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05-07-2018, 10:02 PM #1Senior Member
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Best practices in Starting TRT
This post is for both the Newbies who want a basic understanding of a “good” protocol to formulate questions for their perspective docs or TRT clinics. Guys with experience in TRT might also find this helpful to consider if they should modify their current protocol.
My general philosophy for TRT is that you want to make it simple and sustainable. You want to strive for consistency and minimize side-effects. I’ve been on my basic protocol for about 6+ years and have only made minor adjustments. It was prescribed to me by one of leading authorities in TRT. It’s simple and it works.
Type of Testosterone
- I only have experience with Testosterone Cypionate (T-cyp), and that’s what I recommend. Mine is blended with a small amount of Testosterone Propionate (T-prop), but I doubt that makes much of a difference.
- From what I’ve read, Testosterone enanthate (T-eth) has the pretty much the same absorption kinetics as T-cyp and can be used interchangeably.
- I do not have experience with gels or creams, but from what I’ve read they are messy and absorption is variable. Also, it’s just too difficult to absorb enough to help you if you have high SHBG.
- I’ve never used pellets or scrotal patches, but pellets sound like a pain in the rear (literally) and the scrotal patch belongs in a medieval torture chamber (I think a woman had to have invented it).
Dosing
- Small frequent dosing is the key to success. This keeps you within the desired range at all times. What folks (and many docs) just don’t get is that the more frequent you dose, the lower you can go on the overall dose, and the better you’ll feel because you eliminate that hormonal rollercoaster to hell.
- I suggest starting at a total of 100 mg/week divided into at least 2 injections (e.g. 50 mg twice per week). However, I find that Every 3 Day (E3D) dosing is much easier to administer, gives more constant hormone levels, and makes lab testing easier because you don’t have to pick a specific day to test (e.g., the 3-day or the 4-day interval). I recommend starting at 45 mg E3D.
- After 6 weeks, you should retest for a minimum of Total T, Free T, and E. Use the results of these tests to determine if you need a dose adjustment and/or need an AI.
- Most guys do not need to go over 120 mg per week if you use small frequent dosing.
Here's some comparison graphs of the amount of testosterone released from T-cyp per day using various protocols. Keep in mind, that the average adult male secretes about 7 mg of T per day. I'm guessing too that there is at least 30% variability about that (but I don't have a reference), so the range is probably around 5 to 9 mg per day. For argument's sake, let's say we naturally top out at around 10 mg per day, which not so coincidentally is where I begin to feel my best.
Here is a graph of my prescribed dose at 0.2 mL E3D of 200 mg/mL T-cyp = 40mg T-cyp E3D = 93mg T-cyp/week. Keep in mind too that T-cyp is only about 68% T. The rest is the cypionate ester. As you can see by the graph, this protocol delivers an average of about 9 mg T per day after stabilizing at about 6 weeks (Range 7.9 - 11.2 mg/day)
Compare this with an old but still used protocol of 100 mg/week in a single injection. This protocol delivers an average of about 10 mg T per day after stabilizing at about 6 weeks (Range 6.2 - 15.4 mg/day). Note that it is much more variable in both the peak and nadir T levels.
Now Compare this with the really archaic protocol of 200 mg/2 weeks sometimes still prescribed by dinosaur docs. Again, this protocol delivers an average of about 10 mg T per day after stabilizing at about 6 weeks (Range 3.4 - 22.3 mg/day). Note that it is much more variable in both the peak and nadir T levels. With this protocol too you spend significant amounts of time in both the superphysiological range (which define as over 15 mg/day) and in the suboptimal range (which I define as less than 5 mg).
How to Inject
- The great thing about small frequent dosing is that you don’t need a harpoon to get it into you. I recommend that you only use on-piece insulin syringes to draw up and inject. There’s no need to go bigger than a 25G needle. I MUCH prefer and recommend a smaller 28G needle.
- I recommend injection straight (no angling) into the upper middle quadriceps muscle (see diagram below). If you’re using small doses with an insulin syringe, there’s no need to aspirate. Chances of hitting a vein are remote to slim in the recommended quadriceps location using a short insulin needle.
