T Nation

Our Initial Treatment Protocols

Hey guys. I’ve been asked to post how we approach TRT initially in my practice. Here it goes :slight_smile:

When a patient ends up with me, during our first consultation I get a very detailed background of health history and environmental history. Work history etc. I want a detailed look at potential exposure to chemicals. During this assessment I do a full blood panel, liver and kidney function, lipids etc. also during this assessment the patient is sent home with a DUCTH collection kit (this is hugely important). DUTCH is dried urine Colleciton. This reveals dramatically more than blood. It shows your hormones over a full day as well as (.more importantly) how they are metabolized downstream. This is hugely important. It tells me whether they are favoring healthy elimination pathways or unhealthy which then tells me how to proceed with treatment. Blood testing for hormones doesn’t tell us shit. It’s like flashing a light in a cave. It’s a snapshot at that moment. Hormones can change by 50% in value every day. So I want to see a total days production. Also they have homework to record seven days of food intake, alcohol, supplements and workouts for when they return. If Dutch shows weird cortisol numbers I usually Order a pituitary MRI just to check :slight_smile: I also run a blood based food sensitivity test.

On the next visit we go over all of this data. I spend about an hour with each new patient doing this FYI. The typical beginning treatment is 50mg test injected twice a week. We roll this protocol six weeks and retest and more importantly go off patient feedback. At this point we adjust up or down depending on their feedback. As you guys are noticing - estrogen management is done by liver health - NOT AI. After my patients feel great, I instruct them to SLIGHTLY alter their protocols every other week. So if it’s 50mg x2 a week, I advise them to go 60mg x2 a week for two weeks then back to 50 then up to 60 etc. this works WONDERS.

I Have patients on dosages from 100 a week to 400 a week (above that level the DEA gets nosy). Some my patients use tamoxifen at 20mg a day, but that is highly individual. Almost no one uses HCG. These initial protocols and assessment have been used for over 10k patients over the last five years. Our total patient load between doctors now is around 30k from all over the world. So there is a ton of empirical evidence that the way I treat works

So this is the essence of the beginning haha.

@anon10035199 @azwildcats here you go :wink:
@NH_Watts @mrmeeseeks @Singhbuilder @CrushCity1

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Out of curiousity what is the benefit of slightly changing protocal every other week? Is it to prevent homeostasis or something, Im gonna try this.

As to chemicals do you mean like radiation, prescription medications or environmental pollutants and stuff (just curious).

30 thousand patients, that’s amazing, good to know so many people are being treated/ helped with various issues. This isn’t relevant but I’m aiming for my profession to be endocrinology.

Thanks a lot for the thread @physioLojik :muscle:t2: And for the tag.

So I live in England, do you have doctors who can treat English patients? For me that is.

The DUTCH sounds verrrry interesting - do you guys deal with female endocrinology as well - for my girlfriend, not me haha.

She has major endocrine stuff going on - like you say about lifestyle analysis - she’s got lots of lifestyle stuff going on!

Basically she works 80 hour weeks trying to build a London business… busted thyroid, weird cortisol & adrenal stuff seems obvious.

It sounds like a DUTCH analysis would be amazing for her. Sadly she won’t reduce the 80 hour weeks

Can you tell us more on how you decide this?

Depends a lot on the patients age as well as how he responds to treatment without any SERM.

@mrmeeseeks I’ll look around for providers in England. We are coming to London end of August actually (my wife is from India and her brother lives in London). So perhaps we can link up

@unreal24278 yes man the subtle changes prevent homeostasis.

I live 40 minutes from London, so that could be great! Please keep me posted :))

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Thanks so much for creating this. It’s just a matter of time until you have your own forum like CT, JW, and PC.

Quick question. Do you prefer IM or SQ? Does it even matter?

@physioLojik - Thank you for sharing your knowledge on TRT with us all.

I’ve been on TRT for 7 months now, first at 50mg 2x a week for 3.5 months, then 18mg eod for the last 3.5 months. Everything is going great, feeling good and having some relief from pre-TRT symptoms… One issue - I’ve started to develop acne on my shoulders and back. I’ve never had issues with acne, even during puberty.

I’m assuming it’s the test, but don’t know if its higher DHT or related to elevated E2?

Through your experiences, what’s the typical cause of increased acne? Do you have any suggestions to help get rid of it? I’m feeling good now and would hate to have to lower my dose. :grinning:

Any info is appreciated.

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DHT is responsible for acne and oily skin, elevated E2 only means there’s plenty of Free T to convert to free estrogen, a coincidence. You need to lower your dosage of testosterone to resolve the acne.

I had a ton of acne 4 weeks ago back when I was doing 50mg twice weekly and is gone now that I have lowered my dosage. I’m doing 16mg EOD and it’s as if I just started TRT, I’m really responding to TRT now!

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Will do sir!

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I really prefer IM. I think too much time is spent majoring in the minors and it’s super easy to have a stable protocol when people look at their food, lifestyle, etc. so yes subq can work but I like to keep things easy :slight_smile:

How long have you been on new protocol? You may want to give it a few weeks and the issue may resolve on its own.

So as was said - DHT is acne causing. Testosterone can metabolize to two basic end points - it can reduce to DHT or oxidized into estradiol or estrone (yes estrone matters as I’ve said over and over again which is why simply testing e2 is dumb). Here’s the good news. Apparently your body prefers DHT (mostly reduced in the liver) which means your liver function is good and you are also probably on the leaner side. 80% of oxidation of test is done in adipose and 20% in the testes. So when someone is reducing to DHT preferentially we can assume they have lower body fat.

This touches on an another part of our practice with protocols - GET LEANER. What’s the best way to prevent estrogen issues ??? Get leaner. Diet is a huge portion of our practice with patients.

Your body will eventually even out on your current protocol and the acne will chill out :slight_smile:

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@physioLojik Thank you for the reply, I appreciate it. Any truth to taking zinc, vitamin A or even DIM to help get the hormonal acne under control?

Really interesting reading your posts, thanks again for sharing your knowledge.

I’ve been on 18mg EOD for roughly 3.5 months. I don’t take anything except for test cyp. I feel real good, I’ll give it some time, but was just curious if there were anything else I could do to help. Back acne doesn’t make a person feel good heading into a 2 week beach vacation…

Thanks for the reply, I appreciate it.

I use this on some of the ones that come out. I only have 1 or 2 at the same time on my upper back.

@anon10230041 Nice. How does it seem to work? Who prescribed that for you? GP, endo, urologist?

Dermatologist. Am sure any doctor should be able to write. The perioxide dries it out nicely and the clindamycin kills any bacteria.
I put on 1 to 2 x a day. And you should see an improvement with a couple of days.

I only apply to the “zit” and immediate area. Not all over skin but maybe you can.