Somebody Get Me A Doctor

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    Somebody Get Me A Doctor


    Well my 41st birthday is just around the corner. My oldest daughter will be 18 a few days later and is graudating HS this year. My youngest daughter just graduated from Pre-K this week. I'm too young for one and too old for the other.

    My son celebrated his 16th birthday without me again in March. His visitation will be shorter this year than anticipated. He calls me often and expresses very maturely his desire to be with his Dad. But he is torn between loving both his mother and I and not wanting to be away from either of us. I am torn with the concept of uprooting my wife and potentially changing the family financial future and security and moving to where he is. It's likely I will not be moving to where he is and likley he will not be coming to reside with me before he graduates HS.

    I will be flying back next week to see my daughter and son. It is my daughters graduation ceremony. I will see her a few days and will not see her again for an undetermined period of time. She will be flying to Greece with my mother for a two week vacation for her graduation gift from my mother. When she returns she has a job and will be starting college in the fall.

    I am comfortable with the shining dome of a head that has squeezed out all that natural thick dark drown hair that used to grow there. I keep my hair cut like a flat-top, or a high n' tight or white walls to keep the gray from being so damn obvious. Actually there is so very little to keep flat on the top.

    I got fairly comfortable with this image when it was accompanied with the most awsome thick goat-t that I have really gotten skilled at grooming and manicuring. I meam pretty bad ass and it makes for quite the intimidation or sexiness, whichever your gender or side of the plate you swing from. But it has been like months since I have grown it out because it has all this gray that grows like a weed.

    I had my double hernia operation last week. I have not been able to train for some 10-12 days now. The pain killers that used to be a 2-3 binge like party back in the day made me quite miserable afterwards. Took me several days to get over the hangover. I feel bloated and fat from the surgery and the lack of activity.

    The last several months I have been dealing with depression issues. I am very sensitive to and aware of my psychological condition. I am a recovering alcoholic addict who has a very good grasp on the issues of family dynamics, predispositions, dependant/codependant relationships, depression, etc. So as you would obviously recognize by the above statements...I have issues.

    Keep in mind that I state all the above with tounge-in-check and a semi morbid sense of sarcasm or humor. I am of fairly sound mind, body and spirit. I am by no means in need of serious concern or worries from anyone. If you can laugh at yourself, than at least you can then join all the others who are laughing at you.

    I went in for a talk with my doctor a month or so ago and we decided to get some treatment for my depression with an SNRI called Effexer XR. Initially it worked very well. It helped with the depressed thought pattern but it did not help with energy, stamina, motivation, and other depression like symptoms. At that time I had some bloodwork. At my request I had a Testosterone test performed with a bunch of other basic stuff. Low and behold my Total Testosterone was at 367 on a range of 250-1100. As suspected it was low. I have not cycled in a few months. I suspected that it may still be somewhat skewed because of cycle history but I always have a decent PCT and recovery in an anecdotal sense as well.

    Went back to the lab again two weeks ago to get more thorough testing done. It was Total, Free and % Free Testosterone as well as FSH and LH. As I suspected the results were fairly conclusive.

    Total Test 454: 250-1100
    Free Test 36.7: 35-155
    % Free Test .81: 1.1-2.8
    FSH 3.7: 0.7-11.1
    LH 17.5: 0.8-7.6

    My Total test was 454 which was 87 points higher but I may have tweeked it higher from fenugreek that I self administered.

    So as we can see my values are all at the low or below and my LH is pumping pretty well. Not extremely high, but reasonably. This further prompted my doctor to order an MRI to rule out adenoma (a pituitary gland issue). I very assuredly suffer from hypogonadism and not a pituitary issue but I am grateful she is very thorough. She also sent me for more bloodwork today which included all of the above and now DHEA, Estrogen, etc etc...6-7 vials worth.

    But here is the main reason for starting this thread. Mr. B5150 has just begun a TRT protocol which presently includes, and/but is presently limited to 5g/d of AndroGel. You read that correctly...AndroGel.

    I am not starting this to debate the effectiveness or efficiency of this method. I know quite a reasonable amount regarding the various methods of administration. I discussed injectable with her and she is very aware of it. I have played as ignorant as I can about my knowledge and history of manipulating hormones so that I am able to get all of the bloodwork and attention needed to get my levels back up to where they need to be for a man my age. If there becomes an issue with me and the gel applications I can push for injectable. I want her to make the call. I have some very good skills of persuation without actually stating what I want.

    "Whatever you do, don't toss me in the brier patch"

    At the very most, via a doctor supervised administration, I would only expect this to elevate me to a level at or above the mean for my age. Theoretically, in the consideration of if and/or cycling, this only means to me that I would not need to implement a extensive PCT protocol to retain and maintain normal to high levels post cycle. That is all I would really expect to gain from this regarding that issue. Outside of that it would elevate my LBM potential and reduce my propensity for fatness as well as improve bone density and all the sexual and libido aspects associated with healthy testosterone levels.

    So it has been a long winded opening post. Who would be surprised with that? I am really starting this thread to open discussion with my senior friends relative to their experiences with TRT/HRT.

    The issues of my psychological condition stated in the opening few hundred words is not something that need be treated. I have a solid foundation of faith and I believe all things will work for good for those who hold onto their faith in a Greater and Higher Power.

    So, here is to verility and vitality...and looking up your dresses.

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    Wow.....Thanks for the honesty, that's not something you find often in the world.......

    I know this is not really what you were looking for but I have a few words about you and your son......

    My mom was an addict and ran off for the first time when we were pretty young. She came back a few times, only to run off again after a few months....finally she left for good.

    My dad is the most wonderful man on the planet (notice my screen-name). He raised us the best he could....the problem with this was that he was gone most of the time working to try to put me, my 2 brothers, and my sister (my moms daughter from a previous marrage...yeah, not even his kid) through school, feed us....well, you get the idea.

    When I came back from college (also courtesy of dad) I got an apartment next door to him, we lived as neighbors for about a year and a half.

    During that time my dad and I got to know each other in a way we never could when I was a kid....we both look back at that time as some of the best times of our lives....just kickin' back, getting to know each other as adults....He was and still is my best friend.....and that didn't happen until I was an adult....

    I guess my point is that you still have plenty of time to get to know your son...and you'll both be richer for it...


    Sorry, Hijack over........
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    Quote Originally Posted by myfathersboy
    I guess my point is that you still have plenty of time to get to know your son...and you'll both be richer for it...
    I found your screen name very prideful when I first saw it months ago. Now you have confirmed that he is also worthy of it. A father is a very important thing. You are blessed.

    My son and I are very very close. He has resided with me several times for several years. His mother and I are still very best of friends. It is just a sacrifice I have made.

    I made a decision a long time ago, that I would rather cry myself to sleep at night because I missed my son than have to hear him cry himself to sleep at night because he missed his mom. I love them both and always will.

    Thanks. You're a good kid
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    AndroGel

    If you read the literature you will see that AndroGel is 1% testosterone. So at a 5g application you are administering 50mg of test. At a 10% absorption rate that is 5mg per day. I find this rather odd at the very least. But if my doctor can show me with data that I am at or above the mean for my age with this I will be satisfied. It comes in daily doses of up to 10g.

    Like I said, if I get the values that are commensurate with a man my age through this method, and/or increased dose, I have no issue. I am going to let her do her job. If we need to use other methods I am game as well
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    In.





    :bb3: Keep yo' head up big man.

    Holla at me if you need to talk - my parents have waaaaaaaaaaaaaaaaaaaaaaaaaaaaa aaaaaaaaaaaaaaay more issues than you and I turned out alright. (Well, some might argue....)
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    Appreciate it man.

    I'm doing just fine, really. I'm not really looking to focus on those issues, as much as I was just venting outloud. Those are normal parenting issues that we all go through. The other things are just issues with growing old(er). Some handle them easier than others. I take things in life hard sometimes. Sometimes harder than I need to. But, thanks, really

    My real issue up for discussion is the Test Replacement Therapy. I'll be keeping this up as well as i can. I will be working my weekend schedule of 3-12's starting tomorrow morning so I may not be able to get back to this too often over the weekend. But I'll do what I can.
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    I don't have any HRT advice but being 38, I can see that day coming. I'll be keeping an eye on this thread. If I recall past threads, Mr. Ageless should have some useful insights.
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    Well this morning was my second dose. I am trying not to be swayed by placebo. I will say that this morning, and really most all of the day at work, was the most energenic that I have been in quite a while. I did get a good 8-10 hour overlap of doses, as I took my first yesterday evening and my second this morning.

