The Testosterone Toolbox

I know you're a busy guy and have a million things to do, but do me a favor:

Sit down, relax, and turn off your cell phone.

Now take a deep breath and close your eyes.

You relaxed yet? Okay, good.

Now ask yourself:

  • Do you still feel like your old self?
  • Do you hop out of bed in the morning feeling energized and ready to take on the world?
  • Do you look forward to your workouts with feverish anticipation because you just seem to get stronger and stronger?
  • Do you catch your wife or girlfriend "complaining" to her friends that you can't keep your hands off of her?
  • Do you make decisions quickly and decisively, whether it's where to invest your tax refund or what to order for dinner?
  • Or does that better describe how you used to be?
  • As for morning erections and marathon sex: who do you think you are, Hugh Hefner? You're supposed to be a grown up!

Perhaps it's something as simple as low Testosterone that's keeping you from having the life you still want to have.

What Exactly is Low Testosterone?

Starting at about age 30, a man's Testosterone levels drop by about 10 percent every decade. At the same time, another factor in the body called Sex Binding Hormone Globulin (SHBG) starts to slowly increase. SHBG traps much of the circulating Testosterone and makes it unavailable to exert its effects in the body. The Testosterone left over to do the work is known as "bioavailable" Testosterone.

Every man experiences a decline of bioavailable Testosterone, but some men's T levels dip lower – and drop faster – than others. The reason may be physical, psychological (stress), or even environmental. And when it happens, these men can experience a variety of negative symptoms that can negatively affect their quality of life and even expose them to other longer-term risks of low-Testosterone.

Is Low Testosterone on The Rise?

This is difficult to say. Skeptics suggest that the incidence of low T isn't on the rise but rather that physicians are more inclined today to identify the symptoms as such. Couple that with the fact that men today are taking a much more proactive role in their health and well-being (not to mention more apt to admit that they even have a problem) and the skeptics may have a point.

But what concerns many in the medical field are the significant increases in younger men – many as young as 30 – presenting all the symptoms of low Testosterone.

Why this problem is occurring in younger populations is highly debatable, with everything from today's 24-7 lifestyle to environmental estrogens to overly constrictive tighty-whiteys being indicated as possible causes.

So Why are Healthy Testosterone Levels so Important, Anyway?

Most of you reading this article are probably well aware of the big T's effect on muscle mass, strength, recovery, and body fat levels. The effects on libido and sexual performance are also well established.

But in truth, we're really just starting to scratch the surface as to how important a role healthy T levels play in the body. Below is just a short list of the medical conditions associated with low Testosterone levels:

  • Cardiovascular disease
  • Cancer
  • Diabetes
  • Osteoporosis
  • Depression
  • Alzheimer's
  • Erectile Dysfunction
  • Metabolic Syndrome X (also called Syndrome X)

The last of these, Metabolic Syndrome, is an insulin-insensitivity condition, believed to be the precursor to adult-onset diabetes. It's defined as the presence of 3 of the following 5 risk factors:

  1. Abdominal obesity: waist circumference greater than 40 inches in men; 35 inches in women.
  2. Elevated blood pressure: greater than 130/85 mmHg.
  3. Decreased HDL "good" cholesterol: less than 40 mg/dL in men; less than 50 mg/dL in women.
  4. Elevated triglycerides: greater than 150 mg/dL.
  5. Elevated fasting glucose: greater than 110 mg/dL.

What are the Symptoms of Low T?

There is considerable variability here, so not all men experience the same effects to the same extent. But typical responses to low T levels include:

  • Emotional changes
  • Decreased Sex Drive
  • Erectile Dysfunction (or less rigid erections)
  • Decreased morning erections
  • Decreased strength and/or muscle mass
  • Decreased mood or overall feelings of well-being
  • Decreased mental quickness and sharpness
  • Decreased energy, strength and endurance
  • Less desire for activity and exercise
  • Increased body fat
  • Night sweats and trouble sleeping
  • Mild to moderate depression and irritability
  • Depression and/or loss of enthusiasm for daily life

What are the Benefits of Boosting up my Testosterone Levels?

Lest you think that bumping up T levels to the high-normal range is a one-way ticket to the Mr. Olympia stage, take note: the effects of high-normal T levels are more subtle, but still highly significant to your health and happiness.

According to experts, in the first two weeks following Testosterone "augmentation," most men will report a general improved enthusiasm for daily life. This is often accompanied by an increase in energy and a desire to be more active.

