What is Testosterone?
Testosterone Replacement Therapy is a topic which an increasing number of men are having to research through every generation. Testosterone is the single most important hormone in a male’s body. Testosterone is produced from the testes in significant amounts particularly during puberty with levels gradually declining after the age of 30.
Testosterone is responsible for sperm production in addition to sex drive, bone mass, fat distribution, muscle size and strength and red blood cell production. Without adequate levels of testosterone, you will find gaining muscle to be difficult with stress and anxiety being an all-pervading element of your life.
Testosterone levels have been dropping with each generation worldwide due to changes in diet, pollution, obesity, chemicals in food and water in addition to lower levels of physical activity. A study by the Journal of Clinical Endocrinology and Metabolism found average testosterone levels declined 17% in American men between 1987 and 2004. This is a primary reason to the increasing levels of men (even young) on Testosterone Replacement Therapy.
What are the Symptoms of Low Testosterone?
- Lower Energy
- Higher levels of body fat
- Decreased sex drive
- Inability to gain muscle
- Problems getting out of bed in the morning
Male hypogonadism is the inability of the body to produce sufficient levels of testosterone. Primary hypogonadism is also known as primary testicular failure which arises from a issue within the testicles.
Secondary hypogonadism is the more common form which indicates a problem in the hypothalamus or pituitary gland within the brain. The Hypothalamus produces gonadotropin-releasing hormone (GnRH) which signals the pituitary gland to release Luteinizing Hormone (LH). LH then signals the testes to produce testosterone. Secondary hypogonadism is what afflicts myself. Testosterone Replacement Therapy is intended to reverse the issue at hand.
Either type can be either caused genetically through an inherited trait or acquired later in life through injury or disease. Testosterone levels play the most significant role in both muscle mass and strength. It will be impossible to gain any significant amount of muscle mass with a low testosterone level no matter how intensive the training. I would recommend PayAsUGym for your training requirements.
PayAsUGym is a marketplace for gyms in the UK, offering single-use passes, classes, contract-free memberships, and full yearly memberships for 2,300 gyms and health clubs across the UK. Men on Testosterone Replacement Therapy with low Testosterone beforehand will find drastic changed in body composition.
How Can you find out your Testosterone Level?
Men in the UK can go to their NHS General Practitioner (GP) and complain of the symptoms labelled above. Your GP will take a blood test however ignore his comments even if he says you are fine and ensure you personally see the numerical value.
The problem is the NHS will say there is no problem even if you have the testosterone level of an 80-year-old man. This is because the NHS reference range for total testosterone is 300 – 1070 ng/dl. The major problem with this range is it is simply far too large and does not differentiate testosterone levels via age.
Men under 25 should have a testosterone level of at least 617 ng/dl, if your NHS blood test comes back at 376 ng/dl your GP will waive you off without treatment even though that is around the average level for a man 50 years older than yourself. The NHS do not want men (especially young males) to go on Testosterone Replacement Therapy.
My personal advice would be to avoid the NHS and use an external blood test company. Medichecks offer a fantastic blood test service where you can collect a finger prick sample at your home and post the sample back to their laboratory which will provide you with the results on your online account page along with doctor analysis usually the very next day. You can also choose to have your blood taken at the Medichecks London facility or visit one of the partner clinics throughout the UK to get bloods drawn. I would recommend the TRT Check Plus; the link is below. Getting regular blood tests is essential on Testosterone Replacement Therapy.
What are the Treatment Options?
Testosterone replacement therapy is the process of external testosterone being prescribed in replacement of your natural levels in order to achieve a more optimal total and free testosterone level. The NHS and private healthcare industry in the UK offer various options.
From my personal experience endocrinologists in the NHS are extremely reluctant to give you testosterone replacement therapy treatment with patients normally waiting a minimum of 12 months after the first referral to get treatment. 3 separate blood tests conducted over that period showing your total testosterone level below 300 ng/dl are also normally required. NHS treatment is designed to increase your testosterone to around 475 ng/dl which can improve low testosterone symptoms however still lead to a lower quality of life than having optimal levels around 750 ng/dl.
The NHS endocrinologists also also very narrow minded in their approach with little attention paid to oestradiol (E2) levels which can rise with testosterone therapy. Rising E2 levels can negate most of the sexual function related improvements of Testosterone replacement therapy. An aromatase inhibitor (AI) such as arimidex tablets can be easily used to control oestradiol however the NHS do not offer this. The NHS Testosterone Replacement Therapy is flawed in many ways with little concern to hormones aside from Testosterone being a primary factor.
NHS endocrinologists also pay very little concern to preserving fertility within their Testosterone Replacement Therapy protocol. Human Gonadotropin (HCG) can be injected subcutaneous (under the skin) using an insulin syringe which would maintain the body’s natural testosterone production whilst on Testosterone replacement therapy. Unfortunately, the NHS again do not offer this as an option alongside the below treatments.