    This stuff dries super quick with no residue. It is clear and begging for more active...

    Beginning to experience pain at the incision of my hernia surgery. Seems as though the 'numbness' of the skin is fading and quite a bit more sensitive. Not liking it.

    I would still welcome some feedback and insight. I have read of very satisfied AndroGel users. Like I said I only expect to elevate my levels to mean and above. I would be interested in some good information on injections. I have done little research to date on 'prescription' options of injectable and will be starting as time allows. I was hoping to have some more knowledge that I can 'share' with my doctor in the event that I feel I want to 'persuade' her to go that route in the future. I have done a whole bunch of TD's before, so one a day applications is only half as many, but I am sure that months of it will grow old.

    Anyway.
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    I went to an endo last fall just to get checked out. I'd been feeling tired, irritable, was showing some signs of ED. My weights had also stagnated, but that wasn't a huge issue.

    The labs came back w/total test at 280. We waited 3 weeks, tried again and got 320. He offered androgel, saying that most people like it, and it's fast acting. However, he said he preferred 'test depot', but few people tolerated it because of the injections.

    I told him that after the first result, I had been researching test levels and HRT, and would be comfortable with the injections. He was glad that I took the time to research and sent me on my way with a script. My insurance (BC/BS) covers most of the test, I think it's around $20 for 10ml/200mg ml. I talked to him about HCG, and he gave me a script, but unfortunately, it isn't covered by insurance, and runs about $80 a bottle! I'm on 200mg/week and it's been good. I feel 'normal' again. My lifts are all up, and so is my weight. My libido is a pain in the ass, but luckliy, my wife is younger than me so she keeps up.

    I'd say the most important thing is to get a good, understanding doc. If you feel good on the androgel, and the levels are good, then great - I'll be honest, after months of self injections with 22gauge pins, it's becoming a hassle. I did quads for a while, but kept getting really sore, not going deep enough (oil spreads under the skin and hurts!), or just got too close to a nerve. Delts get sore easily from the shots. Hip and glutes are good, but I worry about scar tissue buildup there.

    Have you check out the CEM HRT forum? It's not very active at all, but there is some good info to be mined from the stickies: http://www.cuttingedgemuscle.com/For...?s=&forumid=35
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    Thanks a bunch intv. Just the kind of feedback I'm looking to hear.
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    Quote Originally Posted by B5150
    I have some very good skills of persuation without actually stating what I want.

    Yo B didn`t we call these Character defects before? Now I call it "Sales skills"


    Good to hear form you man! Well 5 days late but I been busy
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    I'll be keeping an eye on this one. I go next week to an endo. Been to a Urologist, but wasn't very happy w/ him. He had his way only and knew nothing of supplements. Not very open to suggestions. Anyway, he put me on clomid. Didn't like it. Vision side effects so I stopped. We'll see...hopefully the endo will have some good knews or at least some new ideas. I'll let you know...
    5150 - good luck!!!!
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    Quote Originally Posted by gettingold
    ... Anyway, he put me on clomid.
    What - clomid just to avoid having to give you some test??? Now that's funny... How much did you have to take?
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    150mg per week. 50 mg - M,W,F. I know my test levels are low and all the signs are there. Honestly, I never put it together until I started reading this board. This place is the balls. The info and input obtained here has been a huge help to me. I'll keep you posted.
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    Quote Originally Posted by gettingold
    150mg per week. 50 mg - M,W,F. I know my test levels are low and all the signs are there. Honestly, I never put it together until I started reading this board. This place is the balls. The info and input obtained here has been a huge help to me. I'll keep you posted.
    Keep us updated.
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    Quote Originally Posted by B5150
    Well this morning was my second dose. I am trying not to be swayed by placebo. I will say that this morning, and really most all of the day at work, was the most energenic that I have been in quite a while. I did get a good 8-10 hour overlap of doses, as I took my first yesterday evening and my second this morning.

    This stuff dries super quick with no residue. It is clear and begging for more active...

    Beginning to experience pain at the incision of my hernia surgery. Seems as though the 'numbness' of the skin is fading and quite a bit more sensitive. Not liking it.

    I would still welcome some feedback and insight. I have read of very satisfied AndroGel users. Like I said I only expect to elevate my levels to mean and above. I would be interested in some good information on injections. I have done little research to date on 'prescription' options of injectable and will be starting as time allows. I was hoping to have some more knowledge that I can 'share' with my doctor in the event that I feel I want to 'persuade' her to go that route in the future. I have done a whole bunch of TD's before, so one a day applications is only half as many, but I am sure that months of it will grow old.

    Anyway.
    About a year ago I started HRT. My test levels were close to yours. The doctor put me on a transdermal cream. He said it would bring me to a sustained level of 900 over time and that I would not need to cycle. Unlike Ando Gel the cream was messy and a pain in the ass to apply. My last test showed total test at 1711, my DHT was high and LH low. The doctor shrugged it off so I decided to change physicians.

    The beginning of the year I read an article in GQ about a world renowned anti-aging clinic. I decided to make an appointment with one of their offices in Florida. Three weeks before blood was drawn the doctor put me on 5000 IUs of HCG per week. It was administered in doses of 2500 units and subq at his request. He told me that I shouldn't need test at my age would most likely prescribe HCG therapy depending on the results of my blood test. June 23rd I will spend 6 hours in a hospital going through a battery of tests including bone density, stress and body fat. That will be followed by a private consultation. Most likely I will be prescribed a regimen of supplements, HCG and GH. Blood tests will follow as needed, however twice per year I will undergo an expensive and thorough exam. As for the meds, I will get a prescription that I can fill anywhere.

    I'm not completely sold on their methods, but I'm willing to give it a try. He assures me that I will maintain a level in the 800s through my own test production. This is the largest clinic of this kind in the world and 25% of their patients are doctors. Two of the head honchos were photographed for the article. Both were 68 years old with physiques at 8.5% body fat that a 20 year old would envy.

    At some point I will post my progress. You seem to have a good relationship with your doctor. I probably wouldn't have gone this route if I felt comfortable with mine.
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    Although i can only offer a (((HUGZ))) and your a strong person, I hope you recover fast and all is well in your world

    Tc
    RIP Ryan, :(
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    MY CURRENT BEST THOUGHTS ON HOW TO ADMINISTER TRT FOR MEN


    -A RECIPE FOR SUCCESS-


    --John Crisler, DO


    We have already learned a practical bit about the various hormones that make up the metabolic “symphony” which comprises our hormonal milieu. We know where these hormones are produced, what modulates their production, and the target tissues of their various and varied actions. But we still need to integrate this knowledge into a practical “recipe”, if you will, so the clinician may return to his/her practice, and immediately begin screening for, and successfully treating, male hypogonadism. In other words, how do you actually administer Testosterone Replacement Therapy for men?

    Should EVERY adult male patient who presents at your office be automatically screened for hypogonadism? About half of all men over the age of fifty are in fact hypogonadal (when tested for Bioavailable testosterone—more on that later). Certainly the answers to Medical History will lead the way toward suspicion of same, yet the complaints related to this insidious condition are sensitive without being specific. Clinical suspicion is further clouded because there is no way to correlate either the number of individual complaints, or the relative magnitude of each, to the severity of the hypogonadotrophic state on laboratory assay. The number one complaint which should hoist the proverbial red flag is Erectile Dysfunction. This is also the symptom of hypogonadism which, aside from all the seriously deleterious effects of same (coronary artery disease, diabetes, osteoporosis, increased risk of cancer, depression, dementia, etc.), is most likely to bring the patient to actively seek TRT—and to remain compliant in your treatment regimen.

