FREQUENTLY ASKED QUESTIONS
If one was to optimize their hormonal levels synthetically, would they still have to worry about the various toxins in the environment (and in food), or not as much?
In a world which is increasingly harmful, not only to human beings but all forms of life, hormonal optimization is the best course of action to protect yourself. Consider it a fail safe against the daily bombardment to our endocrine systems. Furthermore, if one has the means to afford it, we still recommend taking further precaution by eating organic and/or grass fed meat and wild caught fish where possible. Also, using the preferred supplements and ancillary medications found inside this book will only further improve your results. We believe as time goes on, we will have research to verify the diseases created by these environmental toxins. Therefore, consider hormonal optimization as one part of your overall strategy to limit your exposure to them.
My blood work prior to beginning TOT showed signs of subclinical hypothyroidism with a 9 TSH but normal T3 & T4. Full list of what I am taking: testosterone, HCG, Anastrozole, multivitamin, DHEA, vitamin D, whey protein, and the IC-5. I am endomorphic. As I look to incorporate the Blowtorch diet, would you suggest I stick with intermittent fasting on training days until I get around 20%, then begin feeding on training days? Or, should I begin with the max fat loss protocol and still feed on training days now?
If you are not a newbie to training, we would do the diet as normal but reduce carbs significantly by 3PM on training days. Obviously, because you are an endomorph, your carbs need to be greatly reduced anyways. Make sure you are doing your cardio 2x per day on fasting days. We would also recommend you fast at least 18 hours (or longer preferably) on your fasting days. Also, no heavy meals after 8PM on long fasting days. Try to make them mostly fat and protein. We love casein protein, almond butter, MCT oil and cinnamon blended together in a shake. We also recommend you ask your doctor to prescribe you Metformin and dessicated thyroid.
I was recently diagnosed with Klinefelter’s syndrome at the age of 24. My doctor is recommending I start TOT, but I would like to try and preserve my fertility at the same time. What are my best options?
Klinefelter’s syndrome is the most common form of primary hypogonadism (Class 1), where men are unable to produce sperm or sufficient levels of testosterone. Normally, men diagnosed with your condition become infertile, as the extra X chromosome affects your ability to produce sperm. The good news is that most studies show TOT being effective in allowing for a normal and productive life (improved cognition, normal fertility, enhanced sense of well being).
There are also studies supporting specialized fertility techniques, such as microsurgical testicular sperm extraction and intracytoplasmic sperm injection, that have helped some men with Klinefelter’s syndrome to father children. Also, make sure you are working with a physician who is experienced in working with men who are diagnosed with Klinefelter’s.
I’m an older gentleman (just turned 63) and have never used testosterone in my life. I’ve probably been suffering from a deficiency for 20 years or so. Is it going to take me longer at my age to get dialed in (i.e. achieve an optimal balance between testosterone and estrogen) than it would if I had started TOT sooner?
Thank you for your question. We’re really glad you made the decision to become proactive. It’s never too late to optimize your health. As long as you don’t suffer from any other unknown or unusual health problems, and work with a progressive & experienced physician who is skilled at working with patients like you, it should not take longer than 3-4 months to get you fully dialed in. And quite honestly, if you’re severely deficient in testosterone, you should see noticeable improvements within a couple of weeks in your cognition, mood, sex drive and energy.
I’m going to be switching to daily intramuscular (IM) injections with a 29-gauge, 0.5 inch syringe. I’m looking for injection sites to rotate. Any suggestions on which sites I can rotate on a daily basis?
Another good question. When considering the possibility of undergoing injectable TOT for the remainder of your life, remember that you’ll be poking a lot of holes in your body. As such, understanding how to inject yourself with small gauge needles is definitely a learned art form. It takes time and practice, and you definitely want to make sure you minimize injection scarring. You should consider the upper arms (tricep/ delt area), the lateral (outside) side of the quads, the outer glute and the lower abs (for those who are able to effectively inject subcutaneously). We demonstrate all of these injection locations in TOT University?
