Thinking about TRT and could use some guidance

[JSMITH1976]

Hello All,


Long time lurker first time poster here. First of all thanks to all the people who make this great resource available. I have had many questions answered and the information here has helped me to better formulate the questions that remain. This is a long post with a lot to unpack so please bear with me and thank you all for any help, guidance, and information you can provide.

A bit of background: I am a 49 y.o. male with a stressful job, family life, etc. etc. Like most people as I am getting older I am beginning to feel the full effects of my age. A few years back (~ when I was 45) I decided to make some changes in my lifestyle and diet. I dropped my weight from 218lbs to 176lbs (I am 5'6" for reference). I slowly started working out - first with simple push up and crunches, then to light weights, and finally cardiovascular exercise. I am at the point now where I exercise about 1 hour a day: 20 – 30 minutes of strength, 20 -30 minutes of cardio, and 10 minutes of stretching. To be clear I am not exercising with heavy weights as I am not looking to get crazy big but just to maintain muscle as I have been losing the weight. At the same time I started taking more interest in my appearance – better fitting clothes, skin care routine and taking minoxidil and finasteride pills to preserve/regrow hair. End result of all of this has been subjectively a slimmer fitter me with better clothes and a fuller head of hair and objectively someone with better numbers: lower BP, better cholesterol profile, and related to this forum an improvement in my T levels. In 2023 my Total T was 444 and my Free T was 80.3. Two years later with exercise and weight loss my Total T is 514 and my Free T is 93. If this had been the whole story I probably wouldn’t be here.

Even though things should all be on an uptrend I don’t feel as if they are. I am more tired, depressed, I have a lack of interest/motivation and even though I feel like I am regularly exercising I am not seeing changes (objectively or subjectively) in my strength, muscle mass, or build. Yes, I am thinner/leaner and I do have more definition but I am not “cut” nor am I lifting significantly more weight than before. I also have not been able to lose more weight, even though I have maintained my weight loss for about 2 years now. Given my height I would like to lose 20lbs more of fat or at least exchange some of it for lean muscle mass. My libido is ok. I have always had a high libido and can still go 2-3 rounds in a day (compared to 5-6 in my 20s). I get and maintain an erection easily but the quality of the erection is not as good/consistent as it used to be and my interest waxes and wanes i.e. I can go a week without any sex and not miss it at all. I discussed all of this with my MD and he suggested that even though my T numbers are “normal” they still may be low for me hence the issues. He suggested that I should start very low dose TRT as a boost for six months to see if things improve.

I am hesitant to start because of a few reasons:

1. I essentially have normal T levels and have managed to improve them by losing weight and exercising. So do I even need TRT at this point
2. I am taking Finasteride which is doing wonders for my hair but does have side effects including loss of libido, watery ejaculate, and depression. The side effects are real. That first month on it I would actually spontaneously cry and couldn’t get an erection if my life depended on it. Luckily most of the side effects went away except for the watery ejaculate. However, they could not have gone fully away which would explain some of the issues I am having (depression, intermittent lowered libido, etc.)
3. Weight: Lets be honest. I am not in the gym pumping heavy iron and going to failure. Heck at my age I wouldn’t want to do that and would rather preserve my joints. I am also not maintaining strict calorie deficit, eating 1.5g of protein per lb of lean body weight, and I am not blessed with good genetics. All of this is to say that my lack of change in body habitus and strength could all be unrelated to a lower T level.

So given all of this would it be recommended for me to start TRT or should I be looking at other solutions to my issues?

If TRT can be helpful any hints/tips?

My MD suggested that I start with 50mg IM injections twice a week and to couple it with HCG 500IU IM twice a week. Fertility is not a real issue for me (I had a vasectomy so can’t get any less fertile at this point) however he believes it would help with my libido, erection quality and to maintain testicular size and T production which could be beneficial.

1. This is a pretty conservative/low dose regiment. Should I be considering something higher?
2. At such a low dose should I be expecting side effects? If so which ones?
3. How long to see results with such a low dose? Would it be the typical 3- 6 months?
4. Will my Finasteride use cause any complications? Or conversely will taking TRT increase my hair loss even with Fin. My dermatologist suggested switching to Dutasteride as a stronger medicine but I worry about a resurgence of the side effects of the DHT blocker. Anyone here experience something similar?

If you made it this far thank you and I appreciate any help or info you guys can provide.

