My contention is that TRT as it is widely practiced is failing many patients, gives sub-optimal results to others and oftentimes, where it does "work", works almost by default.
If a guy is symptomatic and is diagnosed as low T he is often started on a regimen of an aromatisable Testosterone (say injectable T Cyp). At a sufficient dosage most patients will quickly reach adequate levels of TT and E2, however many don't have relief of symptoms: their lack of 5-ar conversion means DHT levels remain too low.
Here's where it often all goes wrong: In order to achieve relief of symptoms the dosage of T Cyp is usually increased, often repeatedly. As the dosages are increased the need for an AI to "balance" levels increases too. Some, fortunate, patients will find relief early enough in this process and before TT has become too elevated. Others won't until their TT levels cause side effects - blood pressure, HCT, lipids, prolactin.
This type of regimen I would describe as balancing hormones from the top down - elevating E2 to excessive levels and then rebalancing to DHT with the use of AIs.
This is fundamentally wrong. Whatever happened to that basic tenet of good medicine: using the minimum efficacious dose for the relief of symptoms?
What symptomatic guys need is a sufficiency and balance of DHT and E2 the 2 metabolites of T. Surely that balance is better achieved by increasing DHT disproportionately to E2. ie balancing from the bottom up.
Guys that are symptomatic are low in androgens, some may have lacked androgens their entire existence: in the womb, at puberty and throughput adulthood. They start therapy and what are they prescribed - large doses of aromatisable T (perhaps topped off with hCG). The prospects for many are a short lived, and possibly bewildering, "honeymoon period" (where androgens and dopamine predominate) followed by a crash where estrogens, prolactin and norepinephrine return with a vengeance.
We know that T Cream, particularly when applied to the scrotum, will raise DHT disproportionately to other modalities. (There was the good news this week that Dr Crisler is introducing this therapy - others will surely follow). We also know that many guys, particularly over time, have absorbency problems with transdermals. We know too that a relatively small amount of injectable T will give us adequate levels of TT and E2.
What I conclude from those 3 facts is that a correctly dosed protocol of T Cyp conjunctive with T Cream has good prospects as an efficacious therapy. That is a weekly dosage of T Cyp (in suitably divided doses) and a daily dosage of T Cream.
A great advantage of this mixed modality of administering T, is the potential to keep a sufficiency of the sex hormones at all times yet allow DHT, and thereby the associated motivation/pleasure/reward neurotransmitters, a degree of diurnal variation.
Potentially a "best of both worlds" situation.
My suggestion to any guy starting therapy, or struggling with their current protocol, would be to consider the following:
Give DHT equal importance to E2. (At least Consider that the DHT:E2 ratio, at adequate levels, is what counts).
Don't be persuaded by the virtual demonisation of DHT as the "stuff that makes you go bald". (Sure raising the level of androgens will exacerbate and accelerate the balding process in those that are predisposed so if you believe or know that you have androgenic alopetia you may have a choice to make).
At the start of therapy ensure DHT is included in your bloods panel. Many providers don't routinely test for DHT as serum levels are though to be a poor indication of activity at receptor/in tissue. Personally I have found serum levels to be instructive.
Don't think of injectables/transdermals as an either/or option but potentially as "what dose of each" to get effective relief of symptoms.
If a guy is symptomatic and is diagnosed as low T he is often started on a regimen of an aromatisable Testosterone (say injectable T Cyp). At a sufficient dosage most patients will quickly reach adequate levels of TT and E2, however many don't have relief of symptoms: their lack of 5-ar conversion means DHT levels remain too low.
Here's where it often all goes wrong: In order to achieve relief of symptoms the dosage of T Cyp is usually increased, often repeatedly. As the dosages are increased the need for an AI to "balance" levels increases too. Some, fortunate, patients will find relief early enough in this process and before TT has become too elevated. Others won't until their TT levels cause side effects - blood pressure, HCT, lipids, prolactin.
This type of regimen I would describe as balancing hormones from the top down - elevating E2 to excessive levels and then rebalancing to DHT with the use of AIs.
This is fundamentally wrong. Whatever happened to that basic tenet of good medicine: using the minimum efficacious dose for the relief of symptoms?
What symptomatic guys need is a sufficiency and balance of DHT and E2 the 2 metabolites of T. Surely that balance is better achieved by increasing DHT disproportionately to E2. ie balancing from the bottom up.
Guys that are symptomatic are low in androgens, some may have lacked androgens their entire existence: in the womb, at puberty and throughput adulthood. They start therapy and what are they prescribed - large doses of aromatisable T (perhaps topped off with hCG). The prospects for many are a short lived, and possibly bewildering, "honeymoon period" (where androgens and dopamine predominate) followed by a crash where estrogens, prolactin and norepinephrine return with a vengeance.
We know that T Cream, particularly when applied to the scrotum, will raise DHT disproportionately to other modalities. (There was the good news this week that Dr Crisler is introducing this therapy - others will surely follow). We also know that many guys, particularly over time, have absorbency problems with transdermals. We know too that a relatively small amount of injectable T will give us adequate levels of TT and E2.
What I conclude from those 3 facts is that a correctly dosed protocol of T Cyp conjunctive with T Cream has good prospects as an efficacious therapy. That is a weekly dosage of T Cyp (in suitably divided doses) and a daily dosage of T Cream.
A great advantage of this mixed modality of administering T, is the potential to keep a sufficiency of the sex hormones at all times yet allow DHT, and thereby the associated motivation/pleasure/reward neurotransmitters, a degree of diurnal variation.
Potentially a "best of both worlds" situation.
My suggestion to any guy starting therapy, or struggling with their current protocol, would be to consider the following:
Give DHT equal importance to E2. (At least Consider that the DHT:E2 ratio, at adequate levels, is what counts).
Don't be persuaded by the virtual demonisation of DHT as the "stuff that makes you go bald". (Sure raising the level of androgens will exacerbate and accelerate the balding process in those that are predisposed so if you believe or know that you have androgenic alopetia you may have a choice to make).
At the start of therapy ensure DHT is included in your bloods panel. Many providers don't routinely test for DHT as serum levels are though to be a poor indication of activity at receptor/in tissue. Personally I have found serum levels to be instructive.
Don't think of injectables/transdermals as an either/or option but potentially as "what dose of each" to get effective relief of symptoms.
