I'm a 43 year-old, diagnosed with hypogonadism nearly two years ago. My T level was tested several times, ranging from 60-250ng/dl, before the diagnosis was made. I was started out on 40.5mg gel, then increased to 81mg, but even at 81mg my T levels didn't exceed 250ng/dl. My endocrinologist refused to increase dose or switch to injections, so I changed to a different endocrinologist in May '21, who agreed that I should move to IM injections, and started me on 150mg/2weeks testosterone cypionate. Doctor had labs done two days before 4th injection, and level was 68ng/dl. But turns out doctor wanted labs done exactly one week after injection, so on day 7 following 4th injection had labs again and T was 319ng/dl. With this result, doctor increased dose to 200mg/2 weeks; doctor is reluctant to, but not completely against, increased frequency. Doctor wants me to get labs again exactly one week after 2nd injection at this new dose, aiming for 500+ng/dl midway between injections. I'm concerned that with 500-600ng/dl midway, my levels will be low again for 3-6 days before injections, resulting in rollercoaster levels between peaks and troughs. From the labs we have thus far, it seems that 175-200mg/week would keep me above 500ng/dl at trough and help maintain more stable levels; guessing between 1200ng/dl at peak and 500+ng/dl at trough, rather than 1200ng/dl at peak and about 250ng/dl at trough with injections every 2 weeks. If my PSA and Hematocrit remain normal with 175-200mg/week, I don't understand why doctor is against this, yet doctor says if the 200mg/2 weeks doesn't work, that we can try 100mg/week, but says that won't increase above that regardless of numbers. Doctor doesn't want to check FT or estradiol, but says we can maybe look at those later on. I'm guessing that my T levels are testing so low is related to my low SHBG (see below); that my body burns through the T rapidly. What are your thoughts on my doctor's approach, protocol, and resistance to prescribing anything in excess of endocrine society's "gold standard" TRT recommendations? Thanks in advance for your feedback!
*I'm 6'0, 235lb., and in otherwise good health according to blood, psa, metabolic, and lipid panels, other than somewhat elevated cholesterol levels (and HDL +/-50). SHBG is low though: was +/-14 before TRT, dropped to +/-10 on gel, and a very low 2-4 on injections.
Welcome to excel!
I'm a 43 year-old, diagnosed with hypogonadism nearly two years ago. My T level was tested several times, ranging from 60-250ng/dl, before the diagnosis was made. I was started out on 40.5mg gel, then increased to 81mg, but even at 81mg my T levels didn't exceed 250ng/dl. My endocrinologist refused to increase dose or switch to injections,
Unfortunately, this was looking disastrous from the get-go!
Although transdermal can be a good starting point when jumping on trt there are men who will continue to be poor responders due to absorption issues or in many cases not using a high enough dose of T seeing as most endos rely on using big pharma transdermal T and the strength/potency is much less than what can be achieved using compounded transdermal T gels/creams.
Keep in mind that absorption using standard transdermal T application whether gel/cream is anywhere from 9-14%.
A common starting dose for Androgel was 50mg T/day which would be roughly 5 mg T/day and in most cases, men would only hit a mid-normal T level at best.
Most men would need the higher end dose of 100 mg T/day which would be roughly 10 mg T/day to achieve a high-end or in some cases very high T level.
Seeing as you were hitting such piss poor T levels then injections would have been the more sensible option.
My endocrinologist refused to increase dose or switch to injections, so I changed to a different endocrinologist in May '21,
Now, who would do such a thing.....LOL.
Looks as though you jumped from one idiot to the next.
so I changed to a different endocrinologist in May '21, who agreed that I should move to IM injections, and started me on 150mg/2weeks testosterone cypionate. Doctor had labs done two days before 4th injection, and level was 68ng/dl. But turns out doctor wanted labs done exactly one week after injection, so on day 7 following 4th injection had labs again and T was 319ng/dl.
Should have run and never looked back when he told you that he wanted to prescribe T injections every 2 weeks let alone 150 mg.
He had you back to being hypogonadal well before the 2 days before the 4th injection as you were hitting an absurdly low-t 68 ng/dL.
Even on 150 mg T (every 2 weeks) 7 days post-injection, you were only hitting a TT 319 ng/dL most likely due to your low SHBG.
With a piss poor trough TT 319 ng/dL your FT would still be low even with low SHBG.
Most endos are still stuck with that neanderthal mindset with those prehistoric protocols of 200mg T every 2 weeks which would have your TT, FT, and estradiol levels absurdly high post-injection/during the first few days only to be followed by much lower levels to the point of being hypogonadal well before the 2 weeks mark.
A rollercoaster ride anyone!
Top it off that many tend to be dead-set on keeping your TT in a specific range regardless of symptoms.
Aim for mid-normal of the physiological range they say!
