Nelson Vergel, author of Testosterone: A Man's Guide (Amazon.com) and founder of ExcelMale.com and DiscountedLabs.com, talks about what he thinks are the 10 most important things that all men on testosterone replacement therapy should know to maximize benefits and minimize side-effects. For questions for Nelson, please register on ExcelMale.com and post them on the forum page. For more detailed information about what blood test parameters are important to monitor while on testosterone replacement therapy, read: Testosterone Replacement Blood Test Targets and Their Management
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Find out more about testosterone replacement therapy and what tests to perform
Hi everybody. Nelson Vergel with ExcelMale.com. Somebody gave me a really good idea on ExcelMale.com. It's a forum of over 14,000 members. We discuss everything related to testosterone replacement, nutrition, exercise, supplements, and other options like Trimix, hCG, and estradiol, et cetera. Somebody asked me, "Nelson, why don't you do a video of Nelson's Top 10 TRT Commandments?" And this is what I'm doing today. So, I'm going to include the different observations and suggestions I have after reading over 40,000 posts over the last three years on ExcelMale.com.
Testosterone is not a magic bullet.
The first one is testosterone is not a magic bullet, and I remind guys who have high expectations when they start testosterone replacement because they have low testosterone that things may improve in many ways, like improvements in sexual function and sex drive, energy, cognitive function, et cetera. But sometimes they may not improve as much as you expect because there are many factors involved, especially in sexual function, libido, and desire. I have another presentation or lecture that I did on the subject, so you can check it out on ExcelMale.com, or on the YouTube channel, also named ExcelMale.com. But there are over 12 factors involved in the sexual desire in men. Testosterone is one of them, obviously, so fixing the low testosterone issue tends to improve things in that department. However, if you're not sleeping well, if you have excessive weight, if you're drinking too much, if you have some illnesses like diabetes or cardiovascular disease, and if you're taking medications that may influence sex drive and erectile function like blood pressure medications, antidepressants, et cetera, you may not get all the benefits that one would expect from testosterone. So, check out that video, and I will get into more details on that subject.
Do not obsess about estradiol.
The second one is the second commandment: do not obsess about estradiol. Estradiol has become the hottest topic of discussion in men's health forums, and it's a topic that is filled with misconceptions and a lot of speculative information. We have data that shows that estradiol is a very important hormone in men. It is produced from the aromatization of testosterone into estradiol by aromatase enzyme in the liver and in fat cells. The body actually produces it for a good reason. There's a good reason why nature put estradiol downstream of testosterone. We need estradiol for bone health, cognitive health, sexual function, and drive, and even keeping good body composition and cardiovascular health.
A lot of men tend to freak out when they start testosterone and they think everything is related, all the side effects are related to high estradiol. Biggest problem I see is that very few men are actually testing their estradiol. Doctors are not monitoring estradiol levels, and if they are, they're using the wrong tests. They're using the immunoassay instead of the liquid chromatography/mass spectrometry assay. The former basically overestimates estradiol. Secondly, water retention and/or nipple sensitivity may have nothing to do with estradiol blood levels. So, men are jumping into starting treatment with an AI, when in fact their estradiol is under 40 picograms per milliliter, and they don't really need to be taking it.
Many crash their estradiol blood levels under 20 mg and they started losing sex drive and they start even getting fatter, because it's being studied in research that that's the case. So, do not obsess about estradiol. Estradiol is not an evil hormone. Estradiol is in our body for a reason. Do not over treat with anastrozole. I'm telling doctors, be very careful. They are giving people high doses, over 1mg a week of anastrozole to men. I'm also really concerned that many clinics out there, and I hope they're listening to me, are starting men on anastrozole at baseline when the fact is, they should have waited or they should way until follow up, after six or eight weeks follow up, and test the men's estradiol after they start testosterone replacement. And then, and only then, determine whether or not they have high estradiol over 40.
And as our testosterone blood levels increase, so does estradiol. Only 0.4% of testosterone becomes estradiol, so it's only logical that we should have higher estradiol when we have obviously higher testosterone levels because of injections or gels or creams or pellets. So that's my biggest concern out there. Estradiol is not an evil hormone and we need it. Do not obsess. Do not put all your ... do not blame it on all the side effects, especially if you're not testing the blood levels.
Monitor your hematocrit.