    INITIAL LABWORK

    Following a good Medical History, which laboratory assays should be run as part of your initial hypogonadism workup? Following is my list, but certainly other specialists in this area run expanded or attenuated panels, per their experience and expertise. Of note, there are several other tests which should be included to complete the true comprehensive Anti-Aging Medicine workup (i.e. homocysteine, fasting insulin, comprehensive thyroid study, etc.), as this chapter is concerned solely with administering TRT. And as always, the panel is tailored to the individual patient. Here they are:

    • Total Testosterone
    • Bioavailable Testosterone (AKA “Free and Loosely Bound”)
    • Free Testosterone (if Bioavailable T is unavailable)
    • DHT
    • Estradiol (specify the Extraction Method, or “sensitive” assay for males)
    • LH
    • FSH
    • Prolactin
    • Cortisol
    • Thyroid Panel
    • CBC
    • Comprehensive Metabolic Panel
    • Lipid Profile
    • PSA (if over 40)
    • IGF-1 (if HGH therapy is being considered)


    FOLLOW-UP LABS

    Two weeks after initiating a transdermal, or five weeks after the first IM injection:

    • Total Testosterone
    • Bioavailable Testosterone
    • Free Testosterone (if Bioavailable T is still unavailable)
    • Estradiol (specify the Extraction Method, or “sensitive” assay for males)
    • DHT (especially if patient is using a transdermal delivery system)
    • FSH (3rd Generation—ultrasensitive assay this time)
    • CBC
    • Comprehensive Metabolic Panel
    • Lipid Profile
    • PSA (for more senior patients)
    • IGF-1 (if GH Therapy has been initiated already)


    INDIVIDUAL ASSAYS EXPLAINED
    TOTAL TESTOSTERONE

    This is the assay your patients will most focus on. It’s also the one physicians who do not understand TRT will use to deny patients the testosterone supplementation they want, and need, when Total T is at low-normal levels. Total T is important for titration of dosing, but its relevance is reduced in older men (by virtue of their increased serum concentrations of SHBG), in favor of:


    BIOAVAILABLE TESTOSTERONE

    Where we actually get the “bang” for the hormonal buck, so to speak. This is the actual amount the body has available for use, as the concentration of hormone available within the capillary beds approximates the sum of the Free Testosterone plus that which is loosely bound to carrier proteins, primarily albumin. If Bio T is not readily available, Free T may be a second choice substitute, as Bio T and Free T serum concentrations are well correlated.


    DHT

    This assay is especially important to draw, up-front and at follow-up, if a transdermal testosterone delivery system is preferred by the patient. I’ll explain why later. DHT level may also help indicate cause for ED symptoms.


    ESTRADIOL

    There are several reasons why this assay is VERY important, and should not be ignored in ANY hypogonadism work-up (or subsequent regimen). First, you definitely need to draw a baseline. Next, elevated estrogen can, in and of itself, explain hypogonadal symptoms. If E is elevated, controlling serum concentrations (usually with an aromatase inhibitor, which prevents conversion of T into E) may suffice in clearing the symptoms of hypogonadism. And finally, rechecking it after beginning the initial dose of testosterone will give the astute physician valuable information as to how the patient’s individual hormonal system functions, as well as making sure estrogen does not elevate inappropriately secondary to the testosterone supplementation.

    I don’t waste time and money drawing estrone and estriol. E2 is the player of interest here. Unless you specify a ‘sensitive’ assay for male patients, the lab will run the Rapid Estradiol for fertility studies in females, which is useless for our purpose here. Quest Diagnostics calls this their Estradiol by Extraction Method.

    Some practitioners believe that it is only the T/E ratio which is significant, and therefore, as long as E “appropriately” rises with elevations in T, all is well. However, the absolute concentration of E is of concern, too, especially in light of new information pointing to elevated estrogen as cause, or adjunctively encouraging, several serious disease processes, including prostate and colon cancer.


    LH

    As everyone knows, it is LH which stimulates the Leydig cells of the testes to produce testosterone. A caveat, however: LH has a half-life of only about 30 minutes. When you combine this fact with the absolute pulsatile nature of its pituitary release, care must be taken to not place too much weight upon a single draw. A luxury would be to acquire serial draws, say, twenty minutes apart. However, such would be both inconvenient and probably prohibitively expensive for the patient. The most important reason to assay the gonadotrophins is to differentiate between primary and secondary (hypogonadotrophic) hypogonadism.

    FSH

    The eight hour half-life of this hormone makes it a better marker for gonadotrophin production. It is also less an acute phase reactant to varying serum androgen and estrogen levels than LH. Greatly elevated FSH levels could signal a gonadotrophin-secreting pituitary tumor.

    Of note, I run FSH (but not LH) on the follow-up labs, the new third generation (“sensitive”) assay, to determine the magnitude of HPTA suppression secondary to androgen therapy. It also provides valuable information for those patients undergoing TRT who are interested in the state of their fertility.

    PROLACTIN

    A very important hormone, and must not be overlooked on initial work-up. Approaching five percent of hypogonadotrophic hypogonadism is associated with hyperprolactinemia, due to inhibition of hypothalamic release of LHRH. Its serum concentration must be maintained within physiological range (meaning neither too high nor too low). Greatly elevated hyperprolactinemia, or hyperprolactinemia plus a Total Testosterone less than 150ng/dL, equals a trip to an Endocrinologist for an MRI of the sella turcica.

    CORTISOL

    True Anti-Aging medicine must be well-familiarized with the ins and outs of this hormone, the only one our bodies cannot live without. Elevated levels can cause secondary (hypogonadotrophic) hypogonadism. I try controlling elevated cortisol with Phosphatidylserine, 300mg QD, with good results. It is just as important to watch for depressed cortisol levels, as well. The assay of choice for that condition is a 24-hour urine.

    THYROID PANEL

    I have, for my own convenience, omitted the specifics of the obligatory thyroid function panel you certainly will want to run. Hypothyroidism mimics hypogonadism in several of its effects.

    CBC

    This is just good medicine. Ruling out anemia is important, of course, as it may be a cause for the fatigue which brought the patient into your office. You also want to establish baseline H&H, for those rare cases where polycythemia becomes a problem (and we are reminded smokers are at increased risk for polycythemia). Above 18.0/55.0 TRT is withheld, and therapeutic phlebotomy recommended.


    CMP

    Again, just good medicine. Baseline for sodium (which may elevate initially secondary to androgen supplementation) is important. We also want to see LFT’s, as elevations in same secondary to androgen supplementation are listed as a possible side effect in the product literature (although I have yet to see this actually happen). I like the BUN/creatinine ratio as a marker for hormonal hemo-concentration, and also it gives me a hint of how compliant the patient will be (because I always tell them to make sure to drink plenty of water while fasting for the test).


    Lipid Panel

    This is drawn to provide your bragging rights when you drop the CHOL 30 points, thanks to your own good administration of TRT. You should expect to see lowered TRIG and LDL’s, too. Be advised, this will not happen if you choose to elevate their androgens above the top of “normal” range, i.e. providing what amounts to an anabolic steroid cycle. Of course, this would no longer constitute TRT, as the practitioner would then be choosing to damage the health and well-being of the patient.

    HDL does frequently drop a bit, but that is believed to be due to increased REVERSE cholesterol transport; so much of the plaque is, after being scavenged from the lining of the CV system by HDL, now being chewed up by the liver. Androgens also elevate hepatic lipase, and this may have an effect. The important thing to keep in mind is that TRT inhibits foam cell formation.

    PSA

    For all patients over 40. Even though prostate CA is rare in men under the age of fifty, we don’t want it happening on our watch, do we? At this time, rises in PSA above 0.75 are a contraindication to TRT (until follow-up by a Urologist). You may find that, at the initiation of TRT in older men, when serum androgen levels are accelerating, PSA may, too. This is especially true when transdermal delivery systems are employed, because they more greatly elevate DHT. Once T levels have stabilized, PSA drops back down to roughly baseline. You won’t really see gross elevations in PSA secondary to TRT administration in younger patients. New TRT patients need to be cautioned, and reminded, to abstain from sexual relations prior to the draw, as they may now be enjoying greatly elevated amounts of same.

    I get a PSA up front on my over 40 patients, at the one month follow-up in my more senior patients, and every six months after that. DRE (Digital Rectal Exam) is recommended twice per year as well, although the American Academy of Clinical Endocrinologists backs “every six to twelve months” in their 2002 Guidelines for treating hypogonadotrophic patients with TRT.

