T Nation

Starting the Journey. Concerned on Prescription

50yo male, well-controlled T2DM (A1C below 6.5), 5’10", 175#, active but body tends to hold fat instead of muscle.

Don’t have thyroid/estro labs.

T panel done twice, 3 weeks apart, with no meaningful difference between the two.

TT: 225 ng/dl (ref: 280-1100)
SHBG: 20 nmol/L (11-80)
FT%: 2.3 (1.6-2.9)
FT: 51 pg/mL (47-244)
Bioavailable: 140 ng/dL (131-682)

Doc (my PCP, not a clinic) was going to rx gels. For several reasons I prefer not having to use dermals, so I asked about injection. He was fine with that. Sent the order over to the pharmacy and I can see on the app that he’s prescribed Cyp at a dose of 200mg every 4 weeks.

I’ve been learning a lot from reading posts here and tend to think I want to divide that out to at least weekly, if not half-weekly doses. What do you all think?

My gut says based on my SHBG I should probably have that broken out to smaller doses - say 50mg/wk or even 25 2x/wk.

Thanks!

You should stop everything and find a knowledgeable doctor because this will end badly. The half life of testosterone cypionate is 7-8 days, so by day 14 you will only have 50% of the amount of testosterone injected, day 24 you will have zero testosterone in your system and you will hate life!

Your doctor is a clueless dude! The reason the pharmaceutical companies suggest these every 2-4 weeks protocol is to limit liability should you encounter a stroke or heart attack for allowing testosterone cypionate to build up in your system, but allowing testosterone cypionate to build up in your system is the only way to benefit from TRT.

What your doctor has chosen is what we call the hormonal roller coaster. HMO’s and insurance plans are mostly useless for TRT, sure the script is covered but a lot of the doctors are inept and have no education on how to prescribe testosterone.

Your doctor wanted you on T-gel because he knows this every 4 weeks injection protocol will fail, ask him about the ups and downs on these types of protocols, he will tell you but is unable to prescribe daily injections which is what’s more than likely needed.

Hormone profiles after intramuscular injection of testosterone enanthate in patients with hypogonadism

In fact, the present study confirmed serum levels of T which were lower than pre-ART value levels on day 14 after administration. Therefore the further decrease in serum T levels on day 14 after administration is considered to relapse of hypogonadal symptoms and to reduce the patients quality of life.

You will need 12-14 mg daily or EOD infections because TRT will suppress your SHBG lower and this changes directions of your TRT protocol. If you’re not willing to do any of these things, you should step away from TRT or you will soon quit.

I have low SHBG as well (14) and struggle on once and twice weekly dosing, read up here and you’ll see low SHBG men having all the problems because of the inept doctors or the unwillingness to inject daily.

No estrogen testing, this lab is critical and without it everything your about to do is uncertain.

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Thanks, SL, That study points out exactly what I’m concerned about - albeit it would probably be slower with cyp than enanthate. Time will tell if that’s enough for me averaged out or not (probably not) but I’m less concerned with trying a smaller dose and asking to up it later than I am with only taking it every 4 weeks.

The 200mg allowance you’ve been prescribe is not enough testosterone to play around with, you have been short-changed and are on a road that leads nowhere.

Your prescription is useless, averages are around 100mg weekly total. I make the exception to being a hyper responder to testosterone needing only 49 mg weekly or 7mg daily, definitely unusual around these forums.

Yep. I’ve read enough posts (especially a bunch of yours) to be aware that’s probably not going to do the trick. Gotta be honest - part of it is it’s going to be hard for me to say “That’s not enough, look at these forum posts!” when I haven’t even tried it yet. The study is awesome - I had seen that one over the 3 weeks I’ve been pondering all this but didn’t make a note of where I’d seen it.

If he doesn’t want to do the estrogen panel, I’ll probably go ahead and do one through discountlabs before I take anything so at least I have a baseline.

I’m pretty sure he’s willing to work with me. What I can see online indicates that this isn’t a “single use” vial (looks like a 10ml @ 200mg/ml) so hopefully discussions will be fruitful.

Thanks again.

I use multi dose vials which last me 3 or more months, never had a problem and I know of no one that has.

The packaging recommends 200 every 2 weeks I believe, which would be 100mg a week, which would be double what he wants to do. Seriously, 50mg would be worse than doing nothing. It would shut down natural production but leave you even lower than your natural levels - or at best the same.

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re: multidose vials - I wasn’t in any way implying that was a bad idea - quite the opposite. It means it’s easy to adjust after discussion.

re: dosing on label - I’ll have to see what is on the label when I pick it up, most likely tomorrow (although I don’t know if it’s been delayed by insurance paperwork or not - I know they are having my doc send in a form). There’s pretty wide latitude in what’s quoted on the net and 200mg/mo IS only 25% of the max I’ve seen indicated. (50-400 every 2-4 weeks).

The vast majority of guys on TRT, whether it be through a TRT clinic or underground, use 150-200mg injections once weekly. Pharmaceutical companies have done studies which indicate there are 600,000 men on TRT through doctor sourcing. I would not be shocked if there are another 600,000 on testosterone through black market sources, no way to know for sure though. Big Pharma would love to increase the dose (sell more product), but will need research to get that approved through the FDA and with generic and compounded products available, the money is not there because they can’t get patents on a dose. Instead, they work on fancy, more elaborate delivery methods, such as a silly autoject pen.