After roughly three to four weeks, there's an increase in sex drive, often demonstrated by sexual dreams, spontaneous erections, "morning wood," and an overall increased interest in sex.

After this initial period, the cosmetic benefits appear (provided diet and lifestyle factors are taken into account). Increased strength, better pumps, and a decrease in bodyfat are common.

Keep in mind, this is in addition to the dramatic decreases in the risks for the serious diseases previously listed.

Is Medically Supervised Testosterone Replacement Therapy (TRT) Dangerous?

As compared to what, skydiving? Or taking dangerous medications that kill thousands of people a year like aspirin?

According to Dr. Jon Crisler, one of the world's leading experts on Testosterone Replacement Therapy (TRT), literally millions of men have enjoyed the benefits of TRT without a single case of appropriate TRT hurting anyone.

(Note the word appropriate, Mr. Two-Grams-A-Week.)

But while prudent Testosterone therapy is safe, it's still not without its contraindications.

At this time, subjects with breast and prostate cancer are absolute contraindications for TRT, while patients with serious cardiac, liver, or kidney disease must be monitored due to possible edema secondary to sodium retention.

Are There Any Health Risks Associated With TRT?

There are a few things you have to watch for. The biggest concern is hematocrit levels. If you're taking T and your hematocrit levels go over 50, think about giving a pint of blood, reducing your weekly dosage of testosterone, or taking tons of fish oil and pray like hell, because a reading over 50 means, statistically at least, that your chances of getting a myocardial infarction are about twice that of someone with a reading below 40.

Secondly, you should also watch your PSA levels (Prostate Specific Antigen). Even though the relationship between prostate disease and T is controversial, you do not want to be the one statistical case that proves the point that there is a relationship between Testosterone and prostate cancer.

And thirdly, you should your watch estradiol levels, and make sure they stay in the low to mid-range. As you get older or fatter, your levels of aromatase increase, leading to higher levels of estrogen in the blood. This higher than normal levels of circulating estrogen in the blood might lead to gynecomastia, or throw a monkey wrench in the whole HPTA axis (Hypothalamic-Pituitary-Adrenal (HPA) Axis), or even, according to some, contribute to prostate disease.

A Final Consideration: Rugrats Anyone?

A lot of guys considering taking the TRT plunge should at least consider the fact that pharmaceutical TRT may greatly reduce (temporarily, at least) their chances of being the next Jon Gosselin.

TRT generally means a significant suppression of spermatogenesis and a marked reduction in viable baby making sperm, hence low fertility and no children until after cessation of TRT. Even then, spontaneous recovery of spermatogenesis may take several months to several years, and in some cases may be permanent.

Back in the early 1990's, the World Health Organization did a 10-nation study where they gave men Testosterone as a presumed male birth control protocol. The experiment worked exceptionally well, leading the WHO to suggest that 200 mg. per week of testosterone cypionate or enanthate would be an effective birth control method.

What Are the Delivery Systems Employed to Increase Testosterone Levels

 Here's a quick look at the most common methods:

 1. Transdermal Gels and Creams: (Androgel, Testim)

This is typically your doc's first course of action for raising Testosterone levels. Docs seem to love these products as they're "well-researched," meaning that the drug reps that bring your doc his sandwich and coffee every day have convinced him that this is the holy grail of TRT.

Interestingly, these preparations have been marketed in a banal, non-descript way to remove any association with words like steroids, athletes, muscle mass, strength, and Jose Canseco. In fact, the average 50 year old guy looking for a little more lead in his pencil would probably never know that this expensive gel he puts on every day is just a socially-acceptable version of the same drug those "idiot bodybuilders" and "cheating athletes" use regularly.

  • Pros: Gels and creams are easy to apply, and they don't require potentially injurious tools like needles (cause you know some baby boomer with ED will try to inject right into his pecker to "speed things up"). Transdermals also work quickly and raise DHT levels fast, which gives a good kick in the libido/erectile dysfunction department.
  • Cons: Expensive, have to apply daily after showering, raises DHT significantly (which may increase steroid side effects like acne, hair loss, and prostate cancer), some do not respond, chance of transmission to partner.
  • Conclusion: Transdermals have been a Godsend to many older men suffering from the symptoms of low Testosterone. But as they become more educated, many men gradually opt to try cheaper, more reliable ways of raising Testosterone.

