Subq vs IM impact on Hematocrit

[madman]

@madman
"FT level will have a significant impact on such blood markers.

As I have stated numerous times on the forum too many get caught up in thinking that injecting more frequently (daily) will have a significant impact on lowering estradiol/HCT which is not a given as unfortunately many still persist to run absurdly high FT levels.

Even then regardless of whether one is injecting sub-q vs IM, injection more frequently, minimizing peak--->trough when it comes to elevated RBCs/hemoglobin/hematocrit, I would be more concerned with what FT level you are running let alone at the trough on such protocol!"

I have attached some of my blood work from two different time periods. On 7/20/18 I was injecting IM 180 mg of T Cyp a week broken down into 90 mg E3.5 Days. I am now injecting IM 24 mg per day of T Cyp, 168 mg per week. I whittled down the spreadsheet so it would fit on one page and show the markers I wanted to compare. My spreadsheet actually goes back to 2005 and I run blood work every three to four months.


For several years I had been struggling with my RBC, Hb and HCT getting a little too high and I decided in September of 2018 to switch to smaller daily injections. For me, the daily injections have worked well and I do not have the swing in peak and trough as much since I have started the daily injections. I probably don't get quite as high as a peak on daily injections as you would with a larger volume injection on E3.5D injections but my troughs are definitely much higher on daily's verse the E3.5D. I am also injecting less total for the week, not by a lot, but still less and my blood markers are better and I have good T levels, both total and more importantly FT.

My DHT levels are a little high but they always have been so I not concerned about them. My doctor isn't concerned about the low amount of thyroid antibodies that show up and he thinks the TSH is better off being a little low than being over-active. I'm not sure yet how I feel about that. Not too concerned but I need to research a little more.

I'm 62 yrs old and overall I am in pretty good shape, body fat is relatively good at about 10%, and I have real good muscle tone, and a healthy sex life.

@HealthMan this is where my blood work is going from E3.5D shallow IM to daily IM. In six to 8 weeks I will run some more bloodwork and see what happens switching to SubQ taking the same dose. I hope I did not hijack your thread.

You are one of the lucky ones and it would seem that switching to dailies (clipping peak--->trough) has made a big difference in bringing down RBCs/hemoglobin/hematocrit.

Mind you although you are hitting higher-end TT/FT levels on such protocol (daily) hard to compare where your FT level truly sat as you never tested it using the most accurate assays the gold standard Equilibrium Dialysis or Ultrafiltration (next best).

Hard to believe you were only hitting a trough TT high 400s injecting a whopping 180 mg T/week split twice weekly (90 mg every 3.5 days) especially with an SHBG 28.6 nmol/L (far from low).

Horrible numbers for the weekly dose of T used.

I was hitting a trough TT 1200 ng/dL on 150mg T/week split twice weekly (75 mg T every 3.5 days).

This is the assay I would prefer to use when testing TT/FT:

070038: Testosterone, Free, Equilibrium Ultrafiltration With Total Testosterone, LC/MS-MS | Labcorp

Labcorp test details for Testosterone, Free, Equilibrium Ultrafiltration With Total Testosterone, LC/MS-MS

www.labcorp.com

 

[MarkM]

You are one of the lucky ones and it would seem that switching to dailies (clipping peak--->trough) has made a big difference in bringing down RBCs/hemoglobin/hematocrit.

Mind you although you are hitting higher-end TT/FT levels on such protocol (daily) hard to compare where your FT level truly sat as you never tested it using the most accurate assays the gold standard Equilibrium Dialysis or Ultrafiltration (next best).

Hard to believe you were only hitting a trough TT high 400s injecting a whopping 180 mg T/week split twice weekly (90 mg every 3.5 days) especially with an SHBG 28.6 nmol/L (far from low).

Horrible numbers for the weekly dose of T used.

I was hitting a trough TT 1200 ng/dL on 150mg T/week split twice weekly (75 mg T every 3.5 days).

This is the assay I would prefer to use when testing TT/FT:

070038: Testosterone, Free, Equilibrium Ultrafiltration With Total Testosterone, LC/MS-MS | Labcorp

Labcorp test details for Testosterone, Free, Equilibrium Ultrafiltration With Total Testosterone, LC/MS-MS

www.labcorp.com

I have had the Total T tested using the LC/MS/MS method on many occasions and the FT using the Equilibrium method too. However, in a few instances, as these, I purchased a hormone package which used a lesser testing assay. I was aware of that and figured there would be a margin of error. Thanks for your feedback @madman

 

[madman]

Using the cFTZ (TruT) 180 mg T/week (90 mg every 3.5 days) TT 479 ng/dL, SHBG 28.6 nmol/L, Albumin 4.3 g/dL(mean) would have FT 16.11 ng/dL.

