If you’ve read and absorbed this guide until now, I commend you. We’ve learnt a tonne of new information that can both change or even save our lives. In part 7, I will reveal my preferred TRT regimes. Now, before I begin, keep in mind these regimes are for those who are new to TRT. From patient to patient, I often have to tweak and tailor each regime to suit the individual’s specific wants and needs. Just like a diet or training program, TRT is not a one size fits all approach. With that said, I would guesstimate that approximately 97% of men will do just fine on any one of these recommended TRT protocols below. You may need to experiment with each if you are unhappy with one or the other. I suggest an experimental period of 3 months before changing regimes. Things in the world of hormones can often take time to balance. It is natural to have your first injection—then to expect to feel like Thor (and many claim they do), but unfortunately science is not often this sexy. Here are my top 3 preferred TRT protocols.
1.) 100-125 mg of testosterone enanthate per week, split into two even injections. That would be 50-62.5 mg of testosterone enanthate injected twice weekly. You may inject this protocol either sub-cutaneously or intra-muscularly.
2.) 30-40 mg of testosterone propionate every other day. You may inject this protocol either sub-cutaneously or intra-muscularly.
3.) 100 mg of testosterone enanthate per week and 1000 iu of HCG per week. That would be 50 mg of testosterone enanthate, injected twice weekly. You may inject this protocol either sub-cutaneously or intra-muscularly. On the same day as your testosterone injection, also inject 500 iu of HCG. The reason for HCG at this dose within a TRT regime would be for the reason of maintaining fertility and also maintaining testicular fullness. Decreased fertility, infertility and testicular atrophy (balls shrinking) are common side effects for more than 50% of TRT users. However, rarely is there a free lunch. It is important to understand that HCG is not always effective in all users to manage these two symptoms and often enough, HCG comes with side effects of its own—thought to be from the increased estrogen production. It seems that in many, HCG will aromatise at a disproportionate rate than conventional testosterone esters will in favour of estrogen. This means that for the same given value of testosterone, with HCG you may have a higher E2 (estrogen) score. Even I just re-read that and it sounds confusing. I’ll try explain that again in terms of ratios to see if that helps some of you understand. With HCG use vs straight testosterone esters, your testosterone:estrogen (T:E2) ratio, may end up narrower, which could increase the chance of excess estrogen side effects. Notice I do not speak in terms of absolutes such as “will” and “certainly.” Anytime you read a science article where the author is too confident, it is probably a good idea to read something else. So, HCG “may” increase the chance of excess estrogen related side effects.
Those who persist with HCG in their TRT regime will find this is a balancing act and most will be able to find a dose of testosterone and a dose of HCG that works for them. On the flipside, there is a large enough community of anecdotes that swear by some extra-gonadal benefits of HCG with their TRT. By “extra-gondal” I mean benefits with HCG aside from testicular fullness and fertility preservation.
These reported benefits include increased mood, libido and energy. This divide seems to be split down the middle though as there is an equally large camp who claim HCG actually causes problems with their mood, libido and energy. With such subjectivity and composite factors surrounding these symptoms, I feel it is hard for me to pick a side. I can say though that HCG has a safe enough profile and because the drug is short-lived in the serum (~72 hours), it is worth a shot if you want to see whether or not HCG is for you. HCG with TRT has become such a huge topic of debate among the TRT community these days, that perhaps HCG needs a dedicated Part of its own. Once again, notice my unbiased viewpoint on HCG. Anyone picking sides confidently in the absence of solid evidence shows a lack of intelligence. Actually, as I get to the end of this section on HCG, I’ve definitely decided to do a Part on HCG now. Stay tuned for that.
I digress a little. Back to my preferred TRT regimes. With any one of these three protocols, 97% are going to find their sweet spot; although, I don’t like how literal that definition sounds. I know for many to over-obsess about a magical “sweet spot” that cannot deviate from a single mg or unit of measure on the blood work. I have strong reason to believe this is untrue, especially considering that in nature both testosterone and estrogen levels can fluctuate from a variety of environmental and developmental factors. Surprisingly, these believers are usually in the 3% camp and although I cannot say they’re wrong because it is their body and they may be right; well, they’re wrong. If your E2 goes from 100 pmol/L to 90 pmol/L and you think that change is the difference between you feeling like you’re on top of the world vs crying yourself to sleep each night—then I would strongly advise you to question that hypothesis.
After you have chosen set protocol above, there are some considerations. First of all, unless something unusually terrible has occurred since you have begun your TRT protocol, please do not change over to another protocol unless at least 3 months has passed. As I mentioned above, hormones often require time to find their way into managing the symptoms we’re looking to resolve. Unless the symptoms are unbearable or obvious such as gynecomastia, we will not be changing a thing.
