Just Started TrT and am Very Confused

Hi, new guy here. After years of trying to combat declining T with diet, fat loss, weightlifting, etc. I finally decided to give TrT a try. At 73 years of age my T had been slowly declining to where I recently got the following report: T=328, SHBG=54.7, Free T = 4.63, Albumin 4.4. In addition, I have been experiencing sluggishness, unreasonable procrastination, ragged sleep patterns, loss of strength when lifting and very slow gains with the weights, loss of libido, and ED. This is such a contrast to what I was in my thirties when I was benching 300+, sleeping soundly for 8 1/2 hours a night, extremely focused and instantly aroused by a nice set of legs, ta-tas or whatever and having marathon sex sessions. I realize that some aspects of aging are inevitable, but surely there is something I can do to combat what's happened to me.

I'm a natural lifter, and the only medication I take is a calcium channel blocker for pre-hypertension. My health is excellent and I want to keep it that way.

I told my urologist that I was interested in discussing TrT with someone and he recommended that I see someone in their affiliated Men's Clinic. Made an appointment and was looking forward to it. It turned out to be the exact opposite of what I wanted.

I told the PA in the Men's Clinic that I didn't want just TrT, that I wanted to keep squeezing my body to produce as much T as possible and wanted to do whatever I could to get more out of my aging gonads. He just shook his head and said, "ain't gonna happen at your age." I asked him why and he just said "because its not." He was one of these guys who is always in a hurry, doesn't really listen, and thinks he knows everything.

He offered me TrT in a pelletized form that is placed in a small incision in my upper buttock and is supposed to last for 4 months. I told him that I was extremely interested in not having my genitals atrophy and he said, "well, you need to take clomid then." I didn't like this guy, but I was there and decided I'd go ahead with the pellets and clomid and see what happened. He said to take one 50 mg tab of clomid twice a week, Monday and Thursday. To me it would've made sense to take 1/2 of that dosage five or even seven days a week, but he said no, just twice a week, the full dosage.

I've read a lot about the body's feedback loops, the conversion of Test to Estrogen and the resultant signal to the brain to shut down T production, etc. and it seems like, to my very unlearned mind, that it would've made sense to take both clomid and HCG along with the Test, as that would keep my body's T production mechanisms operating. I always thought that clomid influenced sperm production with a side benefit of more T and HCG influenced T production with a side benefit of a slight increase in sperm production. This dude said no, they both did the same thing. That just doesn't seem to make sense.

My question is, given my desire to squeeze every last drop of T production possible out of this aging body, does a better protocol make sense? And if so, where do I go to find a doc who is actually interested in hearing what I'm saying and providing the services I want?

If you made it to the end of this epistle and have some helpful advice, thank you very much in advance.

I would suggest a telemedicine consult with Defy medical if you can't find a good local provider. They are very responsive to the patient's wishes and they would have probably started you on enclomiphene (without any TRT) based on your expressed desire to "get more out of your aging gonads".

First of all, congratulations on making it to where you are and on doing your homework on basic hormone systems in the body. I don't think you're confused at all. You sound like you're on a good path with your thinking. Like Funk above, I have also been with Defy for many years and have found them to be very reasonable (I have no financial affiliation with them.) Several things...I think @Cataceous is closer to this topic than I am, but I thought enclomiphene was a bit of a dud and the first step was now (back to ) clomid, but I could be out of date there. Either way, Defy would know. Also, the leading edge for the first step of TRT from what I've heard is intermittent dosing of fast-clearing testosterone such as in a cream (this apparently creates minimal suppression of your own production, and MAY improve symptoms.) That is leading edge and not yet common, but is something to consider if supporting your own production alone does not do the job. Also, note that other things besides T can be involved in your symptoms so a work-up from a good holistic practitioner may be in order, although Defy will look at common risks like thyroid. Finally, there are things that don't affect your own hormones as much as T that many of us find to be just as important. DHEA, PT-141, Ipamorelin/ModGRF and something in the viagra family are four big ones that I would consider first line therapies and if I had it to do over again I would have started with those in conjunction with clomid and/or HCG instead of jumping straight to T. They provide overlapping benefits and don't seem to have nearly the number of issues with getting dialed-in as T does. Since you still have your natural production you have options that many of us on here don't have.