168 mg T/week (24 mg daily) TT 1055 ng/dL, SHBG 32.7 nmol/L, Albumin 4.3 g/dL(mean) would have FT 37.88 ng/dL.

You basically took your TT from 479 ng/dL--->1055 ng/dL and more importantly FT from the low end of healthy 16.11 ng/dL--->37.88 ng/dL (very high).

Definitely impressive that your blood markers dropped!

 

[MarkM]

I have seen some people report that blood markers stabilize after being on TRT after a period of time. I believe @Vince has made that comment before. Maybe that is something I am benefiting from?

Using the cFTZ (TruT) 180 mg T/week (90 mg every 3.5 days) TT 479 ng/dL, SHBG 28.6 nmol/L, Albumin 4.3 g/dL(mean) would have FT 16.11 ng/dL.

168 mg T/week (24 mg daily) TT 1055 ng/dL, SHBG 32.7 nmol/L, Albumin 4.3 g/dL(mean) would have FT 37.88 ng/dL.

You basically took your TT from 479 ng/dL--->1055 ng/dL and more importantly FT from the low end of healthy 16.11 ng/dL--->37.88 ng/dL (very high).

Definitely impressive that your blood markers dropped!

I have seen some people report that blood markers stabilize after being on TRT after a period of time. I believe @Vince has made that comment before. Maybe that is something I am benefiting from?

 

[MarkM]

Using the cFTZ (TruT) 180 mg T/week (90 mg every 3.5 days) TT 479 ng/dL, SHBG 28.6 nmol/L, Albumin 4.3 g/dL(mean) would have FT 16.11 ng/dL.

168 mg T/week (24 mg daily) TT 1055 ng/dL, SHBG 32.7 nmol/L, Albumin 4.3 g/dL(mean) would have FT 37.88 ng/dL.

You basically took your TT from 479 ng/dL--->1055 ng/dL and more importantly FT from the low end of healthy 16.11 ng/dL--->37.88 ng/dL (very high).

Definitely impressive that your blood markers dropped!

I was not aware of the TruT calculator. I have been using the Free and Bioavailable Calculator, Free & Bioavailable Testosterone calculator. They seem to produce quite different results. Do you know which is more accurate? Didn't you use to use the Free and Bioavailable Calculator at one time? Thanks

 

[madman]

I have seen some people report that blood markers stabilize after being on TRT after a period of time. I believe @Vince has made that comment before. Maybe that is something I am benefiting from?

Most definitely as it tends to happen for some.

 

[madman]

I was not aware of the TruT calculator. I have been using the Free and Bioavailable Calculator, Free & Bioavailable Testosterone calculator. They seem to produce quite different results. Do you know which is more accurate? Didn't you use to use the Free and Bioavailable Calculator at one time? Thanks

This is where I stand when it comes to testing FT!

I would not rely on the piss poor direct immunoassay let alone outdated calculated methods especially in cases of altered SHBG

Although the newer cFTZ algorithm (TruT) should give fairly consistent results I would prefer to rely on direct testing using the most accurate assays such as the gold standard Equilibrium Dialysis or Ultrafiltration especially in cases of altered SHBG.

The EAM (cFTZ) appears to be an accurate and testable model for calculating free testosterone levels, but this model needs further validation in large populations.

This will be a part of the ongoing phase II.

As I am patiently waiting on the completion of Phase II for the TruT (cFTZ) Algorithm let alone standardization and harmonized reference ranges for Free testosterone which is in the works as we speak.


The new dynamic model leads to the reconsideration of several dogmas related to testosterone's binding to SHBG and has important physiologic and clinical implications.

*First, the fraction of circulating testosterone that is free is substantially greater (2.9±0.4%) than has been generally assumed (% cFTV 1.5±0.4%).

*Second, percent FT is not significantly related to total testosterone over a wide range of total testosterone concentrations. However, the percent FT declines as SHBG concentrations increase, although it does not decline as precipitously as predicted by Vermeulen's model. Due to the allostery between the two binding sites, SHBG is able to regulate FT levels in a much larger dynamic range.