Many go on ranting and raving about where your TT sits without giving any thought to SHBG level let alone FT and top it off that brushing off the importance of testing e2 can be common.
Although TT is important to know FT is what truly matters as it is the active unbound fraction of testosterone responsible for the positive effects.
This is a complete mess.
You need to look into finding someone who understands the ins and outs of treating a man for low-t.
With this result, doctor increased dose to 200mg/2 weeks; doctor is reluctant to, but not completely against, increased frequency. Doctor wants me to get labs again exactly one week after 2nd injection at this new dose, aiming for 500+ng/dl midway between injections. I'm concerned that with 500-600ng/dl midway, my levels will be low again for 3-6 days before injections, resulting in rollercoaster levels between peaks and troughs
Again you should have run and never looked back when he told you that he wanted to prescribe T injections every 2 weeks let even when using 200 mg T.
I stated previously:
Most endos are still stuck with that neanderthal mindset with those prehistoric protocols of 200mg T every 2 weeks which would have your TT, FT, and estradiol levels absurdly high post-injection/during the first few days only to be followed by much lower levels to the point of being hypogonadal well before the 2 weeks mark.
A rollercoaster ride anyone!
Top it off that many tend to be dead-set on keeping your TT in a specific range regardless of symptoms.
Aim for mid-normal of the physiological range they say!
Many go on ranting and raving about where your TT sits without giving any thought to SHBG level let alone FT and top it off that brushing off the importance of testing e2 can be common.
From the labs we have thus far, it seems that 175-200mg/week would keep me above 500ng/dl at trough and help maintain more stable levels; guessing between 1200ng/dl at peak and 500+ng/dl at trough, rather than 1200ng/dl at peak and about 250ng/dl at trough with injections every 2 weeks. If my PSA and Hematocrit remain normal with 175-200mg/week, I don't understand why doctor is against this, yet doctor says if the 200mg/2 weeks doesn't work, that we can try 100mg/week, but says that won't increase above that regardless of numbers.
Regardless of where your trough TT/FT levels would truly sit when injecting 175-200mg T/week, it would still be a piss poor protocol seeing as you have low SHBG.
Most men on trt are injecting 100-200 mg T (high-end).
Most can easily achieve a healthy let alone very high or in some cases absurdly high trough FT on 100-150 mg T/week whether split twice weekly (every 3.5 days), M/W/F, EOD let alone daily even men with highish/high SHBG.
Sure some may need the higher end dose but it is far from common.
SHBG is critical to know as not only will it have a significant impact on TT/FT but can dictate what injection frequency may suit you best.
Men with highish/high SHBG may fair better when injecting less frequently as in once weekly or twice weekly (every 3.5 days)
Although it is not a given and comes down to the individual as many men with highish/high SHBG inject more frequently.
The downfall of injecting higher doses of T less frequently is there will be a big difference in peak--->trough and blood levels will not be as stable throughout the week which can have a negative impact on mood/energy/libido/erectile function due to the rollercoaster ride.
Injecting a lower dose more frequently will clip the peak--->trough let alone result in achieving more stable blood levels throughout the week.
Men with lowish/low SHBG tend to do better injecting a lower dose of T more frequently as in daily or EOD.
Keep in mind that men with lowish/low SHBG can get away with running a lower TT and still achieve a healthy let alone high FT.
Most tend to get caught up on TT and although important FT is what truly matters as it is the active unbound fraction of T responsible for the positive effects.
Doctor doesn't want to check FT or estradiol, but says we can maybe look at those later on. I'm guessing that my T levels are testing so low is related to my low SHBG (see below); that my body burns through the T rapidly. What are your thoughts on my doctor's approach, protocol, and resistance to prescribing anything in excess of endocrine society's "gold standard" TRT recommendations? Thanks in advance for your feedback!
He is out to lunch!
Definitely not coming back.
FT let estradiol are critical blood markers and should always be included when getting blood work done.
You definitely need to find a new doctor and would do much better-injecting daily or EOD using lower doses of T.
The best piece of advice would be to start low and go slow.
100-120 mg T/week split into more frequent injections would be a sensible move.
*I'm 6'0, 235lb., and in otherwise good health according to blood, psa, metabolic, and lipid panels, other than somewhat elevated cholesterol levels (and HDL +/-50). SHBG is low though: was +/-14 before TRT, dropped to +/-10 on gel, and a very low 2-4 on injections.
Your SHBG was low 14 nmol/L before TRT and driven into the ground 2-4 nmol/L on the piss poor injection protocol.
When using exogenous T many factors can come into play when it comes to what dose of T is needed to achieve a healthy FT level.
SHBG level, injection frequency, metabolism, the sensitivity of the AR, polymorphism of the AR, and CAG repeat length (long/short), bodyweight.