Should You Be Injecting Testosterone Under the Skin?

[Nelson Vergel]

Endocr Rev, Vol. 34 (03_MeetingAbstracts): MON-594

Evaluation of the efficacy of subcutaneous administration of testosterone in female to male transexuals and hypogonadal males


FDA-approved indications for depot testosterone (T) only allow it to be administered intramuscularly (IM). Barriers to IM testosterone injections are pain/discomfort/hematoma and the frequent necessity for a nurse or other person to administer the injection which can be inconvenient and expensive. Barriers to alternative transdermal preparations are expense (often not covered by insurance), local reactions, and the fear of skin to skin transmission. Based on the personal experience of one of us (NS) and the late Jack Crawford MD with weekly subcutaneous (SC) T injections for the management of female to male (FTM) transgender patients, we have initiated a prospective study with the intent of enrolling 20 patients to assess the safety and absorption of SQ T therapy in a population of FTM individuals and classical hypogonadal males. The initial 7 patients (5 FTM and 2 hypogonadal males) ranged in age from 18-58 (mean 28.2 ± 5.9SE). T enanthate or cypionate was administered at a dose of 50-60 mg sc once weekly using 5/8" 23g or 25g needles. Serum total T concentrations were measured by tandem mass spectrometry. T levels were well within the therapeutic range varying from 320-824 ng/dL (mean 608± 82SE). No adverse reactions at the site of injection or otherwise were reported or observed. The injections were easily self-administered except for one patient who was blind. Initial data from our study are promising regarding the SC administration of T. SC T was well tolerated and produced therapeutic serum concentrations at doses generally lower than required for IM injections. These data will provide a foundation for additional studies of pharmacokinetics, efficacy and safety to hopefully characterize SC T as a safe, convenient, and affordable alternative to IM injections.

Note from Nelson: At the doses used, half of the subjects had total testosterone blood levels under 608 ng/dL but some were able to attain TT as high as 824 ng/dL, so we are all different in our response to testosterone injections.


Here is another study in men:
Weekly testosterone levels with one subcutaneous testosterone injection per week

 

[Nelson Vergel]

In this video the people from LowTestosterone.com teach us how to properly measure the dose for injecting testosterone under the skin. A must-watch for anyone considering this delivery method.
LowTestosterone.com - Proper Injection and Dosing Procedures - Videos

 

[Nelson Vergel]

This is the technique Dr John Crisler uses to inject himself subcutaneously (under the skin) with testosterone. This method is useful for those who are injecting smaller doses more than once a week to keep more constant blood levels of testosterone. It is not a commonly used method. Intramuscular injections of 100-250 mg once per week are the standard dose, frequency and application method recommended by most doctors.

 

[JWSimpkins]

Any idea on the potential cost?

 

[Dr. John Crisler]

Endocr Rev, Vol. 34 (03_MeetingAbstracts): MON-594

Evaluation of the efficacy of subcutaneous administration of testosterone in female to male transexuals and hypogonadal males


FDA-approved indications for depot testosterone (T) only allow it to be administered intramuscularly (IM). Barriers to IM testosterone injections are pain/discomfort/hematoma and the frequent necessity for a nurse or other person to administer the injection which can be inconvenient and expensive. Barriers to alternative transdermal preparations are expense (often not covered by insurance), local reactions, and the fear of skin to skin transmission. Based on the personal experience of one of us (NS) and the late Jack Crawford MD with weekly subcutaneous (SC) T injections for the management of female to male (FTM) transgender patients, we have initiated a prospective study with the intent of enrolling 20 patients to assess the safety and absorption of SQ T therapy in a population of FTM individuals and classical hypogonadal males. The initial 7 patients (5 FTM and 2 hypogonadal males) ranged in age from 18-58 (mean 28.2 ± 5.9SE). T enanthate or cypionate was administered at a dose of 50-60 mg sc once weekly using 5/8" 23g or 25g needles. Serum total T concentrations were measured by tandem mass spectrometry. T levels were well within the therapeutic range varying from 320-824 ng/dL (mean 608± 82SE). No adverse reactions at the site of injection or otherwise were reported or observed. The injections were easily self-administered except for one patient who was blind. Initial data from our study are promising regarding the SC administration of T. SC T was well tolerated and produced therapeutic serum concentrations at doses generally lower than required for IM injections. These data will provide a foundation for additional studies of pharmacokinetics, efficacy and safety to hopefully characterize SC T as a safe, convenient, and affordable alternative to IM injections.

Note from Nelson: At the doses used, half of the subjects had total testosterone blood levels under 608 ng/dL but some were able to attain TT as high as 824 ng/dL, so we are all different in our response to testosterone injections.

"Based on the personal experience of one of us ...."