Great question. Look for an experiential-based practice. The physician should have a documented record of working with multiple patients (ideally hundreds), both males and females. Asking them if they’ve read our book will help too. If you’ve read the first book and this updated version, you will be fully educated, and be able to ask them the necessary questions. Remember to use the 10 questions found in Chapter 8, under “Vetting Your TOT Doctor.”
Is there a natural way to produce extra testosterone? I’m in my 50’s now and would like to increase my libido. I’m wondering if there is a safe way to raise my testosterone levels?
Not really. If all your lifestyle factors are dialed in and you are genetically blessed, you can likely stay in mid-range until 40. But after that it’s a downhill road, especially if you’re living in densely populated areas (due to the environmental siege brought on by endocrine-disrupting chemicals).
I know 200 mg/mL injectable testosterone weekly is pretty common, but I’m on 100 mg/mL a week. If I want to know what gauge I should use to determine the dosage, would it be just “how I feel’?
Essentially, yes. It comes down to regular blood work in combination with how you feel. Two primary goals of TOT are to balance the ratio between testosterone and estrogen, and improve one’s happiness. Happiness is defined as “I feel great, full of energy ready to take on the world.”
Free testosterone vs total testosterone for assessment: my free testosterone levels have dropped (-65% due to SHBG doubling), much more than my total testosterone levels (-35%) over the last 4 years. Are there any specific lifestyle recommendations you’d make to help reverse this?
Lose body fat, improve diet and exercise (via resistance and cardiovascular training). Fix everything naturally first via optimizing your lifestyle factors, and then medicate with TOT once all lifestyle factors are accounted for.
Can you provide advice for folks in the UK, where this type of medicine is perceived as legally selling ‘steroids’ (versus a perspective of well-being and anti-aging)?
We highly recommend you have your healthcare provider read The TOT Bible. There is more and more evidence accumulating on a daily basis which shows that out-of-range hormone levels represent a REAL global health risk. As always, I would approach this subject with the end goal of preventing various disease processes.
When meeting with a clinician (physician), it is always advisable to print out the studies that you will base your arguments on. That way, you can make a clear and concise case for using TOT. Remember that these people are extremely busy! Therefore, if you don’t make a great case in front of them with your claims backed up and available at that exact moment, you greatly decrease your chances of opening their minds on this subject.
Within 10 years, TOT will be a widely accepted practice, even in areas where it’s currently viewed as ‘fringe’ (most of Europe and Asia).
Is there hope for 30+ year olds who want to reach and maintain optimal testosterone levels without TOT? I think it’s really hard to keep +800 ng/dL naturally at this age. Do you think it’s possible if all of your lifestyle factors are optimized, or is it really just a case of trying to fix something that inevitably goes down hill (and TOT is thereby the best option for lifelong testosterone optimization)?
There are genetic components, and certainly an onslaught of environmental factors involved in trying to speculate if you will have your testosterone levels within an acceptable range at 30 years old. As we’ve clearly explained in this book, due to living in large populated areas, most male endocrine systems are under siege on a daily basis from environmental contaminants. As you get older, the ultimate way to fight the natural decline of your hormonal systems is through TOT with a progressive doctor who has a broad experiential based practice. There are some men (few, we might add) who can stay above 700 ng/dL of total testosterone and maintain high levels of free testosterone into their 50’s. However, most men will feel the inevitable decline by ages 40 and up. And some men will experience it even sooner.
We highly recommend you optimize all the lifestyle factors that you can, and don’t focus so much on hard numbers. If you are not experiencing negative symptoms, you are probably in the generally accepted total testosterone ranges of 500-900 ng/dL. With that said, we strongly recommend you track your testosterone levels every year and see if you can identify a linear decline over time.
At 30 years old, if you don’t have any negative symptoms present, simply get your hormone levels checked once a year and keep track of them that way. Of course, if you have low numbers AND the negative symptoms, then some type of intervention is warranted. Whether it’s lifestyle changes (such as reducing cortisol, lowering body fat and improving adherence to proper nutrition and resistance training, etc.), or some type of clinical intervention (such as hormone optimization), do it NOW!