 

[Phil Goodman]

1.) no, I don’t think you need to be aiming for a higher starting dose. 50 mg twice per week should be able to tell you whether or not trt will significantly improve your situation. This is especially true considering you’re also adding HCG to maintain natural production. However, I would recommend settling in on trt for at least eight weeks before starting HCG.

2.) yes, you’ll likely experience side effects. What those are, no one can say. The most likely would be acne, possible anxiety for a few weeks around the six week mark, slight increase in hematocrit, and possible sleep disruptions at some point. But again, it varies from person to person so there’s no way to know.

3.) different results will occur on different timelines. Within three to six months you should have a great idea of what to expect though.

4.) I’d say fin use will cause issues with or without trt. Actually, I’d say that’s probably where a decent amount of your issues are coming from. I would never touch the stuff, even at this point when trt has slightly increase the rate of hair loss. But I understand that decision is up to the individual, so if you’re willing to risk feeling like crap to save your hair then that’s up to you(or anyone else making the decision).

 

[Vince]

Based on recent scientific and clinical research, there is evidence supporting the claims that finasteride can alter brain chemistry, potentially cause epigenetic changes, and, in some patients, lead to permanent adverse effects consistent with persistent hormone dysregulation. This cluster of lingering side effects is known as Post-Finasteride Syndrome

 

[Cataceous]

There are better options than conventional TRT. First, strongly consider switching to topical finasteride. The side effects profile is considerably improved, reducing your risks in the long run. If you still feel as though there's a lot of room for improvement then try a fast-acting testosterone product, such as a nasal gel. When compared to regular TRT, fast-acting testosterone is much less disruptive of other hormones. At a minimum, TRT disables the HPTA, which can lead to loss of fertility and other problems. There are also indirect effects on other hormones that may cause issues in some men.

If you are set on regular TRT then consider a low-and-low approach. In spite of popular belief, 50 mg of testosterone cypionate twice a week is excessive for starting out, providing more testosterone than most men could ever make naturally. A better starting point is 60-70 mg per week in divided doses, e.g. 32 mg twice a week. It is a lot easier to start low and raise slowly as needed than to start high, experience side effects, and have to cut back.

 

[FunkOdyssey]

I am more tired, depressed, I have a lack of interest/motivation

I get and maintain an erection easily but the quality of the erection is not as good/consistent as it used to be and my interest waxes and wanes i.e. I can go a week without any sex and not miss it at all.

These are likely finasteride side effects.

even though I feel like I am regularly exercising I am not seeing changes (objectively or subjectively) in my strength, muscle mass, or build. Yes, I am thinner/leaner and I do have more definition but I am not “cut” nor am I lifting significantly more weight than before.

Lets be honest. I am not in the gym pumping heavy iron and going to failure. Heck at my age I wouldn’t want to do that and would rather preserve my joints.

It doesn't sound like your workout regimen *should* be causing substantial gains in mass and strength given the limited intensity.

I also have not been able to lose more weight, even though I have maintained my weight loss for about 2 years now. Given my height I would like to lose 20lbs more of fat or at least exchange some of it for lean muscle mass.

Testosterone is not an effective fat loss agent. Building muscle, yes. Losing fat, no. This particular goal would be better served by other compounds, like a low dosed GLP-1 drug.

It sounds like you are asking whether you should start TRT for the primary purpose of mitigating side effects from your use of finasteride. The answer to that question, in my opinion, is no. In the continued presence of oral finasteride, I think TRT is unlikely to resolve any of your complaints, except to put on a bit more muscle.

A couple of better ideas: switch to a topical dutasteride formula, which has been shown to be much more effective than oral finasteride for hair loss, while only inhibiting serum DHT 10-20% depending on dose (contrast with 70% for 1 mg oral finasteride). Or accept the inevitable and shave your head, allowing you to fully embrace DHT and all of the benefits that come with it.

 

[Guided_by_Voices]

My two cents:
- Stop the finasteride and go to topical
- It's way too soon for TRT. HCG or Clomid/monotherapy would be much lower risk, but may not be necessary either. You could add a low dose of oxandrolone to that if gym performance is still a concern at that point
- Are you using viagra or cialis?
- What is your diet like?
- What supplements are you taking? Lithium? Vitamin D/K2?
- Stop the finasteride

 

[FunkOdyssey]

My two cents:
- Stop the finasteride and go to topical
- It's way too soon for TRT. HCG or Clomid/monotherapy would be much lower risk, but may not be necessary either. You could add a low dose of oxandrolone to that if gym performance is still a concern at that point
- Are you using viagra or cialis?
- What is your diet like?
- What supplements are you taking? Lithium? Vitamin D/K2?
- Stop the finasteride

I feel like this response was twice as effective as my longer reply, because you said "Stop the finasteride" twice, which is really the crux of the matter.

