New to this...

June 1, 2005

Just learned a new net acronym. DH = Dear Husband.

Amy-

If someone doesn't beat me to posting this, the response you will

get here is that the nurse is quite a bit off as to how normal your

husband's T level is. With the symptoms you describe, HRT may really

ameliorate his condition. Testosterone levels in healthy men are

correlated with age. If you look in the Files section of this group

you can look at the chart called T_By_Age and see that statistically,

239 is low even for a healthy 90 year old man. The medical community

is evolving in understanding " non classical " hypogonadism so it is

very likely you may go through a few doctors before you see one who

will diagnose hypogonadism for your husband. The AACE guidelines

found in the files section are wordy, but it is a respectable primer

for hypogonadism.

Best wishes,

Dano

> My DH has had a low libido as long as I have known him (8 years

> now). Over the past few years he has had prostate infections.

> After trying to find out what low testosterone levels do - I saw

> that it could affect the prostate and aid in getting infections.

>

> Earlier this year my DH had his annual and I went with him. I

> addressed my concerns to the MD and he kind of blew me off. Told us

> he would run a test but more than likely his low libido is just due

> to high stress and nothing else to worry about.

>

> So he said they would run the test but they would do it with his TSH

> level in 8 weeks. So they ran the test in May and I get a call

> while DH is out of town to tell me - his thyroid is still off and

> now his testosterone is low (Testosterone level was 239 - Test. Free

> was 10.3). The nurse said it isn't off but by a few points and so

> nothing will probably need to be done about it.

>

> I found a list of symptoms and he fits a lot of them (depression but

> he doesn't think he is; weight gain in abdomin; anger; aggression;

> and many more). Yet he doesn't have a problem with ED and wakes

> with erections often (so that is why the MD didn't think it was a

> big deal).

>

> I am trying to gain as much knowledge as I can before we meet with

> the Dr. in a couple weeks.

>

> I am very grateful to have some kind of answer but I guess until I

> find out for sure what is going on other than low testosterone I

> don't really have one.

>

> Amy

June 1, 2005

Thank you very much. I saw that early and according to that he

should be up over 650 (he is 35). The problem is - if his regular

MD doesn't feel it is a big deal then he isn't going to either.

Having a low libido aids him in his work actually. He doesn't think

of or want sex all to often (like once every 3 to 6 months) so this

works for his advantage actually. It frustrates me but if he

doesn't find someone right away who thinks there is a problem -

nothing will happen from it.

So on that note - if nothing is done about it - what can happen to

him because of the low testosterone?

Amy

> Just learned a new net acronym. DH = Dear Husband.

> Amy-

>

> If someone doesn't beat me to posting this, the response you will

> get here is that the nurse is quite a bit off as to how normal your

> husband's T level is. With the symptoms you describe, HRT may

really

> ameliorate his condition. Testosterone levels in healthy men are

> correlated with age. If you look in the Files section of this group

> you can look at the chart called T_By_Age and see that

statistically,

> 239 is low even for a healthy 90 year old man. The medical

community

> is evolving in understanding " non classical " hypogonadism so it is

> very likely you may go through a few doctors before you see one who

> will diagnose hypogonadism for your husband. The AACE guidelines

> found in the files section are wordy, but it is a respectable

primer

> for hypogonadism.

>

> Best wishes,

> Dano

>

June 1, 2005

Amy your DH has very low levels of T and the nurse is not up on low t is she

said that. You DH levels are so low a 100 yr. old man has higher levels. He

need to see a Dr. that knows what he is doing.

Here is a cut & paste from a Dr. that knows how to test and treat low t. Print

it and show it to the Dr. this Dr. teaches other Dr.'s on how to treat Low T.

Sorry guys for the long post but can't link this.

Phil

MY CURRENT BEST THOUGHTS ON HOW TO ADMINISTER TRT FOR MEN

-A RECIPE FOR SUCCESS-

-- Crisler, DO

We have already learned a practical bit about the various hormones

that make up the metabolic " symphony " which comprises our hormonal

milieu. We know where these hormones are produced, what modulates

their production, and the target tissues of their various and varied

actions. But we still need to integrate this knowledge into a

practical " recipe " , if you will, so the clinician may return to

his/her practice, and immediately begin screening for, and

successfully treating, male hypogonadism. In other words, how do you

actually administer Testosterone Replacement Therapy for men?

Should EVERY adult male patient who presents at your office be

automatically screened for hypogonadism? About half of all men over

the age of fifty are in fact hypogonadal (when tested for

Bioavailable testosterone—more on that later). Certainly the answers

to Medical History will lead the way toward suspicion of same, yet

the complaints related to this insidious condition are sensitive

without being specific. Clinical suspicion is further clouded

because there is no way to correlate either the number of individual

complaints, or the relative magnitude of each, to the severity of

the hypogonadotrophic state on laboratory assay. The number one

complaint which should hoist the proverbial red flag is Erectile

Dysfunction. This is also the symptom of hypogonadism which, aside

from all the seriously deleterious effects of same (coronary artery

disease, diabetes, osteoporosis, increased risk of cancer,

depression, dementia, etc.), is most likely to bring the patient to

actively seek TRT—and to remain compliant in your treatment regimen.

