2.) Why Do More & More Men Need Testosterone Replacement Therapy?
3.) What Are The Benefits of Testosterone Replacement Therapy?
4.) Your Questions on TRT Answered
5.) In Closing / Relevant Reading
I have tried to make this guide as comprehensive as possible. I am not above updating it and improving it in the future.
I do not claim to know everything, claim to go into the greatest biological and scientific detail on each point, nor be a medical expert, but I know enough to answer almost any question someone who is just beginning or thinking about beginning TRT could want to know.
I may know more than the average general practitioner, or even endocrinologist, but I am not a doctor, nor licensed to give medical advice.
So even if your doctor is a complete idiot who knows less than I do, it is he/she who is licensed with the necessary credentials that legally permit them to give you medical advice, so you should only take advice from them, not me.
This is a practical, rather than intellectual piece. I will employ a simple writing style accordingly.
The structure of this article will take a questions and answers format from section 4 onward, with some background into the importance of TRT beforehand.
I have fielded questions from across the internet (email, blog, Twitter, Reddit) and the purpose of this article is to answer the plethora of questions put to me on TRT in a single, centralised location despite the controversy my thread fielding questions for this post generated. TRT is, unfortunately, something of a taboo mired in ignorant fearmongering.
There’s a lot of interest in TRT in the men’s part of the internet, and as a website dedicated to the betterment of man, I do not believe Illimitable Men would be complete in fulfilling the vision I have for it if I shied away from covering this topic simply because its controversial.
Men don’t shy away from things just because it’s going to elicit some outrage and disapproval.
I have no doubt that, upon the publication of this piece, there will be additional questions in the comments. Valuable questions that haven’t already been answered may be added to the article in future revisions, time permitting.
I want this piece to be as helpful, truthful and comprehensive as possible.
It’s taken me awhile to publish this since I first announced I would be working on it, but alas, you will see it has been worth the wait. Reading this will tell you many of the most relevant things you need to know about TRT.
But before we begin, let me reitrate the following: any test recommendations, health services or health information provided by illimitablemen.com, written or verbal, is for educational purposes only and is not intended to diagnose, treat, or cure any disease or condition.
2.) Why Do More & More Men Need Testosterone Replacement Therapy?:
There is a generational decline in testosterone levels amongst men independent of typical age expected decline.
This means men aren’t just losing testosterone as they get older, but men of all ages have lower testosterone than men who were their age the year before. So 2012’s 20 year olds would have 1% greater testosterone than 2013’s 20 year olds.
The later you were born, the lower your testosterone is likelier to be at any given age relative to men who were your age in a previous year.
The average 20 year old man in 2017 has less testosterone than the average 20 year old man in 1997 who has less testosterone than the average 20 year old man in 1977.
This is true for men in every age bracket. Men of all ages across the board have lower testosterone levels. Your grandfather will have higher testosterone at 75 than your father, and your father will have higher testosterone at 75 than you will.
Male hormonal health and fertility is in crisis, and little is being done about it. In fact, blood testing laboratories continually lower their “acceptable range” of blood serum testosterone levels as the population’s testosterone decreases year on year.
They do this, because they devise the range based upon a sample of men from the population.
But if the average man’s health is deteriorating over time due to poor lifestyle choices and inhospitable environmental factors, then the quality standards for male health is effectively decreasing over time.
Men who would’ve gotten help with old reference ranges will no longer get help with newer, revised reference ranges because most doctors will not treat men who fall within the reference ranges even if they’re symptomatic.
And naturally, if the reference range was taken from a population whose health is deteriorating over time anyway, and there is a long-term trend in testosterone decline that hasn’t been fully investigated, then revising the range downward is foolish, as it makes it harder for men with ever poorer health to get the treatment they need.
Look at these recently revised testosterone ranges from LabCorp in July 2017 for instance.
A 25 year old man with say 400ng/dL of testosterone and showing symptoms of hypogonadism (low T) might’ve gotten help back in June from a sympathetic doctor, because although he was in range, he was barely within range.
Now in September 2017, the same 25 year old would be “much more deeply entrenched” within the accepted range, and therefore, although his symptoms of low T remain the same as they did back in June…
He is now far less likely to get the treatment he needs because the revised range makes him appear healthier, even though he isn’t.
