Transdermal vs. Injections of Testosterone

[paco]

Nelson and Gene, I'm loving the site!

After many months of trying clomid monotherapy, then clomid plus HCG, then HCG mono and never feeling better, I'm just about ready to start TRT. I'd like to be better educated about gels vs. injections when I meet with the doctor. Can someone please remind me of pros and cons of each?

 

[Gene Devine]

Here's what our good Dr. Crisler has to say about both in his epic paper TRT: A recipe for Success. It's a bit dated now so keep that in mind, like having to go to Doc office to get IM injections...that's all done at home now. Nevertheless, the basic principals are the same.

TESTOSTERONE GELS AND CREAMS

The only way to go, in my professional opinion, if physician and patient agree on a transdermal (TD) delivery system. Or TRT at all. As I have gained knowledge and experience, my position is now that TD's are vastly superior to other modalities in TRT medicine. They are easy to apply, usually well absorbed, and rapidly establish stable serum androgen levels (by the end of the third day). I recommend all practitioners first try a testosterone gel for their TRT patients. Gels are better than creams, as I want the rapid T uptake into the dermal layer, which serves as reservoir for distribution throughout the day. Men do better on lower serum T levels on TD's than IM.

The constant variability of serum androgens provided by T gels mimic the hormones of a young man; the stable daily level provided by T injections mimic the hormones of an old man; those of implantable pellets mimic the hormones of no one. Entropic hormone levels are part and parcel of the process of youth.
Much is made of the risk posed by accidental transferal of testosterone to others, such as children or sexual partners. Simply covering with a T-shirt has been shown to block transfer of the hormone. The testosterone sinks into the skin within an hour. One may shower, or even swim, without worry, usually after four hours. I remind my patients most of us have neither the time, nor the opportunity, for romance until evening (given the usual early morning application), and a quick shower is always nice for a gentleman to “freshen up” prior to same.

Gels and creams, like all transdermal delivery systems, provide a greater boost in DHT levels, compared to injectable testosterone preparations. As DHT is responsible for all the things of manhood--literally, AllThingsMale--the transdermals are better at treating sexual dysfunction than are injectables. However, issues of hair loss (which I treat with a compounded topical DHT blocking mixture) and possible prostate morbidity (a contentiously debatable point, to be sure, but resolved in the negative to my mind) then come into play. This might be a good time to mention I vehemently oppose adding finasteride or similar medication.

To end the debate on this topic, transdermal T gels/creams are more likely to elevate estrogen than injections, as long as the shots are properly administered once per week. That is because aromatase lives in the skin, along with higher concentrations of 5-AR, which converts T to E. Even so, the benefits of TD TRT outweigh the weekly convenience of shots.

Some have reported an increase in hair growth over the application area(s). All physicians who administer TRT must be prepared to disappoint their patients at this time by pointing out, sadly, this same effect cannot be achieved upon the scalp.

TESTOSTERONE INJECTION

I'll start out by describing the drawbacks of IM testosterone. They are inconvenient for patients who do not wish to give themselves their own injections, as they must then make weekly trips to your office for same. Why IM test MUST be dosed weekly will be described in detail in another section. And this TRT modality represents hundreds of holes poked in their body over a lifetime. Some patients, as you well know, just hate shots (although I have noticed patients who had initially claimed this, but admitted, once they had come to enjoy the benefits of TRT, came to very much look forward to their shot day). And no doubt an invasive delivery system brings more risk than, for instance, a testosterone gel or cream (the best choice for TRT), although I have yet to hear of a single bad outcome from any of the tens of thousands of IM injections my patients have self-administered.

As a good and proper Osteopathic Physician, I am loath to introduce any substance to the body not absolutely necessary. Therefore the oil and preservative necessary to the injectable preparation are best avoided when possible, in my professional opinion.

When considering dosing of testosterone cypionate, it is important to remember that, due to the weight of the cypionate ester, a 100mg injection delivers, at best, 70mg of testosterone. This is important to keep in mind when comparing the effects of a 100mg weekly injection of test cyp to the 35mg total initial dose provided by Androgel/Testim 5gms QD over the same period.