 

[BadassBlues]

There are better options than conventional TRT. First, strongly consider switching to topical finasteride. The side effects profile is considerably improved, reducing your risks in the long run. If you still feel as though there's a lot of room for improvement then try a fast-acting testosterone product, such as a nasal gel. When compared to regular TRT, fast-acting testosterone is much less disruptive of other hormones. At a minimum, TRT disables the HPTA, which can lead to loss of fertility and other problems. There are also indirect effects on other hormones that may cause issues in some men.

If you are set on regular TRT then consider a low-and-low approach. In spite of popular belief, 50 mg of testosterone cypionate twice a week is excessive for starting out, providing more testosterone than most men could ever make naturally. A better starting point is 60-70 mg per week in divided doses, e.g. 32 mg twice a week. It is a lot easier to start low and raise slowly as needed than to start high, experience side effects, and have to cut back.

What he^ said... Oral Finasteride is pure poison. Get off of it ASAP and make no other changes for 30-60 days. Then see how you feel.

From a personal perspective, I was on oral Finasteride for 30 days back when it was new and people didn't have the info they do now. I lost all sensitivity in my penis and diminished ability to ejaculate that lingered for YEARS.

I now use a low dose topical (1%) that has zero side effects but has a far better effect on hair loss.

 

[BadassBlues]

There are a lot of different opinions on TRT and HCG protocols. IMHO, your doctor started you on a protocol that I have had major success with personally. That is almost identical to what I have been doing for years.

But since your concerns have been addressed by some very smart people above, it's recommended you consider all alternatives.

But... GET OFF THE ORAL FINASTERIDE! (Hoping the Funkmeister gives me prop's for the caps )

 

[BadassBlues]

Embrace DHT fully, don't fall into the trap set by those who demonize it due to potential hair loss. As stated above, if it comes down to it you can buy a great hairpiece or just shave your head.

Manly mojo brings far more overall satisfaction than hair does.

 

[JSMITH1976]

Based on recent scientific and clinical research, there is evidence supporting the claims that finasteride can alter brain chemistry, potentially cause epigenetic changes, and, in some patients, lead to permanent adverse effects consistent with persistent hormone dysregulation. This cluster of lingering side effects is known as Post-Finasteride Syndrome

Thanks for the information. I hadn't heard about this before. I did some looking around in the scientific literature and I think this pub med article sums it up nicely (link removed because of forum rules):

" Studies to date cannot refute or confirm this syndrome as a nosological entity. If it actually exists, it seems to occur in susceptible people, even if exposed to small doses and for short periods, and symptoms may persist for long periods."

While I am a full believer that Fin has side effects I also believe they mostly resolve just like any other drug. Could there still be a minor effect from the oral fin I am taking? Sure. I mean I still have watery ejaculate so somethings are happening (although this is not really a side effect and more an outcome of how the drug works). The problem is teasing out what is the cause: am I depressed because of residual Fin sides, low T, stressful life/work, or something else entirely. I definitely don't have clinical depression and my lack of interest/motivation can easily be explained by 60-90 hour work weeks and is far more likely then residual sides from Fin.

 

[JSMITH1976]

1.) no, I don’t think you need to be aiming for a higher starting dose. 50 mg twice per week should be able to tell you whether or not trt will significantly improve your situation. This is especially true considering you’re also adding HCG to maintain natural production. However, I would recommend settling in on trt for at least eight weeks before starting HCG.

Thanks for this. I was under impression that 200mg/wk was the usual minimum effective starting dose so 100mg would be a conservative dose. If I do decide to go with TRT I will start at 50mg/wk and check levels in 3 months to see how things are going.

 

[JSMITH1976]

My two cents:
- Stop the finasteride and go to topical

Why? Yes there is a lower chance of systemic side effects but what evidence is there that my issues have anything to do with Fin side effects (or low T for that matter) as opposed to general stress and over work?

- It's way too soon for TRT. HCG or Clomid/monotherapy would be much lower risk, but may not be necessary either. You could add a low dose of oxandrolone to that if gym performance is still a concern at that point

This is my main question. As a guy with "normal" Total and Free T should I even consider TRT? I looked at Comid and the risk of permanent eye floaters is just unacceptable to me
.