Key points:

EAM (cFTZ) SHBG: T binding

*Intra-dimer complex allostery suggests that SHBG can regulate FT fraction over a wide range of total testosterone concentrations without getting saturated.

*Indeed, it was found that percent FT calculated using the new model changed very modestly over a wide range of total testosterone concentrations.

*Due to the allostery between the two binding sites, SHBG is able to regulate FT levels in a much larger dynamic range.

 

[madman]

CDC STANDARDIZED TOTAL T and ESTRADIOL ASSAYS and soon to be FREE TESTOSTERONE!

How the CDC Clinical Standardization Programs Are Improving Hormone Tests - AACC.org WHAT PROGRESS HAS CDC MADE WITH STANDARDIZING TOTAL TESTOSTERONE AND ESTRADIOL TESTS? Since HoSt began in 2010, CDC has had more than 350 participants in 15 countries. Participants have shown measurable...

www.excelmale.com

Look over the pdf below: CDC Hormone Standardization Program (CDC HoSt) Certified Total Testosterone Procedures (UPDATED 7/2021) .....this is going to happen for FT eventually!


*Measuring FT is technically challenging and shows high variability. The CDC clinical standardization program is developing a high throughput method using the gold-standard equilibrium dialysis (ED) procedure with isotope dilution ultra-high-performance liquid chromatography-tandem mass spectrometry (ID-UHPLC-MS/MS).



post #21

Measurement of Free Testosterone in Serum Using Equilibrium Dialysis Coupled With ID-UHPLC-MS/MS: Comparison Between Equilibrium Devices (2021)​

Hui Zhou, Ph.D., Ashley Ribera, BS, Amonae Dabbs-Brown, BS, Uliana Danilenko, Ph.D., Hubert W. Vesper, Ph.D.

Centers for Disease Control and Prevention, Atlanta, GA, USA.

​

Abstract

Free testosterone (FT) has been used as a biomarker in clinical patient care and public health research to assess and manage patients with androgenic abnormalities. The latest Endocrine Society clinical practice guideline for testosterone therapy in men with hypogonadism recommends measuring FT for those with borderline and low total testosterone concentrations, or those who have conditions that change SHBG concentrations, such as some metabolic or hormonal diseases, certain medication use, or SHBG genetic polymorphisms. Measuring FT is technically challenging and shows high variability. The CDC clinical standardization program is developing a high throughput method using the gold-standard equilibrium dialysis (ED) procedure with isotope dilution ultra-high-performance liquid chromatography-tandem mass spectrometry (ID-UHPLC-MS/MS).

A serum sample was dialyzed against a protein-free HEPES buffer (pH 7.4) at 37 °C until equilibrium. After isolating endogenous FT from protein-bound testosterone by ED, isotope-labeled internal standard (13C3-testosterone) was added to the dialysate for quantification. Certified pure primary reference material (National Measurement Institute M914) was used to prepare calibrators, enabling traceable quantitation and ensuring measurement trueness. FT was further isolated from the dialysate matrix using supported liquid extraction and a chromatographic separation from interfering compounds and quantitation by tandem MS. The dialysis step requires maintaining the endogenous free hormone equilibrium so that results in dialysate reflect FT concentrations in the blood without influence from dilution, temperature, or pH. The dialyzer system has a 1:1 sample-to-buffer volume and has been used in reference measurement procedures for free hormone measurements, serving as the standard for method performance comparison. Four commercially available devices designed for high throughput in multiple well-plate formats, requiring respective sample-to-buffer ratios, were evaluated for their recovery, speed, ease of automation by a liquid handling system, repeatability, and robustness. Preliminary results showed that a device with 1:1 sample-to-buffer volume had the most comparable results to those obtained from the standard dialyzer, with the mean bias less than 15%. The device with the highest sample-to-buffer ratio showed bias as high as 50%. These data suggest that controlling the sample-to-buffer ratio is a critical step in the ED FT method.

 

[MarkM]

This is where I stand when it comes to testing FT!

I would not rely on the piss poor direct immunoassay let alone outdated calculated methods especially in cases of altered SHBG

Although the newer cFTZ algorithm (TruT) should give fairly consistent results I would prefer to rely on direct testing using the most accurate assays such as the gold standard Equilibrium Dialysis or Ultrafiltration especially in cases of altered SHBG.

The EAM (cFTZ) appears to be an accurate and testable model for calculating free testosterone levels, but this model needs further validation in large populations.

This will be a part of the ongoing phase II.

