Post TRT - Libido is DEAD :(

[Vince]

I reviewed every one and It appeared that you hadn't read them; many have no bearing on the discussion, and at least one provides direct evidence in favor of physiological dosing. None support the premise that supraphysiological dosing is preferable to physiological dosing for treating hypogonadism.

For those who are interested, the discussion begins around here:

T

Thread 'New to TRT. Received first labs. Concerned and need help.'

Aug 12, 2025

Male. Mid 50’s.

Symptoms prior to TRT: excessive fatigue, no energy, brain fog, difficulty concentrating, depression, anxiety, low libido, loss of muscle mass, reduced strength.

Prior to TRT, my total testosterone was 460. I know that may sound high to start TRT but I have been searching for a solution to my symptoms for a long time. My doctors have ruled out Vitamin D, B12, Folate, Anemia, infections, liver, kidney, hydration, thyroid, Iron, etc. Even at 460, I needed to see if TRT could help. I started with a low dose, waited 3 months, did my labs, and here I am.

I started TRT 3...

• trtguy8
• Replies: 69
• Forum: Blood Test Discussion

AI Summary:
The key debate in the ExcelMale thread (primarily on page 3) between Cataceous and Phil Goodman centers on optimal TRT dosing strategy: physiological replacement (aiming to mimic or restore natural, mid-to-high normal testosterone levels) versus somewhat supraphysiological (higher-than-natural levels for perceived greater benefits in well-being, energy, etc.).

Cataceous's Main Positions (Advocating Physiological Doses)

• Physiological dosing is safer and more logical: Start with modest doses to replicate healthy natural production (equivalent to ~50-70 mg testosterone cypionate/week for young men; top natural range ~90 mg/week). 100 mg/week is already supraphysiological for most, often leading to peaks well above normal (e.g., user's trough free T of 31.91 ng/dL — above the 5-21 range — implies even higher peaks).
• No strong evidence for supraphysiological benefits beyond muscle: Higher doses don't reliably improve non-muscular outcomes (energy, mood, cognition) and may cause imbalances across dozens of hormones. Testosterone isn't directly tied to energy/focus at supraphysiological levels; excess can worsen symptoms (e.g., sleep issues, libido problems, raised HCT, poor lipids).
• Risks of starting too high: Immediate exposure to supraphysiological levels (especially with infrequent injections) skips the chance to experience true physiological restoration first. Suggests experimenting with lower doses (e.g., 40 mg twice weekly) or faster-acting forms to minimize prolonged high exposure and long-term risks.
• Counters community anecdotes: Dismisses polls showing many feel better at higher levels, arguing they're biased toward those already on supraphysiological doses rather than true physiological ones.

Phil Goodman's Main Positions (Advocating Somewhat Supraphysiological Doses)

• Higher levels often feel better anecdotally: Cites community polls (e.g., 68% of members report feeling better with above-normal levels), suggesting many men need/respond better to doses pushing levels somewhat supraphysiological for optimal symptom relief (libido, muscle, strength, energy).
• Dismisses excessive concern over ratios/free T/SHBG: Low SHBG (common on TRT) makes users less tolerant to estrogen but doesn't inherently require ultra-low doses; % free T or ratios aren't the main issue. Nothing much can be done about low SHBG anyway, and it shouldn't dominate symptom troubleshooting.
• Adjustment takes time: Users may see partial improvements (e.g., better libido/muscle) but need more time or slight tweaks rather than immediately dropping to very low doses.

Key Back-and-Forth Exchanges/Rebuttals

• Cataceous challenges the "100 mg/week is low/normal" myth as pervasive but incorrect, urging lower starting doses to avoid supraphysiological exposure from the outset.
• Phil pushes back with poll data and community experience, arguing higher doses work well for most without needing to obsess over SHBG or free T ratios.
• Cataceous rebuts that many "higher-level" successes likely stem from supraphysiological exposure (not true physiological restoration), and risks (e.g., vascular issues, cardiac strain from studies) increase dose-dependently beyond physiological.
• The debate ties into the original poster's labs (high free T at trough, low-ish SHBG), with Cataceous recommending dose reduction (e.g., to ~40 mg twice weekly) to stabilize levels and potentially raise SHBG, while Phil leans toward patience and accepting higher ranges if symptoms improve partially.