    IGF-1

    For those who are considering the addition of GH to their Anti-Aging regimen. IGF-1 will rise from testosterone supplementation, and vice versa. Let’s grab a baseline now, before that happens.


    THINGS TO LOOK OUT FOR
    CO-MORBIDITIES. Currently, only breast and active prostate cancer are absolute contraindications for TRT. Patients with serious cardiac, hepatic or renal disease must be monitored carefully due to possible edema secondary to sodium retention. Also, TRT may potentiate sleep apnea in some chronic pulmonary disease patients, although studies have also shown it can actually ameliorate the symptoms of sleep apnea.

    DRUG INTERACTIONS. TRT decreases insulin or oral diabetic medication requirements in diabetic patients. It also increases clearance of propranolol, and decreases clearance of oxyphenbutazone in those receiving such medications. TRT may increase coagulation times as well.


    TESTOSTERONE DELIVERY SYSTEMS

    Now we have to decide, TOGETHER with our patient, what form of testosterone delivery system we will START with. There are two basic subsets of same—transdermals and injectables. Here are the current options:

    TESTOSTERONE GELS AND CREAMS

    The only way to go, in my professional opinion, if physician and patient prefer a transdermal delivery system. They are easy to apply, well absorbed, and rapidly establish stable serum androgen levels (usually by the end of the second day). I recommend all practitioners first try a testosterone gel for their TRT patients.

    Much is made of the risk posed by accidental transferal of testosterone to others, such as children or sexual partners. Simply covering with a T-shirt has been shown to block transfer of the hormone. The testosterone sinks into the skin within an hour, which acts as the actual reservoir for the hormone’s delivery. One may then shower, or even swim, without worry. I remind my patients that most of us have neither the time, nor the opportunity, for romance until evening (given the recommended early morning application), and a quick shower is always nice to “freshen up” then anyway.

    Gels and creams, like all transdermal delivery systems, provide a bigger boost in DHT levels, compared to injectable testosterone preparations. This can be a double-edged sword. As DHT is responsible for all the things of manhood, the transdermals are better at treating ED than the injectables. However, issues of hair loss and possible prostate morbidity (a contentiously debatable point, to be sure) then come into play. Either way, please make sure to monitor DHT with the transdermals. I’m just not comfortable with gross elevations in DHT, and prefer to avoid adding finasteride whenever possible.

    Some have reported an increase in hair growth over the application area(s). All physicians who administer TRT must be prepared to disappoint their patients at this time by pointing out, sadly, this same effect cannot be achieved on the scalp.

    TESTOSTERONE PATCHES

    These can be quite effective, but are inconvenient to use. Approaching 2/3’s of your patients will develop a contact dermatitis from them at some point. Another drawback is that some patients report they are constantly aware of their placement, and the patches are embarrassingly obvious to other gentlemen in certain public places, such as in the locker room.

    The scrotal application variety is the most inconvenient. To see what I would be putting my patients through, I tried them. After just a couple days, I’d had more than enough. Men do not generally enjoy shaving their scrotum, and the patches just do not stay on well anyway. Applying a hair dryer to the patch, as they must be warmed first, is also an annoyance. If you go to the gym during the day, they look strange affixed to the genitals, and must be removed, then reapplied, to shower. They do not stick well in the first place, and even less so once they have been reapplied. Of the two options, I found only the type with the extra adhesive had any chance of remaining in place. The scrotal variety causes the largest increases in DHT—which can be good or bad, as previously explained.

    TESTOSTERONE PELLETS

    In my opinion, their use is absolutely Stone Age. Sure, they can provide extra revenue by virtue of a billable office based procedure. However, needlessly exposing patients to the risks ALL surgeries pose—hemorrhage and infection—is unwarranted. And the area of insertion will be much tenderer than that following a mere IM injection. But the real issue which selects against pellet implantation is concerned with dosing. Let’s say you establish a “usual” initial dose for the pellets. As will be described in the next section, there is absolutely no way to predict, up front, how a patient will react to a given dose of testosterone, regardless of the delivery system. So you bury these pellets in your patient’s backside, and (hopefully) draw follow-up labs in a month or so. What are you to do if the total testosterone ends up greatly exceeding the top of normal range (meaning the patient hyper-responded to the treatment)? Now you must make a much wider incision to remove them, or a portion of them (and who knows how many to take out?). With their very long half-life, SOMETHING must be done, lest you risk actually damaging the health of the patient by elevating testosterone levels into what might be considered a bodybuilding steroid cycle. And what if the pellets do not elevate T enough? You must bring them back in to implant more, and it’s difficult to sell them on this idea, since they probably are not yet feeling the advantages of TRT enough yet to motivate them into undergoing another surgical procedure. It just doesn’t make sense, to my way of thinking.
    Testosterone pellets do have some benefit in that selected patients may believe it more convenient to come in every month or six weeks, and then be done with it for a while. Also, because they release T in a slow, steady rate, the pellets are less likely to induce increases in aromatase activity.

    TESTOSTERONE INJECTION

    I’ll start out by describing the drawbacks of IM testosterone. They are inconvenient for patients who do not wish to give themselves their own injections, as they must then make weekly trips to your office for same. Why IM test MUST be dosed weekly will be described in detail in another section. Some patients, as you well know, just hate shots (although I have noticed several who had initially claimed this, but admitted, once they had come to enjoy the benefits of TRT, actually came to look forward to their weekly injection). And no doubt, an invasive delivery system brings more risk than, for instance, a testosterone gel or cream (the other best choice for TRT).

    When considering dosing of testosterone cypionate, it is important to remember that, due to the weight of the cypionate ester, a 100mg injection delivers, at best, 70mg of testosterone. This is important to keep in mind when comparing the effects of a 100mg weekly injection of test cyp to the 35mg total dose provided by Androgel 5gms QD over the same period.

    HCG

    Many practitioners consider this incredible hormone treatment of choice for hypogonadotrophic (secondary) hypogonadism. Such certainly makes sense, as supplementing with a LH analog indeed increases testosterone production in patients who do not concurrently suffer primary hypogonadism. But often, upwards of 1000IU per day must be given to achieve the desired serum T level. Even then, for some unexplained reason, while serum T levels may be adequately elevated, the patients simply do not report realization of the benefits of TRT, when HCG is administered as sole TRT. You also run the risk of inducing LH insensitivity at that dosage, and therefore may actually cause primary hypogonadism while attempting to treat secondary hypogonadism. HCG, especially at higher doses, also dramatically increases aromatase activity, thus inappropriately elevating estrogens. Personally, I recommend never giving more than 500IU of HCG at a time.

    A real benefit of HCG is that it will prevent testicular atrophy. I do not think we should ignore the aesthetics of that consideration. Your patients will feel the same way.

    OTHER MEDICATIONS

    I occasionally hear of physicians trying to use a SERM (Selective Estrogen Receptor Modulator) such as Clomid or Nolvadex, or even an Aromatase Inhibitor (AI), such as Arimidex, as sole “TRT”. All have been shown to elevate LH, and therefore Total Testosterone levels. However, patients report no long-term subjective benefits from these strategies, and the studies thus far reported no long-term changes in lean body mass, fatigue levels, libido, etc. An added risk of using an AI is of driving estrogen levels too low, with deleterious consequences for the lipid profile, calcium deposition, libido, etc.

    Finally, Deca-Durabolin (Nandrolone) has no place in TRT. It has a nasty side effect profile, including uncontrollable progesterone-like effects (including gynocomastia) and risk of long-term impotence.


    THE MEAT AND POTATOES OF TRT

    Now we will delve into the general strategy for administering TRT.

    The decision is made, TOGETHER with the patient, which of the various testosterone delivery systems is to be tried first. Be prepared to make adjustments, and try other application methods. You just don’t know which will be best for each particular patient until you try. Besides the simple fact the patient may have a personal preference, or a logistical consideration (i.e. inability/unwillingness to self-inject) for a given application, every-body reacts differently to hormonal manipulation. Some hyper-respond to a given initial dose, others show hardly any bump in serum T levels on same. Yet when you switch to a different delivery system, on initial dosing, they may convert to supraphysiological androgen levels. The same is true of the subjective benefits from TRT. I have patients who love testosterone gel because it successfully treated their ED (the expected outcome because of dramatically increased DHT production), others get more from IM testosterone cypionate. My experience thus far has taught me two lessons: (1) You don’t know how a patient will react to a given dose/system until you try and (2) NOTHING surprises me anymore.

