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TRT – Chasing Numbers

| By: Dr Robert Stevens
TRT – Chasing Numbers

Optimising testosterone with Testosterone Replacement Therapy supposedly improves quality of life, but what does that actually mean?  Quality of Life is described as the general well-being of a person or society, defined in terms of health and happiness.  It is something that is difficult to quantify, interpretation of quality is very much subjective, not objective.  There are so many factors that dictate and influence how we appreciate the world, how are a few direct questions supposed to quantify it?  What does it mean to you?

Guys on Testosterone Replacement Therapy (TRT) tend to attribute every single emotion, both positive and negative, to either testosterone or oestradiol.  Just search the forums, “It’s your E2 bro”.  It’s easy to rationalise why, but we need to remember causation.  It’s similar to the short-sighted argument that you don’t need HCG alongside testosterone.

I quite like the analogy of comparing the HPG axis to the internal workings of a car:-

The Alternator is your Hypothalamus & Pituitary / HCG

The Battery is your Testes / Testosterone

The Ignition is a Hot Girl in Yoga Pants

Electrical Fault is Lifestyle / Nutrition / Exercise

Jump Leads is HCG Monotherapy and/or Clomid

The AA is a Doctor

The Mechanic is a TRT Doctor

If you turn the ignition and nothing happens you first look to see if anything is draining the charge, such as an electrical fault.  You can call the AA out, attach a set of jump-leads and most likely get the car started.  However, if there’s a problem with the alternator and/or battery, you will eventually need to replace the alternator and battery.  Why repeatedly call the AA out?  Just take it to a garage and get it replaced!

When your testosterone levels have been restored, you still have to look after the electrics.  If you don’t, your car still won’t run properly.  Ok, it’s not a perfect analogy, but it works, sort of…

On the surface, TRT might seem like a rather blunt tool.  However, intentionally suppressing the pituitary actually allows us to effectively control your testosterone levels.  Simple manipulation of the dose and/or frequency of testosterone and/or HCG allows us to optimise your levels and have you feeling like your old self again.  The beauty of TRT is in its simplicity.  So, when I hear of people being prescribed Anastrazole and Proviron from the outset, or ‘just in case’, I wonder whether they are simply trying to justify supra-physiological levels, for want-to-be bodybuilders, or they simply don’t know what the f### they are doing.

We have a tendency, to over complicate things, focus on quantitative markers that are easy to define and pigeon-hole.  We give them far too much significance.  They can provide us with false assurance as much as they can alert us to a particular issue.  Remember, quality is very much subjective, not objective.

Your testosterone level is particular to you.  Your genetic make-up, lifestyle, nutrition and physical activity are some of the major players.  If you have a healthy hypo-pituitary gonadal axis, your body will make the appropriate responses to stimuli or change.  The thing is, your testosterone level isn’t a constant, there is diurnal variation, we have periods of anabolism and catabolism.  It fluctuates and that is perfectly normal.  To fixate on a constant magic number is to not understand, or have a true appreciation of how the body works.

Does that mean you shouldn’t manipulate your levels to suit your goals?  Of course not.  There is no one size fits all protocol, there is also room for manoeuvre, I like the term ‘wiggle’.  We can manipulate your testosterone and oestradiol levels with alteration of your dose and/or injection frequency of either hormone, according to your needs.  If you make a dramatic change in your lifestyle for example, your needs will change as a result.  If you lose weight or stop drinking alcohol for example, you influence aromatisation of oestrogen.

I have an ex-bodybuilder who came to me with hypogonadism after several years of steroid abuse, he just wanted to feel normal again.  We started him on our gold standard treatment – testosterone enanthate and HCG.  Here are his results on his current protocol:-

  • 02/08/2017        Total Testosterone 30 nmol/l & Oestradiol 182 pmol/l
  • 04/10/2017        Total Testosterone 21 nmol/l & Oestradiol 77 pmol/l
  • 03/01/2018        Total Testosterone 12.2 nmol/l & Oestradiol 129 pmol/l

You’d expect him to feel worse each time, but quite the contrary, he felt great.  In fact, with a testosterone level of 12, he said he never felt better!  Essentially, his utilisation had increased, ergo his circulating levels had dropped.  The numbers would suggest the need for an immediate protocol change.  One could rationalise that his E2 dropped because of weight loss through alteration of diet and increased physical activity.  There was no qualitative drop with a decreased total testosterone.  We are controlling his levels with TRT, his levels aren’t lower because something is wrong, things are very much right according to him.  He has more lean muscle mass, he’s out walking the dog every morning and still hitting the gym hard.  In his words he’s never felt better, people are asking him what he’s on at the gym!

What conclusions can we draw from this?

  1. Symptoms are more important than blood test results.
  2. Measuring exogenous testosterone levels does not always correlate with symptoms, as the measure is not a reflection of causation.

That being said, I’m still uncomfortable with a level of 12 and so we have tweaked his protocol.  But I think it’s a perfect example of the difference between natural vs artificial measurements of testosterone.  Having a fixed dose of testosterone enanthate and HCG means that his body can’t respond appropriately to a significant change in lifestyle or physical activity, the HPG axis cannot react since we are in control.

I always review my guys without their blood results in front of me, and I do that for a reason.  You can’t measure qualitative changes with quantitative figures, they are too distracting.  They leave with a provisional plan, which we finalise after correlating the quantitive markers with the qualitative review.

So what testosterone level should you aspire to?  In my opinion, you want a level that makes you feel like you again, you want a level that will allow you to lead a healthy and productive life.  TRT can’t provide you with quality of life, it can only give you the ability to achieve it, the rest is up to you.  You could rationalise that you want to attain a level as high as possible, without experiencing the negative side effects of excess oestrogen or dihydrotestosterone.

If you are trying to justify supraphysiological levels that necessitate you needing an aromatase inhibitor, then more fool you, I think you are missing the point.  We have evolved over millions of years, to be so presumptuous to attempt to alter that design simply demonstrates the arrogance and ignorance of modern man.

You could argue that more is better, with the caveat, as long as you don’t have side-effects?  But would you be right?  Would concentrating on achieving this level bring the rewards that you aspire to?  I don’t know, I’m happy to work with you to achieve this level, I’m just not sure that that’s where you should be concentrating your attention.  Am I doing my guys a disservice by not bumping them all up to 40+ nmol/L?  Have a read of the testimonials section on our website and find out…

You Can’t Measure Qualitative Changes with Quantitative Figures

Optimising testosterone has become a crusade for some guys, they are perpetually chasing the hypothetical magic number and they believe that everyone else should be to.  The guys that do best have an open mind, if you are fixed in your belief system then I wish you the best of luck – “No comments can deter my stance”!!.  I try not to raise my guys expectations too much at their initial consultation, I’m always talking about ‘normal’ and ‘how you should feel’.  On review, some of them sit down with an almost mischievous look and a cheeky wry smile comes across their face when I say “So..”.

I appreciate that some guys who have battled with low levels often fear feeling like they did before TRT.  The truth of it is, the hardest part is letting go.  I understand that whilst autonomy and control are very important, you should be able to trust your doctor, your doctor should be working with you so that TRT just becomes part of your normal routine.  If you’re obsessing about a magic number, be prepared for disappointment.

 “See, the problem is that God gives men a brain and a penis, and only enough blood to run one at a time.” – Robin Williams

Dr Robert Stevens MBChB MRCGP Dip.FIPT