THIS is where scientific studies comes from. A practitioner figures something out, or learns it by "mistake', OR A PATIENT DOES SOMETHING....and it is found to somehow make things better. Then he/she tells their colleagues, and they try it, too. Then it is announced on stage at a "fringe" medical conference, and...a few years later...becomes published in a peer-reviewed scientific journal.

...and all along the way, those without deep knowledge of the art, or intuition, have constantly decried "Show me a scientific study!", and even attacked the practitioner who is now more successfully treating their patients.

...but at least those lucky patients have spent all those years being healthier and happier.

 

[Dr. John Crisler]

This thread is AWESOME!

Thank you, Nelson.

 

[Dr. John Crisler]

This is the technique Dr John Crisler uses to inject himself subcutaneously (under the skin) with testosterone. This method is useful for those who are injecting smaller doses more than once a week to keep more constant blood levels of testosterone. It is not a commonly used method. Intramuscular injections of 100-250 mg once per week are the standard dose, frequency and application method recommended by most doctors.

https://www.excelmale.com/?s=75-Dr-John-Crisler-on-Subcutaneous-Testosterone-Injections

I now personally inject into the fat pad on top of my glutes. It's like the old IM shot, but with a shorter/smaller needle.

....looks like Vince and I need to film an update.

 

[Gene Devine]

"Based on the personal experience of one of us ...."

THIS is where scientific studies comes from. A practitioner figures something out, or learns it by "mistake', OR A PATIENT DOES SOMETHING....and it is found to somehow make things better. Then he/she tells their colleagues, and they try it, too. Then it is announced on stage at a "fringe" medical conference, and...a few years later...becomes published in a peer-reviewed scientific journal.

...and all along the way, those without deep knowledge of the art, or intuition, have constantly decried "Show me a scientific study!", and even attacked the practitioner who is now more successfully treating their patients.

...but at least those lucky patients have spent all those years being healthier and happier.

^^^^Amen to that!!!

 

[Nelson Vergel]

Oh man....are we going to start again about "show me the scientific study vs my experience is best" argument? Please don't.

 

[Jasen Bruce]

Anyone fine that a particular oil vehicle works better than others? I would think grapeseed oil or EO would be "thinner" however I don't know if there is Ph variations between oils which must be considered. I have used GS for a long time and tolerate it well both IM and sc.

It might be depending on the pharmacy, but some seem to tolerate SC sesame oil and some cannot tolerate well, even when confirmed that proper inj. technique is followed.

 

[Dr. John Crisler]

Oh man....are we going to start again about "show me the scientific study vs my experience is best" argument? Please don't.

This point is intrinsic to providing a cutting edge discussion about this field of medicine. That is because we are at the very cutting edge. And we are at the cutting edge ONLY because the entire world is so far behind in its ability to solve the health problems of adult males; which is, IMPO, shameful.

Patients--too often failed by their own doctors, sometimes numerous doctors--seek out the top Thought Leaders not because they practice ten year old medicine, but because they get the best results. They are the top Thought Leaders for good reasons.

IOW, because they are the ones who provide the impetus that, a decade later, appears in peer-reviewed journals.

When a doctor proclaims "show me a study"....what they really are saying, is "I don't have a deep understanding of the fundamental principles, and I don't have the experience to know the difference".

The reality of the situation is scientific studies are only good for distinguishing between treatment protocols which are questionable. A list of the medical treatments which have become Standard of Care--without ever being shown effective in a study--is quite impressive.

Do men come here to learn how to solve their health problems, or not?

If not, why are we here?

 

[Dr. John Crisler]

Oh man....are we going to start again about "show me the scientific study vs my experience is best" argument? Please don't.

I would add, a doctor--with a reputation for success with their patients--who says "I have found this to be effective" has an opinion which should not be discounted.

 

[Nelson Vergel]

I do not know of any doctor who tells a patient "show me the study"

That is usually asked by a physician to another, or by people like me who are educated advocates in this field.

Any doctor can practice medicine within what he thinks is effective based on his experience even if that experience is not based on research and published data. But if a physician wants to bill insurance, then studies have to be available for insurance companies to reimburse. Even with data, may insurers will not reimburse what is not part of current guidelines.

So, patients with no extra cash who want to have insurance reimbursement of their testosterone replacement and blood tests will have to seek a physician that is willing to find and use published studies and guidelines. Those with disposable income can afford to pay cash to see a physician who practices based on his experience even if that experience is not supported by published studies.

So, studies are important in testosterone replacement therapy. Pharmaceutical companies that jump at generating missing data to get an easy indication approved for drugs that already exist in the market are the real winners. That is why I showed the example of Antares since they will go after the subcutaneous injection indication when there is little data on the subject.

I have asked for studies on estradiol because I strongly believe that men have been over treated with anastrozole. I also ask for studies from anyone who says there is a "sweet spot" when it comes to blood values.

For me, the smart clinicians are the ones who jump at the opportunity when they see something that works but that may not have data behind it. Those clinicians generate the data to support their statements and become leaders in the field. Some write books with their experiences and present their data in conferences. Bravo to all of them.