Guided_by_Voices said:

... Also, the leading edge for the first step of TRT from what I've heard is intermittent dosing of fast-clearing testosterone such as in a cream (this apparently creates minimal suppression of your own production, and MAY improve symptoms.) That is leading edge and not yet common, but is something to consider if supporting your own production alone does not do the job. ...

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Unfortunately topical testosterone doesn't qualify as fast-acting with respect to the HPTA. The skin acts as a reservoir and ensures a relatively long half-life. Instead we have testosterone nasal gel or troches delivered bucally. There is direct research showing that the HPTA continues to function when Natesto is used. Buccal troches provide similar pharmacokinetics, so it's inferred that results should be similar if the amount of testosterone absorbed is similar.

I think fast-acting testosterone is a better starting point than Clomid or enclomiphene. These latter drugs work for some men, but they introduce complexity and sometimes do as much harm as good. Clomid may be thought of as a mixture of enclomiphene and a long-acting estrogen (zuclomiphene). If the anti-estrogenic activity of enclomiphene happens to properly balance against the pro-estrogenic activity of zuclomiphene — and the added HPTA activity — then there may be decent results. If not, well some guys report feeling awful on Clomid. With enclomiphene alone it's hypothesized that there's insufficient estrogenic activity in certain regions of the brain in some cases, leading to poor subjective outcomes even when lab work looks fine.

Thank you all. I’ll give Defy a call.

Cataceous said:

Unfortunately topical testosterone doesn't qualify as fast-acting with respect to the HPTA. The skin acts as a reservoir and ensures a relatively long half-life. Instead we have testosterone nasal gel or troches delivered bucally. There is direct research showing that the HPTA continues to function when Natesto is used. Buccal troches provide similar pharmacokinetics, so it's inferred that results should be similar if the amount of testosterone absorbed is similar.

I think fast-acting testosterone is a better starting point than Clomid or enclomiphene. These latter drugs work for some men, but they introduce complexity and sometimes do as much harm as good. Clomid may be thought of as a mixture of enclomiphene and a long-acting estrogen (zuclomiphene). If the anti-estrogenic activity of enclomiphene happens to properly balance against the pro-estrogenic activity of zuclomiphene — and the added HPTA activity — then there may be decent results. If not, well some guys report feeling awful on Clomid. With enclomiphene alone it's hypothesized that there's insufficient estrogenic activity in certain regions of the brain in some cases, leading to poor subjective outcomes even when lab work looks fine.

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Thanks for clarifying, very helpful. I'll add two things. I was someone who did "ok" on clomid for the first 2 years or so of my hormone journey, but it only helped symptom-wise at a very low dosage of 12mg every other day. Most people report starting at a higher dose than that so I think some of the negative reports are due to excessive dosing, but I agree that chances of long-term success are not good.

Also for the OP, starting with the ancillaries I listed first (and possibly other things also) may reduce your list of symptoms, and what's left could have very different options depending on what it is. For example, poor sleep (which could cause everything else on the list) is one thing to address, whereas if gym performance (which I prefer to think of as vigor and having an excess of youthful physical abilities, IOW not being frail) is the remaining issue, then that is a different set of options.

Postscript: after dillydallying around due to a low testosterone-induced high level of procrastination I finally got in touch with Defy. I had just had my annual physical and Defy accepted the lab results without making me go to the expense of re-doing them. They had me go get a couple of additional labs including running the LH level. I then had my interview with one of their doctors on staff. The interview lasted about an hour and was pretty thorough. He noted that my LH was very high and that this is indicative of primary hypogonadism as my pituitary is telling my gonads to step it up and produce more T but they aren’t responding very well. That had led to my most recent test level of 234, 21.6 free and 43.6 bio available. No wonder I felt like I was in a downward spiral. Two years ago my test was 425 and dropping.

My sleep has been horrible, waking up after just a couple of hours and tossing and turning the rest of the night nearly every night. My mind seemed jumbled up and I didn’t seem able to concentrate on anything. Prostate had begun to swell, with my local physician diagnosing as BPH. All I know is getting up five to seven times a night to pee was draining me of more than urine.