2. Patches: (Androderm)

Testosterone patches are like jacked up Band-Aids; adhesive patches that when used correctly provide 5mg of Testosterone every 24 hours. Typical adhesion sites include the back, stomach, upper arms, or thighs. To mimic natural Testosterone production, it's recommended that patients apply the patch at approximately 10 PM nightly, which can be problematic if you're at the opera.

  • Pros: Much the same as transdermals.
  • Cons: The patches are designed to remain in place during normal daily activities, as well as showering, swimming, and strenuous exercise; yet there are frequent reports of the patches sliding off and being difficult to put back on. Many men also develop dermatitis from them at some point. Given the visibility of the patches, some men may suffer locker room embarrassment. Perhaps Androderm should manufacture the patches with cartoon images of Barry Bonds and A-Rod?
  • Conclusion: Testosterone patches are reported to be quite effective, but are much more inconvenient to use.

3. Testosterone Pellets: (Testopel)

Another method is to surgically place Testosterone pellets under the skin. Using a needle under local anesthetic, six to ten pellets are usually placed in the fat of the buttocks. The pellets are made of crystals of pure Testosterone that slowly release Testosterone into the bloodstream.

  • Pros: To some, being anesthetized (locally) and having pellets surgically inserted into their keesters every three to six months is more convenient than pesky daily gel applications or weekly intramuscular injections. Also, because of their slow breakdown, Testosterone pellets tend to reduce aromatase conversion.
  • Cons: Besides the obvious, the pellets make dosing adjustments very difficult. And like any surgical procedure, there is also the very real risk of complications like rejection or hemorrhaging.
  • Conclusion: There are better ways.

4. Testosterone Capsules: Testosterone Undecanoate (Andriol)

As interest in long term Testosterone therapy grew, researchers began to search for ways to increase Testosterone that were safe, effective, and convenient for the general public. Oral Testosterone medications have been around for generations, and they're obviously effective, just ask any Golden Era bodybuilder.

However, in order to survive digestion, oral Testosterone must be chemically altered via a process called 17 alpha alkylation, which also increases the potential for liver toxicity when taken for extended periods of time, as opposed to intermittent cycles.

To get around this liver conundrum, researchers started playing with different delivery systems, and Testosterone Undecanoate (Andriol) was born. Testosterone Undecanoate bypasses the liver and is reabsorbed from the intestine through the lymphatic system. Liver function is in no way affected by this process of re-absorption, and Andriol is generally considered very safe for prolonged use.

Unfortunately, all is not rosy in Andriol-land. Many users report feeling nada, and those that do are generally using much more than the suggested use; which can exhaust your insurance or your bank account in a hurry.

  • Pros: Safe, super convenient, easily dosed and adjusted.
  • Cons: Widely considered to be among the least effective means of raising Testosterone unless dosages are increased into the cost-prohibitive zone. This may be one of those cases where the research hype simply didn't match the real world results.

5. Testosterone Injections: Testosterone Cypionate (Depo-Testosterone)

Testosterone injections are the gold standard in therapeutic Testosterone replacement, and despite what the uninformed may tell you, sport a safety record that anti-depressants, Tylenol, and aspirin can only dream of.

As you investigate TRT, a distinct pattern seems to emerge. As patients become more educated about Testosterone and begin to separate the drug from bodybuilding, baseball, and mass media-driven hysteria, they begin to appreciate the simplicity and predictability of intramuscular Testosterone injections. Eventually, the other modalities are often discarded as expensive, overly complicated, and just plain ineffective.

  • Pros: Easy to dose, predictable, and effective. It just plain works, 'mkay?
  • Cons: Inconvenient for people who don't wish to give themselves their own injections. Interestingly, many men start to gleefully look forward to their "pain in the ass" weekly injections as they begin to experience the positive effects of Testosterone.

So, How High Exactly does Testosterone Cypionate Injections Raise Serum Testosterone Levels?

That's an extremely tough question. It all depends on the user's age, the functionality of his testis, his natural levels of SHBG, his levels of aromatase, etc.

The ballpark guess is, at 100 mg. a week, TRT would probably take him between 700 and 900 ng/dl; 200 would bring him up between 1200 and 1500; and 300 would take him above 2,000.

Those familiar with steroids might raise an eyebrow at dosages of 300mg a week being discussed in the context of Testosterone replacement, and with good reason. Once a user gets past 200 mg a week, we're not talking testosterone replacement; we're pretty much talking a relatively low-dose but perpetual steroid cycle.