The reference ranges really skew the frame of reference doctors use in deciding whether treatment is necessary or not. And the reference ranges are continually lowered to permit an ever declining state of health in men.
Likewise, the WHO (World Health Organisation) keeps downward revising what constitutes an acceptable quality and quantity of sperm.
Lower natural testosterone levels, means lower sperm count, and poorer sperm quality.
In 1968, around 38% of sperm was abnormal in the average man. In 2008, 97% of all sperm was abnormal.
So effectively, there is an epidemic in male hormonal health and fertility and little if anything being done by the medical establishment to redress it.
If you don’t take your health into your own hands and look after yourself, no one else will.
The doctors are busy fiddling numbers downwards instead of helping those who need it by basing their testosterone ranges on erroneous population samples that reflect the state of societal health as it is, rather than reflect an actual desirable healthy state in the body.
The fatal flaw in this is the presupposition that the current state of health in 18-39 year old men with a BMI under 30 is desirable, and that it is wise to gauge reference ranges based upon a large sample derived from this population.
The downward trends over time in both testosterone level and sperm quality and quantity suggest otherwise.
Perhaps one day male health will be taken seriously and society will do something to rectify this truly shocking state of affairs.
But until that time, it’s good to be a man that’s ahead of the curve, and proactively taking matters into his own hands instead of waiting for his nuts to shrivel into nothingness.
3.) What Are The Benefits of Testosterone Replacement Therapy?:
There are two primary reasons to take TRT. Replacement, or optimisation. Replacement applies to men who have low testosterone, and so wish to replace their body’s poor natural production with a higher level in order to reap the benefits of high testosterone.
Optimisation applies to men who are not low in testosterone, but want an edge in life. Not only low testosterone men want to enjoy the benefits of testosterone. Mid testosterone men often do too.
This is a controversial and unorthodox reason for taking testosterone, and is shunned by both the public and much of the medical establishment, yet many men take testosterone for precisely this reason. I’m not here to sugarcoat or hide information from you, so here it is.
What benefits are to be had from a high testosterone level?
– Improved mood/confidence
– Improved energy
– Reduced anxiety
– Improved erections (occur more frequently, and when they occur, are stronger)
– Increased penile girth/length (for some TRT users, but not all)
– Deeper voice (for some TRT users, but not all)
– An increase in muscularity and a decrease in body fat (not instantly, but over time) – even occurs in men who don’t work out, but the effect is even more pronounced in men who do
– Increased insulin sensitivity, meaning greater protection against diabetes
– Greater exercise tolerance (greater strength and endurance)
– Increased ability to gain muscle mass
4.) Your TRT Questions Answered:
“I don’t want to inject testosterone, but am doing everything right with my diet, sleep and exercise and believe I can no longer increase my T naturally. Are there any other options aside pharmaceutical testosterone for increasing my natural testosterone levels?”
Yes, you have three options that I’m aware of, which, despite not being natural methods, will increase your testosterone level without requiring you to inject testosterone.
The first two options are applicable to any man, whilst the final option is context dependent in that it will help increase testosterone levels in some men, but not in all men due to its method of action.
The first option is clomid monotherapy, clomid is a drug which increases your luteinizing hormone (LH) and follicle stimulating hormone (FSH). It is your LH and FSH that are responsible for communicating to your testicles how much testosterone (and sperm) they should be making.
Think of them as hormonal signal instructions that biologically dictate to your testicles how hard they should be working.
The higher your LH and FSH, the more testosterone your testicles will make, the lower your LH and FSH, the less testosterone your testicles will make.
Now despite not being a “natural method to increase testosterone”, clomid increases your body’s endogenous (internal) production of testosterone as opposed to shutting it down by introducing an exogenous (external) source of testosterone.
The first advantage to this treatment method is it’s an oral, so it gives the needle phobic a way of treating their low testosterone without injecting.
Secondly, the body’s natural ability to produce testosterone is not reduced by this treatment method, but rather, for the duration of the treatment, is ramped up.
The downside is that many men who employ this treatment method feel absolutely horrendous while on it. Reports of fatigue and a general poor sense of well-being are not uncommon.
Having high T but feeling terrible seems completely pointless, and that’s why I wouldn’t recommend clomid for this purpose.
The second option is HCG monotherapy. Rather than injecting testosterone intramuscularly (into a muscle), you would inject HCG subcutaneously (into stomach fat).