As I am patiently waiting on the completion of Phase II for the TruT (cFTZ) Algorithm let alone standardization and harmonized reference ranges for Free testosterone which is in the works as we speak.


The new dynamic model leads to the reconsideration of several dogmas related to testosterone's binding to SHBG and has important physiologic and clinical implications.

*First, the fraction of circulating testosterone that is free is substantially greater (2.9±0.4%) than has been generally assumed (% cFTV 1.5±0.4%).

*Second, percent FT is not significantly related to total testosterone over a wide range of total testosterone concentrations. However, the percent FT declines as SHBG concentrations increase, although it does not decline as precipitously as predicted by Vermeulen's model. Due to the allostery between the two binding sites, SHBG is able to regulate FT levels in a much larger dynamic range.


Key points:

EAM (cFTZ) SHBG: T binding

*Intra-dimer complex allostery suggests that SHBG can regulate FT fraction over a wide range of total testosterone concentrations without getting saturated.

*Indeed, it was found that percent FT calculated using the new model changed very modestly over a wide range of total testosterone concentrations.

*Due to the allostery between the two binding sites, SHBG is able to regulate FT levels in a much larger dynamic range.

This is certainly new and interesting information for me. Is there a timeline on when it is expected that Phase II will be completed? Does this change the way that Albumin is considered to behave in it's binding? Thank you for sharing.

 

[MarkM]

@madman "Preliminary results showed that a device with 1:1 sample-to-buffer volume had the most comparable results to those obtained from the standard dialyzer, with the mean bias less than 15%. The device with the highest sample-to-buffer ratio showed bias as high as 50%. These data suggest that controlling the sample-to-buffer ratio is a critical step in the ED FT method."

15% to 50% is a huge variance depending on the device/method used. Do you think once this study is completed it will change the lower and upper ranges that the medical field uses for Total and FT? Should FT levels be used more in determining if an individual should be placed on TRT verse Total T which is it what it seems the medical field focuses on. Very interesting.

 

[madman]

This is certainly new and interesting information for me. Is there a timeline on when it is expected that Phase II will be completed? Does this change the way that Albumin is considered to behave in it's binding? Thank you for sharing.

Regarding the CFTZ (Tru T).....hard to say but should be within the next year or two.

You have been away from the forum too long and hard to believe you have not seen the numerous threads I have started regarding free testosterone let alone TruT!

Standardization and harmonization program for Free Testosterone is in the works as we speak and it is just a matter of time before this happens.

Once this takes place then everyone will have the option of choosing a lab that offers assays (EquilibriumDialysis or Ultrafiltration) certified through the CDC Hormone Standardization Program (CDC HoSt) Certified Free Testosterone Procedures.

 

[MarkM]

Regarding the CFTZ (Tru T).....hard to say but should be within the next year or two.

You have been away from the forum too long and hard to believe you have not seen the numerous threads I have started regarding free testosterone let alone TruT!

Standardization and harmonization program for Free Testosterone is in the works as we speak and it is just a matter of time before this happens.

Once this takes place then everyone will have the option of choosing a lab that offers assays (EquilibriumDialysis or Ultrafiltration) certified through the CDC Hormone Standardization Program (CDC HoSt) Certified Free Testosterone Procedures.

Yes, I have been away for few years. Why? Just life I guess. I used the forum to help me find my way and a protocol that worked for me. I was fairly up to speed when I was on the forum on a regular basis, enough to get me dialed in real well. Hopefully along the way I helped a few others.

I did not see your numerous threads on FT and TruT because I was not coming to the sight except occasionally. Because I have been dialed in and feeling great I was not searching for an alternative protocol or information on FT. I saw the thread on IM vs SubQ that @HealthMan started and that got me interested in trying SubQ again.

Being away for a while makes me feel like I have lost all the knowledge I had gained over the years on the site. I should have probably stayed involved as that would have kept me more knowledgeable about changes like this. You were and are a wealth of knowledge @madman! You're a real asset to @Nelson Vergel as are the other moderators! Thank you

 

[madman]

@madman "Preliminary results showed that a device with 1:1 sample-to-buffer volume had the most comparable results to those obtained from the standard dialyzer, with the mean bias less than 15%. The device with the highest sample-to-buffer ratio showed bias as high as 50%. These data suggest that controlling the sample-to-buffer ratio is a critical step in the ED FT method."