HCG

Many practitioners consider this incredible hormone treatment of choice for hypogonadotropic (secondary) hypogonadism. Such certainly is intuitive, as supplementing with a LH analog indeed increases testosterone production in patients who do not concurrently suffer primary hypogonadism. But for some unexplained reason, while serum T levels may be adequately elevated, the patients simply do not report realization of the subjective benefits of TRT, when HCG is administered as sole TRT. You also run the risk of inducing LH insensitivity at higher dosages, and therefore may actually cause primary hypogonadism while attempting to treat secondary hypogonadism. HCG, especially at higher doses (defined as >500IU per shot), also dramatically increases aromatase activity, thus inappropriately elevating estrogens. Progesterone—a feminizing hormone in adult males—also elevates at those dosages. Personally, I recommend giving no more than 100IU of HCG per day, as starting dose. And please give it some time to work.

A real benefit of HCG is that it will prevent testicular atrophy. I do not think we should ignore the aesthetics of that consideration. Your patients will feel the same way.

 

[robs2nd75]

I seem to recall that Dr. Crisler recently stated that he had a new updated version of this position. Does anyone have a link or perhaps Dr. Crisler would be generous enough to post it here?

 

[Gene Devine]

He's not finished it yet and don't hold your breath.

He busier than a one handed paper hanger these days...kid you not.

I've been busting him to get it done and he will someday.

 

[SuperDutyDave]

Paco

I tried the clomid route similar to you for over a year with a well respected Boston Endo. After wasting a year with him with no tangible results I moved on to Dr Crilser. He was awesome and continues to treat me to this day.

Daily application of transdermal tends to mimic the bodies highs nd lows in T level.....plus you get the low dose high frequency thing going which prevents peaking then falling, typical with larger IM T-Cyp injections. I tried for a long while to use transdermals but I never had good absorbtion and as such my levels were never consistent nor sufficiently high as desired.

I therefore moved to T-Cyo injections via Sub-Q and HCG Low dose high frequency. Since that switch I have seen excellent results, higher numbers very consistent levels. I therefore a big fan of this method.

I would try ttopicals first and judge your results but if you don't see good things I would move immediately to Sub-Q

 

[Nelson Vergel]

Am J Physiol Endocrinol Metab. 2015 Apr 21:ajpendo.00111.2015. doi: 10.1152/ajpendo.00111.2015. [Epub ahead of print]

Injection of Testosterone May be Safer and More effective than Transdermal Administration for combating Loss of Muscle and Bone in Older Men.

Borst SE1, Yarrow JF2.



Abstract
The value of testosterone replacement therapy (TRT) for older men is currently a topic of intense debate. While US testosterone prescriptions have tripled in the last decade (7), debate continues over the risks and benefits of TRT. TRT is currently prescribed for older men with either low serum testosterone (T) or low T plus accompanying symptoms of hypogonadism. Serum T ≤ 300 ng/dL is considered to be low and T ≤ 250 is frank hypogonadism. Treatment for men who have low T without accompanying symptoms remains somewhat controversial. TRT produces benefits including increased muscle mass and strength, decreased fat mass, increased and bone mineral density. TRT also produces known risks including development of polycythemia, decrease in HDL, breast tenderness and enlargement, prostate enlargement, and increases in serum PSA and prostate-related events. Importantly, TRT does not increase the risk of prostate cancer. Several recent reports have also indicated that TRT may produce cardiovascular (CV) risks, while others report no risk or even benefit. To address the potential CV risks of TRT, we have recently reported via meta-analysis that oral TRT increases CV risk and suggested that the CV risk profile for i.m. TRT may be better than that for oral or transdermal TRT. Herein, we review the literature which indicates that i.m. TRT produces greater musculoskeletal and may be safer that either oral or transdermal preparations. We also review the literature discussing the use of 5α-reductase inhibitors as a promising means of improving the safety profile of TRT.

 

[Markee]

Gene What legit topical DHT blocking products do you recommend ?

Which one do you use ?

 

[Henry]

Am J Physiol Endocrinol Metab. 2015 Apr 21:ajpendo.00111.2015. doi: 10.1152/ajpendo.00111.2015. [Epub ahead of print]

Injection of Testosterone May be Safer and More effective than Transdermal Administration for combating Loss of Muscle and Bone in Older Men.

Borst SE1, Yarrow JF2.



Abstract
The value of testosterone replacement therapy (TRT) for older men is currently a topic of intense debate. While US testosterone prescriptions have tripled in the last decade (7), debate continues over the risks and benefits of TRT. TRT is currently prescribed for older men with either low serum testosterone (T) or low T plus accompanying symptoms of hypogonadism. Serum T ≤ 300 ng/dL is considered to be low and T ≤ 250 is frank hypogonadism. Treatment for men who have low T without accompanying symptoms remains somewhat controversial. TRT produces benefits including increased muscle mass and strength, decreased fat mass, increased and bone mineral density. TRT also produces known risks including development of polycythemia, decrease in HDL, breast tenderness and enlargement, prostate enlargement, and increases in serum PSA and prostate-related events. Importantly, TRT does not increase the risk of prostate cancer. Several recent reports have also indicated that TRT may produce cardiovascular (CV) risks, while others report no risk or even benefit. To address the potential CV risks of TRT, we have recently reported via meta-analysis that oral TRT increases CV risk and suggested that the CV risk profile for i.m. TRT may be better than that for oral or transdermal TRT. Herein, we review the literature which indicates that i.m. TRT produces greater musculoskeletal and may be safer that either oral or transdermal preparations. We also review the literature discussing the use of 5α-reductase inhibitors as a promising means of improving the safety profile of TRT.

http://ajpendo.physiology.org/content/ajpendo/early/2015/04/16/ajpendo.00111.2015.full.pdf

 

[Nelson Vergel]

Thanks Henry! I was looking for the paper.

 

[Nelson Vergel]

Markee

DHT gel is not approved in the US. Germany has it (Andactrim). A few sites sell it but not sure which one is trustworthy.

 

[ReGenesis1]

We, at ReGenesis, have used both injectable, as well as creams/gels. To obtain similar blood levels as an injection you have to assume that only about 10% of the cream dosage ever makes it through the skin. So, you have to use 300mg of testosterone cream/gel PER DAY, in order to get about 200mg per week. Most patients, even with that dose, don't get to quite the levels on 1cc per week of testosterone injection (200mg/mL.) For the men we have on cream, their levels held steady at 700-800 for about a year or so. After that, I've seen their levels dramatically decrease down to as low as 300! This is due to transdermal fatigue. Additionally, testosterone creams/gels convert to DHT much more readily than injectable testosterone; thus, requiring addition of finasteride which can/does steal some of the benefits of testosterone. Having treated hundreds of patients with low T we, at ReGenesis, feel that there is no substitute for good old fashioned injectable testosterone with anastrazole and maybe a baby dose of finasteride, depending on the patient.

 

[SuperDutyDave]

We, at ReGenesis, have used both injectable, as well as creams/gels. To obtain similar blood levels as an injection you have to assume that only about 10% of the cream dosage ever makes it through the skin. So, you have to use 300mg of testosterone cream/gel PER DAY, in order to get about 200mg per week. Most patients, even with that dose, don't get to quite the levels on 1cc per week of testosterone injection (200mg/mL.) For the men we have on cream, their levels held steady at 700-800 for about a year or so. After that, I've seen their levels dramatically decrease down to as low as 300! This is due to transdermal fatigue. Additionally, testosterone creams/gels convert to DHT much more readily than injectable testosterone; thus, requiring addition of finasteride which can/does steal some of the benefits of testosterone. Having treated hundreds of patients with low T we, at ReGenesis, feel that there is no substitute for good old fashioned injectable testosterone with anastrazole and maybe a baby dose of finasteride, depending on the patient.

I ran ran into similar with transdermal. Numbers were good for a short while then feel quickly. I switched to EOd SubQ and haven't looked back. Good numbers and good health. No big issues with conversion etc

low dose frequent SubQ is where it's at

 

[Vince]

We, at ReGenesis, have used both injectable, as well as creams/gels. To obtain similar blood levels as an injection you have to assume that only about 10% of the cream dosage ever makes it through the skin. So, you have to use 300mg of testosterone cream/gel PER DAY, in order to get about 200mg per week. Most patients, even with that dose, don't get to quite the levels on 1cc per week of testosterone injection (200mg/mL.) For the men we have on cream, their levels held steady at 700-800 for about a year or so. After that, I've seen their levels dramatically decrease down to as low as 300! This is due to transdermal fatigue. Additionally, testosterone creams/gels convert to DHT much more readily than injectable testosterone; thus, requiring addition of finasteride which can/does steal some of the benefits of testosterone. Having treated hundreds of patients with low T we, at ReGenesis, feel that there is no substitute for good old fashioned injectable testosterone with anastrazole and maybe a baby dose of finasteride, depending on the patient.

Most ExcelMale members try to avoid an AI, we know all the trouble low estradiol levels can cause.
Here's a good thread on the damage that finasteride can cause.

https://www.excelmale.com/forum/sho...ide-Syndrome-Persistent-Propecia-Side-Effects

Finasteride, even at low doses, may cause reduced sperm counts in some men. In this population, counts improved dramatically for the majority of men after finasteride discontinuation. The hormone parameters, sperm motility, and sperm morphology were unchanged after cessation. Finasteride should be discontinued in subfertile men with oligospermia, and used with caution in men who desire fertility.