Point being, there are hundreds of thousands taking once weekly, or even twice monthly, dosing and doing fine. What you see here on the internet are outliers, overly focused on their levels, being “stable”, their estrogen, etc. Not that these issues are irrelevant, note I said “overly” focused. Walk around all day worrying about your moods and your nipples will lead you the find a problem there.

I will allow for some guys who are overly sensitive to hormones, but they are few and far between. These guys will talk of 200mg as a “massive” dose. Having competed in weightlifting in the high octane PED days of the '70s and '80s, I find that laughable as 200mg would be a baby dose (and consider that would be stacked on top of other injectables and orals) used by novices and guys in the lighter weight classes.

As for you specifically, the prescribed dose is ridiculous. I would not even bother to start with that dose. As systemlord mentioned, you should find a TRT doctor, or BHRT doctor, a practice that only does hormones.

If I am you, given your labs, I’d start with 200mg per week. I think you could start with 150mg if you’d like and if happy there, stay. Like over 90% of the guys on TRT, you’ll do fine with once weekly. It’s always interesting to hear others’ results and protocols. Injecting more often won’t hurt you, I just doubt you’ll need it. I’m actually surprised someone hasn’t tried twice daily injections. Keep in mind testosterone levels vary as much as 140-200ng/dL per day in normal guys.

For reference, my last labs had me at 906 total, 213 free, 51 E2 and SHBG of 21 taking 200mg once a week.

Good luck, you’re a perfect candidate for TRT and should obtain great results. You’re going to wish you did this ten years sooner.

I’m in the middle of drafting an email back to my doc and will paste it here for a couple of you to comment on before I send it. For further information for you guys here, I am probably in the 25% +/- body fat range, so I’m definitely concerned about estrogen levels. I do tick off a number of the low testosterone symptoms and suspect I have been low much of my life - no matter how much I do or don’t work out or what I eat, my weight and fat % have not changed much since I was 15. Just a few years ago I was able to “run” 10 miles and didn’t get injured on the way to getting there. My gastroc became a little more defined (and still is) in the process but other than that no real body shape changes. I have absolutely zero interest in getting bodybuilder/steroid use testosterone levels but I am hoping that once I balance things out that I can knock that fat% down to a much fitter level. I’ll be happy anywhere in the 160-180 range as long as it’s lower fat.

That would mean 600-2000mg a week. Probably not a good idea to focus on numbers, but triple your free test level and you should feel a lot better.

Yep! I got that. Just making my intentions clear. Thanks!

Since I wasn’t clear, in case it affects any discussions here…the symptoms I’m primarily facing are libido, motivation/focus, muscle/fat mass. Never felt any significant depression etc. The message I was talking about for my doc, I’ll post later on tonight. Got some other things to get to for a while.

Thanks again for the input guys, it’s appreciated.

How about ask your doc where he got 50mg/week? I’d bet there no literature backing that.

Well, I think at this point I can make a useful contribution to the group knowledge here as well as asking that question. His dosage is in line with the US FDA suggested starting dose…whereas what I’m planning to propose in response is in line with the US Endocrine Society Clinical Practice Guidelines - 75-100 per week (preferably the 100 for starters for me…I’m fine with re-evaluating in 6 weeks).

This link might prove a useful addition to Systemlord’s above and contains exactly the wording I was looking for to make a compelling case without saying “but I read on t-nation that…” :smiley: …about 3/4 of the way down under IM Administration.

Read that link and in 6 weeks when you feel like shit read this forum

Pardon? I am trying to learn here and not screw myself up here. I’m telling my doc I don’t think 200mg once a month (or even split up) is going to do it, and suggesting something that is at least more in line to what I’ve seen recommended here lots of times. I’m not a know-it-all. I’m looking to make sense from various sources of information, including reading between the lines here in this forum on information that is sometimes in conflict. Happens all the time on the internet of course. I’m not discounting what anyone says out of hand but I am saying that going to my doc with a t-nation post isn’t going to carry the weight, so i’m looking to back up what I’ve learned here and elsewhere with scientific sources.

Don’t order steak at a diner. Don’t order TRT from a doc that doesn’t know TRT. I can imagine the best case scenario is that you are a great salesman and after an amazingly moving email the doc doubles your current dose 50mg/week to 100mg/week. Unless you are one of the super unfortunate rare folks that have extremely low SHBG it’s still not going to be enough. So then best case scenario is after another two to three months when he sees your total T is at 500 you’re going to have to convince him that it’s still not doing it. I’m sure by then my last post will sound less like that from an asshole and more like that of someone who has been in this exact position and realized for $150/month there’s literally a million docs that will give you more than enough after a 10 min phone call to get you where you need to be.

If you talk to enough people on TRT, and face to face is better than an internet forum, you will find that there a many varied responses to TRT. This is not unlike anything else in health care. Pick a drug and google it and find a discussion board. One person’s life saving medication may almost kill someone else. Simply read the package insert on any prescription under adverse reactions.

It seems you’re doing the best you can, get as much research as possible, consider the source, and move ahead. As @dextermorgan stated with his steak at a diner analogy, find a TRT doctor, one who is not only well versed on the literature, but has treated several hundred patients. They will have learned from those experiences, and that is better than a being detailed by a drug rep dropping by the office with lunch trying to sell Androgel.

@dextermorgan def wasn’t thinking of you an asshole - especially after taking time to explain the response. I tend to think my SHBG is already “ridiculously low” at 19 and is going to drop further on T.

I’m probably going to at least start with my regular doc…knowing it may not work out long term What I haven’t seen is where one goes to find a proper TRT doc. While I’m being deliberately vague, the only places I know of are the kinds of places I wouldn’t trust my health to.