INITIAL LABWORK

Following a good Medical History, which laboratory assays should be

run as part of your initial hypogonadism workup? Following is my

list, but certainly other specialists in this area run expanded or

attenuated panels, per their experience and expertise. Of note,

there are several other tests which should be included to complete

the true comprehensive Anti-Aging Medicine workup (i.e.

homocysteine, fasting insulin, comprehensive thyroid study, etc.),

as this chapter is concerned solely with administering TRT. And as

always, the panel is tailored to the individual patient. Here they

are:

• Total Testosterone

• Bioavailable Testosterone (AKA " Free and Loosely Bound " )

• Free Testosterone (if Bioavailable T is unavailable)

• DHT

• Estradiol (specify the Extraction Method, or " sensitive " assay for

males)

• LH

• FSH

• Prolactin

• Cortisol

• Thyroid Panel

• CBC

• Comprehensive Metabolic Panel

• Lipid Profile

• PSA (if over 40)

• IGF-1 (if HGH therapy is being considered)

FOLLOW-UP LABS

Two weeks after initiating a transdermal, or five weeks after the

first IM injection:

• Total Testosterone

• Bioavailable Testosterone

• Free Testosterone (if Bioavailable T is still unavailable)

• Estradiol (specify the Extraction Method, or " sensitive " assay for

males)

• DHT (especially if patient is using a transdermal delivery system)

• FSH (3rd Generation—ultrasensitive assay this time)

• CBC

• Comprehensive Metabolic Panel

• Lipid Profile

• PSA (for more senior patients)

• IGF-1 (if GH Therapy has been initiated already)

INDIVIDUAL ASSAYS EXPLAINED

TOTAL TESTOSTERONE

This is the assay your patients will most focus on. It's also the

one physicians who do not understand TRT will use to deny patients

the testosterone supplementation they want, and need, when Total T

is at low-normal levels. Total T is important for titration of

dosing, but its relevance is reduced in older men (by virtue of

their increased serum concentrations of SHBG), in favor of:

BIOAVAILABLE TESTOSTERONE

Where we actually get the " bang " for the hormonal buck, so to speak.

This is the actual amount the body has available for use, as the

concentration of hormone available within the capillary beds

approximates the sum of the Free Testosterone plus that which is

loosely bound to carrier proteins, primarily albumin. If Bio T is

not readily available, Free T may be a second choice substitute, as

Bio T and Free T serum concentrations are well correlated.

DHT

This assay is especially important to draw, up-front and at follow-

up, if a transdermal testosterone delivery system is preferred by

the patient. I'll explain why later. DHT level may also help

indicate cause for ED symptoms.

ESTRADIOL

There are several reasons why this assay is VERY important, and

should not be ignored in ANY hypogonadism work-up (or subsequent

regimen). First, you definitely need to draw a baseline. Next,

elevated estrogen can, in and of itself, explain hypogonadal

symptoms. If E is elevated, controlling serum concentrations

(usually with an aromatase inhibitor, which prevents conversion of T

into E) may suffice in clearing the symptoms of hypogonadism. And

finally, rechecking it after beginning the initial dose of

testosterone will give the astute physician valuable information as

to how the patient's individual hormonal system functions, as well

as making sure estrogen does not elevate inappropriately secondary

to the testosterone supplementation.

I don't waste time and money drawing estrone and estriol. E2 is the

player of interest here. Unless you specify a `sensitive' assay for

male patients, the lab will run the Rapid Estradiol for fertility

studies in females, which is useless for our purpose here. Quest

Diagnostics calls this their Estradiol by Extraction Method.

Some practitioners believe that it is only the T/E ratio which is

significant, and therefore, as long as E " appropriately " rises with

elevations in T, all is well. However, the absolute concentration of

E is of concern, too, especially in light of new information

pointing to elevated estrogen as cause, or adjunctively encouraging,

several serious disease processes, including prostate and colon

cancer.

LH

As everyone knows, it is LH which stimulates the Leydig cells of the

testes to produce testosterone. A caveat, however: LH has a half-

life of only about 30 minutes. When you combine this fact with the

absolute pulsatile nature of its pituitary release, care must be

taken to not place too much weight upon a single draw. A luxury

would be to acquire serial draws, say, twenty minutes apart.

However, such would be both inconvenient and probably prohibitively

expensive for the patient. The most important reason to assay the

gonadotrophins is to differentiate between primary and secondary

(hypogonadotrophic) hypogonadism.

FSH

The eight hour half-life of this hormone makes it a better marker

for gonadotrophin production. It is also less an acute phase

reactant to varying serum androgen and estrogen levels than LH.

Greatly elevated FSH levels could signal a gonadotrophin-secreting

pituitary tumor.

Of note, I run FSH (but not LH) on the follow-up labs, the new third

generation ( " sensitive " ) assay, to determine the magnitude of HPTA

suppression secondary to androgen therapy. It also provides valuable

information for those patients undergoing TRT who are interested in

the state of their fertility.

PROLACTIN

A very important hormone, and must not be overlooked on initial work-

up. Approaching five percent of hypogonadotrophic hypogonadism is

associated with hyperprolactinemia, due to inhibition of

hypothalamic release of LHRH. Its serum concentration must be

maintained within physiological range (meaning neither too high nor

too low). Greatly elevated hyperprolactinemia, or hyperprolactinemia

plus a Total Testosterone less than 150ng/dL, equals a trip to an

Endocrinologist for an MRI of the sella turcica.

CORTISOL

True Anti-Aging medicine must be well-familiarized with the ins and

outs of this hormone, the only one our bodies cannot live without.