Doc prescribed a staring regimen of test (40 units by injection twice a week), HCG (50 units by injection twice a week) and anastrozole (.125 mg tablet 2x week). He also added 25 mg of DHEA to be taken daily at bedtime and additional Vitamin D and Omega-3 fatty acid capsules over what I was already taking.

I’m two weeks into this regimen now and I have noticed a much improved sleep pattern and a lot less brain fog. Also, the BPH seems to has lessened substantially. I am able to go all night with one or sometimes zero pee breaks resulting in much more restful sleep. No changes noticeable in body composition or workout capability but everything I’ve read says that’s down the road yet. Libido is higher, but my capabilities to do something about it have shown only a tad bit of improvement. I’m very hopeful that this regimen is going to do the trick for me, perhaps with some dosage tweaking.

More reports to follow if you’re interested.

EasyCompany said:

Postscript: after dillydallying around due to a low testosterone-induced high level of procrastination I finally got in touch with Defy. I had just had my annual physical and Defy accepted the lab results without making me go to the expense of re-doing them. They had me go get a couple of additional labs including running the LH level. I then had my interview with one of their doctors on staff. The interview lasted about an hour and was pretty thorough. He noted that my LH was very high and that this is indicative of primary hypogonadism as my pituitary is telling my gonads to step it up and produce more T but they aren’t responding very well. That had led to my most recent test level of 234, 21.6 free and 43.6 bio available. No wonder I felt like I was in a downward spiral. Two years ago my test was 425 and dropping.

My sleep has been horrible, waking up after just a couple of hours and tossing and turning the rest of the night nearly every night. My mind seemed jumbled up and I didn’t seem able to concentrate on anything. Prostate had begun to swell, with my local physician diagnosing as BPH. All I know is getting up five to seven times a night to pee was draining me of more than urine.

Doc prescribed a staring regimen of test (40 units by injection twice a week), HCG (50 units by injection twice a week) and anastrozole (.125 mg tablet 2x week). He also added 25 mg of DHEA to be taken daily at bedtime and additional Vitamin D and Omega-3 fatty acid capsules over what I was already taking.

I’m two weeks into this regimen now and I have noticed a much improved sleep pattern and a lot less brain fog. Also, the BPH seems to has lessened substantially. I am able to go all night with one or sometimes zero pee breaks resulting in much more restful sleep. No changes noticeable in body composition or workout capability but everything I’ve read says that’s down the road yet. Libido is higher, but my capabilities to do something about it have shown only a tad bit of improvement. I’m very hopeful that this regimen is going to do the trick for me, perhaps with some dosage tweaking.

More reports to follow if you’re interested.

Click to expand...

Doc prescribed a staring regimen of test (40 units by injection twice a week), HCG (50 units by injection twice a week) and anastrozole (.125 mg tablet 2x week).


You have been overdosed on T from the get-go!

The most commonly used esterified T (TC/TE) are the 200 mg/mL strength.

You were started on a fairly high dose of T 160 mg T/week (80 mg every 3.5 days) with hCG thrown in to boot let alone the use of an AI to control elevated estradiol!

Throwing in hCG is going to drive up your TT, FT and estradiol further depending on the dose used and how you react to such!

Chances are you are going to jack up your trough FT too high which can lead to sides especially elevated RBCs, hemoglobin and hematocrit and at your age you need to pay attention to your hematocrit.

You never even posted where your baseline/pre-TTh hematocrit sat before hoping on T.

RBCs, hemoglobin and hematocrit are critical blood markers here and you need to know where they sit before f**king with exogenous T!

Common starting dose is 100 mg T/week or better yet 50 mg T twice-weekly (every 3.5 days)

Most men are injecting 100-200 mg T/week whether once weekly or split into more frequent injections as in twice-weekly (every 3.5 days), M/W/F, EOD or daily.

Most men can easily hit a healthy let alone high and in some cases very high trough FT injecting 100-150 mg T/week especially when split into more frequent injections.