Overall, Cataceous emphasizes evidence-based caution, risk minimization, and physiological mimicry as the default, while Phil leans on real-world forum anecdotes and optimization for subjective well-being even if it means exceeding natural levels. The discussion remains civil but pointed, highlighting a broader divide in the TRT community. For full context, refer to page 3 of the thread: New to TRT. Received first labs. Concerned and need help. - Page 3 - ExcelMale - #1 TRT & Testosterone Forum | Expert-Moderated Men's Health Community

You're still grouping everyone together. You really think everyone needs to do trt like you do. Be real. Yes, start thinking rationally.

Rational thinking involves making decisions based on logic, evidence, and objective facts rather than emotions or cognitive biases.

Could you give me the "elevator pitch version"?

 

[FunkOdyssey]

so what's the solution? should I stop 12.5ng daily enclomiphene?

should I add hcg? some say take dht? maybe small dose or cabergoline?

Yes, stop the enclomiphene. You didn't need to PCT after using androgel in the first place.

Don't add random things. Stop the enclomiphene, wait some weeks, and re-assess.

 

[Phil Goodman]

Two can play that game, but I can get favorable results with a neutral question:

Question: Statistically speaking, based on all information available to you, which approach is more likely to maximize quality of life for hypogonadal men?

Based on a comprehensive review of available medical literature, including multiple meta-analyses and clinical guidelines, the physiological replacement dose approach—aiming to restore testosterone levels to the mid-normal range (typically 400-700 ng/dL or equivalent) without exceeding natural peaks—is more likely to maximize quality of life (QoL) for hypogonadal men. This conclusion is supported by evidence showing consistent, clinically meaningful improvements in symptoms like sexual function, mood, energy, and body composition at physiological levels, while supraphysiological dosing (e.g., leading to sustained levels above the normal range) offers limited additional benefits but increases risks of adverse effects that could detract from overall well-being.

Key Evidence Supporting Physiological Dosing

• Improvements in QoL and Symptoms: Meta-analyses indicate that testosterone replacement therapy (TRT) at doses achieving physiological levels yields small to moderate enhancements in overall QoL, as measured by tools like the Aging Males' Symptoms (AMS) scale or SF-36 questionnaire. For instance, TRT improves depressive symptoms (standardized mean difference [SMD] -0.19), fatigue, and general well-being, with effects plateauing within 30 days. These benefits are most pronounced in men with confirmed hypogonadism (baseline testosterone <300 ng/dL), and guidelines emphasize titrating to mid-normal ranges for optimal symptom relief without overexposure.
• Sexual Function and Libido: TRT significantly boosts libido (SMD 0.17), erectile function (SMD 0.16), and sexual satisfaction (SMD 0.16), meeting minimal clinically important differences for mild erectile dysfunction. These gains are achieved at physiological levels and do not reliably improve further with higher doses.
• Body Composition and Physical Health: Physiological TRT increases lean body mass (by ~1.5-3 kg over 6-12 months) and bone mineral density, while reducing fat mass. It also modestly improves insulin sensitivity and lipid profiles in some studies, though evidence is mixed. Supraphysiological doses may enhance muscle gains more (e.g., in athletic contexts), but for QoL in hypogonadal men, the focus is on restoring natural function rather than performance optimization.
• Mood and Cognitive Benefits: TRT reduces negative mood parameters (e.g., anger, fatigue) and may improve cognitive function, but effects are inconsistent and small. Physiological dosing is sufficient; higher levels do not show superior outcomes.