Elevated levels can cause secondary (hypogonadotrophic)

hypogonadism. I try controlling elevated cortisol with

Phosphatidylserine, 300mg QD, with good results. It is just as

important to watch for depressed cortisol levels, as well. The assay

of choice for that condition is a 24-hour urine.

THYROID PANEL

I have, for my own convenience, omitted the specifics of the

obligatory thyroid function panel you certainly will want to run.

Hypothyroidism mimics hypogonadism in several of its effects.

CBC

This is just good medicine. Ruling out anemia is important, of

course, as it may be a cause for the fatigue which brought the

patient into your office. You also want to establish baseline H & H,

for those rare cases where polycythemia becomes a problem (and we

are reminded smokers are at increased risk for polycythemia). Above

18.0/55.0 TRT is withheld, and therapeutic phlebotomy recommended.

CMP

Again, just good medicine. Baseline for sodium (which may elevate

initially secondary to androgen supplementation) is important. We

also want to see LFT's, as elevations in same secondary to androgen

supplementation are listed as a possible side effect in the product

literature (although I have yet to see this actually happen). I like

the BUN/creatinine ratio as a marker for hormonal hemo-

concentration, and also it gives me a hint of how compliant the

patient will be (because I always tell them to make sure to drink

plenty of water while fasting for the test).

Lipid Panel

This is drawn to provide your bragging rights when you drop the CHOL

30 points, thanks to your own good administration of TRT. You should

expect to see lowered TRIG and LDL's, too. Be advised, this will not

happen if you choose to elevate their androgens above the top

of " normal " range, i.e. providing what amounts to an anabolic

steroid cycle. Of course, this would no longer constitute TRT, as

the practitioner would then be choosing to damage the health and

well-being of the patient.

HDL does frequently drop a bit, but that is believed to be due to

increased REVERSE cholesterol transport; so much of the plaque is,

after being scavenged from the lining of the CV system by HDL, now

being chewed up by the liver. Androgens also elevate hepatic lipase,

and this may have an effect. The important thing to keep in mind is

that TRT inhibits foam cell formation.

PSA

For all patients over 40. Even though prostate CA is rare in men

under the age of fifty, we don't want it happening on our watch, do

we? At this time, rises in PSA above 0.75 are a contraindication to

TRT (until follow-up by a Urologist). You may find that, at the

initiation of TRT in older men, when serum androgen levels are

accelerating, PSA may, too. This is especially true when transdermal

delivery systems are employed, because they more greatly elevate

DHT. Once T levels have stabilized, PSA drops back down to roughly

baseline. You won't really see gross elevations in PSA secondary to

TRT administration in younger patients. New TRT patients need to be

cautioned, and reminded, to abstain from sexual relations prior to

the draw, as they may now be enjoying greatly elevated amounts of

same.

I get a PSA up front on my over 40 patients, at the one month follow-

up in my more senior patients, and every six months after that. DRE

(Digital Rectal Exam) is recommended twice per year as well,

although the American Academy of Clinical Endocrinologists

backs " every six to twelve months " in their 2002 Guidelines for

treating hypogonadotrophic patients with TRT.

IGF-1

For those who are considering the addition of GH to their Anti-Aging

regimen. IGF-1 will rise from testosterone supplementation, and vice

versa. Let's grab a baseline now, before that happens.

THINGS TO LOOK OUT FOR:

CO-MORBIDITIES. Currently, only breast and active prostate cancer

are absolute contraindications for TRT. Patients with serious

cardiac, hepatic or renal disease must be monitored carefully due to

possible edema secondary to sodium retention. Also, TRT may

potentiate sleep apnea in some chronic pulmonary disease patients,

although studies have also shown it can actually ameliorate the

symptoms of sleep apnea.

DRUG INTERACTIONS. TRT decreases insulin or oral diabetic medication

requirements in diabetic patients. It also increases clearance of

propranolol, and decreases clearance of oxyphenbutazone in those

receiving such medications. TRT may increase coagulation times as

well.

TESTOSTERONE DELIVERY SYSTEMS

Now we have to decide, TOGETHER with our patient, what form of

testosterone delivery system we will START with. There are two basic

subsets of same—transdermals and injectables. Here are the current

options:

TESTOSTERONE GELS AND CREAMS

The only way to go, in my professional opinion, if physician and

patient prefer a transdermal delivery system. They are easy to

apply, well absorbed, and rapidly establish stable serum androgen

levels (usually by the end of the second day). I recommend all

practitioners first try a testosterone gel for their TRT patients.

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, which

acts as the actual reservoir for the hormone's delivery. One may

then shower, or even swim, without worry. I remind my patients that

most of us have neither the time, nor the opportunity, for romance

until evening (given the recommended early morning application), and

a quick shower is always nice to " freshen up " then anyway.

Gels and creams, like all transdermal delivery systems, provide a

bigger boost in DHT levels, compared to injectable testosterone

preparations. This can be a double-edged sword. As DHT is

responsible for all the things of manhood, the transdermals are

better at treating ED than the injectables. However, issues of hair

loss and possible prostate morbidity (a contentiously debatable

point, to be sure) then come into play. Either way, please make sure

to monitor DHT with the transdermals. I'm just not comfortable with

gross elevations in DHT, and prefer to avoid adding finasteride

whenever possible.

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 on the scalp.

TESTOSTERONE PATCHES

These can be quite effective, but are inconvenient to use.