HCG is not luteinizing hormone, but rather mimics it and tricks the body into thinking it is it, this causes the testicles to produce more testosterone and sperm.
Men often take HCG as an ancillary drug when injecting testosterone in order to maintain their fertility, but it can be used alone.
Men who take HCG by itself, as well as in conjunction with TRT, often report a greater sense of well-being.
For those on HCG monotherapy, this is because their testosterone levels are higher.
For the men on TRT who already have high testosterone, this is because the precursor hormones that were depleted (the hormones necessary to synthesise testosterone naturally) have been replenished.
The third option is an aromatase inhibitor.
An aromatase inhibitor will increase testosterone significantly in a man who has low testosterone and high estrogen, but will have little to no effect in men who have low testosterone and normal estrogen.
Before supplementing with an aromatase inhibitor, you should get blood work to see your total testosterone and your estradiol (E2).
If estradiol is in the high range whilst total testosterone is in the mid-range or lower, you may see significant increases in testosterone without going on TRT by opting for an aromatase inhibitor protocol.
Naturally, as with TRT and HCG, the dosage and frequency with which the aromatase inhibitor is to be taken is person dependent. What works for one does not necessarily work for another.
“If I start TRT, will I have to stick a needle in my vein like junkies do? How does the injection work?”
No. Testosterone is not injected intravenously (into the vein). It is injected intramuscularly (directly into the muscle) or subcutaneously (directly into the abdominal or love handle fat tissue).
Doctors at the forefront of developing TRT practice via experimentation (primarily, Dr. John Crissler of allthingsmale.com) recommend subcutaneous injections as the safest and most effective method of administering testosterone replacement.
This method of administration allows you to pierce the fat layer with a tiny 29, 30 or even 31 gauge needle that reduces the injection pain associated with larger needles and avoids muscle scar tissue.
Intramuscular is more common and is still preferred by many as it was the standard for many years.
There are numerous muscles you can inject into, such as the deltoid (beneath the shoulder on the outer arm), the ventrogluteal (the hip) and the gluteus maximus (ass cheek).
Personally I prefer to inject subcutaneously into the abdominal fat, as it’s not at an awkward angle to inject and I’m not tearing up my muscle tissue by sticking a needle in it.
“My doctor has given me a 300mg/ml vial of testosterone to self-inject 100mg per week at home, how do I inject 100mg if the vial is 300mg per ml?”
Very simple. You don’t need to inject an entire millilitre of oil.
If you were injecting 100mg once every 7 days, you’d draw 0.33ml of oil into the syringe because 100 is a third of 300 and 1ml of oil contains 300mg of testosterone.
If you were injecting 50mg twice a week, you’d draw 0.165ml of oil into the syringe, because we know 0.33ml of oil contains 100mg of testosterone which naturally means 0.165, which is half of 0.33, will contain 50mg of testosterone.
When drawing such small amounts of oil, you’re best off using a 1ml syringe so that you can better titrate the dose.
If you use a bigger syringe, say a 2.5ml one, the measurements for each line on the syringe will go up in 0.1’s (0.1ml up to 0.2ml up to 0.3ml) rather than 0.01’s (0.10ml, to 0.11ml to 0.12ml) making it very hard to accurately dose between hundredths of a millilitre rather than tenths.
So for small injection volumes (1ml or less) you’re better off with a 1ml syringe so you can more accurately titrate the dose.
Typically, testosterone propionate has fewer milligrams of testosterone per millilitre, at a ratio of 10mg of testosterone to each 0.1ml of carrier oil.
Whereas testosterone enanthate and cypionate tend to have 20mg, 25mg, or in your case, 30mg of testosterone to each 0.1ml of carrier oil, allowing you to get higher testosterone for a smaller injection volume.
You will never need to inject more than 0.5ml at any one time when doing TRT level doses of testosterone.
Larger volumes (and thus bigger syringes that can accommodate a greater volume of oil) are for steroid users.
“I’ve had big issues with acne in the past, mostly on my back. Will TRT cause this to inflame?”
Yes. Testosterone converts into estrogen via the aromatase enzyme, and into dihydrotestosterone (DHT) via the 5-alpha-reductase enzyme. The higher your DHT level, the more acne you will have.