Yes there are some outliers who may need the high-end dose 200 mg T/week but it is far from common as in RARE!

More sensible to start on a T only protocol off the hop without any ancillaries (hCG, aromatase inhibitor) as we want to see how your body reacts to testosterone and where said protocol (dose of T/injection frequency) will have your trough TT and more importantly FT let alone estradiol and other critical blood markers RBCs, hemoglobin and hematocrit.

There will always be time to increase your dose of T if need be let alone throw in hCG to prevent/minimize testicular atrophy and maintain fertility (men still interested in such).

Yes some men do fare better using micro doses of an AI but even then I would try to avoid the use of an AI as this can easily backfire on you due to driving estradiol too low or worst case scenario crashing it!

Most relying on such are overmedicated and running way too high a trough/steady-state FT level.

Ts metabolites estradiol and DHT are needed.

Having healthy levels of estradiol is critical!

Ts metabolites estradiol and DHT are needed in healthy amounts to experience the full spectrum of testosterones beneficial effects on (cardiovascular health, brain health, libido, erectile function, bone health, tendon health, immune system, lipids, and body composition)

Again the best piece of advice is to start low and go slow on a T-only protocol.

Patience is key.

Lots of time to increase your dose down the road if need be.

Much easier going up than having to come down trust me on this one.

Blood work will be done 6 weeks in so we can see where such protocol (dose of T/injection frequency) has your trough TT, FT and estradiol let alone other critical blood markers (RBCs, hemoglobin, and hematocrit).

Keep in mind when first starting TRT or tweaking a protocol (dose of T/injection frequency) hormones will be in FLUX during the weeks leading up until blood levels have stabilized (4-6 weeks TC/TE) and it is common to experience ups/downs during the transition as the body is trying to adjust.

Even then once blood levels have stabilized (4-6 weeks) it will still take time (a few months) for the body to adapt to the new setpoint and this is the critical time period when one needs to gauge how they truly feel overall regarding relief/improvement of low-t symptoms and overall well-being.

This is where the rubber meets the road.

Every protocol needs to be given a fighting chance (12 weeks) to claim whether it was truly a success or failure.

Again patience is key.

Again blood work is always done once steady-state is reached which is 6 weeks after starting a new protocol (TC/TE).

Labs should be done a the true trough (lowest point) over the week just before your next injection.

If you are injecting once weekly then the true trough would be 7 days post-injection, and if you are splitting your weekly dose by injecting twice-weekly then the true trough would be 3.5 days (84 hrs) post-injection.

The dose of T you start on should only be increased at the 6-week mark if labs show that your trough FT level is too low which is highly unlikely in the majority of cases and if anything many end up with too high a trough FT level as they are started on that high-end dosed T protocol 200mg/week pushed by those CLUELESS SHEEP with that more T is better mentality!

Too many make the mistake of increasing their T dose 6 weeks because they do not feel great.

Unless your trough FT was too low (highly doubtful) in most cases then you need to ride it out well past the 6-week mark.

Otherwise, you will be left in a constant state of confusion chasing your tail endlessly.



My reply from previous threads.

Too many are still caught up in jumping the gun off the hop!


*As such, patients should be counseled that symptom response will not be immediate. Expectations for treatment response should be established with each patient. Patients can anticipate improvements in many of the common symptoms of TD (libido, energy levels, sexual function) after 3 months of treatment or longer. Metabolic and structural (body composition, muscle mass, bone density) changes may take upwards of 6 months.

*Following the initiation of testosterone therapy, serum concentrations of testosterone are known to correct earlier than the symptomatic, structural, and metabolic signs associated with TD.





26. What is a reasonable timeline to begin to observe improvements in the signs and symptoms of testosterone deficiency?


*Following the initiation of testosterone therapy, serum concentrations of testosterone are known to correct earlier than the symptomatic, structural, and metabolic signs associated with TD.76,77 As such, patients should be counseled that symptom response will not be immediate. Expectations for treatment response should be established with each patient. Patients can anticipate improvements in many of the common symptoms of TD (libido, energy levels, sexual function) after 3 months of treatment or longer. Metabolic and structural (body composition, muscle mass, bone density) changes may take upwards of 6 months. 77 In addition, patients should be counseled that diet and exercise in combination with testosterone therapy are recommended for body composition changes.