Approaching 2/3's of your patients will develop a contact dermatitis

from them at some point. Another drawback is that some patients

report they are constantly aware of their placement, and the patches

are embarrassingly obvious to other gentlemen in certain public

places, such as in the locker room.

The scrotal application variety is the most inconvenient. To see

what I would be putting my patients through, I tried them. After

just a couple days, I'd had more than enough. Men do not generally

enjoy shaving their scrotum, and the patches just do not stay on

well anyway. Applying a hair dryer to the patch, as they must be

warmed first, is also an annoyance. If you go to the gym during the

day, they look strange affixed to the genitals, and must be removed,

then reapplied, to shower. They do not stick well in the first

place, and even less so once they have been reapplied. Of the two

options, I found only the type with the extra adhesive had any

chance of remaining in place. The scrotal variety causes the largest

increases in DHT—which can be good or bad, as previously explained.

TESTOSTERONE PELLETS

In my opinion, their use is absolutely Stone Age. Sure, they can

provide extra revenue by virtue of a billable office based

procedure. However, needlessly exposing patients to the risks ALL

surgeries pose—hemorrhage and infection—is unwarranted. And the area

of insertion will be much tenderer than that following a mere IM

injection. But the real issue which selects against pellet

implantation is concerned with dosing. Let's say you establish

a " usual " initial dose for the pellets. As will be described in the

next section, there is absolutely no way to predict, up front, how a

patient will react to a given dose of testosterone, regardless of

the delivery system. So you bury these pellets in your patient's

backside, and (hopefully) draw follow-up labs in a month or so. What

are you to do if the total testosterone ends up greatly exceeding

the top of normal range (meaning the patient hyper-responded to the

treatment)? Now you must make a much wider incision to remove them,

or a portion of them (and who knows how many to take out?). With

their very long half-life, SOMETHING must be done, lest you risk

actually damaging the health of the patient by elevating

testosterone levels into what might be considered a bodybuilding

steroid cycle. And what if the pellets do not elevate T enough? You

must bring them back in to implant more, and it's difficult to sell

them on this idea, since they probably are not yet feeling the

advantages of TRT enough yet to motivate them into undergoing

another surgical procedure. It just doesn't make sense, to my way of

thinking.

Testosterone pellets do have some benefit in that selected patients

may believe it more convenient to come in every month or six weeks,

and then be done with it for a while. Also, because they release T

in a slow, steady rate, the pellets are less likely to induce

increases in aromatase activity.

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. Some patients, as you well know, just

hate shots (although I have noticed several who had initially

claimed this, but admitted, once they had come to enjoy the benefits

of TRT, actually came to look forward to their weekly injection).

And no doubt, an invasive delivery system brings more risk than, for

instance, a testosterone gel or cream (the other best choice for

TRT).

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 dose provided by Androgel

5gms QD over the same period.

HCG

Many practitioners consider this incredible hormone treatment of

choice for hypogonadotrophic (secondary) hypogonadism. Such

certainly makes sense, as supplementing with a LH analog indeed

increases testosterone production in patients who do not

concurrently suffer primary hypogonadism. But often, upwards of

1000IU per day must be given to achieve the desired serum T level.

Even then, for some unexplained reason, while serum T levels may be

adequately elevated, the patients simply do not report realization

of the benefits of TRT, when HCG is administered as sole TRT. You

also run the risk of inducing LH insensitivity at that dosage, and

therefore may actually cause primary hypogonadism while attempting

to treat secondary hypogonadism. HCG, especially at higher doses,

also dramatically increases aromatase activity, thus inappropriately

elevating estrogens. Personally, I recommend never giving more than

500IU of HCG at a time.

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.

OTHER MEDICATIONS

I occasionally hear of physicians trying to use a SERM (Selective

Estrogen Receptor Modulator) such as Clomid or Nolvadex, or even an

Aromatase Inhibitor (AI), such as Arimidex, as sole " TRT " . All have

been shown to elevate LH, and therefore Total Testosterone levels.

However, patients report no long-term subjective benefits from these

strategies, and the studies thus far reported no long-term changes

in lean body mass, fatigue levels, libido, etc. An added risk of

using an AI is of driving estrogen levels too low, with deleterious

consequences for the lipid profile, calcium deposition, libido, etc.

Finally, Deca-Durabolin (Nandrolone) has no place in TRT. It has a

nasty side effect profile, including uncontrollable progesterone-

like effects (including gynocomastia) and risk of long-term

impotence.

THE MEAT AND POTATOES OF TRT

Now we will delve into the general strategy for administering TRT.

The decision is made, TOGETHER with the patient, which of the

various testosterone delivery systems is to be tried first. Be

prepared to make adjustments, and try other application methods. You

just don't know which will be best for each particular patient until

you try. Besides the simple fact the patient may have a personal

preference, or a logistical consideration (i.e.

inability/unwillingness to self-inject) for a given application,

every-body reacts differently to hormonal manipulation. Some hyper-

respond to a given initial dose, others show hardly any bump in

serum T levels on same. Yet when you switch to a different delivery

system, on initial dosing, they may convert to supraphysiological

androgen levels. The same is true of the subjective benefits from

TRT. I have patients who love testosterone gel because it

successfully treated their ED (the expected outcome because of

dramatically increased DHT production), others get more from IM

testosterone cypionate. My experience thus far has taught me two

lessons: (1) You don't know how a patient will react to a given

dose/system until you try and (2) NOTHING surprises me anymore.