Risks and Limitations of Supraphysiological Dosing

• Increased Adverse Events: Higher doses are linked to greater risks of polycythemia (hematocrit >54%, relative risk 8.14), which can strain cardiovascular health and reduce QoL through symptoms like fatigue or headaches. Other potential issues include elevated estrogen leading to gynecomastia, worsened sleep apnea, or prostate symptoms, though meta-analyses show no significant increase in prostate volume or lower urinary tract symptoms overall.
• Cardiovascular and Long-Term Concerns: Evidence on cardiovascular risks is inconclusive, but supraphysiological levels may contribute to blood pressure increases or lipid imbalances (e.g., reduced HDL cholesterol). A large trial found no increased major adverse cardiovascular events with TRT at physiological targets, but cautioned against exceeding them.
• No Clear Superiority for QoL: While anecdotal forum discussions (e.g., from ExcelMale threads) suggest some men report better subjective well-being at higher doses based on polls, these are biased toward users already on supraphysiological regimens and lack rigorous controls. Scientific meta-analyses find no strong evidence that exceeding physiological levels enhances QoL metrics beyond what's achieved at mid-normal ranges; instead, it may lead to diminishing returns or rebound issues upon adjustment.

Comparison of Approaches in Context
The table below summarizes outcomes from key meta-analyses, focusing on QoL-relevant domains:

Domain	Physiological Dosing Benefits (Evidence Strength)	Supraphysiological Dosing Considerations
Sexual Function	Small-moderate improvement (e.g., IIEF score +2-5 points); high certainty.	Minimal added gain; higher estrogen risks may worsen libido.
Mood/Depression	Reduces symptoms (SMD -0.19); moderate certainty.	Inconsistent; potential for mood swings with peaks/troughs.
Energy/Fatigue	Modest reduction in fatigue; low-moderate certainty.	Anecdotal boosts, but higher polycythemia may cause fatigue.
Body Composition	+1.5-3 kg lean mass, -0.8 kg fat; moderate certainty.	Greater muscle gains possible, but at cost of sides like fluid retention.
Overall QoL	Small improvement (e.g., AMS score -3.3 points); moderate certainty.	No superior evidence; increased risks may offset benefits.

Practical Recommendations

• Start with physiological doses (e.g., 50-100 mg testosterone cypionate/week, titrated based on labs) to mimic natural production and minimize sides.
• Monitor symptoms, testosterone levels (trough and peak), hematocrit, and PSA regularly.
• Individual factors like age, SHBG levels, and comorbidities influence response; some may need slight adjustments, but evidence favors staying within physiological bounds for long-term QoL maximization.
• Lifestyle interventions (weight loss, exercise) can enhance TRT benefits and naturally raise testosterone.

This assessment prioritizes evidence-based outcomes over anecdotal reports, as statistical data from RCTs and meta-analyses consistently support physiological dosing as the safer, more reliable path for QoL gains in hypogonadal men.

1.) ask for links to the studies..



2.) it plainly says

• Start with physiological doses (e.g., 50-100 mg testosterone cypionate/week, titrated based on labs) to mimic natural production and minimize sides.

Which according to you starting at 100 is a terrible idea.



3.) I don’t really care to get into this with you again, but I will continue to call you out when you suggest people start around 50-60 with no evidence to support how that maximizes benefits of treatment

 

[Cataceous]

You're still grouping everyone together. You really think everyone needs to do trt like you do. Be real. Yes, start thinking rationally.

Rational thinking involves making decisions based on logic, evidence, and objective facts rather than emotions or cognitive biases.

Once again you're projecting. You foist high doses on anyone looking for help because you think they work for you, even though you don't acknowledge having tried anything else. You're a perfect example of the bias inherent in the anecdotes that Phil Goodman relies on.

Meanwhile, I would expect very few men to thrive on <4.5 mg/day of testosterone as I do, let alone even start with such low doses. The possible exception is with short-acting forms of TRT. For example, Nastesto users might be using 11 mg three times a day, but absorption could be on the order of 10%, meaning 3.3 mg T absorbed per day. This still probably relies on some natural production to fill in the gaps.

The AI quote in my previous post summarizes my position pretty well: start low or mid-range with dosing and increase slowly if needed for symptom resolution. I do not set hard upper limits for the final dose level. The pages of this and other forums are littered with human misery caused by starting out with excessive doses. This is inexcusable and completely avoidable if a rational approach were adopted, one that shunts aside misguided more-is-better thinking.