Testosterone Gel (Testogel)
- A clear gel containing around 10% testosterone rubbed onto the shoulders, chest or back once a day. The gel should dry within 10 minutes.
- The gel as a form of Testosterone Replacement Therapy is non-invasive and maintains steady testosterone levels throughout the day which mimics the body’s natural production. (Higher levels in the morning gradually falling throughout the day).
- Most patients find difficulty absorbing the testosterone in the gel which leads to total testosterone levels not significantly changing or only increasing to around 450-475 ng/dl.
- The testosterone in the gel can easily be transferred to family members which can be a cause on concern especially around children and pets.
Testosterone Injection (Nebido)
- Nebido Testosterone Replacement Therapy consists of Testosterone Undecanoate which is the long chain ester of synthetic testosterone. Nebido is injected intramuscularly by a nurse every 12 weeks within the buttocks.
- Nebido can be significantly more convenient than frequent injections although oestradiol levels can be hard to maintain on Nebido which can cause problems with your libido. (Some testosterone when injected is converted to oestradiol which where levels are too high can be suppressing on your sex drive).
- Most patients find it difficult reaching a sufficient total testosterone level with Nebido due to the 12 week intervals between injection, this can lead to total testosterone to only rise to the 450-500 ng/dl level.
- Significant numbers of patients ‘crash’ in the last 4-5 weeks due to their natural testosterone production being shutdown and Testosterone Undecanoate levels declining in the body leading to low testosterone symptoms once again.
- In my opinion Nebido Testosterone Replacement Therapy would be a good option if the intervals between injection were 6-8 weeks and oestradiol was closely monitored and controlled through the use of an aromatase inhibitor (AI) such as Arimidex. Unfortunately, the NHS endocrinologists will not normally grant these wishes for patients on testosterone replacement therapy.
Testosterone Tablet (Striant SR)
- A testosterone containing tablet applied to the outside of the gum every twelve hours. It sticks to the gum and gradually dissolves. Testosterone is absorbed through the gum tissue.
- Most people again have difficulty absorbing the testosterone with the rise in testosterone level being rarely sufficient to remove low testosterone symptoms.
- There can be significant risk of hepatotoxicity (liver damage) from the body attempting to absorb the tablet. This leads to testosterone tablets being arguably the most controversial and least effective Testosterone Replacement Therapy protocols.
Endocrinoglists in the private sector can offer the same treatments for Testosterone Replacement Therapy as the NHS in addition to the treatments listed below which have a number of advantages on NHS testosterone replacement therapy. Private Endocrinologists will also be much more flexible with the minimum testosterone level before testosterone replacement therapy treatment and much more open to changes in the treatment method.
Testosterone Cypionate/Ethanoate Injection
- Medium chain esters of testosterone which are injected intramuscularly within the quads/glutes once every 7 days.
- A dose of 125mg every 7 days should get your testosterone level up to a minimum of 750 ng/dl with levels peaking above 1000ng/dl 24 hours after injection and troughing at around 550 ng/dl. This will ensure peaks and trough do not occur leading to crashes as would be the case with a longer timeframe dosing protocol.
- Libido, muscle mass/strength, brain function and bone strength will be significantly improved from having a high/normal testosterone level of 750 ng/dl.
- Private endocrinologists are also happy to prescribe arimidex to control oestradiol levels and HCG to maintain fertility.
- Test Cypionate/Ethanoate Testosterone Replacement Therapy injections may be more time consuming with the added hassle of having to carry Testosterone replacement therapy vials, needles, syringes and HCG when travelling.
Testosterone Propionate Injection
- Short chain ester of testosterone which is injected intramuscularly in the delts every other day.
- Testosterone levels remain extremely stable due to the frequent injections and with very little conversion of testosterone to oestradiol via the aromatase enzyme. This means a AI such as arimidex is not necessary.
- Most patients find frequent Testosterone Propionate injections will increase their libido to a greater extent than any other TRT protocol.
- Injecting every other day can be less convenient than other longer chain testosterone esters and greater hassle when travelling.
- Test Prop will be most beneficial to men with low SHBG (See more on SHBG below) who find their body excretes medium and longer chain testosterone esters.
- In my case of low SHBG Test Prop still did not work to its full ability, I believe this is because my SHBG has been tested multiple times below 5 nmol/L. Men with a SHBG of 10-12 nmol/L or greater should have some more success with Test Prop.
- Blend of 4 testosterone esters (30 mg testosterone propionate, 60 mg testosterone phenylpropionate, 60 mg testosterone isocaproate and 100 mg testosterone decanoate). Injected intramuscularly in the quads/glutes every 14 days.
- Due to each of the esters having a different half life, sustanon injections as a method of Testosterone Replacement Therapy can be more convenient injecting once every fortnight rather than weekly.
- Average testosterone level should also be more stable over that 14 days due to each ester kicking in at a slightly different time. This could prevent the need for arimidex to control oestradiol.
- Used to be commonly prescribed on the NHS however budget cuts and a sustanon shortage have led to nebido and testogel being the favoured treatment method of NHS endocrinologists.