There simply is no way to predict how a particular patient will

respond—not Medical History (i.e. number or severity of symptoms),

body weight, baseline hormone levels, even anabolic steroid history.

I have had very slight gentlemen barely elevate on 100mg of test cyp

per week, and massively muscled former steroid athletes who went to

nearly two times the top of " normal " range on the same dosage (they

had similar baselines). Likewise, one man may see only a modest

increase in DHT on 5gms of Androgel, another may become quite

supraphysiological on same.

I start my guys out on either testosterone cream/gel 5mgs QD or

testosterone cypionate 100mg per week. The IM test cyp must be

administered in weekly injections, as opposed to taking twice the

dosage every other week. Some physicians even dose every third or

fourth week, producing wide swings in serum androgen levels. This

puts the patient on an emotional roller coaster, increases the risk

of developing polycythemia, greatly accentuates aromatase activity,

and actually leaves them lower than they were when they started for

the last half of the cycle. In order to get the serum androgen

concentration to a stable level more quickly, I " frontload " 200mg

the first injection (unless converting over from a gel/cream).

No other medications which manipulate hormone levels are provided

until follow-up labs are returned. For IM test cyp patients, the

second panel is run following the fifth injection. I also keep in

mind the coordination of the injection with the lab draw, as peak

serum levels are attained at about the 48 hour point, then fall to

about 35% at the one week point. However, by the end of the fifth

week, the pharmacodynamics of testosterone cypionate (half life is 5-

8 days) are such that relatively stable serum levels are now being

produced via weekly injections.

Transdermals can be rechecked in two weeks. They produce stable

serum levels, as previously mentioned, for most by the end of the

second or third day. Logistically, it makes sense to send the

patient for follow-up labs after a fortnight, as there is then time

to get the labs back, and bring the patient in, before the initial

30-day supply of the medication runs out. This is better if an

adjustment in dosage is mandated by the follow-up labs, or to

convert to IM dosing should the patient produce too much DHT. It

would be a shame to have the patient refill a script for 5gms of

Androgel, when they, by their labs, are going to have their dosage

reduced to 2.5gms per day because they hyper-responded to the

initial dose, or waste money when what they reallyneed is to be

converted to test cyp.

The question of which testosterone delivery system is to be tried

first (IM or transdermal) is one which brings much confusion amongst

beginning practitioners of TRT. I would, when possible, always start

out a patient on a testosterone cream or gel. Ease of application,

avoidance of intrusion by injection, and increased probability of

successful ED treatment make this so. Also, stable serum levels are

attained quickly, determination of successful treatment is more

forthcoming (although the manufacturer of this product recommends at

least a couple months as adequate trial of therapy). If the labs AND

patient's answers to follow-up subjective report lead to a change to

IM testosterone, the conversion is an easy one to make. Simply apply

the gel, give the shot, then D/C the gel. However, if a patient is

started out on IM test cyp, for instance, yet the patient still does

not feel " right " (and thus you may want to try a transdermal

delivery system to better raise DHT levels), how are you, given the

pharmacodynamics of the testosterone ester, going to safely and

successfully dose the conversion to a transdermal?

Dosing changes are made, TOGETHER with the patient, once follow-up

labwork is back AND the patient is interviewed regarding their

subjective reports of changes in libido, sexual performance,

fatigue, strength, mental outlook, etc. Often they will tell you

they felt " incredible " the first couple of weeks (and bursting with

libido), but they don't feel quite as good now, but still much

better than before they started the TRT. This is because subjective

findings are the best while serum androgen levels are accelerating.

Adjunctive to this phenomenon is the fact their HPTA was not yet

being suppressed, so their endogenous production was higher then

than it would be by the end of the month. TRT patients are always

HPTA suppressed to greater or lesser degree.

Much weight is placed upon the patient's subjective findings, as

they are not likely to remain compliant in the TRT program unless

they feel noticeably better, irrespective of the less obvious long

term improvements in CV health, bone density, decreased risk of

dementia and cancer, etc. Certainly, if the patient reports they are

quite happy at a Total Testosterone level of 600ng/dL, I feel there

is little reason to increase their dosage. As an Osteopath, I am

loath to provide ANY medication, or increase in dosage, without

proven need. As a practical limit, the top of " normal " range for

Total Testosterone provides a ceiling, more or less, above which we

can expect to find the benefits of TRT beginning to reverse

themselves. Actions following androgen receptor binding dramatically

improve health and happiness as we go from the hypogonadal state to

the top of " normal " range, but beyond that the Lipid Profile and

level of insulin sensitivity, for instance, are damaged.

Changes in IM dosing are made in small increments, as response to

same is not linear. It is convenient and practical to increase, or

decrease IM dosing by 20mg at a time, as this is one " tick mark " on

the side of the syringe (for the 200mg/mL concentration). For

Androgel patients, we are more limited by their provided dosing

whereas we can only either drop down to 2.5gms, or add an extra pack

each day (at which time BID dosing may be considered) to reach the

7.5gm, or even 10gm, per day dose. More flexibility is provided

through compounded products for those committed to employment of

transdermal testosterone delivery systems.

Another risk of jumping the dosage too much is that, should serum

androgen levels greatly exceed the top of " normal " range, the

patient risks becoming " spoiled " at that level. They would then feel

the subjective benefits steroid athletes report, and it would be

difficult to get the patient then to be happy at a more moderate—and

proper—dose. It is likely you would also therefore produce elevated

estrogen activity as well, and further muddy the waters with respect

to how the patient feels—and looks (due to emotional changes and

even water retention issues from the elevated estrogen). It is far

better to make changes in dosing conservatively.