You can use alpha-reductase inhibitors (ARIs) to block the 5-alpha-reductase enzyme from converting your testosterone into dihydrotestosterone, but they are not very well tolerated TRT ancillary drugs.
DHT is likewise responsible for things such as voice depth and overall body hair growth – thus I cannot, in good conscience, recommend the use of alpha-reductase inhibitors.
“Does taking an estrogen blocker mean I need to have an additional injection?”
No. Estrogen blockers (known as aromatase inhibitors) are orals, not injectables, and thus the control of estrogen does not require an injection.
“How does TRT affect fertility?”
Negatively. TRT makes you subfertile, lowering the quality and quantity of your sperm because your body is sending far below normal amounts of LH and FSH to your testicles.
The reason this is happening is because TRT is suppressive of your body’s natural production of testosterone, that’s why it’s called testosterone replacement therapy – it is replacing your body’s natural testosterone.
So because you have high testosterone from injections, your body sees this, and your testicles decide they don’t need to do any work because you have more than enough testosterone in your body.
The side-effect of this is the testicles are not only responsible for producing testosterone, but likewise sperm. So your fertility is negatively impacted.
You can run HCG concurrently with TRT to increase the quality and quantity of your sperm, and failing that, come off TRT in order to conceive.
By doing this, the body’s natural sperm and testosterone production will begin again. Permanent infertility is incredibly rare.
People who say TRT will make you infertile are fearmongering and do not know what they are talking about. It makes you temporarily subfertile for the duration of treatment and there are concurrent treatments you can use with TRT in order to abate this entirely.
“How do I know my estrogen is high without getting blood work done?”
If you start getting general fatigue, fatigue after eating meals that don’t have a high glycemic index, a sense of social anxiety, sore/itchy nipples, no morning erections, or weaker erection strength when stimulated, your estrogen is probably spiking via aromatisation of the extra testosterone in your body.
The more of these symptoms you have, the likelier excess estrogen is to blame. And at the same time, you could have none of these symptoms, and still have high estrogen.
The more body fat you have, the more you aromatise testosterone into estrogen and the likelier estrogen is the cause of your problems.
Be mindful not to crash your estrogen levels with large doses of aromatase inhibitors, as this will lead to general fatigue and joint pain.
Only people who are very experienced with TRT and know their bodies very well are able to accurately gauge if their estrogen is high or low without blood work. In short, you’re going to need to get regular blood work, otherwise you’re just playing guessing games.
“I’m 24 years old with 576ng/dL testosterone. Can Modafinil/Ritalin or Nootropics in general make up for low T?”
You have suboptimal testosterone for your age, but not low testosterone. If you have the symptoms of low T, you might have low free T or high estrogen. You need to run blood work to determine this.
You can’t really compare CNS (central nervous system) stimulants to a hormone. If you’re thinking of using stimulants, I will assume fatigue is the main thing you’re looking to fix.
The stimulants will alleviate fatigue for as long as tolerance to said stimulants remains low, but they will not alleviate any of the other issues associated with low T. Your body does not build up tolerance to testosterone like it does stimulants, so from a tolerance perspective alone TRT is superior.
And that’s not even the main reason TRT is better.
Higher testosterone has a whole range of benefits, including but not limited to: improved mood, insulin sensitivity and erections. In a nutshell, don’t look for a band-aid to fix issues caused by suboptimal testosterone, address the root cause of the problem.
“I’ve read that TRT before 25 isn’t advisable because your brain is still developing, is this true?”
Most physicians won’t prescribe TRT if you are under the age of 25 out of fear it will permanently screw up your hypothalamic pituitary testicular axis (HPTA). Unless you have extremely low levels, say 100ng/dL, or are missing a testicle or something, they are unlikely to prescribe you testosterone.
“Will TRT make me go bald?”
Only if you have the male pattern baldness gene. If you have the male pattern baldness gene, no matter what you do, you’re going to go bald.
Higher levels of testosterone will make it happen quicker and sooner.
Are any of the men in your family bald? If not, more testosterone isn’t going to make you magically go bald either.
If you want to know for definite, get your genes analysed by 23andme.com to see if the MPD (Male Pattern Baldness) gene is present in your genome.
Men who do not have this gene will not go bald irrespective of whether they use TRT or not.
“What is the maximum allowable interval between injections?”
This depends on the type of testosterone you’re using. If you use testosterone propionate, every 2 days. If you’re using testosterone enanthate, every 7 days. If you’re using testosterone cypionate, every 8 days.