Most men today will see a decline in hormone levels, and a great majority of them will have symptoms that justify some type of correction. For most of those men, TOT becomes a lifelong solution for maintaining optimal levels of health.
What is your take on SARMs (Selective Androgen Receptor Modulators)? Are any of them truly worth using instead of TOT? What about in combination?
While there are numerous ‘Fit Bros’ and ‘Underground Bodybuilding Board Gurus’ who claim otherwise, we have read all of the research pertaining to this question. In comparison to TOT, the answer is an unequivocal NO. Not a chance, actually.
The use of typical SARMs such as Ostarine (there are many others that will go unmentioned) will not fix declining testosterone levels. Talking to many users from the underground fitness scene, it’s a split decision where some people ‘might have gotten an effect’, while others claim adverse reactions or none at all. However, most of these men are using SARMs in a cyclical fashion and have no idea what is happening to their estrogen and testosterone levels while using them. The majority of these users are also NOT drawing proper labs to evaluate their biomarkers, nor are they working with physicians. If you have suboptimal hormone levels and have attempted to maximize them with proper lifestyle habits, then the best way to get optimized is with TOT.
For the past 2 years, I was on 160 mg of testosterone cypionate (80 mg on Sunday, 80 mg on Thursday). I was also prescribed 0.25 mg of Anastrozole for use alongside each shot, but we discontinued it because we found that it dropped my sensitive E2 levels too low. Then, my hematocrit levels seemed to jump up into the 51- ish percent range, so I began donating blood every 56 days. That didn’t seem to regulate my hematocrit levels in the long run, so my physician slowly dialed back my testosterone dose, where it is now at 50 mg on Sunday and 50 mg on Thursday. My hematocrit levels seem to still be creeping up every 2 months, and now I am barely under the limit for where the Red Cross will allow you to donate blood. Do you have any suggestions on how to keep hematocrit levels under control without having to do blood donations every 9 weeks for someone like me that appears to be more susceptible to polycythemia? I really don’t want to drop my testosterone dose any lower.
First of all, your doctor (like most on this issue) is confused. It is not polycythemia vera, but erythrocytosis that is causing your hematocrit levels to increase. This is actually a good thing because you are increasing the oxygenated blood supply available to your body.
There are 3 things you can do.
- Increase the FREQUENCY (not the dosage amount) of your injectable testosterone dose to daily or every- other-day shots (i.e. NOT your total weekly testosterone dosage, that stays the exact same). As a result, each individual dose will be smaller.
- Improve your cardiovascular efficiency and drop body fat. Do steady state cardio at a heart rate of 125-140 BPM (i.e. low to moderate intensity), 4-7 days a week and 30- 45 minutes per session.
- Have your platelets measured. Elevated platelets would be a much greater indication that you need to be phlebotomized. If there is no platelet elevation, besides following the first two steps, DO NOTHING as your levels are well within normal ranges (i.e. safe and healthy) as already discussed by Dr. Kominiarek in Chapter 12.
We would also ask you about how you are feeling.
If you are tired, sluggish, and feel out of breath, then that *may* be a sign of your blood thickening and a good indication that you should consider donating blood.
We can’t blame your doctor here, as very few physicians understand this situation because it involves science that is currently being developed. Much of the accepted practices regarding phlebotomy are based off incorrect interpretations of past misunderstandings.
Dr. Neil Rouzier has research data he collected from his patients, and based on that data, he does not phlebotomize patients with hematocrit values under 55% when there is no corresponding elevation in blood platelets. As stated in the book with Dr. Rob Kominiarek’s explanation in Chapter 12, if you feel fine when your hemoglobin levels are under 22 and hematocrit levels are under 54%, there are no conclusive studies indicating the need for therapeutic phlebotomy (as long as your physician is also checking your platelets for a corresponding elevation).