- Are you using viagra or cialis?

No. Why? I have no issues with getting an erection or performing multiple times a day. Maybe I wasn't clear. When I say "quality of erection" I am not talking being soft or barely erect. What I am saying is that out of 20 times 2-3 will be raging erections, 15-16 will be normal/functional if that makes sense, and one time I will get an erection but without stimulation I start losing it immediately hence the quality issue. As for my lack of interest neither of those drugs will help with that. I may go one week without missing it but the next week I can be a total horn dog needing it 2-3/d. Even then I won't turn it away if offered. I just won't be actively pursuing.

- What is your diet like?

Now a days better. I don't eat tons of processed food but I also don't avoid junk food or fatty food either. I eat everything I want but I try to eat in moderation as opposed to finishing off a box of cookies.

- What supplements are you taking? Lithium? Vitamin D/K2?

Multivitamin, Biotin, Lecithin

 

[JSMITH1976]

It doesn't sound like your workout regimen *should* be causing substantial gains in mass and strength given the limited intensity.

Again, I am not looking to get jacked here. However, I would think that after 3-4 weeks of consistent reps at the same weight the weights should get easier or the reps less straining which is not happening. Or atl east not as fast as I recall them happening when I was younger.

Testosterone is not an effective fat loss agent. Building muscle, yes. Losing fat, no. This particular goal would be better served by other compounds, like a low dosed GLP-1 drug.

I understand it is not necessarily a fat loss agent. However, T does help increase metabolism and the increased lean body mass helps with a higher basal rate that helps eight loss. GLP1s are great if you just want o get thin and don't care that you are losing as much muscle as fat.

It sounds like you are asking whether you should start TRT for the primary purpose of mitigating side effects from your use of finasteride.

No I am asking if a guy with a "normal" total T and free T should start TRT because he has symptoms that could be consistent with low T? After all those symptoms could be caused by other things such as oral Fin, life/work stress, lack of sleep, etc. Put another way if I wasn't on oral Fin, everything else being equal, would you still say no to TRT for me?

A couple of better ideas: switch to a topical dutasteride formula, which has been shown to be much more effective than oral finasteride for hair loss, while only inhibiting serum DHT 10-20% depending on dose (contrast with 70% for 1 mg oral finasteride).

I have considered topical but with my lifestyle it just wouldn't work out. This is the same reason I wouldn't consider T-Gel/Foams. I have no issues with needles, it is effective, produces consistent result, and is quick to administer like oral Fin.

Or accept the inevitable and shave your head, allowing you to fully embrace DHT and all of the benefits that come with it.

 

[BadassBlues]

Again, I am not looking to get jacked here. However, I would think that after 3-4 weeks of consistent reps at the same weight the weights should get easier or the reps less straining which is not happening. Or atl east not as fast as I recall them happening when I was younger.



I understand it is not necessarily a fat loss agent. However, T does help increase metabolism and the increased lean body mass helps with a higher basal rate that helps eight loss. GLP1s are great if you just want o get thin and don't care that you are losing as much muscle as fat.



No I am asking if a guy with a "normal" total T and free T should start TRT because he has symptoms that could be consistent with low T? After all those symptoms could be caused by other things such as oral Fin, life/work stress, lack of sleep, etc. Put another way if I wasn't on oral Fin, everything else being equal, would you still say no to TRT for me?



I have considered topical but with my lifestyle it just wouldn't work out. This is the same reason I wouldn't consider T-Gel/Foams. I have no issues with needles, it is effective, produces consistent result, and is quick to administer like oral Fin.

"I understand it is not necessarily a fat loss agent. However, T does help increase metabolism and the increased lean body mass helps with a higher basal rate that helps weight loss. GLP1s are great if you just want to get thin and don't care that you are losing as much muscle as fat."

That is not entirely correct. There are far too many variables to make that kind of statement. The most important factor is where you are at the starting point. Someone who is obese and has very low physical activity is different from a person who is trying to shed a few pounds and leads an active lifestyle. If you are an active person who gets regular resistance exercise and maintains a healthy diet with adequate protein, the muscle loss is negligible.

All weight loss, regardless of the method results in some muscle loss as your body doesn't just burn fat while losing weight.

I personally know of several people who use GLP1's for cutting, they are jacked. My wife has been on them for over a year and has had no muscle loss whatsoever.