    There simply is no way to predict how a particular patient will respond—not Medical History (i.e. number or severity of symptoms), body weight, baseline hormone levels, even anabolic steroid history. I have had very slight gentlemen barely elevate on 100mg of test cyp per week, and massively muscled former steroid athletes who went to nearly two times the top of “normal” range on the same dosage (they had similar baselines). Likewise, one man may see only a modest increase in DHT on 5gms of Androgel, another may become quite supraphysiological on same.

    I start my guys out on either testosterone cream/gel 5mgs QD or testosterone cypionate 100mg per week. The IM test cyp must be administered in weekly injections, as opposed to taking twice the dosage every other week. Some physicians even dose every third or fourth week, producing wide swings in serum androgen levels. This puts the patient on an emotional roller coaster, increases the risk of developing polycythemia, greatly accentuates aromatase activity, and actually leaves them lower than they were when they started for the last half of the cycle. In order to get the serum androgen concentration to a stable level more quickly, I “frontload” 200mg the first injection (unless converting over from a gel/cream).

    No other medications which manipulate hormone levels are provided until follow-up labs are returned. For IM test cyp patients, the second panel is run following the fifth injection. I also keep in mind the coordination of the injection with the lab draw, as peak serum levels are attained at about the 48 hour point, then fall to about 35% at the one week point. However, by the end of the fifth week, the pharmacodynamics of testosterone cypionate (half life is 5-8 days) are such that relatively stable serum levels are now being produced via weekly injections.

    Transdermals can be rechecked in two weeks. They produce stable serum levels, as previously mentioned, for most by the end of the second or third day. Logistically, it makes sense to send the patient for follow-up labs after a fortnight, as there is then time to get the labs back, and bring the patient in, before the initial 30-day supply of the medication runs out. This is better if an adjustment in dosage is mandated by the follow-up labs, or to convert to IM dosing should the patient produce too much DHT. It would be a shame to have the patient refill a script for 5gms of Androgel, when they, by their labs, are going to have their dosage reduced to 2.5gms per day because they hyper-responded to the initial dose, or waste money when what they reallyneed is to be converted to test cyp.

    The question of which testosterone delivery system is to be tried first (IM or transdermal) is one which brings much confusion amongst beginning practitioners of TRT. I would, when possible, always start out a patient on a testosterone cream or gel. Ease of application, avoidance of intrusion by injection, and increased probability of successful ED treatment make this so. Also, stable serum levels are attained quickly, determination of successful treatment is more forthcoming (although the manufacturer of this product recommends at least a couple months as adequate trial of therapy). If the labs AND patient’s answers to follow-up subjective report lead to a change to IM testosterone, the conversion is an easy one to make. Simply apply the gel, give the shot, then D/C the gel. However, if a patient is started out on IM test cyp, for instance, yet the patient still does not feel “right” (and thus you may want to try a transdermal delivery system to better raise DHT levels), how are you, given the pharmacodynamics of the testosterone ester, going to safely and successfully dose the conversion to a transdermal?

    Dosing changes are made, TOGETHER with the patient, once follow-up labwork is back AND the patient is interviewed regarding their subjective reports of changes in libido, sexual performance, fatigue, strength, mental outlook, etc. Often they will tell you they felt “incredible” the first couple of weeks (and bursting with libido), but they don’t feel quite as good now, but still much better than before they started the TRT. This is because subjective findings are the best while serum androgen levels are accelerating. Adjunctive to this phenomenon is the fact their HPTA was not yet being suppressed, so their endogenous production was higher then than it would be by the end of the month. TRT patients are always HPTA suppressed to greater or lesser degree.

    Much weight is placed upon the patient’s subjective findings, as they are not likely to remain compliant in the TRT program unless they feel noticeably better, irrespective of the less obvious long term improvements in CV health, bone density, decreased risk of dementia and cancer, etc. Certainly, if the patient reports they are quite happy at a Total Testosterone level of 600ng/dL, I feel there is little reason to increase their dosage. As an Osteopath, I am loath to provide ANY medication, or increase in dosage, without proven need. As a practical limit, the top of “normal” range for Total Testosterone provides a ceiling, more or less, above which we can expect to find the benefits of TRT beginning to reverse themselves. Actions following androgen receptor binding dramatically improve health and happiness as we go from the hypogonadal state to the top of “normal” range, but beyond that the Lipid Profile and level of insulin sensitivity, for instance, are damaged.
    Changes in IM dosing are made in small increments, as response to same is not linear. It is convenient and practical to increase, or decrease IM dosing by 20mg at a time, as this is one “tick mark” on the side of the syringe (for the 200mg/mL concentration). For Androgel patients, we are more limited by their provided dosing whereas we can only either drop down to 2.5gms, or add an extra pack each day (at which time BID dosing may be considered) to reach the 7.5gm, or even 10gm, per day dose. More flexibility is provided through compounded products for those committed to employment of transdermal testosterone delivery systems.

    Another risk of jumping the dosage too much is that, should serum androgen levels greatly exceed the top of “normal” range, the patient risks becoming “spoiled” at that level. They would then feel the subjective benefits steroid athletes report, and it would be difficult to get the patient then to be happy at a more moderate—and proper—dose. It is likely you would also therefore produce elevated estrogen activity as well, and further muddy the waters with respect to how the patient feels—and looks (due to emotional changes and even water retention issues from the elevated estrogen). It is far better to make changes in dosing conservatively.

    Once the method and dosing is set, by laboratory assay AND subjective report from the patient, then you may address any side effects due to elevated estrogen levels which have occurred. I do not use an AI initially, even when E2 is elevated, because some patients will actually see a drop in estrogen over baseline on follow-up. We would have otherwise added an unnecessary (and relatively expensive) medication. Should the patient develop any “nipple issues” secondary to accelerating serum androgen levels and/or elevated estrogen, you cannot start them on a SERM right away because doing so will invalidate your estradiol assay at follow-up. Of note, males can experience said “nipple issues” even while estrogen levels are within physiological range, due to changes in hormone levels. A drug of the class SERM is treatment of choice in this case, until symptoms subside.

    If a patient has “nipple issues”, even while estrogen is within normal range, I add a SERM, emergently. I prefer Nolvadex over Clomid, and Evista is probably best of all for antagonizing estrogen (although much more expensive). Clomid often induces untoward visual effects (i.e. “tracers”), and can cause emotional lability by virtue of its estrogen agonistic effects at the more peripheral (emotion) brain sites. I do like my patients to keep some Nolvadex on hand, should they experience nipple swelling or sensitivity, so they may begin 40mg per day until the symptoms abate, and then taper to 20 mg QD for a few days, then 10mg for a few more, then finally 5mg QD to taper off.

    My TRT male patients who suffer E2 elevations above the top of normal range are placed on 0.25mg of Arimidex every third day. If that is not enough, I use the same dose EOD. It is possible to cut the tiny 1mg tabs into quarters, but here a gel or cream preparation, compounded to convenient dosing, makes a lot of sense. A month later I recheck E2, and make further adjustment if necessary. It is important to not lower estrogen too far, which is easy to do with an AI, as doing so has disastrous effects on the Lipid Profile, bone deposition, etc. I prefer to maintain E in mid-range.

    So now let’s say we have the patient in a state where Total Testosterone is in the upper quartile of “normal” range, Bioavailable Testosterone is nicely elevated, with E2 safely in check. At this point I offer the patient my HCG protocol. I add in 250-500IU of HCG, on day five, and day six of the week, for those who use the IM injection. In other words, the two days prior to their shot. For those using a transdermal delivery system, every third day. For the IM patients, this compensates for the drop off in serum androgen levels by the half-life of the test cyp. But the main reason is to stave off atrophy of the testicles, by directly stimulating them with the LH analog.