Your hematocrit. Monitor your hematocrit, is number three, very closely during the first six to eight months. Hematocrit is the proportion of the blood, the blood volume, that is made up of red blood cells. Testosterone replacement increases the production of red blood cells, which is a good thing if you have anemia. However, overproduction of red blood cells and an increase of hematocrit obviously, can increase the viscosity of the blood, and that can lead to cardiovascular risks and events. So, doctors pretty much monitor this parameter using a very cheap panel called the CBC, the cells and chemistry, cell count and chemistry profile. Very cheap. I think you can buy it on discountedlabs.com for $29, and that includes hematocrit. As your hematocrit starts climbing up closer to 52, it is time for you to go and donate blood at a blood center. What I'm seeing, I'm seeing a few problems there. I'm seeing men waiting too long so they get to 53, 54 in hematocrit and they get rejected for donations because the Red Cross and different blood centers have a limit of 53. So do not wait too long, otherwise you are not going to be able to donate blood for free.
If you do wait that long and your hematocrit is 53, 54, 55, whatever. I've seen guys walking around with a 65, which is crazy. That's when doctors don't monitor that. Very upsetting. Anyways, if you get to those high levels, you're rejected from the nation and you will need an order from your doctor, like a prescription. Your doctor calls in any blood center and you may have to pay for the ... it's called a therapeutic phlebotomy. You would probably have to pay. Many centers charge over $100. So, do not wait too long. Do not donate blood or do therapeutic phlebotomies more frequently than every three months, because that has been shown to decrease iron levels and ferritin, which may make you fatigued. So, if you are by any chance one of those unlucky men that really produces a lot of red blood cells, you may have your doctor check your iron or ferritin after you donate blood. If they are low, you can take an iron supplement for a few weeks until it's normalized.
The high hematocrit issue does not happen to everybody. Most men have a bump around three to four points higher. Most of the time, hematocrit stabilizes after 18 months. For instance, as an example, I've been using testosterone for over 34 years, and I've only donated blood once, and usually it's within the first six months that you know whether or not your hematocrit will be increasing. After six months, chances are ... unless you increase the dose of testosterone, obviously, that you will stay pretty much stable there. So, it's not a long-term concern.
Inject testosterone using easier methods: Subcutaneous or shallow IM.
Okay, the next commandment is exploring easier ways to inject, subcutaneously, shallow, IM, which is shallow intramuscular injections. The old way of injecting testosterone with a big old syringe of one and half inches on your glutes or quads is pretty much gone. There is no need to suffer through painful injections with big needles anymore. We have good data that shows that a subcutaneous, injections under the skin with a very tiny, half an inch, 27 gauge or even 29-gauge syringe, it's enough to get the body to absorb and get the blood levels up. So, no need to suffer. I inject in the shoulders at 90 degrees with a 27-gauge, one inch ... I'm sorry, half an inch syringe, and it's basically painless. Also, inject twice a week instead of injecting once a week. We are moving from the world where doctors were prescribing testosterone at 200mg every two weeks to know 100 to 150, depending on the blood levels that you need, every week to 50 to 75mg every two weeks. So, there are clinics that are prescribing it once a week, but there's nothing wrong with that. I really believe so. But many clinics are now splitting the dosage in two, and also bringing in something called hCG, that I will talk about.
So, do not suffer. Do not dwell anymore with big needle syringes. You can inject under the skin. You can inject shallow, at half an inch, anywhere in the quads, delts, even in the glutes. And that will basically ensure that most of us adhere to a long-term therapy like testosterone replacement. As you all know, testosterone replacement is a long-term commitment, a lifetime commitment.
Never cycle testosterone on and off.
The next commandment is obviously never cycle testosterone replacement on and off. This is a lifetime commitment. If you stop testosterone replacement, basically your blood levels will crash. You will not produce testosterone for a while. People tend to email to ask me how many weeks they're going to be in that situation. It is impossible to predict, impossible to predict. Some studies in bodybuilders have shown that it takes probably as long as you were on, the period that you were on the testosterone, to get back to your baseline. Remember, all of us that started testosterone replacement had a low testosterone at baseline. That's why we got into testosterone replacement. So even if your body tends to readjust after a few weeks and bring you back to what you used to be, you're probably going to have low testosterone. So, that's a discussion that I don't see doctors doing very well with patients that are about to start therapy. The fact that it is a commitment. No, you're not going to die if you stop testosterone. It is yes that you're going to have a rough time with low libido, energy, cognitive function for a few weeks, but things will move on and you'll basically go back to where you used to be before testosterone.
Know your TRT blood tests.