Once the method and dosing is set, by laboratory assay AND

subjective report from the patient, then you may address any side

effects due to elevated estrogen levels which have occurred. I do

not use an AI initially, even when E2 is elevated, because some

patients will actually see a drop in estrogen over baseline on

follow-up. We would have otherwise added an unnecessary (and

relatively expensive) medication. Should the patient develop

any " nipple issues " secondary to accelerating serum androgen levels

and/or elevated estrogen, you cannot start them on a SERM right away

because doing so will invalidate your estradiol assay at follow-up.

Of note, males can experience said " nipple issues " even while

estrogen levels are within physiological range, due to changes in

hormone levels. A drug of the class SERM is treatment of choice in

this case, until symptoms subside.

If a patient has " nipple issues " , even while estrogen is within

normal range, I add a SERM, emergently. I prefer Nolvadex over

Clomid, and Evista is probably best of all for antagonizing estrogen

(although much more expensive). Clomid often induces untoward visual

effects (i.e. " tracers " ), and can cause emotional lability by virtue

of its estrogen agonistic effects at the more peripheral (emotion)

brain sites. I do like my patients to keep some Nolvadex on hand,

should they experience nipple swelling or sensitivity, so they may

begin 40mg per day until the symptoms abate, and then taper to 20 mg

QD for a few days, then 10mg for a few more, then finally 5mg QD to

taper off.

My TRT male patients who suffer E2 elevations above the top of

normal range are placed on 0.25mg of Arimidex every third day. If

that is not enough, I use the same dose EOD. It is possible to cut

the tiny 1mg tabs into quarters, but here a gel or cream

preparation, compounded to convenient dosing, makes a lot of sense.

A month later I recheck E2, and make further adjustment if

necessary. It is important to not lower estrogen too far, which is

easy to do with an AI, as doing so has disastrous effects on the

Lipid Profile, bone deposition, etc. I prefer to maintain E in mid-

range.

So now let's say we have the patient in a state where Total

Testosterone is in the upper quartile of " normal " range,

Bioavailable Testosterone is nicely elevated, with E2 safely in

check. At this point I offer the patient my HCG protocol. I add in

250-500IU of HCG, on day five, and day six of the week, for those

who use the IM injection. In other words, the two days prior to

their shot. For those using a transdermal delivery system, every

third day. For the IM patients, this compensates for the drop off in

serum androgen levels by the half-life of the test cyp. But the main

reason is to stave off atrophy of the testicles, by directly

stimulating them with the LH analog.

Patients all report they feel dramatically better once the HCG

regimen is initiated (and they were properly tuned up on

testosterone before they started it). HCG, as a LH analog, increases

the activity of the P450 SCC enzyme, which converts CHOL to

pregnenolone. Thus all three hormonal pathways are stimulated in

patients who may be either entirely, or very nearly, HPTA

suppressed. It is my belief this may be a factor in the heightened

sense of well-being my patients report throughout the week—far in

excess of what a minimal dose of HCG would produce by virtue of

induced testosterone production.

Many TRT practitioners add in HCG for a short course every few

months, to re-stimulate the testes. My opinion is that it is far

better to keep them up to form and function all along the way. The

physicians who intermittently use HCG also use it as a " break " in

TRT, much the same way hormonally-supplemented athletes manage the

typical anabolic steroid cycle. TRT should not be " cycled " . Once I

get my patients properly tuned up, I want them to stay that way.

They also erroneously believe this allows the HPTA to recover, when

it clearly does not. The HCG-induced testosterone production is

every bit as suppressive of the HPTA as the TRT, and the

supplemented testosterone is still at suppressive serum levels

during that time, anyway.

Once the patient is all set, I like to run follow-up labs every six

months. It is important to monitor the general health and well-being

of the patient, but also insure compliance with treatment protocols

and continued effectiveness of same.

**************************************************

**

My hope is that the preceding diatribe will gainfully assist the

practitioner in implementing Testosterone Replacement Therapy

regimens for their qualifying patients. Be prepared, however, to

blush as they shower you with accolades following their vast

improvements in health and happiness. You may even receive thank you

notes from their wives!

Please watch for coming articles and books by Crisler, DO on

this, and other, continuing subjects related to anti-aging.

Copyright Crisler, DO 2004. This article may, in its entirety

or in part, be reprinted and republished without permission,

provided that credit be given to its author, with copyright notice

and www.AllThingsMale.com clearly displayed as source. Written

permission from Dr. Crisler is required for all other uses.

Dr. Crisler may be reached at:

Doctor@...

Amy <apowers0900@...> wrote:My DH has had a low libido as long as I have

known him (8 years

now). Over the past few years he has had prostate infections.

After trying to find out what low testosterone levels do - I saw

that it could affect the prostate and aid in getting infections.

Earlier this year my DH had his annual and I went with him. I

addressed my concerns to the MD and he kind of blew me off. Told us

he would run a test but more than likely his low libido is just due

to high stress and nothing else to worry about.

So he said they would run the test but they would do it with his TSH

level in 8 weeks. So they ran the test in May and I get a call

while DH is out of town to tell me - his thyroid is still off and

now his testosterone is low (Testosterone level was 239 - Test. Free

was 10.3). The nurse said it isn't off but by a few points and so

nothing will probably need to be done about it.