Injecting this infrequently will not give most men optimum testosterone levels, but will instead start you off high and leave you mid level before you next inject.
If you want to keep your level high all the time, you would inject more frequently. The propionate daily, and the cypionate/enanthate every 3-3.5 days.
There is a form of testosterone known as testosterone undecanoate that would allow you to have a single injection every 3 or 4 weeks, but it is not approved for use in the US and does not keep your testosterone levels as stable as the faster acting esters, so is not recommended.
“My doctor gave me 23 gauge needles to inject my testosterone, but I’m in considerable pain when I inject. I don’t understand all the different needle sizes. Can you explain how the needle sizes work, and which ones I should use to inject my TRT?
The gauge is the thickness of the needle, the inch measurement is the length. The lower the gauge, the greater the thickness. An 18 gauge needle is a lot thicker than a 25 gauge needle.
The largest available needle is a gauge 6, and the smallest is a 34, although gauges outside the 18 – 31 range are so uncommon there’s an extremely low chance you will ever use them.
Needle length varies, and is proportional to the gauge. Thicker needles with lower gauge numbers have greater lengths than thinner needles with higher gauge numbers.
Your average 18 gauge needle is 1.5 to 2 inches long, whereas a 25 gauge needle is usually 5/8th’s of an inch and a 27 gauge needle is usually 1/2 an inch in length.
I would recommend using an 18 gauge needle to draw the fluid into the syringe, and nothing bigger than a 25 gauge 5/8″ to inject it.
A number of men prefer to use 29-31 gauge 1/2″ needles subcutaneously to minimise pain when injecting.
“What would the optimal TRT protocol look like?”
Firstly, you run blood work and see what your levels are. You get your testosterone checked, you get your SHBG checked, your PSA, your LH, your FSH, your prolactin and your estrogen (E2) checked.
You get your free testosterone calculated included in the test otherwise you’re going to be working it out manually with a calculator such as this one when you get your blood work back.
You get put on 100mg of testosterone enanthate or cypionate per week.
You do 2 injections per week, once on Monday, once on Thursday.
You inject 50mg each time into the subcutaneous fat tissue, rotating between the left and right abdomen.
You do this for 4-6 weeks, then you get more blood work done.
You time the blood test so your sample is taken just before you’re due for your next injection. This allows you to see the lowest level your testosterone reaches between injections.
You’ll be mainly looking at testosterone, estrogen, prostate specific antigen, hematocrit and hemoglobin to see if they’re at desirable levels. You don’t want your blood getting too thick.
If your blood gets too thick, you will have to have a therapeutic phlebotomy (give blood), you may have to do this regularly.
If your testosterone is too low (say 500ng/dL when you only injected 3 days ago) – you increase your weekly dose to 150mg of testosterone, splitting the dose to 75mg twice weekly.
If estrogen is too high, you introduce an aromatase inhibitor. A starting protocol is 12.5mg of exemestane every other day.
If you plan on having children in the future, you add HCG into the mix, usually 1000IUs per week split between two 500IU injections.
You run blood work again in 4-6 weeks and adapt your dosages and frequency of injections/consumption of aromatase inhibitor as necessary.
This is called “getting dialled in” – adjusting the dosages of what you take and when you take them so you feel good and get good blood work back. It takes time, money and patience.
It will take a while to optimise your TRT protocol. You will not be fixed instantly. This is hard work. It’s for men who are mature enough and frankly bold enough to take control of their health, and can handle all the responsibility that comes with that, and would prefer that rather than spend their lives in a low testosterone state because injections are scary and monitoring blood work sounds like a lot of effort.
5.) In Closing / Relevant Reading:
Tired all the time? Depressed for no reason? Go and get your blood work done. I’ve already told you what to check.
When you get your blood work done, make sure you actually have a physical copy of the results so you can interpret your own blood work.
The number of times doctors have said “your levels are normal” to sick people is so off the charts, it’s criminal.
If you’re in the continental US, there are some online mail order TRT clinics you can use (I am affiliated with neither group):
If you want to do further reading on TRT before committing yourself to what is ultimately a lifelong endeavour of injections and blood work monitoring, I recommend the following books:
Testosterone: A Man’s Guide
The Definitive Testosterone Replacement Manuel