Reference ranges for normal Testosterone levels are broad and vary greatly depending on the source, with approximately 250-800 ng/dl being an accepted normal range.

The Estrogen Factor: Estrogen Chases Testosterone

Many uninformed physicians think that treating low Testosterone (T) is as simple as writing a script for T and calling it a day. Unfortunately, this is just the beginning.

As T levels go up, so will estrogen (E) levels. If measures aren't being taken to control E then you're really just spinning your wheels, because higher E levels will cancel out many of the benefits of higher T levels.

If you've younger and have low T for some other reason, aromatase may not yet be as much of an issue. But for those with age-related low T, this is a serious issue because the body naturally increases aromatase activity with age.

Aromatase conversion occurs primarily in fat cells, so young or old, if you're carrying a lot of extra bodyfat, one of the best things you can do to help your hormonal balance is to simply lose some chunk.

But regardless of age or bodyfat percentage, a number of other drugs to combat estrogen and other aspects of the hormonal feedback loop are indicated.

Other Medications:

  • Aromatase Inhibitors (Anastrozole/Armidex): AI's block the production of estrogen. TRT patients who suffer estrogen elevations above the top of normal range are often given an aromatase inhibitor, usually .25mg taken two or three times a week.
  • Selective Estrogen Receptor Modulators (SERMs), (Nolvadex/Tamoxifen): SERMs hinder the action but not the production of estrogen. In TRT contexts, this drug is usually taken to counter the physical manifestations of estrogen-related problems like gynecomastia (bitch tits).
  • Human Chorionic Gonadotropin (hCG): even at TRT does, Testosterone supplementation suppresses natural T production. Over time, this can lead to testicular atrophy and the balls drawing back up into the body like a Jonas brother. hCG helps restore and maintain Testosterone production and testicular size by mimicking LH and stimulating the production and release of natural Testosterone. In addition to keeping the boys intact, many guys on HRT report just plain feeling better when they have a bit of their own T floating around. Typical dosages are 250-500 iu twice a week.
  • 5 Alpha Reductase Inhibitors (Finasteride, Duasteride/ Propecia, Proscar): These drugs are specific inhibitors of the 5a-reductase, the enzyme responsible for conversion of Testosterone to DihydroTestosterone (DHT). In men, DHT is kind of a good cop/bad cop. DHT is three times more potent than Testosterone, doesn't aromatize to estrogen, and is associated with the high libido all men covet. But it's also linked to male pattern baldness, acne, and prostate cancer. Guys worried about their hairline or their plumbing often take these drugs when taking T.

The Nuts and Bolts of TRT

Here is what an effective TRT schedule could look like:

  • 100mg test cypionate or enanthate injected per week, injected weekly or divided into two or more injections per week.
  • 250iu hCG EOD [every other day], or twice per week; injected subcutaneously.
  • 1.0mg Anastrozole (Arimidex) per week, in divided doses.
  • 5-Alpha Reductase Inhibitors (Finasteride, Dutasteride/ Propecia, Proscar, Avodart), if necessary.

Why so many damn shots? Injecting Testosterone less frequently than once a week induces spikes in T levels followed by lows. This can make many feel as bad or worse at the end of the week than even their pre-TRT state. Injecting lower amounts more frequently seems to mitigate this side effect as it more closely resembles the body's natural Testosterone production.

With lower doses and more frequent injections, one can inject in the quads (vastus lateralis) with 29 gauge 0.5ml/0.5 inch [50iu] insulin syringes. But generally speaking, rotating injection sites is always a good idea.

These little pins are slow to load, but injection times are reasonable as the small plunger diameters create very high pressures. This same size syringe can be used for the hCG injections, which are subcutaneous injections.

Those afraid that all these shots will have them hobbling around the office, take comfort- using small needles like these greatly reduces muscle damage and residual soreness.

Getting the Testosterone

If you're looking through that list of common symptoms and suspect you may have low T, your journey has just begun. And just be aware, it is all too often a long and winding road.

If you're going to go the legal route (and considering that for all intents and purposes, you will be doing this for the rest of your life, so you probably should) be prepared to have to jump a few hurdles.

If you're under 40, your doctor may think you're either a drug seeking bodybuilder or simply spend too much time on the internet looking for ailments that you don't actually have.