*Appreciating this pattern of response to testosterone therapy is fundamental when determining the impact of treatment and the appropriate timing of follow-up evaluations while on therapy. For example, if patients undergo a symptom review and measurement of testosterone levels too early (< 3 months), it may lead both physicians and patients to conclude that the treatment has not been impactful (i.e. normal levels of testosterone without symptomatic/structural/metabolic benefit). However, if the same assessment was scheduled 3-6 months after the initiation of therapy, the clinical response tends to be more reflective of normalized levels of serum testosterone.



Although you will find many on the forum who use Defy that have positive experiences you still need to tread lightly as the downfall here is from what I have seen on the forum over the years is that some of the doctors tend to overmedicate (150-200 mg T/week) from the get-go let alone they are still clueless when it comes to testing one of the most important blood markers free testosterone as they are still using/relying upon a known to be inaccurate assay the direct immunoassay!

Top it off that direct IA has been shown to underestimate FT.

Again it is critical to have your FT tested using the most accurate assay which would be the gold standard Equilibrium Dialysis especially in cases of altered SHBG!

If anything I would pay out of pocket and test your trough FT through Quest or Labcorp!

The most sensible/cost effective option would be through Nelson's discounted labs or you can use Labcorp but it is more costly!

I agree with @madman that this cookie-cutter protocol is far from ideal. Even less so with a possible diagnosis of primary hypogonadism. I am disappointed in Defy for prescribing it. There is an alternative treatment approach that may be better for your overall health than the current blast with high amounts of testosterone and ancillaries. Basically, you only need relatively small amounts of testosterone, and the correct amount is determined by your level of LH. Start low and slowly increase the testosterone dose until LH reaches and stabilizes in the midrange. This is the level your body prefers. Other men with primary hypogonadism have had good results with this approach. Because you still produce normal amounts of LH you do not need hCG. You also most likely do not need an aromatase inhibitor.

I realize you have a lot of inertia pushing you to continue with Defy's approach. However, I would urge you to consider trying the above method first. There is little to lose, since you can always increase to higher doses later. But it is more difficult to go the other direction, from high to low. With continued high doses of testosterone your HPTA will be suppressed, and many other hormones may be disrupted, leading to side effects, some subtle, some not.

Oh, wow. I went to Defy because I specifically didn’t want to be over-dosed on T to the extent it adversely affected other things and it looks like I really didn’t get much better care than I did from that nurse practitioner who just slapped some pellets in my butt and after 30 days was proud that my total T had gotten up to 1100 (no measurement of free T or bio available T, hemocrit or anything else).

It seems that perhaps the best approach would be for me to email the Defy Doctor and express the concerns that Madman has pointed out and see if he wants to adjust. Madman, your approach seems logical, in that “dialing it in” would best start off in small increments and evaluating where each step takes me after a period of time to allow that step to settle in. I actually thought that’s what the Defy doc was doing, only I had no idea that the starting dosage could be considered high as I had no idea of what high looked like.

I even paid up to have a doctor advise me rather than a nurse practitioner.

I'm 68 and started T a year ago with an endocrinologist, somebody who should know about Tth, but didn't. Things didn't work out until I started reading this board in earnest. I found the best for me was to educate myself on what to do and then hopefully find a doctor to prescribe the T for me. I don't need a lot of TE (70-80mg/wk) and if I keep things conservative then I don't need an AI and neither do I need HCG (balls might have shrunk a bit, say 10%, nobody notices or cares). At that lower T dose I can still lose weight and build some good muscle, no complaints. Learn and then keep it simple . . .

Yep. I tried what I thought was putting myself in the hands of a doc group who people on this board recommended highly, for while I knew some things about T, LH, HCG, etc. it seemed wise to let a doctor who is an expert in these things dial it in for me. I am going to discuss all of this with the doc, but not in a way that puts him on the defensive. I’m going to try to boil it down to why did he start me out with such a high dose. He may have had a good reason, but we’ll see.