There are four main types of testosterone replacement that are available.

Transdermal testosterone includes patches (which will not be covered due to their low absorption rates) and gels such as Testim and Androgel, which are both 1% concentrations, and creams from a compounding pharmacy which range from concentrations of 1% to 10% with higher concentration rates equating to lower skin surface area for application. A study indicated Testim absorption to be better than Androgel, however my personal experience is that both are good absorbers. The smell of Testim turns most men off to its use, but I found that women particularly like the odor. However, my insurance does not cover Testim. Androgel efficacy is improved in my case by rubbing it on the flanks as well as the arms. Remember, the more surface area the higher the DHT, which can lead to unwanted side effects such as acne, accelerated hair loss in those prone to male pattern baldness, and hair growth in unwanted areas. However, the boost in libido and improvement in erections is noticeable for me. Shots, mentioned next, worked fine in my case for about 1 month. Two months into the treatment I had profound lack of libido and total erectile dysfunction unresponsive to PDE5 inhibitors such as Viagra and Levitra.

The second type of TRT is the shots including Testosterone Cypionate and Testosterone Enanthate. This is usually the first type of TRT attempted by many doctors, and is also the TRT many return to who are poor absorbers of the gels – often due to hypothyroidism and the concomitant increase in skin thickness which reduces the gels efficacy. Shots are given typically once per week at a starting dose of 100mg. A few words of caution are in order – many doctors will start their patients on very high doses once per month. This is stone age TRT and should be avoided at all costs. Injections once per week are better, twice per week even better, and for those on Plavix concerned about scar tissue, taking your weekly dose and diving it by 3.5 offers two benefits. One, instead of intra-muscular injections – which can be done at home if your doctor is a human being – lower doses offer the ability to administer shots via an insulin needle subcutaneously. Also, dosing this frequently offers the user more consistent levels of Estradiol, which if shown to be too high are more easily controlled via an aromatase inhibitor such as Arimidex. This protocol is described here, although I would not start with as high a dose of Arimidex as this protocol calls for. Instead, start low at about .25 mg/week or even lower and increase from there. You don’t want to tank your E2 due to the horrible side affects that can be associated with low levels of Estradiol (E2), especially in the presence of thyroid or adrenal issues.

HCG or human chorionic gonadotropin is a glycoprotein hormone produced during pregnancy. This hormone can be cultivated for use as Luteinizing Hormone (LH) analog. The benefits of using HCG in conjunction with TRT is twofold. One, subjective experiences of libido and erectile function improve with the addition of HCG. HCG is typically administered at home with a dose of about 250IU every three days using an insulin needle. The other benefit of HCG is its affect on mitigating testicular atrophy. During TRT, the testicles are no longer needed to produce testosterone. This causes the glands to atrophy, sometimes to the point of pain. The average male testicular size is that of a small egg. With TRT, the testicles can become small lumps of collagen about the size of a raisin. Recall from a previous post that LH acts to stimulate the Leydig cells in the testicles to produce testosterone. HCG, in acting like an LH analog, achieves the same response. As long as your Leydig cells are not damaged (as in primary hypogonadism), HCG should keep testicular size at or near normal.

With one caveat. HCG can cause E2 levels to bounce around like a ping-pong ball. For many, including myself, the 250IU every three days proves to be too much. We are hyper-responders to the administration of this hormone. I get by on 50 IU every three days anchor. The state of my E2 given this lower dose will be reflected in my latest labs to be administered in a couple of weeks. HCG mono-therapy in the absence of any TRT is not recommended. Long-term, high-dose HCG can desensitize or damage the Leydig cells, driving the user into a primary hypogonadal state – permanently. Use HCG with caution and in lower doses. High dose HCG can be used to kick-start the testicles during an attempted restart protocol if the user is known to be neither primary nor secondary. Some protocols use 1500-2000IU every other day. The jury is out and the debate is raging on whether this is truly necessary. Often, a restart protocol will use a Selective Estrogen Receptor Modulator (SERM) to kick-start the hypothalamus or pituitary gland into producing LH. In order for this to be effective, the testicles must be ready to make use of the increased LH. Hence the feeling that high dose HCG is necessary to prepare the testicles. However, many in the field believe that a lower dose can be used or, if HCG is used during TRT, the need for increased HCG prior to the administration of a SERM is unnecessary. The SERM use alone should work. SERMs include drugs such as Clomid or Tamoxifen. Future posts will deal with restart protocols as I intend on attempting one myself (for a second time) after the basic building blocks are present to buttress testosterone production. This is an area where Shawn Bean and Dr. Freeland and working in consultation with each other for my particular case.

Third there is oral testosterone. It is useless so don’t even go there.

Fourth is the of pellets. While this shows some promise, I am not impressed with this approach and have yet to find anyone undergoing this therapy who is. It requires minor surgery to implant the devices which release testosterone evenly over a period of months before needing to be removed and replaced. As release can be too quick for some, optimal levels may be difficult to achieve and control. Maybe in the future as the technology improves, but for now I would steer clear of this therapy.

One last item needs to be mentioned. When starting TRT the body’s own production will naturally shut down. TRT is an exogenous approach (testosterone outside the body and not produced by the body). Endogenous production of testosterone is described as ones own testosterone from the Leydig cells. If you initiatve TRT, endogenous production shuts down. This takes time and varies from patient to patient. This is the only time I would allow 1 month for gel replacement prior to a measurement. Often a patient will find their levels are lower than before starting TRT. A complete check of E2 levels, SHBG, and free-T should indicate if there is a reason why. If all systems check out, then increasing the dose is required – for both gels and shots. Don’t despair because the results did not match your expectations. While TRT is a science, it is also an art. Nobody’s body is the same and your ideal approach, be it shots or gels alone (or together), the use of progesterone to lower SHGB, the use of HCG, or moving to a higher dose compounded gel to control DHT is something you and your physician will figure out as you progress. This is why it is so critical to find a doctor who either knows what they are doing or is willing to work with a health consultant such as Shawn Bean to ensure you reach you goals as quickly as possible.

Side effects of TRT are covered in the links above and will not be repeated here. Side effects not covered in the above links such as affects on E2 and DHT for the various approaches will be covered in the next post.

Good luck out there.

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Filed under: Testosterone Replacement

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