Ask The Urologist Anything (Dr Michael Rotman)

Great provider option and nice example here:

Thanks for your service Dr. Rotman.

I used your patient's example as my poster boy here:

Props.

DrRotman said:

Hi guys, I have a question for all of you on or who have been on TRT at some point. Has anyone reading this not achieved normal or high normal levels when taking at least 200 mg testosterone weekly? Curious as I have reviewed a few patients labs lately and noticed an occasional lack of response even with high doses of testosterone. Thanks in advance for all your commentary.

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Quite rare.

readalot said:

Tool to Assess your TT Dose Response -- Percentile Curves

Summary: Tools to estimate your individual dose response for injectable testosterone ester in comparison to a normal distribution (95 percentile confidence estimate) of adult males (Ref). Plot below shows a summary of data from (1) clinical trials gathered from the literature + (2)...

forums.t-nation.com

Quite rare.

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How about people who respond with a high level but feel nothing from TRT? I have very low SHBG (not diabetic, pre-diabetic, or obese), and TRT feels the same as low T. I have been on TRT for ten years and tried everything.

doctor, i am 44yrs old, 5.8 feet, 88kgs, muscular
i am taking daily 25mg of testosterone enanthate subcutaneous using insulin syringe 32g needle for almost 6yrs now. i workout 6 times a week and i am in great form now. i don't have any side effects except my Hb is at 16g/dl and Hct is at 50%. doing blood donation at every 3months. is this dosage correct and should i continue for long-term ???. my serum PSA is at 1 ng/dl. we dont get testosterone cypionate in India so using testosterone enanthate

scorpion said:

doctor, i am 44yrs old, 5.8 feet, 88kgs, muscular
i am taking daily 25mg of testosterone enanthate subcutaneous using insulin syringe 32g needle for almost 6yrs now. i workout 6 times a week and i am in great form now. i don't have any side effects except my Hb is at 16g/dl and Hct is at 50%. doing blood donation at every 3months. is this dosage correct and should i continue for long-term ???. my serum PSA is at 1 ng/dl. we dont get testosterone cypionate in India so using testosterone enanthate

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This means nothing without knowing where your daily trough FT (24 hrs post-injection) sits.

175 mg T/week (25 mg T daily) is a fair dose.

Post up your trough TT, FT and estradiol and make sure to include your SHBG.

If you need to donate blood let alone every 3 months and you are still hitting a hematocrit 50% then your trough FT is most likely too high.

Even then the cut-off for hematocrit is 54%.

Most doctors in the know would recommend donating or reducing your weekly T-dose and bringing down your trough FT once you hit 54%.

Some will be more cautious and take measures once hematocrit hits 52%.

If you have no underlying cardiovascular/health issues are not experiencing any negative symptoms from a slightly elevated hematocrit then I would not be too concerned.

Downfall here is you are donating way too frequently to try and manage elevated hematocrit and there is a good chance you will crash your iron/ferritin which can open up another can of worms.

If you plan on being stuck on that donating too often merry go round then you need to keep an eye on your iron/ferritin!






post #3 (34:04-49:36)

scorpion said:

doctor, i am 44yrs old, 5.8 feet, 88kgs, muscular
i am taking daily 25mg of testosterone enanthate subcutaneous using insulin syringe 32g needle for almost 6yrs now. i workout 6 times a week and i am in great form now. i don't have any side effects except my Hb is at 16g/dl and Hct is at 50%. doing blood donation at every 3months. is this dosage correct and should i continue for long-term ???. my serum PSA is at 1 ng/dl. we dont get testosterone cypionate in India so using testosterone enanthate

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Hi, thank you for the question, I would like to see your blood values to give a more complete answer. Regarding the Hct levels, recent studies indicate that hct levels above 52 put one at risk of complications so at your levels it should not be a concern. Your psa level is great and you seem to be on a good course overall.

DrRotman said:

Urological Issues involved in Hypogonadism and its treatment

Hi Guys,

I am always willing to answer any questions involved with TRT and it's urological implications. Will check back frequently answer all your questions. Thanks !

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Thank you @Nelson Vergel for sending out this invite. Thank you very much @DrRotman
for taking time out of your busy life to answer question here.

DrRotman said:

Hi, thank you for the question, I would like to see your blood values to give a more complete answer. Regarding the Hct levels, recent studies indicate that hct levels above 52 put one at risk of complications so at your levels it should not be a concern. Your psa level is great and you seem to be on a good course overall.