We think the connection between obstructive sleep apnea and testosterone has to do with the tendency to gain water weight on testosterone, especially when estradiol levels are not properly controlled. Normally, this affects a small number of people. It also occurs in men with too much body fat. As we’ve stated multiple times in the book, reducing body fat will always improve EVERYTHING in relation to health, fitness and extending your life.
I’m an emergency room doctor transitioning into Integrative and Functional Medicine (i.e. leaving ‘Sick Care’). I see so many well-known doctors who mention starting patients on hCG and an Aromatase Inhibitor when starting TOT. Can most men receiving TOT do fine in the long term without hCG and Arimidex? To me, extra injections with hCG, on top of taking extra meds, makes compliance and biomarker evaluation more complicated.
Most of the progressive physicians in the optimization space will start patients on testosterone first, and then take bloods in 4-6 weeks to get a better idea of what type of estrogen response is taking place before treating it (if necessary). Of course, if the patient comes in with estrogen levels that require immediate action via treatment (normally with an aromatase inhibitor (AI) as the standard front line therapy), a conservative dosing approach with regular blood work is advised.
With hCG, it depends entirely on the needs of the patient. This means that if the patient desires fertility, starting with hCG may be the best course. If fertility is not a desire, starting the patient on testosterone and getting a baseline for blood work could be advantageous to see if hCG adds real-life value to the patient’s TOT or not. Also, in regards to AI medications, the newest research – cited throughout this book – shows that they can wreak havoc on bone mineral density (BMD). We believe these medications should be used on rare occasions as a last resort. If they must be used, the minimum effective dosage (MED) principle should be applied with the immediate goal of weaning the patient off the AI as soon as a therapeutic level of estrogen (E2) (in the absence of symptoms) is attained.
Can you define the optimal weekly dosage, and also discuss the upper range limit of weekly injectable testosterone dosages to stay within ‘therapeutic levels’?
There is no such thing. What’s optimal for you might not be optimal for me. Again, this is why it’s imperative to work with a physician who is skilled at “dialing you in” while you are on TOT. “Normal” injectable dosage ranges are between 80-200 mg per week. The highest dose we have seen progressive physicians use to help a patient stay within accepted total testosterone levels is 250 mg per week. Therapeutic total testosterone levels are somewhere between 650-1500 ng/dL, and that number coincides with the elimination of negative side effects.
What level do you attempt to keep your total testosterone, free testosterone and estradiol numbers at? I know it’s all dependent upon an individual’s biochemistry and needs, but just curious at where your levels remain on a week to week basis?
This question cannot be answered universally. We can paint a broad picture by saying that numbers should typically be within normal lab ranges (along with the absence of symptoms). Jay has been very open about his total testosterone lab readings that come from 150 mg of injectable testosterone per week (normally spread out over 2-3 injections, depending on lifestyle convenience). His peak (highest levels) to trough (lowest levels) over a 7-day moving average are normally about 1450 to 720 ng/dL, respectively. What’s most important, however, is how one feels in the absence of side effects. We consistently hear from patients about their doctors trying to keep their total testosterone numbers in a ‘mystical’ but measurable range between X and Y. This is silly. As long as your physician understands the half life of the testosterone delivery system being used, only a super high level (likely over 2200 ng/dL) that is not measured within 24 hours post-injection would be any reason to lower your dosage and measure again.
What is the prudent course of action knowing that there are NO CONCLUSIVE long-term studies proving the safety of TOT?
There are NO conclusive studies showing a definitive association between statistically significant ADVERSE cardiovascular events and TOT in otherwise normal men. The benefits of testosterone, as opposed to being wholly biochemical in nature, may be a function of the hormone’s effect on fatigue. Secondly, it increases one’s tendency to exercise and pursue a more physical lifestyle. This, by virtue, provides protection AGAINST coronary disease. No one questions the health-improving effects of exercise in aging individuals, right?