- Some guys like to inject into the deltoids and/or rotate between 4 locations with the left/right quadriceps and left/right deltoids. I've tried deltoid injections with no problems, but I have a preference for the quadriceps, mostly because I live in a warm climate and wear shorts nearly year round, so they are easy for me to access. However, I do like to wear sweaters and long sleeve shirts in the winter, which requires some disrobing to access the deltoids. Again, it's just a personal preference.
- I do not recommend subcutaneous injections, though some have had success with this technique. I always seem to bruise and/or get lumps. Perhaps that's because my T has some T-prop in it. I've not tried it with pure cypionate ester. I've searched the medical literature and there's not a lot published on subcutaneous injections, but what is published (mostly using transgender subjects) is favorable both for maintaining stable hormone levels and for patient preference. The problem I have with these studies is that they use larger volume weekly injection, which I don't recommend. Here's one study that used hypogonadal men and showed they were able to achieve stable hormone levels with subcutaneous injections, but they don't discuss dosage or frequency of administration in the abstract (full paper unavailable): https://www.ncbi.nlm.nih.gov/pubmed/17143361. Here's an excellent video made by Dr. John Crisler that discusses the benefits of subcutaneous injections and demonstrates the technique: https://www.youtube.com/watch?v=UH1yTqt1sK8.
Use of HCG
- I highly recommend that you do incorporate HCG into your protocol. It replaces the lost LH/FSH signal and that is important for several reasons.
1) It helps to maintain normal testicular size. Yes, it’s a cosmetic benefit, but what guy want’s almond size testicles?
2) For younger guys it helps maintain testicular function and preserve fertility.
3) For all guys, it’s important for synthesis of intermediary steroid hormones (like DHEA and Pregnenolone), which have various health-promoting functions in the body.
4) For all guys, it helps to maintain normal ejaculate volume. There’s good histological evidence that the seminal vesicles, which produce about 60% of the ejaculate, need both T and LH to function properly. HCG substitutes for the lost LH while on TRT. - I recommend a dose of about 450 IU per week divided into at least 3 doses (e.g., 150 IU M, W, & F). Alternatively inject on an E3D protocol.
- If you desire to conceive a child while on TRT, consider increasing your HCG dose to 1000 IU per week. Here are two peer reviewed papers that support the use of 1000 IU of HCG per week to help maintain fertility while on TRT: https://www.ncbi.nlm.nih.gov/pubmed/15713727 and https://www.ncbi.nlm.nih.gov/pubmed/...t%3A+an+update. Both are available with free full text. The first one is particularly interesting. You have to do a little digging and interpreting the data to fully understand the implications. When I plot out the recovery to baseline Intratesticular Testosterone (ITT) levels in the groups receiving various doses of HCG (see graph below), I see that it crosses 0% suppression at a dose of about 1000 IU per week. That is in healthy adult male subjects receiving a whopping 200 mg T-eth per week, approximately 1000 IU of HCG was able to fully restore ITT levels (a known marker of fertility).
- Even if fertility is not your goal, I do believe there are benefits to 1000 IU per week, but HCG is the most expensive part of your protocol and you can certainly get by with a lower dose.
Use of an Aromatase Inhibitor (AI) or Estrogen blocker
- If you stick to the recommended protocol of small frequent dosing, you should not need an AI or E blocker.
- NEVER start an AI unless you have the correct labs to show you are high in E. It’s a simple fact that in the human body, E is made from T. If you keep T within normal physiological ranges at all times, E should also remain within normal physiological range.
- GUYS NEED E TOO. Without it our dicks go limp with a bad case of ED. We also need it for normal libido and for growth hormone secretion. I’ve seen way too many guys crush their E with an aromatase inhibitor (AI) like Arimidex (anastrozole) and then wonder why TRT is not working for them.
- Guys get nipple erections too! Most guys who have low T also have low E and have forgotten what it’s like to have nipple erections when stimulated. When their T suddenly comes back into range and their E climbs back to normal, they start getting normal nipple erections and immediately think they are coming down with gynecomastia.