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Dr. Rotman,
Sincerely appreciate your help. I live in Colorado and run a higher HCT. What are the new studies you are referencing? Thanks in advance for your thoughtful replies and care for this community.

DrRotman said:

Hi, thank you for the question, I would like to see your blood values to give a more complete answer. Regarding the Hct levels, recent studies indicate that hct levels above 52 put one at risk of complications so at your levels it should not be a concern. Your psa level is great and you seem to be on a good course overall.

Click to expand...

Thank you Doctor.

madman said:

This means nothing without knowing where your daily trough FT (24 hrs post-injection) sits.

175 mg T/week (25 mg T daily) is a fair dose.

Post up your trough TT, FT and estradiol and make sure to include your SHBG.

If you need to donate blood let alone every 3 months and you are still hitting a hematocrit 50% then your trough FT is most likely too high.

Even then the cut-off for hematocrit is 54%.

Most doctors in the know would recommend donating or reducing your weekly T-dose and bringing down your trough FT once you hit 54%.

Some will be more cautious and take measures once hematocrit hits 52%.

If you have no underlying cardiovascular/health issues are not experiencing any negative symptoms from a slightly elevated hematocrit then I would not be too concerned.

Downfall here is you are donating way too frequently to try and manage elevated hematocrit and there is a good chance you will crash your iron/ferritin which can open up another can of worms.

If you plan on being stuck on that donating too often merry go round then you need to keep an eye on your iron/ferritin!

Management of erythrocytosis during TRT

Dear Editor, Testosterone is the primary sex hormone and anabolic steroid in men. It is a widely used drug which is used by males as an anabolic–androgenic steroid but it is also the cornerstone in treatment of both hypogonadal men and transgender people. This letter will focus on the use of...

www.excelmale.com

post #3 (34:04-49:36)

New Perspectives in the Diagnosis and Management of Hypogonadism

Only at Nelson's domain. Enjoyed this one. Dr. Khera and Dr. Mulhalll, are two giants in the field here!

www.excelmale.com

I am on week 5-6 anxiety comes and goes

Free test - 15.39 The Free T will be higher at trough 2x weekly.

www.excelmale.com

Insights on Testosterone, Libido, Premature Ejaculation, Painful Sex, and Men’s and Women’s Sexual Dysfunction

https://podcasts.apple.com/ca/podcast/ep-16-medical-and-lifestyle-approaches-to-intimacy/id1683559994?i=1000626092413 Summary In this episode of The Luke Coutinho Show, I had an opportunity to engage in a riveting dialogue with the acclaimed Urologist, Dr. Mohit Khera, an authoritative...

www.excelmale.com

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Thanks a lot for the advice. My total test level is around 1400 to 1700 ng/dl. I have not checked my free test and shbg till date. My HCT used to be good around 47 to 48 with same dosage. It has increased to 50 when I started on high protein diet. Consuming 350g of chicken daily.

scorpion said:

Thanks a lot for the advice. My total test level is around 1400 to 1700 ng/dl. I have not checked my free test and shbg till date. My HCT used to be good around 47 to 48 with same dosage. It has increased to 50 when I started on high protein diet. Consuming 350g of chicken daily.

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Even if it turns out that you had a high SHBG 80 nmol/L with a whopping trough TT 1400-1700 ng/dL your trough FT would still be highish/high.

More importantly if you have normal SHBG with a whopping trough TT 1400-1700 ng/dL your trough FT would be very high/absurdly high.

Highly doubtful increasing protein will drive up your hematocrit.

Chances are your trough FT is too high!

Again If you need to donate blood let alone every 3 months and you are still hitting a hematocrit 50% then your trough FT is most likely too high.

350 grams (raw weight) boneless/skinless chicken breast daily is roughly 83 grams of protein which is not a lot of protein.

Hopefully you are eating a variety of complete protein sources allowing you to hit around 1 gram/lb of LBM.

I used to eat 2.2 lbs (1000 g raw weight) boneless/skinless chicken breast daily!

madman said:

Even if it turns out that you had a high SHBG 80 nmol/L with a whopping trough TT 1400-1700 ng/dL your trough FT would still be highish/high.

More importantly if you have normal SHBG with a whopping trough TT 1400-1700 ng/dL your trough FT would be very high/absurdly high.

Highly doubtful increasing protein will drive up your hematocrit.

Chances are your trough FT is too high!