 

[Dr. John Crisler]

Just to be clear, I have never said, or even implied, scientific studies are of no use in medicine. But they are not a substitute for reality; especially when so many are poorly designed, executed, evaluated, and contain false date (and/or are ghost written--as so many are these days).

Insurance companies do not ask for scientific studies to show, for instance, 50mg twice per week is better than 100mg once per week. They also do not require studies which show less HCG is better than more, etc.

There is no defined "sweet spot", because everyone has their own. That is what "sweet spot" means.

Doctors who have patients they are unable to successfully treat learn what doctors do who are successful, and perhaps try their techniques. It is as simple as that (AS LONG AS "Do no harm"). Constantly demanding "show me a study" means they want to wait 10 years, or longer, to successfully treat their patients. What it REALLY means is they have no deep understanding of their field. For nearly all of what we do is intuitive...once you REALLY learn what you are doing.

I think the last paragraph you just wrote is as well-spoken as any I have read...or written.

 

[robs2nd75]

Under what circumstance/s does SC not work? My TT dropped significantly while doing SC shots? FWIW my insurance continued to cover my T Cyp. and Dr. visits even after my Dr. prescribed SC injections twice weekly and he's a GP. However, they would not cover the needles and syringes.
I am going to try SC again as I am having a great deal of pain and have tried every trick in the book. If anyone has any suggestions as to how I can reduce the drop beyond the obvious increase in amt. injected I would greatly appreciate it. I have a significant amount of adipose around my trunk but am lean everywhere else. Could it behoove me to inject superficially, 1/2", in a more lean area? Any thought would be greatly appreciated.

 

[Nelson Vergel]

I am not fond on subcutaneous testosterone injections but some guys love it. I have no issues whatsoever injecting in my glutes using a 23 gauge 1 inch long needle. Subcutaneous injections hurt more in my case. Also, for those of us with little subcutaneous fat it may not work as well.

 

[EmpowerPharmacy]

Jasen, great questions about the different carrier oils and their respective viscosities as well as pH.

Firstly, pH isn't a factor in Oil based Injectables as pH is a measure of the amount of Hydrogen Ions is an AQUEOUS solution.

Pressure gradients when drawing are negligible due to the small cross sectional area of the needle acting as an effective choke. I ran an experiment with different gauge syringes and our Testosterone Cypionate in Sesame Oil.

Size of Needle 25G 27G 29G 31G Amount drawn in 1 minute 2mL 0.8mL 0.32mL 0.07mL

As the results show the amount drawn becomes exponentially smaller with a smaller gauge needle. This is due to the Radius^4 variable in our equation.


So what else does Poiseuille's law teach us? When you have a small radius changing the viscosity won't cause a huge difference in flow rates. It's the radius value that dominates the equation, not the viscosity, pressure differential or length. From this we can determine that the carrier oil wouldn't make a measurable difference in draw time.

Using the above data I recommend either a 27G or 29G needle to draw and inject Testosterone Cypionate/Enanthate for a SQ injection. Preferably a 29G as it will only take 1-2 minutes out of a patient's week to draw their dose and 10-20 seconds to inject it.

 

[robs2nd75]

TT tanked again with SC injections...really at a loss. Spoke with Endo today and she stated that she has had a few patients try SC and it never seems to work for them. Wondering if this failure could have something to do with Diabetes? Dr. Crisler have you had any patients that have not had positive results and if so did you see any factor/s they had in common?

 

[Dr. John Crisler]

TT tanked again with SC injections...really at a loss. Spoke with Endo today and she stated that she has had a few patients try SC and it never seems to work for them. Wondering if this failure could have something to do with Diabetes? Dr. Crisler have you had any patients that have not had positive results and if so did you see any factor/s they had in common?

I have seen this, but only a couple times in many hundreds of patients.

A long time ago, I decided to never be surprised by anything I see in Interventional Endocrinology.

IF SHBG is high or high-normal, it can be an issue, because you then aren't getting the peak you need to get over the top; but that would be for subjective response, not lab values.

BTW, I don't see you commenting on how you feel, only what shape the ink is on a piece of paper.

BTW, a tip of the hat to the Endo for using SC injections!

 

[Dr. John Crisler]

Anyone fine that a particular oil vehicle works better than others? I would think grapeseed oil or EO would be "thinner" however I don't know if there is Ph variations between oils which must be considered. I have used GS for a long time and tolerate it well both IM and sc.

It might be depending on the pharmacy, but some seem to tolerate SC sesame oil and some cannot tolerate well, even when confirmed that proper inj. technique is followed.

Jasen, my old friend Dr. Michael Bedecs first told me about using grape seed oil at the AAMG conference a few weeks ago. He says it works much better for SC shots.

Haven't tried it yet.