30-45 days after you have begun your chosen TRT protocol, I suggest checking lab work. Refer to Part 6 for what to check for. Unless a value is out of whack and/or you are symptomatic, we will continue and check labs again in another 30-45 days. If you are one of the 97% you will likely notice that either one of the protocols will work more or less the same for you. If you are in the 3% it is likely all we need to change is something small. I like to tease the 3% but there are some rare, but real things that can occur. They are:
1.) Excess estrogen. I’m hoping we can all agree at this point that estrogen has been unfairly demonised by some pretty poor extrapolations of science, but that should not discredit that there still are some potentially nasty symptoms one can experience due to excessive estrogen or unfavourable ratios of T:E2. An obvious one is gynecomastia, or bitch tits. I do not worry about this one all that much in TRT. With a sensible TRT regime such as those I outlined above, you would be surprised just how rare gynecomastia actually is. Gynecomastia is a phenomenon most commonly experienced by pre-pubescent males, AAS users and those who choose poorly constructed TRT regimes.
If I do encounter a symptom in a patient that I believe may be related to excess estrogen and is also confirmed via lab work—what do I do? Contrary to some popular prescribing methods, the first thing I do here is not to add an aromatise inhibitor, but instead decrease the dose of testosterone. It is a common-sense method of treatment if you know the HPTA basics. Less testosterone, should mean less estrogen also. In before those that say more testosterone is better and that you have to be at the top of the normal range. Untrue. However, what if with one of these protocols your testosterone is on the low end of the scale because you’re aromatising so much estrogen? Well, in my clinical experience with these protocols this kind of patient is rare—but I’ve seen it none the less. It is at this point I will introduce a small dose of an aromatise inhibitor, such as 0.25 mg of arimidex twice weekly. I will adjust up (or even down sometimes) based on the usual—which is? Yep, you guessed it. I will adjust the dose of arimidex up or down based on the lab-work and symptoms. Aromatise inhibitor use in TRT also needs its own Part too, so stay tuned for that. Until I go in depth on aromatise inhibitor use, for now just know that the less medications you require for TRT, the better. The moment you add another medication, you add another variable you may need to tweak. Things can get tricky and there are some risks and side effects with aromatise inhibitors that I prefer to avoid unless necessary.
2.) The next thing that could go wrong with any of these TRT protocols is increased Haematocrit beyond acceptable limits. Simply stated, increases in haematocrit above 54% are associated with an increased risk of heart attack or stroke. Some argue that the 54 should be 52, but the evidence is unclear. I should note that the elevations in haematocrit with testosterone therapy may be different to that of the one’s studied that have been associated with these cardiovascular events. None the less, until further notice, it is my recommendation that you keep haematocrit below 54 to be on the safe side. There is a dose dependent increase in haematocrit with testosterone, so my first method of treatment would be to decrease the dose of testosterone as well as donate blood. Every pint of blood is estimated to decrease haematocrit by 3%. You should donate volume according to how high your haematocrit levels are. For example: if your haematocrit is 57, you may want to donate 2 x pints of blood in the hopes of bringing your haematocrit levels to approximately 51. Donating blood is also of no harm and may save another’s life. If you do not meet the criteria for blood donation, you will require a therapeutic phlebotomy, which is essentially the same thing as a blood donation except the blood pulled goes in the trash. Sadly, a therapeutic phlebotomy is not the easiest procedure to get a referral for in Australia, but with enough kicking and screaming I think you’ll get it done. Retest FBC including HCT after 30 days to check if your haematocrit has returned to a safer range. Often, the dose of testosterone is related to these increases in haematocrit, so a viable long-term solution could be a lower dose of testosterone, which hopefully mitigates the need for blood donation. Some however, will need to donate blood 2-4 x per year in order to maintain health. This number is not that rare, but not that common either.
3.) The last thing that could go wrong with any of these TRT protocols is increased fluid retention. A watery appearance that is “waterier” than usual, even if you’re a watery looking guy. Not uncommon and almost always related to the dose. The treatment? Reduce the dose of testosterone and consider eliminating HCG from your protocol if you are experiencing any excess fluid that is bothering you. Of course, there are several other factors involved in why you may be holding excess fluid, so do not always point to the medication, especially if you’ve been eating a lot of carbohydrates lately.
That covers things for Part 7. I hope by now you’re confident with your knowledge base in TRT and perhaps after reading this, you’ve chosen a TRT protocol that you’re ready to experiment with. If you do manage to find a protocol that is right for you and you’ve gone through the tedious stages of constantly picking your veins to see what is going on with your blood work—then I have good news for you Sir. If you have found your TRT protocol and all has been otherwise healthy, then it is my recommendation that you only check your blood work every 12 months from here on out. If you are getting on past 55, check it twice a year. Life is too short to keep on getting blood tests that after a certain point provide no additional benefit to your health—and cause harm to your wallet. Until next time.