 

[Cataceous]

1.) ask for links to the studies..

See below

2.) it plainly says

• Start with physiological doses (e.g., 50-100 mg testosterone cypionate/week, titrated based on labs) to mimic natural production and minimize sides.

Which according to you starting at 100 is a terrible idea.

It is, as it results in non-physiological levels for a vast majority of men.

3.) I don’t really care to get into this with you again, but I will continue to call you out when you suggest people start around 50-60 with no evidence to support how that maximizes benefits of treatment

Since you're so fond of anecdotes, take a spin through the Excel Male forums and look for posts describing symptoms that are clearly linked to excessive doing, such as elevated hematocrit. This will be easy since there are several a week, on average. Next look for instances where the dose is objectively too low and the poster was given no option to increase it. Consider the ratio of these two types of posts and what is says about the way TRT should be approached.

Testosterone Therapy in Men With Hypogonadism: An Endocrine Society* Clinical Practice Guideline

This update to the Endocrine Society’s 2010 testosterone guideline, prepared by an expert panel, describes the diagnosis, screening, treatment, and monitor

academic.oup.com

Testosterone Deficiency Guideline - American Urological Association

Testosterone testing and prescriptions have nearly tripled in recent years; however, it is clear from clinical practice that there are many men using testosterone without a clear indication. AUA identified a need to produce an evidence-based document that informs clinicians on the proper...

www.auanet.org

https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(23)00169-1/fulltext

https://jclinque.com/article/the-effectiveness-and-safety-of-testosterone-replacement-therapy-in-the-musculoskeletal-system-of-males-with-hypogonadism-a-systematic-review-and-meta-analysis

Additional Studies of Testosterone Therapy - Testosterone and Aging - NCBI Bookshelf

Testosterone therapy in hypogonadal men: a systematic review and network meta-analysis - PMC

To assess the relative effects of individual testosterone products among hypogonadal men. Systematic review and network meta-analysis. We searched MEDLINE, Embase, Cochrane CENTRAL, and grey literature (25 May 2017) for randomised-controlled trials ...

pmc.ncbi.nlm.nih.gov

(088) Impact of Testosterone Replacement Therapy on Adverse Cardiovascular Events in Hypogonadism Patients: A Comprehensive Evaluation of Physiological and Supraphysiological T Levels

AbstractIntroduction. Sustained treatment with elevated levels of exogenous testosterone (T) has been linked to various adverse events, particularly concer

academic.oup.com

Frontiers | An updated systematic review and meta-analysis of the effects of testosterone replacement therapy on erectile function and prostate

Introduction: Testosterone replacement therapy (TRT) is a generally accepted method treating for aging-related late-onset hypogonadism (LOH). However, the ef...

www.frontiersin.org

Cardiovascular Effects of Testosterone Replacement Therapy in Hypogonadal Men: A Systematic Review of Lipid Profiles, Inflammatory Markers, and Vascular Function

Testosterone replacement therapy (TRT) is commonly used to treat men with hypogonadism in order to replace the physiological levels of testosterone, although the cardiovascular safety and metabolic advantages of this treatment are still controversial. This article is a systematic review of the...

www.cureus.com

https://www.nejm.org/doi/full/10.1056/NEJMoa2215025

https://doi.org/10.1136/dtb.2018.2.0585

https://www.acpjournals.org/doi/10.7326/M19-0830

What are the physiological impacts of Testosterone Replacement Therapy (TRT)?

Testosterone replacement therapy produces clinically meaningful improvements in sexual function, mood, muscle mass, bone density, and quality of life in hypo...

www.droracle.ai

 

[Vince]

See below



It is, as it results in non-physiological levels for a vast majority of men.



Since you're so fond of anecdotes, take a spin through the Excel Male forums and look for posts describing symptoms that are clearly linked to excessive doing, such as elevated hematocrit. This will be easy since there are several a week, on average. Next look for instances where the dose is objectively too low and the poster was given no option to increase it. Consider the ratio of these two types of posts and what is says about the way TRT should be approached.