Again If you need to donate blood let alone every 3 months and you are still hitting a hematocrit 50% then your trough FT is most likely too high.

350 grams (raw weight) boneless/skinless chicken breast daily is roughly 83 grams of protein which is not a lot of protein.

Hopefully you are eating a variety of complete protein sources allowing you to hit around 1 gram/lb of LBM.

I used to eat 2.2 lbs (1000 g raw weight) boneless/skinless chicken breast daily!

FoodData Central

View attachment 42893

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actually my HCT levels hit 50% last year and it never touched to 50 hct for 6yrs (never did a single blood donation for 6yrs). the only major change i did was , change in my diet. i bumped up my protein and calorie intake to almost 40% more to gain muscle. my strength and stamina doubled but then hct touched 50. i am thinking to reduce calorie intake. i am at 2200 calorie per day with intermittent fasting of 16hrs. my subcutaneous fat is around 20 to 25percent. i looks muscular when compared to previous years. i achieved great form and doing very good in my life ... both financial and personal life. i am very confident and make decisions very fast when issues rise up compared when i was not on TRT. my wife is also very happy.

SHBG and FT is very expensive. so, i rely on TT and E2. i think my trough sits around 1000 to 1200 and it peaks at around 1600 in 24hrs. i have done lots of serum TT tests in my initial first year.

i started with 250mg/ im per week in the beginning (1st year) and the now i am doing 25mg/day sc for almost 5yrs

E2 levels are on higher side ...but never had any side effects. i am taking 10mg tamoxifen daily for this.

Hi @DrRotman . Thank you for answering all our TRT questions here! It’s very helpful that this is all public because many of us may have the same questions that you already answered as an expert!

I want to throw a couple of questions your way:
* How do you differentiate between true gynecomastia and pseudo-gynecomastia (fatty tissue)? Are there specific tests or imaging required or is it just by touch?
* What is the minimum dose of Testopel (# of pellets) you would use to start someone with secondary hypogonadism? For more context, pre-TRT my total T was 150-180, FSH low, LH low normal. On T cyp 50mg subq 3x week and hcg 500iu 4 times per week, my total T was 650-750 and estradiol 17-23.

phalloguy100 said:

Hi @DrRotman . Thank you for answering all our TRT questions here! It’s very helpful that this is all public because many of us may have the same questions that you already answered as an expert!

I want to throw a couple of questions your way:
* How do you differentiate between true gynecomastia and pseudo-gynecomastia (fatty tissue)? Are there specific tests or imaging required or is it just by touch?
* What is the minimum dose of Testopel (# of pellets) you would use to start someone with secondary hypogonadism? For more context, pre-TRT my total T was 150-180, FSH low, LH low normal. On T cyp 50mg subq 3x week and hcg 500iu 4 times per week, my total T was 650-750 and estradiol 17-23.

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I dont diagnose gynecomastia usually as it's rare in doses I use and patients I treat. I usually will defer to a general surgeon near me to differentiate fat vs gynecomastia. Certainly there are some cases I see that are obvious, but I dont do the surgical repair on these cases.

Generally my testopel dose I use is about 600mg but many times it is dictated by the insurance company as they will not reimburse past a certain amount of mg. I dont do testopel in combination with hcg usually, havent seen this to be a good approach. There would not be a difference in dosages between primary and secondary; labs, patient symptoms etc will dictate proper dosing.

DrRotman said:

I dont diagnose gynecomastia usually as it's rare in doses I use and patients I treat. I usually will defer to a general surgeon near me to differentiate fat vs gynecomastia. Certainly there are some cases I see that are obvious, but I dont do the surgical repair on these cases.

Generally my testopel dose I use is about 600mg but many times it is dictated by the insurance company as they will not reimburse past a certain amount of mg. I dont do testopel in combination with hcg usually, havent seen this to be a good approach. There would not be a difference in dosages between primary and secondary; labs, patient symptoms etc will dictate proper dosing.

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Hey doc, I was told pellets were a better delivery method than injections because pellets release testosterone based off metabolic load. I cannot find literature to support this. Literature simple shows that pellets release based on surface area of the pellets.

Weasel said:

Hey doc, I was told pellets were a better delivery method than injections because pellets release testosterone based off metabolic load. I cannot find literature to support this. Literature simple shows that pellets release based on surface area of the pellets.

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I don't know of any literature to support this belief. I prefer injections over pellets all the time as they are much easier to adjust and dont hang around for 3 months.