But let’s play devil’s advocate and assume the worst. From this standpoint, all you can say is that the data is somewhat mixed with respect to an overall consensus. However, considering that the “risk” associated with TOT is likely a function of flawed study design, we say HELL YES – it is WORTH the risk! At 46 years of age, aging backwards with respect to our appearance and measurement of our metabolic health, we are living proof that the reward crushes the perceived risk. And if you accept that TOT provides you the key to a real life of vigor and increased energy, is the tradeoff of having neither really worth it to you?
This is a myth. If you want to have children, make sure you include either hCG, clomid, and/or hMG therapy as part of your TOT protocol. As previously stated, you should also visit your urologist to get a measured sperm count in order to understand your baseline values before starting TOT. It also wouldn’t hurt to freeze your sperm in the event of a worst-case scenario. Usually, TOT will not permanently damage your ability to get a woman pregnant. In the worst cases, we have seen a rigorous course of hCG, clomid, and/or hMG restore fertility within six months, and sometimes sooner than that. These ‘worst cases’ include men who were on TOT for more than 10 years and were totally inhibited via low luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels. Even these men restored their fertility completely!
I’m 32 and obese at 5’7” and 285 lbs. I’m seeing an endocrinologist in a few days and I’d like to know what my options are?
Being FAT (i.e. obese) will limit your ability to experience optimal results while using TOT. Too many men think that they can live a FAT lifestyle and use TOT as a magic bullet to get good results – WRONG! Testosterone is not a panacea or a magic pill. It’s one part of living an optimized lifestyle. Using TOT when you are obese can lead to issues with the aromatase enzyme, ultimately leading to high E2 readings (estradiol) that will likely cause negative estrogenic side effects. These effects include increased estrogenic fat deposition, moodiness, water retention, and feeling ‘off’ due to a lack of balance between testosterone and estrogen. More research is coming out by the day, indicating that being obese (with a testosterone deficiency) dramatically increases your risk of death.
Do you recommend the usage of a 5/16 gauge or 1-inch insulin syringe to inject testosterone intramuscularly (thereby potentially reducing scar tissue formation)? What is your take on this?
The use of an insulin syringe (27-31 gauge) to inject testosterone, both intramuscularly and subcutaneously, is strongly recommended (even though few physicians provide these options to their patients). These syringes are usually less than 0.5 inches long and have a very narrow needle barrel. Injecting with such a small needle drastically minimizes the chances of injection scarring, especially over a lifetime of injections.
One major consideration you should keep in mind during injections is your body fat levels. After all, you are taking a needle that is less than a half inch long and trying to reach into your muscle with it. If you have a high percentage of body fat, you may not be able to get through the fat into the target area. It is also extremely difficult to push the testosterone solution through the syringe when injecting because of the thinness of the needle, so take your time and become skilled at it. Many men are now using insulin syringes to inject their TOT subcutaneously, so feel free to give this a try.
About a day after injection, I’m getting some soreness/ bruising at the place where I injected. Is that normal? I just recently started TOT.
Yes. As a newbie to TOT, when first receiving intramuscular injections, you may experience minor soreness at the point of injection several hours later. It feels just like the soreness you’d experience if someone punched you in the arm. Most of the time you will feel nothing, but either way it’s nothing to worry about and you’ll just get used to it. Eventually, you won’t feel anything at all! In rare instances, you could be having a reaction to the ester that involves a greater amount of pain and swelling.
It is possible to experience an allergic reaction from the chemical that keeps the testosterone ester stable in injectable solution form (usually ethyl oleate or propylene glycol). Very rarely, an allergic reaction to an injection will lead to a localized skin infection. Often known as cellulitis, it appears as a burning sensation at the point of injection. Sometimes, the skin turns red or fills up with white blood cells. If you are experiencing any of these symptoms, it may be a good idea to see your doctor right away. In the worst case scenario (and this is rarely seen or experienced), your doctor might have you do a round of antibiotics for several days to treat the cellulitis.
After researching TOT, it seems that lots of bodybuilders have died of renal failure – will testosterone damage my kidneys?