    Patients all report they feel dramatically better once the HCG regimen is initiated (and they were properly tuned up on testosterone before they started it). HCG, as a LH analog, increases the activity of the P450 SCC enzyme, which converts CHOL to pregnenolone. Thus all three hormonal pathways are stimulated in patients who may be either entirely, or very nearly, HPTA suppressed. It is my belief this may be a factor in the heightened sense of well-being my patients report throughout the week—far in excess of what a minimal dose of HCG would produce by virtue of induced testosterone production.

    Many TRT practitioners add in HCG for a short course every few months, to re-stimulate the testes. My opinion is that it is far better to keep them up to form and function all along the way. The physicians who intermittently use HCG also use it as a “break” in TRT, much the same way hormonally-supplemented athletes manage the typical anabolic steroid cycle. TRT should not be “cycled”. Once I get my patients properly tuned up, I want them to stay that way. They also erroneously believe this allows the HPTA to recover, when it clearly does not. The HCG-induced testosterone production is every bit as suppressive of the HPTA as the TRT, and the supplemented testosterone is still at suppressive serum levels during that time, anyway.

    Once the patient is all set, I like to run follow-up labs every six months. It is important to monitor the general health and well-being of the patient, but also insure compliance with treatment protocols and continued effectiveness of same.

    ****************************** ****************************** ********************
    My hope is that the preceding diatribe will gainfully assist the practitioner in implementing Testosterone Replacement Therapy regimens for their qualifying patients. Be prepared, however, to blush as they shower you with accolades following their vast improvements in health and happiness. You may even receive thank you notes from their wives!

    Please watch for coming articles and books by John Crisler, DO on this, and other, continuing subjects related to anti-aging.

    Copyright John Crisler, DO 2004. This article may, in its entirety or in part, be reprinted and republished without permission, provided that credit be given to its author, with copyright notice and AllThingsMale.com clearly displayed as source. Written permission from Dr. Crisler is required for all other uses.


    Dr. John Crisler may be reached at:

    DoctorJohn@AllThingsMale.com
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  19. The horror
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    That was an interesting article. I voiced those same concerns about HCG therapy to my doctor. This is his opinion:

    By
    Jeffry S. Life, M.D., Ph.D. and Alan P. Mintz, M.D.
    Cenegenics Medical Institute
    Las Vegas , Nevada


    Men and Testosterone

    Testosterone is a hormone that has been intimately tied throughout time to a man's virility and sexuality. It is the major steroid hormone of the testicles. However, testosterone is much more than just a sex hormone. With testosterone receptor sites in the brain and heart, and in fact throughout the entire body, testosterone plays a critical role in maintaining a healthy immune system, insuring proper heart function, and regulating mood and cognition, controlling blood sugars, regulating healthy cholesterol levels, controlling blood pressure, preventing heart attacks, and even reducing the risk for prostate cancer.

    Testosterone production in the male begins when the pituitary gland, located deep inside the brain, secretes lutenizing hormone (LH), which in turn, stimulates the Leydig cells in the testicles to produce testosterone. It is estimated that men are born with 700 million Leydig cells and they begin losing 6 million each year after their twentieth birthday. In spite of these losses, studies have found that testosterone levels peak in men at about age 30. After this, testosterone levels begin declining an average of 2% a year.
    Declines in testosterone production are due to several factors besides decreases in Leydig cell numbers. Diminished testicular response to pituitary signals that initiate testosterone production and a poor coordination of the release of these pituitary signals play the most important role in testosterone decline. Another reason for testosterone decline is because most of the testosterone that is secreted into the bloodstream attaches to a protein called sex hormone binding globulin (SHBG). Testosterone that is not bound to SHBG is called free testosterone and it is only in this form that testosterone can exert its powerful effects on all of the body's cells. An increase of SHBG occurs in many men as they age, especially if they are obese. As SHBG levels increase, the amount of testosterone that is available to act on cells diminishes even further.

    These age-related declines in total and free testosterone levels in men are associated with easily identifiable, classic signs and symptoms called andropause. Andropause can cause significant problems that include negative attitudes about life in general, a loss of focus and drive, a questioning of one's values and accomplishments, loss of goals and directions in life, decreased libido, depression, and even cognitive impairments. Declines in sex drive, frequency of sexual thoughts, and erectile dysfunction are additional problems that are directly related to falling levels of free testosterone and these can have a profoundly negative impact on the male psyche and relationships.

    Physical changes also occur and are characterized by thinning hair, a decline in lean muscle tissue, and an increase in body fat (particularly abdominal and pectoral fat). As muscle mass declines, strength declines and risk for falls and fractures increases. A decrease in bone mass is another major problem associated with declining levels of testosterone. Osteoporosis is not just a woman's disease—up to 30% of men aged 60 and over become osteoporotic. One out of every six men will fracture a hip at some point in their life as a result of decreased bone density. Declines in stamina and exertional performance are also a direct result of inadequate levels of testosterone as are declines in mental skills, concentration, and memory.

    Testosterone can be converted, by enzymes, into other hormones. One of these enzymes is called 5-alpha reductase. It is found in especially high concentrations in the prostate gland where it converts testosterone into dihydrotestosterone (DHT). Another enzyme, called aromatase, is found in skin, brain, fat, and bone. Aromatase converts testosterone into estradiol, the human form of estrogen. As men age, more of the testosterone they produce is converted into estradiol. When there is too much estradiol it competes with testosterone and negative consequences develop. These include prostate cancer, heart disease, and stroke. Abnormal increases of estradiol are caused by excess amounts of aromatase enzyme, impaired liver function (often caused by excessive alcohol or certain drug interactions), obesity (which increases aromatase enzyme), and zinc deficiency (zinc is a natural aromatase enzyme inhibitor). In addition to declining levels of testosterone and increasing levels of estradiol, growth hormone, thyroid hormone, and DHEA levels fall during andropause. As these levels decline, profound changes occur with growth and metabolism that affect men both physically and mentally and add to their testosterone deficiency problems.

    Today the signs and symptoms of andropause should not be accepted as an inevitable consequence of the aging process. By utilizing bio-identical hormones and accurate monitoring techniques, replacement therapy is now possible. Hormone optimization programs offered by Age Management Medicine physicians have rapidly moved into the forefront of preventive medical care and have greatly contributed to the enhancement of quality of life as men and women age.

    Women and Testosterone

    Testosterone may be well known as a hormone that has been tied to a man's virility and sexuality, but few realize that it is also a very important hormone for women. As women age, estradiol and progestin levels begin falling as they enter menopause. Testosterone (produced in the ovaries and adrenal glands), thyroid hormone, and growth hormone levels also decline during this time. As the levels of these key hormones diminish, profound degenerative changes begin occurring with growth and metabolism that affect the breasts, vagina, bones, blood vessels, gastrointestinal tract, urinary tract, cardiovascular system, skin, brain, and energy levels.
    We now know testosterone is critically important for a woman's libido, sexual responsiveness, mood, and generalized feelings of well-being. Women, like men, also need adequate testosterone levels for peak mental acuity and the maintenance of healthy bone density and muscle tissue. Maintaining bone density is absolutely critical for women. Unsupplemented women have a 50% chance of experiencing a pathological fracture of their hip or vertebra at some point in their life. This is a frightening statistic because a hip fracture carries with it a 25% six-month mortality rate, and a 50% two-year mortality. Testosterone also plays a key role in the prevention of the accumulation of unwanted body fat, heart disease, and loss of cognitive function in women. Testosterone replacement therapy is now recommended for women with suboptimal blood levels. Like men, women must have all of their hormones at optimal levels and be followed with laboratory studies on a regular basis after therapy is started.