- If you have labs to support you need an AI, I strongly suggest you try the ‘Vodka/Eye Dropper’ method I previously posted. It’s the only way I’ve found to dependably dose small amount of anastrozole. Here’s a link to the method: https://forums.steroid.com/hormone-r...astrozole.html
The minimum Pre-TRT Labs you should have done
- If your doc won’t order them, get them done yourself. Here’s a source that I regularly use to supplement my doc’s once per year testing. https://www.discountedlabs.com/
- Minimum labs for screening for low T: Total T and Free T.
- Minimum follow up labs if either or both Total T or Free T (the more important) are low: SHBG, LH/FSH (first thing in the morning!), PSA, Estradiol (sensitive LC/MS/MS method), Lipids, CMP, CBC.
- Consider also: Prolactin, DHT, TSH, Free T3, Free T4
Follow Up Labs
- You should never do a dose adjustment or add in an AI without labs to support that you need it.
- I suggest you follow up at least twice per year with the minimum follow up labs discussed above.
Last edited by Youthful55guy; 08-25-2018 at 01:38 PM.
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05-08-2018, 04:44 AM #2
Great info, thanks Youthful!
Question: how much does age play a role in total test dosing? For example, and all other things being equal, will I likely need to dose more in my 60's than my 40's to maintain similar lab levels?
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05-08-2018, 07:27 AM #3
Sticky post
ty y55g
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05-08-2018, 07:31 AM #4
Sticky for future
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05-08-2018, 07:50 AM #5Senior Member
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Only if SHBG levels increase, which they often do with age. Only testing can tell. Always adjust your dose on Free T (not Total T). Free T takes SHBG into account. I also think that it is important to get at least one SHBG test done at the start because there is about 10% of men affected by a genetic anomaly (like myself) that adds an extra sugar molecule to the SHBG protein and this effectively more than doubles the half life of the protein. Therefore, for every nmol of SHBG we produce, it effectively more than doubles the circulating concentration.
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05-08-2018, 11:04 AM #6Associate Member
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05-08-2018, 11:36 AM #7
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05-08-2018, 04:34 PM #8
Great info Y55!
Just a heads up for the non-USA readers, pretty much the prescribed protocol wont be testosterone cypionate , or enanthate . AFAIK, at least in europe and australia, the prescribed therapy will be with nebido, which is a slower form of testosterone that has the advantage of having the injections every 12 weeks. If you go to your doctor dont ask for testosterone enanthate as it is likely he will think you want to use it as AAS, and not to treat hypogonadism.
EDIT: Im including UK in EuropeLast edited by Mr.BB; 05-08-2018 at 04:36 PM.
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05-08-2018, 05:03 PM #9Senior Member
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Yes, you can ask, but I have to qualify the answer.
I started TRT because my free T was abysmal (7.1 pg/mL) due to high SHBG (67.5 nmol/L). My total was excellent (618 ng/dL), which made it look like I did not have a low T issues. SHBG is a two-edge sword. It binds T and keeps it from liver metabolism (good), but bound T does not pass through the blood-brain barrier, only Free T can do that. So the net effect is that SHBG pushes your Total T up while at the same time starving your brain of this vital hormone.
I initially went to a low T clinic after being turned down by several docs. They all wanted to put me on antidepressants. The Low T clinic, to their credit, recognized the problem but they had a one-size fits all stretcho weekly interval protocol that did not work well for me. After 4 months, I decided to spring for the high end male hormone specialist that cost an arm and a leg and did not take insurance. He put me on a protocol of essentially 40 mg T-cyp (it had a small amount of T-prop blended in) E3D. his goal was to saturate the SHBG protein so that enough T spilled over into Free T. This drove my Total T way up into the 1000 to 1600 ng/dL (remember SHBG bound T is protected from metabolism) and my Free T came up to a respectable 13-16 pg/mL range. Not ideal, but I felt normal again. This went on for several years.
The problem with this protocol is that SHBG bound T is still somewhat active in the peripheral blood. Due to the very high Total T, I was beginning to have difficulty controlling hemoglobin, even with the maximum allowable blood donations. That's when I decided to go off the reservation and treat my high SHBG with very low doses of a synthetic anabolic called Winstrol (Stanozolol ). I found some research to show that it was effective in suppressing SHBG production. My experience corroborated this research. I started at 15 mg per day, dropped it to 10 mg, and then again to 5 mg (2.5 mg PM & PM). My labs show this extremely low dose (bodybuilders typically take 40 to 100 mg by comparison) very effective in keeping my SHBG around 30 (normal being 19-76).
The net effect of dropping my SHBG was to lower my Total T to the 800-900 range with no dose reduction (more got metabolized) but raised my Free T to the 20-30 range. My current goal is to keep SHBG where it is with 5 mg/day Winstrol and refine my T dose to about get Free T in the 21-22 pg/mL (upper 75th percentile for a 25-35 year old male). I'll talk more about controlling SHBG in a future thread.
Complicating things just a bit is that I'm also slowly (very slowly) bringing my Armour Thyroid dose down. I read a couple of good peer-reviewed publications that indicate that thyroid supplementation can increase SHBG.
So, long answer to your short question is that I currently take roughly the equivalent of 45 mg T-cyp (you have to take into account that mg for mg, T-prop carries a bigger T payload than T-cyp) every 3 days and 2.5 mg instrol (Stanozolol) twice daily.
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05-08-2018, 05:07 PM #10Senior Member
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Yes, Testosterone Undecanoate (nibido) seems to be the direction the Europeans are going. I probably will never jump on that band wagon because I've got a stable protocol that works well. My approach is not to try to fix what isn't broken. I also like the fact that low dose T-cyp or T-eth can be delivered with a 28G insulin syringe. Nibido requires a mega harpoon. Also, from posts I've read, they are still trying to figure out the dosing. I think optimum will probably be less than the advertised 12 weeks. Time and experience will tell.
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06-01-2018, 03:36 PM #11Staff ~ HRT Optimization Specialist
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Just wanted to add on some information from a Canadian perspective even though there aren't many of us here and the ones that are here hide in the igloos.
Depending on location, you can either get needles/syringes for dirt cheap ($12 box of 100) from the hospital or free from the health unit. Online is a great option as well.
Like the US, we have Test E / Cyp. The price seems to be exact same regardless of the pharmacy you go to (Walmart, Shoppers, Grocery Store, etc) so pick whatever your usual or closest is.
I didn't see the original post talk about needle length but I may be blind. I use 1.5" but 1" is also a great option.
As far as $$$ goes, expect to pay approx $45-50 for a 10ml 200mg/ml vial assuming no medical insurance.
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06-01-2018, 05:30 PM #12
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06-01-2018, 05:51 PM #13Productive Member
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Great timing on post OP, I just made an appointment for TRT consultation. Appreciate the info
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06-01-2018, 07:38 PM #14
Stickie
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06-01-2018, 08:01 PM #15
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06-02-2018, 06:16 AM #16Staff ~ HRT Optimization Specialist
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06-02-2018, 08:08 AM #17
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06-02-2018, 01:29 PM #18Senior Member
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I use one-piece insulin syringes. My choice for size is 28G 1/2 inch length (which is a standard size for this type of syringe). I have also tried 25G 5/8 inch, and which comfortable and easy to use, I see no reason to go that large. I've also tried 30G 1/2 inch and it works with a little effort. Going way down in size to a 31G 3/8 inch needle is painfully slow to draw up my 0.25 mL dose. I see no reason to go with a longer needle (e.g., 1.5 inch). To do this, you have to switch to a 2-piece system and that adds cost and discomfort and increases the risk of contamination.
Regarding cost of T, it's about the same here. I pay about $63 (USD) for a 10 mL supply at my local pharmacy. I am not particularly price sensitive, so I have not shopped around.
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06-02-2018, 01:32 PM #19Senior Member
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06-04-2018, 03:33 AM #20
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06-04-2018, 11:48 AM #21Staff ~ HRT Optimization Specialist
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I don't think I could ever go to that small of a needle but have considered switching down to 1". My local Health centre has a free needle exchange and they give you unlimited needles but its only 22G 1.5" or 23G 1".
I calculated I spend about $800 a year on TRT between the gear, needles, bloodwork, gas to drive to/from the pharmacy/doctors office/clinic for BW, and my time (it might only take 5 minutes to inject, or 10 minutes to drive to the pharmacy, or a 20 minute doctors appointment, but it all adds up).
The younger generation doesn't think big picture or long term. An 18 or 19 year old cycles, ends up on TRT at 20. Well even if they live only to 65 thats still over $40, 000.00 they are going to invest over their lifetime. Could spend that on a brand new vehicle, down payment on a house, travel most if not the whole world, etc.Last edited by Windex; 06-04-2018 at 11:59 AM.
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06-04-2018, 12:37 PM #22
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06-04-2018, 12:40 PM #23
It definitely is an investment, unfortunately for me , I was given the ride awakening with a exstremly low t ( granted I taken the test in the afternoon ) but my morning t level tests showed I was low normal . But the feelings I was going through was terrible. I’m also 35 so it would make sense why something like this would be happening .. anyone below their 20’s in my opinion have no business messing with any type of AAS at all.
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06-04-2018, 01:23 PM #24Senior Member
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Agree that young and older guys alike should consider the long-term implications of using AAS for non-medical reasons. I don't pass judgement, but like any other form of drug abuse, it has it's hidden costs.
Regarding needle size, I suggest guys use whatever they are comfortable with. However, my experience is that if you confine TRT to levels that maintain normal physiologic ranges at all times, that the volume of T is such that there is no need to go larger than a 25G needle and you can easily get by with a 28G 1/2 inch. There are several studies that show no real differences in effectiveness or absorption profiles between subcutaneous or IM. It's all about what comfortable and sustainable for you. Each has to make their own decision, and sometimes as in your case, availability of the syringes/needles drives the decision. Though in the USA, you can obtain one-piece insulin syringes on-line t a very reasonable cost virtually everywhere.
I don't have the bumps/abscesses problems some discuss, though I do sometimes bruise.
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06-04-2018, 04:32 PM #25
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06-04-2018, 04:49 PM #26
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06-04-2018, 05:29 PM #27Productive Member
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06-04-2018, 05:41 PM #28
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06-04-2018, 05:46 PM #29
I used to, now I use needles that are attached to the syringe. People tend to draw with a lower gauge for faster drawing and switch to a higher gauge for injection, also the needle dulls after plunging over and over which can cause more pain but with a higher gauge, you barely notice a difference.
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06-04-2018, 08:48 PM #30Senior Member
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It's volume dependent. If you inject at least twice per week (I prefer E3D), the volume for most guys to keep them within physiological ranges is between 0.20 mL and 0.4 mL. I personally inject 0.25 mL E3D. I've timed it many times and it's less than a minute to draw up that volume with a 28G needle and about 5 seconds to inject. I can sacrifice about 65 seconds E3D out of my life for the comfort of a 28G 1/2 inch needle. If you go up to a 25G needle, you can cut that time in about half.
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06-08-2018, 09:27 AM #31Associate Member
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06-13-2018, 10:21 AM #32Junior Member
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06-13-2018, 02:51 PM #33
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06-13-2018, 02:58 PM #34Junior Member
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06-14-2018, 05:27 AM #35
I look at it like this if your levels are good ( especially if you are working with more free test ) and your diet and training is on point , I see no problems getting gains on TRT doses. If I ever cycle , it’s only going to be with the basic test runs or low TRT doses and mast.
I always find it to be what we eat and how good our training is.
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06-14-2018, 07:55 AM #36Junior Member
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06-14-2018, 08:54 AM #37
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06-14-2018, 11:13 AM #38Junior Member
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Self prescribed. I wanted to do a 12 week 400 mg per week cycle but when my cycle got cut short with high bp I am just looking for a way to finish out the cycle with a lower dose to keep getting some gains and keep my bp in check. I will only run it for 6 to 7 weeks or so just to finish up my original 12 week cycle.
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06-18-2018, 05:03 AM #39Staff ~ HRT Optimization Specialist
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Pro tip: Make sure you remember to switch the needle you draw with to the injection needle. I draw with an 18G and one day was in la-la land forgot to switch. Screamed bloody murder.
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06-18-2018, 06:29 AM #40
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Yes sir, when you drop your estrogen down to nothing you generally feel shitty and ache like hell. Try backin off the AI some next time.
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