Testosterone Therapy in Men With Hypogonadism: An Endocrine Society* Clinical Practice Guideline

This update to the Endocrine Society’s 2010 testosterone guideline, prepared by an expert panel, describes the diagnosis, screening, treatment, and monitor

academic.oup.com

Testosterone Deficiency Guideline - American Urological Association

Testosterone testing and prescriptions have nearly tripled in recent years; however, it is clear from clinical practice that there are many men using testosterone without a clear indication. AUA identified a need to produce an evidence-based document that informs clinicians on the proper...

www.auanet.org

https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(23)00169-1/fulltext

https://jclinque.com/article/the-effectiveness-and-safety-of-testosterone-replacement-therapy-in-the-musculoskeletal-system-of-males-with-hypogonadism-a-systematic-review-and-meta-analysis

Additional Studies of Testosterone Therapy - Testosterone and Aging - NCBI Bookshelf

Testosterone therapy in hypogonadal men: a systematic review and network meta-analysis - PMC

To assess the relative effects of individual testosterone products among hypogonadal men. Systematic review and network meta-analysis. We searched MEDLINE, Embase, Cochrane CENTRAL, and grey literature (25 May 2017) for randomised-controlled trials ...

pmc.ncbi.nlm.nih.gov

(088) Impact of Testosterone Replacement Therapy on Adverse Cardiovascular Events in Hypogonadism Patients: A Comprehensive Evaluation of Physiological and Supraphysiological T Levels

AbstractIntroduction. Sustained treatment with elevated levels of exogenous testosterone (T) has been linked to various adverse events, particularly concer

academic.oup.com

Frontiers | An updated systematic review and meta-analysis of the effects of testosterone replacement therapy on erectile function and prostate

Introduction: Testosterone replacement therapy (TRT) is a generally accepted method treating for aging-related late-onset hypogonadism (LOH). However, the ef...

www.frontiersin.org

Cardiovascular Effects of Testosterone Replacement Therapy in Hypogonadal Men: A Systematic Review of Lipid Profiles, Inflammatory Markers, and Vascular Function

Testosterone replacement therapy (TRT) is commonly used to treat men with hypogonadism in order to replace the physiological levels of testosterone, although the cardiovascular safety and metabolic advantages of this treatment are still controversial. This article is a systematic review of the...

www.cureus.com

https://www.nejm.org/doi/full/10.1056/NEJMoa2215025

https://doi.org/10.1136/dtb.2018.2.0585

https://www.acpjournals.org/doi/10.7326/M19-0830

What are the physiological impacts of Testosterone Replacement Therapy (TRT)?

Testosterone replacement therapy produces clinically meaningful improvements in sexual function, mood, muscle mass, bone density, and quality of life in hypo...

www.droracle.ai

Again, you're a totally lost. It's about being healthy and feeling healthy. I know your struggles are well documented and I know you will never be 100% well. Again, you assume everyone's the same. We are not.

 

[Observer]

Yes, stop the enclomiphene. You didn't need to PCT after using androgel in the first place.

Don't add random things. Stop the enclomiphene, wait some weeks, and re-assess.

That's interesting, so a PCT like enclomiphene isn't as necessary when using a daily administration modality like androgel? I'm guessing that would apply to cream and prop as well?

 

[FunkOdyssey]

That's interesting, so a PCT like enclomiphene isn't as necessary when using a daily administration modality like androgel? I'm guessing that would apply to cream and prop as well?

Depends on the dosage, application frequency, and the levels reached.

With once daily scrotal application of 100 mg testosterone as cream, a dose sufficient for 9 in 10 men to exceed 1,000 ng/dL total testosterone at peak, the vast majority of men will have a detectable LH level greater than 1.0 IU/L at trough. Many of them will even land in the low normal range. This is data I am privy to via my association with a telemedicine clinic.

Now, imagine how much higher the trough LH would land with once daily application of 1% or 1.62% concentration androgel, which produces testosterone levels far lower than 20% concentration scrotal cream.

You never needed any PCT.