15% to 50% is a huge variance depending on the device/method used. Do you think once this study is completed it will change the lower and upper ranges that the medical field uses for Total and FT? Should FT levels be used more in determining if an individual should be placed on TRT verse Total T which is it what it seems the medical field focuses on. Very interesting.

Regarding free testosterone, there is much more going on behind the scenes.

Even then it will have no impact on the reference ranges for Total Testosterone.

The harmonized reference range for Total Testosterone was already changed as of 2017.

CDC Hormone Standardization Program (CDC HoSt) Certified Total Testosterone was already completed and has been around for a while now.

As I stated previously.....CDC Hormone Standardization Program (CDC HoSt) Certified Free Testosterone Procedures is in the works as we speak.




The Solution Standardized Laboratory Measurements

In 2007, CDC began a project to standardize hormone measurements to ensure accurate and comparable results across testing systems (assays), across laboratories and over time. The two key elements of the solution are the development of reference materials that have highly accurate and precise values, and reference methods that provide highly precise and accurate measurements.

Reference methods are used to assign concentrations to reference materials. Reference materials are used to calibrate assays and to verify calibrations. Thus, laboratories performing research or patient care testing can anchor their results to a common standard, regardless of the technology employed. This approach simultaneously minimizes method bias and improves method precision.


WHAT PROGRESS HAS CDC MADE WITH STANDARDIZING TOTAL TESTOSTERONE AND ESTRADIOL TESTS?

Since HoSt began in 2010, CDC has had more than 350 participants in 15 countries. Participants have shown measurable improvements for both total testosterone (TT) and estradiol (E2). Specifically, the among-laboratory bias has decreased from 16.5% in 2007 to 2.8% in 2017 for TT and from 54.8% in 2012 to 13.9% in 2017 for E2. Not only has bias improved, but data from proficiency testing programs also show that standardized testosterone assays are more accurate and consistent compared to non-standardized assays.

Recently, CDC CSP also collaborated with the Endocrine Society and PATH to develop reference ranges for testosterone in non-obese men ages 19-39 years old. These reference ranges are now part of an Endocrine Society clinical practice guideline and according to this guideline can be used by laboratory tests standardized to CDC’s criteria.




Harmonized Reference Ranges for Circulating Testosterone Levels in Men of Four Cohort Studies in the United States and Europe (2017)

Conclusion: Harmonized normal range in a healthy nonobese population of European and American men, 19 to 39 years, is 264 to 916 ng/dL. A substantial proportion of intercohort variation in testosterone levels is due to assay differences. These data demonstrate the feasibility of generating harmonized reference ranges for testosterone that can be applied to assays, which have been calibrated to a reference method and calibrator. (J Clin Endocrinol Metab 102: 1161–1173, 2017)

 

[madman]

Unfortunately, this is what many fail to understand!

*Measuring FT is technically challenging and shows high variability.

 

[AnotherPersonOnTRT]

HealthMan, I just switched from IM to SubQ this morning. So in time I will be able to tell if any of my numbers; testosterone, hematocrit, E2, etc.....change. I've been on the same protocol for years with consistent numbers so I will easily be able to tell if I see any measurable difference.

Hi, did switching to subq help any of your lab values? Like RBC, hemoglobin and hematocrit??

 

[Duff]

@HealthMan Also keen to find out. I'm sure there are many of us battling with the same issue.

 

[HealthMan]

Hi, did switching to subq help any of your lab values? Like RBC, hemoglobin and hematocrit??

Well not an easy answer. When i switched from E3.5D intramuscular to daily Suqb i increased my weekly dosage. Long story short my TT and FT levels plummeted in subq (i tested this a couple of times with same results). And hematocrit was unchanged to 1-2 points lower but still 52+

 

[entreleader77]

Yes, I have been away for few years. Why? Just life I guess. I used the forum to help me find my way and a protocol that worked for me. I was fairly up to speed when I was on the forum on a regular basis, enough to get me dialed in real well. Hopefully along the way I helped a few others.

I did not see your numerous threads on FT and TruT because I was not coming to the sight except occasionally. Because I have been dialed in and feeling great I was not searching for an alternative protocol or information on FT. I saw the thread on IM vs SubQ that @HealthMan started and that got me interested in trying SubQ again.

Being away for a while makes me feel like I have lost all the knowledge I had gained over the years on the site. I should have probably stayed involved as that would have kept me more knowledgeable about changes like this. You were and are a wealth of knowledge @madman! You're a real asset to @Nelson Vergel as are the other moderators! Thank y

Any update on your subq vs IM experiment?