Absolutely not. Do not confuse the supraphysiologic (i.e. excessively high dosages of many drugs, including testosterone) that professional bodybuilders use with the therapeutic dosages of testosterone found in TOT. There is not a single study found in medical literature which proves that testosterone causes issues with the kidneys. The bodybuilders that come to mind with kidney issues were either genetically prone to these issues from the start, or using other kidney- affecting drugs (such as diuretics and NSAIDs) while ignoring the increasing warning signs.
Will it be an issue going through airports and countries while traveling with testosterone and syringes? Do I need to have a prescription with me?
You should have a copy of your prescription, or at the very least have your medications indicated with the prescription labeling on the packaging and storage bag. It is unlikely to ever be an issue. For convenience purposes, however, pack your TOT equipment in your checked baggage using something like this diabetic organizer bag.
How much of a hassle is it to go from self-medicating your testosterone therapy (grey market) to being under a doctor’s care?
This is an excellent question. It really depends on where you’re being self-medicated. Are you in the USA? How much does it cost you to get your hands on testosterone, acquire ancillary medications and get your blood work done regularly? It is crucially important to find a doctor who is not only willing to prescribe testosterone, but who will also monitor you and your blood work properly.
We highly recommend working with doctors via telemedicine providers692 who can treat you remotely. Having an outside perspective on your blood work, and receiving treatment from someone who is qualified and objective, will only benefit your health.
If you have medical benefits, many of the anti-aging medications (Metformin, Dessicated Thyroid, etc.) and TOT ancillaries (Arimidex, hCG, Nolvadex or Clomid, etc.) discussed in the book can be billed through insurance. Some of the medications will be more expensive than others, and sometimes you will be denied access on the basis of certain factors. Said factors can include (but are not limited to) your individual diagnosis, your age and the level of coverage you currently have.
Having a physician who can counsel you through your attempts to find a balance between testosterone and estrogen is critical.
No dosage, or any reaction to said dosage, is universal to all humans. Any hormone therapy is, as Dr. Crisler states, ‘dropping a pebble into an ocean’. In other words, optimizing your body can be a complicated process. The more you know about using TOT and how it may or may not affect your individual biochemistry, the higher your chances of long-term success.
ONCE MORE: If you live in a country or state where it is illegal to administer testosterone without a doctor’s prescription, then choosing the route of self-administration without a legitimate prescription is breaking the law.
I was diagnosed with varicoceles in my left testicle, and I’m going to have the microsurgery. Will I need TOT post-surgery to maintain optimized hormone levels for the rest of my life?
As many as 15% of men have varicoceles, which are masses of enlarged and dilated veins in the testicles. There is new evidence showing that varicoceles, long known to be a cause of male infertility, interfere with the production of testosterone691. In your situation, it depends on how well your testes are producing LH, both before and after the surgery. You need to work with an experienced and progressive doctor who will monitor important biomarkers, before and after your surgery, to effectively determine if you will need TOT for the remainder of your life. There are multiple cases in the scientific literature showing men who have recovered without having to use TOT.
I hear the term HRT (hormone replacement therapy) a lot. Is that for women? How is TOT different from (or the same as) HRT?
Here is the definition of HRT, as defined by Wikipedia:
“…any form of hormone therapy wherein the patient, in the course of medical treatment, receives hormones, either to supplement a lack of naturally occurring hormones, or to substitute other hormones for naturally occurring hormones.”
The term is definitely more visible in women’s circles, referring to hormone replacement for pre- and post-menopausal women. In this instance, it involves the use of one or more medications designed to artificially boost hormone levels. The main types of hormones involved are estrogen, progesterone/progestins, and usually testosterone. Just as we changed the acronym TRT to TOT in men, Dr. Jim Meehan and Monica Campbell are doing the same for women by changing HRT to HOT (Hormone Optimization Therapy).