I found a list of symptoms and he fits a lot of them (depression but

he doesn't think he is; weight gain in abdomin; anger; aggression;

and many more). Yet he doesn't have a problem with ED and wakes

with erections often (so that is why the MD didn't think it was a

big deal).

I am trying to gain as much knowledge as I can before we meet with

the Dr. in a couple weeks.

I am very grateful to have some kind of answer but I guess until I

find out for sure what is going on other than low testosterone I

don't really have one.

Amy

---------------------------------

June 1, 2005

Phil thank you very much for this article. I have copied it. I

read through it but will be sure to read through it again.

The nurse was just reading the notes from the Dr. in regards to the

levels and comments that she made. I guess that is my biggest

concern. He is going to go in there once - hear the MD and say it

isn't a big deal.

Thank you again!

Amy

> Amy your DH has very low levels of T and the nurse is not up on

low t is she said that. You DH levels are so low a 100 yr. old man

has higher levels. He need to see a Dr. that knows what he is doing.

> Here is a cut & paste from a Dr. that knows how to test and treat

low t. Print it and show it to the Dr. this Dr. teaches other

Dr.'s on how to treat Low T.

> Sorry guys for the long post but can't link this.

> Phil

]

June 1, 2005

He should be concerned about chronic health problems that can result

if it is left untreated - For some of us, the symptoms in the here and

now were unbearable so that we sought out treatment. He may want to

know that left untreated, hypogonadism is a risk factor for:

alzheimers

osteoporosis

muscular wasting

cardiovascular disease

prostate infections (prostatitis)

COPD

just to name a few...

June 2, 2005

Well he has had prostatitis a few times in the past year. That is why

I got concerned when I was seeking out info on low testosterone and

found a connection to the prostate. Yet since the Dr. kind of blew it

off he wasn't all to worried about it.

So unless the Dr. has had a huge change of heart and is seriously

concerned about it - that will be the attitude my DH will have as

well.

I always to my best to go to the Dr. office armed with all the info I

can possible get. I guess it is good for me that we have a couple of

weeks before we go. There is plenty to absorb around here!

Amy

> He should be concerned about chronic health problems that can result

> if it is left untreated - For some of us, the symptoms in the here

and

> now were unbearable so that we sought out treatment. He may want to

> know that left untreated, hypogonadism is a risk factor for:

>

> alzheimers

> osteoporosis

> muscular wasting

> cardiovascular disease

> prostate infections (prostatitis)

> COPD

>

> just to name a few...

June 2, 2005

Amy - I too went to my GP and got a 220 T and was told it was borderline low and

let it ride - this was the wrong diagnosis. Find a Dr. - I went to urologist and

be prepared to discuss all of the symptoms your hubby has. Also take the

guidelines mentioned by others and be firm with the Dr. This is a long process

to find what will work best for him but it is well worth it both physically and

mentally. It is such a great advantage that you are this understanding and

involved. It means so much to have the support - he will need it. The only other

comment I will make is get him to read through this groups archives. There is so

much to be learned by some of the experienced guys that are members. Once he

sees he is not alone, and that there is light at the end of the tunnel that will

help also.

Best of Luck - Dan

Amy <apowers0900@...> wrote:

My DH has had a low libido as long as I have known him (8 years

now). Over the past few years he has had prostate infections.

After trying to find out what low testosterone levels do - I saw

that it could affect the prostate and aid in getting infections.

Earlier this year my DH had his annual and I went with him. I

addressed my concerns to the MD and he kind of blew me off. Told us

he would run a test but more than likely his low libido is just due

to high stress and nothing else to worry about.

So he said they would run the test but they would do it with his TSH

level in 8 weeks. So they ran the test in May and I get a call

while DH is out of town to tell me - his thyroid is still off and

now his testosterone is low (Testosterone level was 239 - Test. Free

was 10.3). The nurse said it isn't off but by a few points and so

nothing will probably need to be done about it.

I found a list of symptoms and he fits a lot of them (depression but

he doesn't think he is; weight gain in abdomin; anger; aggression;

and many more). Yet he doesn't have a problem with ED and wakes

with erections often (so that is why the MD didn't think it was a

big deal).

I am trying to gain as much knowledge as I can before we meet with

the Dr. in a couple weeks.

I am very grateful to have some kind of answer but I guess until I

find out for sure what is going on other than low testosterone I

don't really have one.

Amy

---------------------------------

June 2, 2005

Thanks Dan but he doesn't feel like anything is wrong. That is where the

problem lies most of all right now. I have read through the symptoms and I

see so many of them about him.

Maybe I should also add he was diagnosed with hyperthyroidism back in 1998.

Then in 1999 he was diagnosed with hypothyroidism. He has been on meds for

that since that time. They have never been able to get his thyroid just

right.. Every time he sees a specialist or his GP he ends up with an

increase or decrease in meds.

So I see a long road ahead of us but he doesn't feel like anything is wrong

or that he needs support for this. He is happy with no libido. He is happy

with being able to focus on work. I have slowly been talking about things I

have read (weight gain in abdomen) and told him maybe if we get his

testosterone sorted out it would help him with that - he was happy about

that but that was about it.

Thank you again!

Amy

On 6/2/05, Dan Meatheany <dmeatheany@...> wrote:

>

> Amy - I too went to my GP and got a 220 T and was told it was borderline

> low and let it ride - this was the wrong diagnosis. Find a Dr. - I went to

> urologist and be prepared to discuss all of the symptoms your hubby has.

