The Perfect TRT Protocol

I suppose the real question should be “What do you want from your TRT protocol?”.  The answer should be “I want to be happy, healthy and horny!”.  I’ve said it many times before, we are simple creatures with simple needs.  We also want convenience, we want to travel the path of least resistance.

I agree, TRT shouldn’t consume your life.  Optimised testosterone levels should mean that YOU can consume life!  With that in mind, there is no one size fits all TRT model because despite our similarities, we are all unique.  Your personalised TRT protocol is specifically tailored to your individual needs and requirements, based on your current physiological state and genetics.  You also need to recognise that some of those variables will necessitate a change to you TRT protocol in the future.  It’s a journey not a destination, but that journey is not one taken alone.

“Perfection is not attainable, but if we chase perfection we can catch excellence.” – Vince Lombardi

It sounds complicated doesn’t it?  Well, it is and it isn’t.  It depends not only on your understanding of the human body and medicine, it also depends on your philosophy towards the ill-placed phrase ‘testosterone optimisation therapy (TOT)’.  A phrase banded around by a group of non-clinicians who believe that more is better and being alpha means being more like Neanderthal man than an evolved Homo Sapien.

So, your perfect TRT protocol, what should it look like?  It should replicate your natural physiological levels from when you were at your most healthy.  There are so many variables involved in attaining health.  Broadly speaking, there’s lifestyle, nutrition, exercise and medicine.  It’s difficult to pinpoint a time when all of those elements were in check or in sync.  If you add your biology to the equation, it was probably in your 20’s.  I’m sure there are plenty of guys out there with optimal testosterone levels who still feel rubbish because of unhealthy lifestyles and unhealthy diets.  In contrast, I’m sure that there are plenty of guys out there with healthy lifestyles but suboptimal testosterone levels who feel ‘ok’.  It’s difficult to know what your optimal testosterone levels should be when we have no reference point.

Numbers…  As men, we are all obsessed by numbers.  Hopefully we’ve learnt that more isn’t always better when it comes to TRT.  If you haven’t, please read my blog Chasing Numbers which will hopefully will give you an insight into my philosophy.

If we were to track our bloods throughout the day, we would notice there is diurnal variation of your testosterone levels.  In addition to that, there is diurnal variation of your sex-hormone binding globulin level (SHBG).  You see, you don’t need high free testosterone levels when you are in fight or flight mode.  Testosterone is an anabolic hormone, it works predominantly at rest when you grow and repair.  In a catabolic state, you actually want cortisol, the much feared ‘stress hormone’.  It helps your body respond to stress or danger, it increases the metabolism of glucose for brain and muscle function, it helps control your blood pressure and it helps reduce inflammation.

We have evolved over millions of years, anabolic and catabolic processes are there for a biological reason, they are a necessity.  From an evolutionary perspective, anabolic processes occur during sleep, which ‘should’ take up a third of our life.  When you are asleep you are susceptible to predation, perhaps not so relevant in the modern world but have you ever wondered why you sleep better at home than away?  Those survival mechanisms are still in play in this modern ‘civilised’ world.

I’m in danger of going off at a tangent so I’ll reign it in.  The perfect TRT protocol would follow the same ups and downs as your body’s natural testosterone production.  Is this possible?  In theory, yes.  Recent advances in the management of diabetic patients means that they now have user-friendly machines that deliver a continuous infusion of insulin which self-regulates according to your blood sugar levels.  Is this practical for TRT?  Hell no!  So what options are available to us here in the UK?

Injections vs Topical Testosterone

It’s no secret that our gold standard treatment at The Men’s Health Clinic is Testosterone Enanthate or Cypionate, plus Human Chorionic Gonadotropin (HCG).  It best mimics natural physiology and allows for stable testosterone and oestradiol levels.  That being said, there is nothing wrong with topical TRT.  I have guys who will not switch to the injections, not because they have a needle phobia, but because they are happy, healthy and horny on the gel. Why switch indeed?!

Human Chorionic Gonadotropin

HCG should be part of your TRT protocol, irrespective of your desire to retain fertility and maintain testicular size.  Patients notice a qualitative difference in their well-being.  There are LH receptors in the brain and there is also upregulation of some of the steroid hormones in the cascade down from Pregnenolone.  It is often the difference between feeling good and feeling great.  Exogenous testosterone works in part because of the sledge-hammer effect it has on the production of LH and FSH, it allows us control of your testosterone levels.  To ignore the need to replace Lutenising Hormone with HCG shows a short-sightedness and ignorance that is unfortunately all too common within medicine and the wider community.

So what testosterone level should you be aiming for?  The answer to that question is very simple.  It’s the level that makes you feel your best.  All of my guys run between 20 and 40 nmol/l, most are between 25-35, but it’s weighted towards the lower end.  It’s really difficult to break that idea that more is better, I know… I get it.  The idea of titrating your levels up to a place where you are not having negative side effects from excess oestrogen and dihydrotestosterone is a difficult one to break.  Although you wouldn’t believe the number of my guys who feel better at the lower end of the spectrum.  Better as in more energy, mental clarity and improved libido, no word of a lie.  They’ve been higher, yet prefer lower, go figure?

Typically, if you are aromatising too much testosterone to oestrogen, something is wrong with your protocol.  If you are experiencing bad acne, it’s most likely due to excess dihydrotestosterone, something is wrong with your protocol.  Don’t unnecessarily add ancillaries such as an aromatase inhibitor or a DHT-derivative until you’ve explored all the possible reasons why, it’s bad science and laziness.

The last 100 years has proved that there are lots of influential idiots out there who appeal to our worst and weakest character traits.  Medicine is a vocation, it’s not a place for failed entrepreneurs and sales people to cash in on people’s misery with false promises.

“By the way if anyone here is in advertising or marketing…kill yourself.  It’s just a little thought; I’m just trying to plant seeds.  Maybe one day they’ll take root – I don’t know.  You try, you do what you can.” – Bill Hicks

We are living longer but we are not necessarily living better.  We have created an artificial environment that goes against mother nature.  When we are long gone, the world will continue and we will only have ourselves to blame for our demise.  More, more, more!  There are so many false prophets giving misinformation out there, it’s sometimes hard to see the woods from the trees and end up getting dragged down the rabbit-hole.

When designing the ‘perfect’ TRT protocol, it’s important to choose the right ester (a single ester), the correct dose and injection frequency and the correct ancillary HCG (no AI!).  It’s just as important, if not more so, to understand that millions of years of evolution have gone into designing this incredible machine and we are not as smart as we think we are.  Testosterone Optimisation Therapy is not about chasing supra-physiological levels, it’s about finding a level that allows you to cross that invisible barrier that exists so that you can keep moving forwards.  TOT – you are doing it wrong!!!!

“This is your last chance.  After this, there is no turning back.  You take the blue pill – the story ends, you wake up in your bed and believe whatever you want to believe.  You take the red pill – you stay in Wonderland, and I show you how deep the rabbit hole goes.  Remember: all I’m offering is the truth.  Nothing more.” – Morpheus

Dr Robert Stevens MBChB MRCGP Dip.FIPT