Hormone Optimization Therapy (HOT) can be just as effective for women as TOT is for men, from a treatment standpoint. As we stated in the preface of the book, there is plenty of scientific evidence showing that HOT for women is highly effective and safe. There are WAY too many popular myths surrounding women and HOT that can be easily debunked, and we believe this topic warrants an entire book unto itself. And that’s exactly why Monica Campbell and Dr. Jim Meehan are releasing their companion series book, set for release in late 2018.
When on injectable TOT and preparing for a blood test, how long should I wait after doing the injection before going to the lab for the test?
You want to get your labs done based on what your physician is specifically looking for. Most of them want to see your levels when peak plasma values are attained. Peak values are generally attained 1.5 to 3.5 days after the injection, depending on the ester being used. Propionate would be 36-48 hours post- injection, and the longer-acting esters (cypionate or enanthate) would be 48-72 hours post-injection. For example, if you’re using testosterone cypionate and your doctor wants to see your peak plasma levels, take your dose on Monday morning and get blood work done on Thursday morning.
Experimenting and measuring the results of said experimentation, is the only guaranteed way to find out what works for your body because we are all biochemically unique. hCG monotherapy (discussed in more detail in Chapter 10) is used by physicians to elevate testosterone levels (by increasing luteinizing hormone). There is research indicating that it works especially well with younger men who don’t want to disturb their endogenous (natural) testosterone production while maintaining their fertility at the same time. Dr. Crisler (interviewed in Chapter 12) recommends using hCG at 250-500 IU (international units) per shot as part of his injection protocol (a.k.a. The Crisler Method687). hCG can also be used daily at 100 IU with great success, due to its ability to produce randomness in the serum androgen profile at varying points in the day. As we noted earlier in the book, this dosing strategy mimics your body’s natural testosterone production. If retaining your fertility is important to you, it is one of the top medications to use in combination with testosterone. Using hCG also prevents testicular atrophy for men who prefer having full testicles. If you do not use hCG, you will still retain gonadal function. Your testicles will be less full, but you will still be able to ejaculate and reach orgasm as normal.
Jay does not use hCG as he has experienced increased E2 conversion, acne flares and an imbalance between testosterone and estrogen levels. Jay is also in his mid- 40’s and has no interest in fathering any more children. However, it’s important to note that experiences on hCG can be very subjective. Some users feel great without hCG and others feel great on it. If you are using it when first starting TOT, it may be difficult to determine what its effects are, especially in comparison to testosterone administered by itself (i.e. without any other drugs or medications). The only thing you can do is experiment on yourself, noting any physiological changes or side effects, while also drawing labs to document variations over time. There are clearly luteinizing hormone (LH) receptors all over the body, and theoretically, using hCG can work well to restore improved mood and well being (for those who respond well to it). Although LH and hCG bind to a common receptor, emerging evidence suggests that LH and hCG have different biochemical downstream effects688. Understanding that we are all biochemically unique, this study substantiates why not all men will respond in a uniform (i.e. positive) fashion when using hCG.
There was an excellent study* done in 2011 that investigated this very same question. Here is what the study found, verbatim:
- Effects on sexual interest appear after 3 weeks pla- teauing at 6 weeks, no further increments beyond.
- Changes in erections/ejaculations may require up to 6 months.
- Effects on quality of life manifest within 3-4 weeks, but maximum benefits take longer.
- Effects on depressive mood appear after 3-6 weeks with a maximum after 18-30 weeks.
- First effects on erythropoiesis (increased red blood cell count) after 3 months, peaking at 9-12 months.
- Prostate specific antigen and volume rise, marginally, plateauing at 12 months; further increase related to aging rather than therapy.
- Effects on lipids appear after 4 weeks, maximal after 6-12 months. Insulin sensitivity may improve within few days, but effects on glycemic control become evident only after 3-12 months.
- Changes in fat mass, lean body mass and muscle strength occur within 12-16 weeks, stabilize at 6-12 months, but marginally continue to improve over years. Effects on inflammation occur within 3 to 12 weeks.
- Effects on bone mineral density detectable after 6 months but continue for at least 3 years.