> Also take the guidelines mentioned by others and be firm with the Dr. This

> is a long process to find what will work best for him but it is well worth

> it both physically and mentally. It is such a great advantage that you are

> this understanding and involved. It means so much to have the support - he

> will need it. The only other comment I will make is get him to read through

> this groups archives. There is so much to be learned by some of the

> experienced guys that are members. Once he sees he is not alone, and that

> there is light at the end of the tunnel that will help also.

>

> Best of Luck - Dan

>

June 2, 2005

On Wed, 01 Jun 2005 23:28:16 -0000, you wrote:

>Thank you very much. I saw that early and according to that he

>should be up over 650 (he is 35). The problem is - if his regular

>MD doesn't feel it is a big deal then he isn't going to either.

>Having a low libido aids him in his work actually. He doesn't think

>of or want sex all to often (like once every 3 to 6 months) so this

>works for his advantage actually. It frustrates me but if he

>doesn't find someone right away who thinks there is a problem -

>nothing will happen from it.

>

>So on that note - if nothing is done about it - what can happen to

>him because of the low testosterone?

Low testosterone leads to fuzzy thinking, low energy, depression like

symptoms, and other mental and psychological effects that lower

ambition and accomplishment.

On the physical side the most notable serious effect is bone loss. I

ended up cracking 8 ribs over two years to learn I had low T.

Believe me he will feel so much better if he gets his T levels up. He

will find himself more focused, energetic and horny too. It's lie a

trip back to 22.

Have you seen the charts for normal T levels by age? Look in the group

files section. He's about 1/3 of what his levels should be and his

levels are low for an 80 year old man.

He needs to present the chart and evidence to his doctor or find a

doctor who knows this stuff (not an easy task).

- - - -

Just another albino black sheep

June 2, 2005

On Thu, 2 Jun 2005 08:38:48 -0400, you wrote:

>

>Thanks Dan but he doesn't feel like anything is wrong. That is where the

>problem lies most of all right now. I have read through the symptoms and I

>see so many of them about him.

I'd suggest get a copy of Shippen's Book The Testosterone Syndrome.

http://www.amazon.com/exec/obidos/tg/detail/-/087131858X/qid=1117732874/sr=1-1/r\

ef=sr_1_1/102-4302284-6180943?v=glance & s=books

http://tinyurl.com/daut6

You'll learn a lot and he may see more of himself in it.

My wife thought I was depressed before my diagnosis. I disagreed I was

happy, content, but listless and without energy or ambition.

In my case I started cracking ribs which led to the diagnosis which

changed everything.

- - - -

Just another albino black sheep

June 2, 2005

The Dr. blew it off because he just is not in the know. I am sure if he felt

like crap and found his levels were low he would not blew it off. Prostate

problems for me were from high E2 Estradiol and when I got it down my problems

were gone. New info comes out everyday and it looks like the big bad guy for

Prostatitis is high E2.

Phil

Amy <apowers0900@...> wrote:

Well he has had prostatitis a few times in the past year. That is why

I got concerned when I was seeking out info on low testosterone and

found a connection to the prostate. Yet since the Dr. kind of blew it

off he wasn't all to worried about it.

So unless the Dr. has had a huge change of heart and is seriously

concerned about it - that will be the attitude my DH will have as

well.

I always to my best to go to the Dr. office armed with all the info I

can possible get. I guess it is good for me that we have a couple of

weeks before we go. There is plenty to absorb around here!

Amy

> He should be concerned about chronic health problems that can result

> if it is left untreated - For some of us, the symptoms in the here

and

> now were unbearable so that we sought out treatment. He may want to

> know that left untreated, hypogonadism is a risk factor for:

>

> alzheimers

> osteoporosis

> muscular wasting

> cardiovascular disease

> prostate infections (prostatitis)

> COPD

>

> just to name a few...

---------------------------------

June 2, 2005

You need to Kick DH ASS it is a big deal. I always tell my wife this if you

keep putting off finding out what is wrong it is not far to me the the kids. If

you keep putting off something that is wrong untill it is to late then we suffer

because now we have to take care of you. So tell DH if he does not get on the

program when he gets real sick and he will we have guys that sneezed and broke

there ribs from the bone loss of low T. That you will put him in a home. I

can't for the life of me see why people do this my wife included. Tell him if

he wonts to kill him self there are faster ways.

Phil

Amy <apowers0900@...> wrote:

Phil thank you very much for this article. I have copied it. I

read through it but will be sure to read through it again.

The nurse was just reading the notes from the Dr. in regards to the

levels and comments that she made. I guess that is my biggest

concern. He is going to go in there once - hear the MD and say it

isn't a big deal.

Thank you again!

Amy

> Amy your DH has very low levels of T and the nurse is not up on

low t is she said that. You DH levels are so low a 100 yr. old man

has higher levels. He need to see a Dr. that knows what he is doing.

> Here is a cut & paste from a Dr. that knows how to test and treat

low t. Print it and show it to the Dr. this Dr. teaches other

Dr.'s on how to treat Low T.

> Sorry guys for the long post but can't link this.

> Phil

]

---------------------------------

June 2, 2005

Amy you need to give you DH tough love marrage is a 50 50 thing and your not

getting your 50. Get him into a marrage consular unless you like living like

this. I don't and made my wife go or I was leaving. Did this in 1997 and it

was the best thing I did for us.

Phil

" Amy L. Powers " <apowers0900@...> wrote: