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.
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Originally Posted by Ephemeral