    Testosterone Measurement

    Clinical signs and symptoms are important indicators that an individual needs testosterone replacement therapy. However, objective laboratory measures must be obtained to properly institute and manage therapy. These lab measurements are also necessary to rule out or address any accompanying medical problems. To adequately measure testosterone levels, both total and free testosterone studies should be obtained. The normal laboratory ranges for these is, ironically, the same for 20 year olds and 70 year olds
    Obviously, the fifty-year span from age 20 through 70 with the same normal range is not a useful guide to determine optimal testosterone levels for older individuals. Typically there is a 70% decline from the more youthful levels to the levels typically seen after age 40, and this will produce most, if not all, of the problems associated with low testosterone levels described above. Yet a level this low does fall in this broad range and is declared "within the normal range" by today's laboratory standards. A more accurate approach would be to use the upper third of the normal range for one's age as the optimal or normal level.
    The decision to institute testosterone replacement therapy should always be made in the context of other hormonal and laboratory studies. Prostate Specific Antigen (PSA) measurement and a digital rectal exam of all men must accompany testosterone blood levels at the time of the initial evaluation to screen for any pre-existing prostate disease and they need to be followed at regular intervals. Other studies, such as thyroid hormones, growth hormone (hGH), leutinizing hormone (LH), dehydroepiandrosterone (DHEA), estradiol, progesterone, blood count, lipid profiles, and other laboratory and metabolic markers (such as body composition and bone density) all play important roles in maximizing a testosterone replacement program in both men and women. Once therapy is initiated, follow up hormone levels, as well as other markers, must be monitored over time at regularly scheduled intervals by a well-trained physician to maximize success and assure safety.

    Testosterone Therapy

    Any hormone therapy including testosterone therapy is very serious business and must be performed by physicians trained in hormonal modulation. Before any testosterone supplementation program is started, all key hormone levels must be evaluated and therapy should be based on the augmentation of all hormones with suboptimal levels. After the decision has been made to optimize hormone levels, the next step is to decide on the best means of administration.

    The best method of testosterone delivery varies from individual to individual, and is dependent upon several factors. Optimally, a testosterone delivery method should be clinically effective in correcting the signs and symptoms of testosterone decline and produce predictable and reproducible optimal levels of testosterone without increasing levels of other potentially harmful hormones. The fact that testosterone can be converted to estradiol by an aromatase enzyme is a serious concern for men because, in some, any intervention that raises testosterone levels will raise estradiol levels. With proper laboratory follow up, this is easily identified and corrected. The raising of serum levels of dihydrotestosterone (DHT) can also be clinically important in men. DHT, as discussed earlier, is the hormone associated with male-pattern baldness and prostate enlargement. These do not become a problem if DHT levels are closely monitored and controlled.
    Testosterone is available directly in injectable, topical, and implantable formulations, and may also be supplemented indirectly by the administration of human chorionic gonadotropin (hCG). At present, there are no recommended oral testosterone formulations in the United States for men. Testosterone pellets have been developed for men that can provide augmented serum testosterone levels for up to six months. Pellets, however, require a surgical procedure for implantation and removal, and once they are placed they do not allow for altering dosages based on an individual's testosterone blood levels.

    An oral preparation that is useful for helping normalize testosterone levels in women is DHEA. Men do not convert DHEA into meaningful levels of testosterone, but many women do. A good first step in improving testosterone levels in women is to optimize DHEA levels and then re-check testosterone levels after 5-7 weeks. If testosterone levels have not increased, direct testosterone therapy can be started at that time.

    Testosterone for use in men is available in a formulation that provides a long biological effect time and can be purchased by prescription in a low cost, easily self-injectable form. A dosage interval of once a week works very well. Delivering testosterone in this way has a 100% success rate in providing every cell with usable hormone. It is also easy to precisely control the dosage of testosterone and manage the results by following levels over time at regular intervals. This is the supplementation of choice for men whose testicles are no longer able to produce testosterone in adequate amounts.

    Testosterone formulations are also available for topical placement, which allows testosterone to be absorbed through the skin. Testosterone cream is the therapy of choice for raising testosterone levels in women. There is only limited application for topical testosterone in men because this method can produce elevated serum levels of DHT. The very small amounts of testosterone cream required to raise testosterone levels in women have not been associated with any problems. Testosterone patches are available by prescription for men but have been associated with problems including, inability to achieve adequate serum testosterone levels and local reactions from the adhesive. Mild to moderate reactions occur in as many as 50% of men using some formulations of the skin patch. Patches have also been shown in studies to produce a 30-50% failure rate in clinical applications.
    An interesting new way of increasing testosterone levels in men has been achieved through the use of human chorionic gonadotropin (hCG). hCG is a hormone that is able to bind to lutenizing hormone (LH) receptors with the same binding affinity as LH. Administration of hCG can, therefore, mimic the same effect as LH and increase testosterone production by stimulating Leydig cells in the testicles. In men who still have a functional LH/testosterone control loop, testosterone production with hCG is the most physiologic method and is not associated with the testicular atrophy that can occasionally happen with direct testosterone administration. The preferred method of administering hCG is to give self-administered subcutaneous doses with a tiny insulin syringe twice weekly. With normal aging, the testicles will at some point stop responding to the LH and hCG signals. If testosterone levels do not rise in a patient receiving hCG after 6 weeks, we know the "disconnect" between the testicles and the pituitary gland has occurred and direct testosterone supplementation is the preferred route*.
    Once a hormonal augmentation program is initiated, laboratory markers, which include hormone blood levels, should be followed at regularly scheduled intervals and therapy must be adjusted accordingly if an endocrine supplementation program is to be safe and effective. Physicians specifically trained and certified in Age Management Medicine are best suited to oversee such programs.
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    NOT attempting to stop the momentum of this informitave thread, but I have noticed that when guys are talking about HRT or the like, they are usually accompanied with blood tests. Also, not debating the actual numbers themselves, but it seems that Every time consecuitive tests are done, the second total test score is higher then the first. This is probably due to an attempt to elevate test levels naturally by the patient (as you had mentioned doing). But again, I say probably (I dont know of one person on this board that wouldn't).
    I guess my point and question (from a wanting to understand the decision) is when seeing that the total scores are up some by last time (and I know that there can be flux's in the scores), Does anyone explore the possibility that even though you havent cycled in months, that because your older, it could just take much longer to get back to "normal"?

    -again, Im not tring to judge anyones decision, and I would expect that the older one gets, the longer it would take to recover to normal after PCT. I am just curious about the test results, and if the second tests that are done prior to HRT show attempts to up natty test ,or is it that as another month goes by, your total test climbs up a little, and eventually, you'll get to a more normal range.?
    -Sorry to interupt-
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    Quote Originally Posted by xtraflossy
    I guess my point and question (from a wanting to understand the decision) is when seeing that the total scores are up some by last time (and I know that there can be flux's in the scores), Does anyone explore the possibility that even though you havent cycled in months, that because your older, it could just take much longer to get back to "normal"?
    Absolutely. To me there is much more than just the anecdotal or asthetic symptoms that are being weighed in with my decision or choice. I have had a history of depression. I have had the benefit of an open minded physician. I have a the ability to treat a quantifiable deficiency in testosterone and/or an unquantifiable seretonin/dopamine/norepinepherine-deficiency/receptor issue.

    The idea of treating my head for depression with a 'aspirin' that has some other sides (BP/liver/lipid) or treating my body with a 'natural occuring' hormone supplementation is one that I am in the process of assessing. The benefits of testosterone treatment on my overall physical and mental health are far reaching, if indeed it is the issue. The benefits of an SNRI are psychologically benefitial, with somewhat limited physical health improvements.

    I will be considering many things as I progress.
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    MRI today. This is likley just an exercise of covering all bases. I am grateful that my doctor is thorough.

    Still have a decent anecdotal response thus far on 5g daily of the AndroGel. My libido is slightly increased. I have never had an ED issue or anything dramatic so there is no issue there. I have been a bit more interested in initiating activities. In the past it has not been an issue of interest but rather being a Dad and husband and provider who was just plain tired...or so I assume.

    Unfortunately I am still recovering from my hernia surgery and have not tarined so I have no feedback as far as performance in this area goes. I do feel like **** without training. I have made an effort to keep the scale stable, but have always seemed to 're-distribute weight' very quicky to areas that I would rather not.

    My assumption is that my pre-AndroGel repeat bloodwork has been back to my physician for some time and we are just waiting for my MRI report to get to her office. I suppose it will be a day or two before that happens. That will be my 2 weeks+ point of being on AndroGel and I assume she will be writing another request for a blood draw.
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    Your kids have something that I don't, a father that gives a damn about them. My father was shot down over Vietnam in 1968 when I was 6, I barely remember him. My mom was killed in a car accident in 1969 and I was bounced around from 1 foster home to another. Take pride in knowing that you are there for them and they have their dad to talk to when they may need him. You sound like a good man to me, I've read quite a few of your posts. As you can see from my post count I don't post often unless there's something I think I can help with and this is one of those times when I can offer some encouragement.

