

• Fatigue
• Low mood
• Weight gain
• Reduced libido
• Brain fog
• Cold intolerance
• Poor exercise tolerance

For this reason, thyroid function should be assessed before assuming every symptom comes from low testosterone.

Levothyroxine, or T4

Levothyroxine is the standard first-line treatment for hypothyroidism.

The body converts T4 into the active thyroid hormone T3. Most patients achieve appropriate thyroid levels with levothyroxine alone.

Compounded levothyroxine might be considered when a patient needs:

• An unusual strength
• A liquid or capsule formulation
• Removal of a specific inactive ingredient
• A carefully prescribed combination product

Compounded thyroid hormone requires strict potency control because small dose differences might have significant effects.

Liothyronine, or T3

Liothyronine acts faster and has a shorter half-life than levothyroxine.

Some clinicians add a small amount of T3 when a patient has persistent symptoms despite appropriate TSH levels. Evidence supporting routine combination therapy remains mixed.

Excess T3 might cause:

• Palpitations
• Anxiety
• Tremor
• Insomnia
• Bone loss
• Irregular heart rhythm
• Muscle loss

Sustained-release compounded T3 is sometimes prescribed, but absorption and potency need careful monitoring.

Desiccated Thyroid

Desiccated thyroid is produced from porcine thyroid glands and contains both T4 and T3.

Some patients prefer it and report improved symptoms. Others experience excessive T3 peaks or unstable thyroid levels.

Porcine thyroid does not have the same T4-to-T3 ratio produced by the human thyroid. It contains proportionally more T3.

Patients taking desiccated thyroid should monitor:

• TSH
• Free T4
• Free T3 when clinically useful
• Heart rate
• Blood pressure
• Symptoms of excess thyroid hormone
• Bone health in higher-risk patients

A compounded capsule might remove dyes, lactose, or fillers found in some commercial tablets. The medication still requires careful dose standardization.

The Potential Advantages of Compounding

Compounding pharmacies provide options unavailable from mass-produced medications.

The main advantages include:

• Smaller or unusual doses
• Different delivery routes
• Alternative carrier oils
• Removal of allergens or unnecessary fillers
• Combination products
• Access during certain commercial shortages
• Personalized treatment based on a prescription

For hormone therapy, these options might improve comfort, adherence, and dosing precision.

The Limitations of Compounding

Compounded medications do not undergo the same FDA approval process as commercially manufactured drugs.

This means a compounded product has not been reviewed as an FDA-approved product for:

• Safety
• Effectiveness
• Manufacturing consistency
• Bioavailability
• Long-term outcomes

This does not mean compounded products are inherently unsafe. It means patients and clinicians should understand the regulatory difference.

Compounding should address a real clinical need rather than serve as a way to market unapproved combinations or unsupported claims.

Questions to Ask Before Using a Compounded Hormone

Before filling a compounded prescription, ask:

1. Why is the commercial product unsuitable for me?
2. What evidence supports this medication and dose?
3. Is this treatment FDA-approved, off-label, or available only through compounding?
4. What laboratory tests will be monitored?
5. What symptoms or side effects should I report?
6. How often will my dose be reviewed?
7. Is the pharmacy licensed in my state?
8. Does the pharmacy perform potency, sterility, and endotoxin testing when appropriate?
9. What inactive ingredients are included?
10. What happens if I stop treatment?

A good clinician should welcome these questions.

What Men Should Monitor During Hormone Therapy

The monitoring plan depends on the medication, age, health history, and treatment goals.

Common tests include:

• Total testosterone
• Free testosterone
• SHBG
• Estradiol using a sensitive assay when appropriate
• Complete blood count and hematocrit
• PSA and prostate evaluation when indicated
• Lipid panel
• Liver enzymes
• Kidney function
• Blood pressure
• Thyroid tests
• IGF-1 during growth hormone treatment
• Semen analysis when fertility matters

Symptoms matter as much as laboratory numbers.

A man with a high-normal testosterone level who feels worse has not reached a successful outcome. A man who feels better but develops a hematocrit of 56 percent also needs a protocol review.

Personalized Treatment Requires More Than a Customized Prescription

Compounded hormone therapy offers more choices, but more choices do not always produce better care.

Good hormone treatment still requires:

• A proper diagnosis
• Clear treatment goals
• Conservative dosing
• Reliable laboratory testing
• Symptom tracking
• Side-effect monitoring
• Periodic reassessment
• A willingness to simplify the protocol

Men should be cautious when a clinic immediately prescribes testosterone, hCG, an aromatase inhibitor, thyroid hormone, growth hormone peptides, and several supplements before evaluating how each treatment affects them.

Start with the main problem. Add medications only when a clear reason exists.

Compounding works best when it solves a specific problem, such as an unavailable dose, an ingredient sensitivity, a preferred delivery method, or a legitimate need for a customized formulation.

The goal is not to take more hormones.

The goal is to use the right treatment, at the right dose, for the right reason.

 

Does Empower Pharmacy have HCG?

Yes, brand name Pregnyl

 

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