 

[BadassBlues]

Thanks for the information. I hadn't heard about this before. I did some looking around in the scientific literature and I think this pub med article sums it up nicely (link removed because of forum rules):

" Studies to date cannot refute or confirm this syndrome as a nosological entity. If it actually exists, it seems to occur in susceptible people, even if exposed to small doses and for short periods, and symptoms may persist for long periods."

While I am a full believer that Fin has side effects I also believe they mostly resolve just like any other drug. Could there still be a minor effect from the oral fin I am taking? Sure. I mean I still have watery ejaculate so somethings are happening (although this is not really a side effect and more an outcome of how the drug works). The problem is teasing out what is the cause: am I depressed because of residual Fin sides, low T, stressful life/work, or something else entirely. I definitely don't have clinical depression and my lack of interest/motivation can easily be explained by 60-90 hour work weeks and is far more likely then residual sides from Fin.

"While I am a full believer that Fin has side effects I also believe they mostly resolve just like any other drug."

For some, that may be somewhat true. But for a very large subset of people who have taken oral Finasteride, the side effects were horrible. Some have never fully recovered. Here is a pretty fair overall study:

Post-finasteride syndrome: An emerging clinical problem - PMC

The presence of side effects during pharmacological treatment is unfortunately a quite common problem. In this review, we focused our attention on adverse events related to 5 alpha-reductase (5α-R) inhibitors (i.e., finasteride and dutasteride), ...

pmc.ncbi.nlm.nih.gov

Abstract​

The presence of side effects during pharmacological treatment is unfortunately a quite common problem. In this review, we focused our attention on adverse events related to 5 alpha-reductase (5α-R) inhibitors (i.e., finasteride and dutasteride), approved for the treatment of benign prostatic hyperplasia and androgenetic alopecia (AGA).

Although these drugs are generally well tolerated, many reports described adverse effects in men during treatment, such as sexual dysfunction and mood alteration. In addition, it has been also reported that persistent side effects may occur in some AGA patients. This condition, termed post-finasteride syndrome (PFS) is characterized by sexual side effects (i.e., low libido, erectile dysfunction, decreased arousal and difficulty in achieving orgasm), depression, anxiety and cognitive complaints that are still present despite drug withdrawal. Indeed, some national agencies (e.g., Swedish Medical Products Agency, the Medicines and Healthcare Products Regulatory Agency of UK and the U.S. Food and Drug Administration) required to include multiple persistent side effects within the finasteride labels.

As here reported, these observations are mainly based on self-reporting of the symptomatology by the patients and few clinical studies have been performed so far. In addition, molecular mechanisms and/or genetic determinants behind such adverse effects have been poorly explored both in patients and animal models. Therefore, results here discussed indicate that PFS is an emerging clinical problem that needs to be further elucidated.

1. Introduction​

Persistent sexual side effects possibly due to finasteride treatment have been also analyzed by Healy and colleagues based on the self-reported alerts into the RxISK.org website (i.e., an independent drug safety website aiming to collect data on all drug-related AEs) (Healy et al., 2018). A total of 24 male subjects completed the report indicating different symptoms related to sexual functions that persisted after finasteride use. In line with previous reports, 92% of patients claimed erectile dysfunction and loss of libido, 44% genital anesthesia and 32% watery ejaculation and testicular atrophy. In this survey, other infrequent symptoms, such as reduced sense of taste (8%) and of smell (4%), were reported (Healy et al., 2018).

 

[Systemlord]

Thanks for the information. I hadn't heard about this before. I did some looking around in the scientific literature and I think this pub med article sums it up nicely (link removed because of forum rules):

" Studies to date cannot refute or confirm this syndrome as a nosological entity. If it actually exists, it seems to occur in susceptible people, even if exposed to small doses and for short periods, and symptoms may persist for long periods."

While I am a full believer that Fin has side effects I also believe they mostly resolve just like any other drug. Could there still be a minor effect from the oral fin I am taking? Sure. I mean I still have watery ejaculate so somethings are happening (although this is not really a side effect and more an outcome of how the drug works). The problem is teasing out what is the cause: am I depressed because of residual Fin sides, low T, stressful life/work, or something else entirely. I definitely don't have clinical depression and my lack of interest/motivation can easily be explained by 60-90 hour work weeks and is far more likely then residual sides from Fin.

The fin is lowering your DHT, which is responsible for libido and well-being. The fin is cutting it down.

Never take a drug your doctor prescribes without doing your own research!

The drug makers of Fin lied to everyone, including the doctors.