If you're over 40, it's likely your doc will go the opposite route, and let you know that you're "no spring chicken anymore" and the symptoms you're experiencing are simply a part of getting older. While you're at it, might as well trade in the gym pass for a lawn bowling league membership and head to Wal-Mart to pick up a new sweater-vest. Bullshit!

In either case, it's your quality of life we're talking about here. And your doctor is supposed to work for you, remember?

So how do you get your good doctor to take you seriously? You probably can't, but you can ask for bloodwork to aid your cause.

Get the Diagnostics

Doctors love bloodwork. It's cold, analytical, and unlike the soccer mom with the 15 symptoms of fibromyalgia, it doesn't distort reality to fit a given set of symptoms.

The other thing is, it covers your doc's ass. If a Testosterone deficiency exists and he or she prescribes supplemental T, your doc has a rock-solid leg to stand on if someone higher up starts asking questions.

According to Dr. Crisler, your initial labwork should consist of the following:

  • Total Testosterone, bound and unbound. Most typical, but limited value.
  • Bioavailable Testosterone (AKA "Free and Loosely Bound"): the actual T the body will use.
  • Free Testosterone (if Bioavailable T is unavailable)
  • SHBG
  • DHT
  • Estradiol
  • LH
  • FSH
  • Prolactin
  • Cortisol
  • Thyroid Panel
  • CBC
  • Comprehensive Metabolic Panel
  • Lipid Profile
  • PSA (if over 40)

But What if My Blood Work Says I'm Normal?

That, my friend, can, paradoxically, be a lousy place to be. And unfortunately, it's a very common phenomenon.

You have many of the symptoms. The quality of your life is affected. And it's not just you who's noticing, it's your spouse, your family, and your friends.

But the blood work tells a different story. You get your values back and you're well, normal. Sure, you're on the low side of the bar graph, but still technically normal. Was all this in your head?

First, let's take a look at what exactly 'normal' is. According to Crisler, the normal reference range for Total Testosterone is found through statistical means, meant to include 95% of all adult males.

Yet, when tested properly with what is called a Bioavailable Testosterone assay, about half of all men tested over the age of fifty have low Testosterone. That means a significant percentage of those included in "normal" range are actually suffering with low Testosterone!

Many experts in the field of anti-aging experts suggest that if a man is experiencing symptoms of low Testosterone, even if his levels are considered normal, TRT is likely warranted. If his symptoms improve or disappear altogether, that proves he had the disease. This approach is known as "therapeutic testing."

If your doctor follows a similar school of thought, he or she may choose to treat your symptoms as opposed to your blood work values. But if not, relax; all is not lost. There may be more suitable options for you to try anyway.

Closing Thoughts on TRT: Is it a Pandora's Box?

Overall, if done correctly, the health benefits to be gained overwhelmingly seem to support Testosterone replacement therapy when you consider the beneficial effects to energy levels, metabolism, muscle mass, functionality, blood chemistry, and cardiac health.

As far as being a Pandora's Box, I suppose there's something disturbing about having old men with high libidos that are easily aroused and sport rock solid erections let loose on society, but that's probably something society can endure.

But Dr. Ziegenfuss is decidedly more cautious. “TRT is not something to be taken casually. I would investigate all the possible reasons for low T: mineral deficiencies, hypopituitarism, hyperprolactemia, testicular infection, hemochromatosis (iron overload) overtraining, etc. and play with Testosterone boosting products before even considering TRT.”

"Let's be clear here. For many, TRT may be life changing, but it should not be taken lightly. Depending on your genetics, it may bring a number of possible health challenges, and remember, it's supposed to be for life.”

"In some ways, TRT is a sledge hammer approach. I'm not saying it's not safe, but it does dramatic things, especially if you go beyond acceptable TRT dosages. And like any drug, it brings along its own set of possible side effects that must be taken seriously."

"I always lean towards optimizing your existing physiology before going on exogenous medications. Natural Testosterone boosters are like getting a tune up and running premium fuel in your sports car. The engine just runs better and performance is usually improved. TRT is more like pulling the factory motor from your classic Camaro and replacing it with 950 bhp Bugatti motor that can go zero to sixty in 2.5 seconds. Your Camaro might go like crazy, but what's all that power doing to your tires or brakes, or your exhaust?”

“Of course, with your Camaro, when you get tired of replacing things you can always dump the original motor back in. But your body only comes with one set of parts. Burn those out and no mechanic on Earth can help you."

Stay Strong,

Brett Place

References for this article include:

www.t-nation.com