    On to the HRT.
    If you can, try to get the Androgel in the pump bottle, it's much easier to deal with and probably a tad cheaper.My prescription plan blows goats so I have to go the cheapest way possible. I personally have had very good luck with fenugreek and maca root for my T level, you might wanna try adding some into your herbs, it's cheap and can't hurt.

    My great, great, great, great grandmother wrote this some 170 years ago, maybe it'll help you out.

    "Great Spirit the path you have chosen for me is hard, but I will see it through for I know the soul would have no rainbow if the eyes had no tears".

    Margret Running Crane

    ROB
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    Quote Originally Posted by GREENFEATHER
    Take pride in knowing that you are there for them and they have their dad to talk to when they may need him. You sound like a good man to me, I've read quite a few of your posts. As you can see from my post count I don't post often unless there's something I think I can help with and this is one of those times when I can offer some encouragement.
    It is kind of you to say. I do find a great sense of pride in knowing that I am able to be there and have an intimate relationship with my kids in spite of all of the 'complications' that life can hand us.

    I know you as well and appreciate your encouragement.

    On to the HRT.
    If you can, try to get the Androgel in the pump bottle, it's much easier to deal with and probably a tad cheaper.My prescription plan blows goats so I have to go the cheapest way possible.
    My thoughts exactly once we determine if AndroGel is the route we will stick with.
    I personally have had very good luck with fenugreek and maca root for my T level, you might wanna try adding some into your herbs, it's cheap and can't hurt.
    I believe that those two are what contributed to a slight increase early on. I was dosing F and M at about 5g each per day.

    My great, great, great, great grandmother wrote this some 170 years ago, maybe it'll help you out.

    "Great Spirit the path you have chosen for me is hard, but I will see it through for I know the soul would have no rainbow if the eyes had no tears".

    Margret Running Crane

    ROB
    Nice
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    Well some more update. I have experience a sense of self confidence as of the last day or two. Just a bit of a lack of inhibition or selfconsciousness especially around members of the opposite sex. A couple few encounters dealing with some business I had to handle. Just an assertive confident feeling that was easy to exhibit. Kind of like a "chicks dig me" sort of feeling.

    I even gave Bobo some **** in the shout box today. But he can give it back pretty well too.

    I have noticed a slight increase in testicular size and a bit more of a 'dangle' like that associated with an vasodilator like yohimbine.

    I also noticed a couple/few pimples on my back. Nothing major but not something that I usually experience.

    Hopefully I can expect a call from my physician tomorrow to schedule me for a visit and some follow up bloodwork.
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    Here's another thought, sleep apnea. The test doesn't hurt, it's a pain to sleep with all that sh!t wired to you, but if your insurance will cover it, go have one done. My test never dropped too much because of my sleep apnea, even when I was a fat bastard at 306 it was in the low 800 ng/dl range. I am finding now that as I approach 12% BF it's seemed to stabilize somewhat.
    Good luck and good medicine,
    ROB
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    OK here is a little update.

    Based on the continued increase in my LH, a negative pituitary MRI and sustained low free test and %free test it does seem that I do have primary hypogonadism. Estrogen and prolactin are normal with DHEA being at the low end of normal.

    Since beginning the AndroGel I have experienced what is to be considered a normal response. Initially I had a very positive effect in regard to energy and libido and well being. These things can be attributed (my speculation) to the increase in overall testosterone and an elevation of DHT (greater chances with transdermal test). Those benefits have diminsished quite a bit in the last week or so. I would likely attribute this to the beginnings of exogenous testosterone induced shutdown. I speculate this based on what all the literature suggests.

    I missed getting my follow-up bloodwork today by ten minutes. The lab closed at 4:00 and I got there at 4:10

    Now back to my Dr. She was very well versed in the field of HRT. I openly challenged her with some questions that gave me a very good feeling that I was in good hands. I explained that I was into bodybuilding and wanted to attain the highest levels of test that I could to support my goals and hard work. She was very open to me attaining the very highest levels as possible without compromising my health and her practice. As soon as I get my blood draw and she gets my labs back and reviews my levels we will address my dose and administration method. She was very opened to IM if I chose to go this route.

    Anyway...I am pleased.
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    check this one out
    Welcome to DrStayWell.com

    legit i hear
    My Little Site about Hair Loss & Anabolics-
    hair loss from steroids dot com
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    Man I feel your thread! About a month ago I started androgel levels were 214. And I just turned 41. I've been on androgel for about a month I go in for a check this week so it will be interesting to see where I'm at. A friend directed me this board, and I'm glad. See my questions after my next test concern stacking or creating a better enviorment for muscle growth. My problem is probably like some on the board. And thats the medical profession lake of knowledge about fitness, nutrition, and working out. I asked my urologist if there were any dietary, or workout considerations to think about now that I'm on androgel. His response was no! And I'm thinking, ok if I'm adding testosterone to my system, how can I not get better results and help my health by changing my diet. AGGGHHH!!! Its just fustrating, just like most doctors that will tell you to stop working out, when you are injured instead of telling you how to train around the injury, and train to helpl prevent the injury. Now on another not. I have to commend you on your comments on parenting. Let me say that I'm a step parent, and I will say that I think its great that you put your childs wellbeing ahead of your wants, even thought your wants are set aside sometimes. My situation is a bit different, my step-childrens father always puts his needs first, no matter what it does to the kids. Thanks for the thread.
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    Welcome!

    Thanks for joining the board and sharing your first post with me. Kind words.

    Stick around and feel free to share you experiences with your TRT.
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    Hey there. Just a quick note. I just switched to androgel from Test Cyp. Was getting tired of having to rely on my wife to shoot me. Also, my doc feels that the daily gels are the way to go.

    Have you had any blood pressure issues? Mine is really high ow and my head hurts a lot. I am not enjoying this and may go back down to 3 pumps a day. Im also contemplating going off entirely and trying a more natural approach with supplements.

    Keep us poste on how you are doing.

    Thanks
    Derek
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    How come you didn't get your IGF levels tested???

    This stuff dries super quick with no residue. It is clear and begging for more active..
    This is pure unadulterated B5150.....just a gem. Hit me up for a chat.....on hushmail.
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    I just called you Friday, I think. I left a voice mail. I will clear some time this afternoon or evening to call or write. I covered a whole bunch in this thread so you are rather up to date with me. I did my first post hernia sugery w/o this morning. Thank goodness. I was loosing what was left of my mind.
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    Quote Originally Posted by doughboy
    Hey there. Just a quick note. I just switched to androgel from Test Cyp. Was getting tired of having to rely on my wife to shoot me. Also, my doc feels that the daily gels are the way to go.
    I am still working out what my dose of AndroGel needs to be, if indeed it will be sufficient at up to 10g/d. I am waiting for test results and it is the holiday so the Dr. ain't in. Anecdotally...I need more, me thinks. I have considered injections for the less frequent dosing, but have never injected and have concern with the fluctuations of levels. AndroGel is pretty level.

    Have you had any blood pressure issues? Mine is really high ow and my head hurts a lot. I am not enjoying this and may go back down to 3 pumps a day. Im also contemplating going off entirely and trying a more natural approach with supplements.
    No BP issues.
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    Quote Originally Posted by B5150
    I just called you Friday, I think. I left a voice mail. I will clear some time this afternoon or evening to call or write. I covered a whole bunch in this thread so you are rather up to date with me. I did my first post hernia sugery w/o this morning. Thank goodness. I was loosing what was left of my mind.

    I have a new cell phone......I can e-mail it to you.
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    It is quite obvious to me now that he loves you more B. I think I've left messages for God knows who twice now... see tha tears? *Dweep* *Dweep*

    I don't even get a hush mail addy... what a rip!


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    Quote Originally Posted by TheUnlikelyToad
    It is quite obvious to me now that he loves you more B. I think I've left messages for God knows who twice now... see tha tears? *Dweep* *Dweep*

    I don't even get a hush mail addy... what a rip!



    I have to publicly appologize to you both. This new job has gone to my head.....in a stressful sort of way. I tried to e-mail B but got a return mailer (he's dissing me). YGPM.....bltches
  

  
 

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