*Onset of effects of testosterone treatment and time span until maximum effects are achieved eur J Endocrinol EJE-11-0221, doi: 10.1530/EJE-11-0221 First published online 13 July 2011.
On a long enough time horizon (i.e. months), is there really any difference between testosterone cypionate and testosterone propionate if you inject both at least 3x/ week, given that you use the same dosage of testosterone equivalently?
As far as efficacy, milligram for milligram it probably won’t matter as much. Injectable testosterone is injectable testosterone, plain and simple. We’d bet that if you did blood work for 7 days in a row, you’d have elevated testosterone levels for each day that you injected propionate (due to the shorter half life of the propionate ester, as previously discussed). Likewise, you’d have days without elevated levels when injecting cypionate (due its longer half life). Therefore, there may or may not be a marginal benefit to using propionate, since you’d be at higher levels every day. The days of having higher levels should avoid any low points (troughs) potentially experienced by patients using the longer-acting testosterone esters (i.e. Cypionate or Enanthate). This is another reason why injecting daily is a recommended option, especially for patients who have lifestyles where it makes sense to do so, as there will never be any troughs throughout a 7 day week.
My doctor recommends Nebido, and argues it is far superior to all other testosterone esters. He is an author of a standard endocrinology textbook, and the head of the WHO Center for andrology. What do you think about Nebido or Aveed?
A: We are very familiar with Professor Eberhard Nieschlag and his comprehensive 2012 textbook Testosterone: Action, Deficiency, Substitution. There are actually citations from his research in this book.
Nebido and Aveed are actually brand names for testosterone undecanoate. It’s an old-school version of testosterone re- engineered as an injectable form of delivery. It used to be available under the trade name ‘Andriol’, and was available in capsule form. Although it’s a very weak (and expensive) form of testosterone, there are no observed side effects from its use on the HPTA (Hypothalamus-Pituitary-Testes-Axis), also known as the HPGA (Hypothalamic–Pituitary–Gonadal-Axis). Apparently, it doesn’t disturb follicle-stimulating hormone (FSH) or luteinizing hormone (LH) levels either.
Nebido has been used in parts of Europe for more than a decade, and Aveed in the USA for close to 4 years. As we already wrote in Chapter 6, practice-based knowledge tells us that this medication looks great in theory but fails in what is most important: The end-user experience. Besides the issues previously discussed that most patients complain about, another massive issue we have is with the injection volume used for the initial dosing (750 – 1,000 mg). That is a lot of injection volume. With that much fluid making its way into your body, there is a great risk of pain at the injection site, or accidentally injecting into a blood vessel (leading to a potential pulmonary embolism). We don’t want that!
I recently started Testosterone Optimization Therapy (2 weekly injections of 60 mg testosterone cypionate) and I’m suffering from extreme and severe panic attacks. My doctor is unable to help. Do you have any idea what might be happening to me?
A: Dr. Rob Kominiarek has seen this issue with some of his patients. It’s very unfortunate and problematic, but select individuals with Monoamine oxidase A Single Nucleotide Polymorphism684 have a genetic predisposition to a slow degradation of neurotransmitter pathways. As soon as these patients take a shot of testosterone, they have full-blown panic attacks. Some attacks are so severe that they are unable to leave their homes, or even function properly. He offers a couple of reasons as to why this may happen, including depletion of pregnenolone or magnesium. If restoring both pregnenolone and magnesium to healthy levels doesn’t help, there’s a good chance that the patient doesn’t tolerate estrogens or androgens very well (if at all). As a result, any dose of testosterone will likely lead to panic attacks, some of which may be profound. If you are one of these men, make sure you work with a physician who truly understands this condition. At the very least, have your doctor reach out to Dr. Kominiarek at RenueHealth.com.
Listen to your physician and their diagnosis based on your lab results and presenting symptoms in addition to your unique lifestyle needs and wants. Optimally, using injectable Testosterone for a total dose of 80-200 mg per week should be more than enough for any adult male to optimize their testosterone levels.