 

[ReGenesis1]

Really? Haven't tried sub q. Only IM. I like the once a week and done. Plus, I'm a subscriber to the bolus injection that gets you over 1,000 ng/dL for 4-5 days, then down to about 800/900 by day 6/7. When you do low doses every other day, you do keep a consistent blood level, but really never see the benefit of being over 1,000 for even 4 days of the week!

 

[ReGenesis1]

I hear you on the finasteride, but you can't avoid it with those men who are very sensitive to DHT, get acne, prostate enlargement and/or hair loss from test converting to DHT. It's a "necessary evil," at times, unfortunately. I've had 3 kids and a vasectomy. We don't have many patients, who are younger and still having children...most are late 30s to late 50s.

 

[ReGenesis1]

AI's and finasteride

With the AI's, if you're doing regular bloodwork, you'll have no trouble keeping your estradiol levels well within the normal range. Taking .5mg of anastrazole twice weekly will not kill all of your estrogen. You just can't take 1mg per day. It also stops you from retaining water, getting Gyno, etc. It's all in the dosing and doing regular bloodwork. Last thing you want is too much OR too little estrogen.

Most ExcelMale members try to avoid an AI, we know all the trouble low estradiol levels can cause.
Here's a good thread on the damage that finasteride can cause.

https://www.excelmale.com/forum/sho...ide-Syndrome-Persistent-Propecia-Side-Effects

Finasteride, even at low doses, may cause reduced sperm counts in some men. In this population, counts improved dramatically for the majority of men after finasteride discontinuation. The hormone parameters, sperm motility, and sperm morphology were unchanged after cessation. Finasteride should be discontinued in subfertile men with oligospermia, and used with caution in men who desire fertility.

 

[SuperDutyDave]

Once. Week IM is old school. Only thing worse was the Doc's office every two weeks. The huge dose weekly gives you a boost but since it's more than your body can normally utilize good chance for conversion to estrogen. BAD

multiple times per week allows for small dosages with less conversion. When done SubQ the t-cyp resides in fat pad and slowly ebbs into your system and keeps your T levels at a more constant and steady level

highly recommended by the leading Docs using TRT

good luck

 

[Jason Sypolt]

With the AI's, if you're doing regular bloodwork, you'll have no trouble keeping your estradiol levels well within the normal range. Taking .5mg of anastrazole twice weekly will not kill all of your estrogen. You just can't take 1mg per day. It also stops you from retaining water, getting Gyno, etc. It's all in the dosing and doing regular bloodwork. Last thing you want is too much OR too little estrogen.

A lot of caution should be used with the AI's. That same dose of Anastrozole almost completely wiped out all of my Estradiol. And I am a low SHBG guy who is supposed to be prone to aromatization problems. AI's are powerful drugs.

 

[Vince]

Really? Haven't tried sub q. Only IM. I like the once a week and done. Plus, I'm a subscriber to the bolus injection that gets you over 1,000 ng/dL for 4-5 days, then down to about 800/900 by day 6/7. When you do low doses every other day, you do keep a consistent blood level, but really never see the benefit of being over 1,000 for even 4 days of the week!

I'm presently injecting daily.
Here's my labs when I was injecting 22mg of testosterone every day, 500mg of HCG every 3 1/2 days and no AI.

Vince's latest labs 4/10/17

https://www.excelmale.com/forum/showthread.php?10351-Vince-s-latest-labs-4-10-17

I've never had high estradiol levels but some inject daily to avoid needing an AI.

 

[ReGenesis1]

That's why it's so important to do bloodwork and see what is the right dose of the AI. Unlike most clinics, we don't charge for bloodwork or consults, and bloodwork is so inexpensive. Most clinics use it to make money. We have well over 300 patients and have never once seen a patient out of the normal range for estradiol on .5mg twice weekly of anastrazole. That's not to say it doesn't or couldn't happen. Just haven't ever seen it on that dose. Usually see high SHBG, even on that dose. Do you know of anything that truly lowers SHBG, aside from your experience with AI's?

A lot of caution should be used with the AI's. That same dose of Anastrozole almost completely wiped out all of my Estradiol. And I am a low SHBG guy who is supposed to be prone to aromatization problems. AI's are powerful drugs.