- Men with lower SHBG might also benefit from the shorter chain esters within the blend whilst avoiding the hassle of having to inject EOD on the test prop protocol. When on Testosterone Replacement Therapy, your protocol should be tailored to your individual needs.
What about Testosterone Replacement Therapy for men with low SHBG?
Sex hormone-binding globulin is a protein which binds to testosterone in the body. This renders that testosterone inactive. The testosterone level which is unbound by SHBG is labelled free testosterone. Testosterone replacement therapy will in the majority of cases of men with low SHBG fail to resolve low testosterone symptoms.
When for example Test Cypionate is injected into a man with low SHBG, the body will convert most of the testosterone into free testosterone as it is unbound by the low levels of SHBG within the body. The body will then breakdown down the excess free testosterone using enzymes which means the testosterone is being ‘excreted’ before it can express its effects.
Smaller dose, greater frequency injections of a short chain ester such as testosterone propionate within Testosterone Replacement Therapy seem to work better in men with low SHBG. Men with very low SHBG levels (Under 8-10 nmol/L) may also struggle even with test prop.
Clomid therapy or HCG monotherapy might be the best route of Testosterone Replacement Therapy for these men or even in men without low SHBG levels. Clomid therapy and HCG monotherapy stimulate the body’s natural production which maintains fertility and can be significantly more convenient than testosterone injections.
Clomid (Clomiphene Citrate) Therapy
- Clomid works by inhibiting estrogen at the hypothalamus, which stimulates GnRH, leading to greater LH production which signal the testes to produce more testosterone.
- Clomid can be seen in a number of cases on the internet to rise testosterone levels up to 600-800 ng/dl.
- Clomid therapy also involves swallowing a tablet which is significantly more convenient than injecting and carrying around vials, needles and syringes. Clomid kick-starts the body’s natural testosterone production and there is no synthetic testosterone which is better than your body’s own.
- Clomid can significantly increase some men/s SHBG which leads to the changes in total testosterone not leading to a significant change in free testosterone levels. This can lead to symptoms of low testosterone persisting. This is more prevalent in men who already have naturally high SHBG levels.
- A number of men have also reported Clomid leading to excellent on paper testosterone results however little change in libido.
- This is because Clomid contains a mixture of 2 isomers, Enclomiphene and Zuclomiphene. If Clomid is dosed too high the Zuclomiphene isomer (which has a significantly greater half life) becomes more prevalent in the blood and express its inherent estrogenic effects on centres in the brain which control sex drive.
- The key is to keep the dose of Clomid no higher than 12.5mg on Monday, Wednesday and Friday. This should maintain testosterone levels at around the 700 ng/dl mark without the anti-libido effects of the Zuclomiphene isomer taking over. Keeping the dose at this level should also prevent any vision sides some men have reported whilst taking larger doses. This is my personal testosterone replacement therapy treatment protocol.
- DIM at 200mg and Calcium D Glucarate at 2 x 500mg tablets each day have also been shown to also negate the estrogenic properties of the Zuclomiphene isomer.
I personally purchase 25mg generic Fertomid tablets from Reliable RX Pharmacy. I use a pill cutter to cut the pills in half and use a dose of 12.5mg on Monday, Wednesday, Friday and alternating Saturdays. This maintains my Testosterone levels around 650-750 ng/dl. Clomid mono therapy has been the only form of testosterone replacement therapy which has lead to improvement of low testosterone symptoms both on paper and in practise.
Since Reliable RX Pharmacy ships internationally from India and only produce generics not brand name medication, the price for testosterone replacement therapy typically ends up being around 3-5 times cheaper than you would pay in the UK or even USA. The link is below.
HCG (Human Gonadotropin) Monotherapy
- Human Gonadotropin (HCG) might be an testosterone replacement therapy option for those men whose libido is still affected by the Zuclomiphene isomer even at clomiphene dosage of 12.5mg 3 times a week.
- Like Clomid HCG preserves the body’s fertility by stimulating natural testosterone production, it does this through being a LH (luteinizing hormone) analogue mimicking LH to stimulate the Leydig cells in the testes to produce testosterone.
- Oestradiol has to be tightly controlled via arimidex due to the high conversion rate of testosterone into estrogen from HCG.
- HCG can also be a hassle to carry when travelling due to having to be stored in a fridge when formed into a solution. This is the main reason I choose clomid mono therapy as my testosterone replacement therapy protocol.
- HCG also has to be injected in the belly fat with an insulin syringe 2-3 times a week which can again be less convenient than Clomid in addition to being more expensive than Clomid therapy.
I would personally recommend purchasing 5000 iu. Ovidac HCG from Reliable RX Pharmacy. Ovidac HCG is known for its purity with a a number of great reviews across the internet.
Again since Reliable RX Pharmacy ships internationally from India and only produce generics not brand name medication, the price for testosterone replacement therapy typically ends up being around 3-5 times cheaper than you would pay in the UK or even USA. The link is below.