The next one is knowing your blood tests and your schedule on blood testing. Yes, your doctor is supposed to remind you when you're supposed to get blood tests done, but it's not brain ... it's not like rocket science. On ExcelMale.com, on discountedlabs.com, which is my company, my lab test company, you can get tests online anywhere in the United States, with exception to New York State, New Hampshire, Massachusetts, basically the northeast states have passed legislation to limit options for consumers there, but most states you can go to discountedlabs.com, order your test there, pay by credit card or PayPal and then we will email you the results after five to seven days when you give your blood at the lab or location closer to you.
You can check the scheduling on testosterone blood testing and monitoring on ExcelMale.com, also through one of my videos that I made on that subject, and also, it's on the blog page of discountedlabs.com. But know at least that you have to have certain blood levels tested at baseline. The doctor will probably have you come in six to eight weeks later, just to see if a dosage is good enough for you. We'll ask you about all your symptoms if they're getting better. They may check not only hematocrit or estradiol or other hormones and see whether you need a readjustment or treatment with anastrozole, like I said before. So, it is important also to tell the doctor when you got your blood test done, your blood draw, because some guys forget that you should be getting your blood drawn right before your next injection. I'm talking about injections. Gels and creams are different because since we're using the same dosage every day, it doesn't really matter when you get the blood drawn.
Do not change more than one variable at a time.
The next one is do not change more than one variable at a time, and I do remind everybody on ExcelMale. We are all kind of our own guinea pigs. Everybody has to do experimentation on themselves. Every time we start something, we can change the dosage or we can change the frequency or we can change other things, but we cannot change more than one variable if you want to measure the impact of that change on your quality of life. And that's one of the biggest problems I'm seeing. Some guys start changing things around and then they forget what worked and what didn't. I know it's a basic concept, but we all get very impatient, and that's another thing I'm seeing, the expectations are not well-described by doctors at baseline. So, we start changing things around without telling the doctor, and then obviously everybody's lost. You and the doctor are lost.
So, one variable at a time. It takes a while to do that. To be a good guinea pig with good experimentation, good dosage adjustment, et cetera, it takes a while. It takes like six months average to get to that point where you say, "Okay, I'm pretty much in the dosage I need to be, frequency I need to be, anastrozole dosage if I need, hCG," which I'll be speaking about hCG, et cetera, et cetera. So, don't be impatient. I know most of us that are getting onto testosterone replacement are a little desperate. We are not feeling that great, our relationships are hurting because of sexual dysfunction or things like that, and we need a quick fix. It is not a quick fix. It takes a while, but generally you will have good results if you do it well
You can’t change what you don’t measure.
The next one is you can't change what you can't measure. I remind people, even I forget how I felt last week. And when you're going to the doctor, you haven't seen the doctor in eight weeks or 12 weeks, and the doctor asks you how to have you been feeling? You pretty much are going to say how you've been feeling the past few days, since you remember that. So, I kept that in mind and we created an app, available on the Apple Store or on Google Play, called TRT Analyzer. That app basically sends you a text message or a message during the day to ask you how you felt, and there are different variables like fatigue, exercise intensity, libido, if you had a morning erection, et cetera. And then you can graph. Inside the app, there's a graphing option and you can actually email the graphs to your doctor, even print them, and bring them to your next office visit. That will show basically what happened in the last 12 weeks or eight weeks that you haven't seen the doctor.
So, doctors love it, because it helps them. It helps them. They actually score with the graph on every single parameter. So TRT Analyzer. Download it for free. There's been over 600 downloads this month, so we're very happy. Another site that I created is called myhealthgraphs.com. Myhealthgraphs.com. We'll probably be changing it into an app too. But it's a website. It's not an app. It's a website where you can add your blood test results, whatever you're following, testosterone, estradiol, hematocrit, et cetera, and it will also plot values for your doctor to see too. Doctors are busy. Doctors need people that save them time. Doctors tend to treat patients that save them time better than those that do not save them time. Doctors are human beings. They are really busy with a lot of pressure, and we walk into a doctor's office expecting the doctor to remember everything we told them last time. Even though it's written, some of them don't even have time to read the notes that they made from last time.
So, be a good patient and monitor everything, chart everything. Bring your reports on how you feel to the doctor. Believe me, you're going to get treated better than those that do not. The same doctor can treat two different patients differently just based on that behavior. I wish I had data to show, but it's my speculation.
Protect your testicles.
The next commandment is protecting your testicles, fertility, and upstream hormones. Talk to your doctor about hCG, human chorionic gonadotropin. I made a video also on hCG, so check it out also on ExcelMale.com or the ExcelMale YouTube channel. But the thing about testosterone replacement, when we started, is that our testicle Leydig cells shut down. They don't produce testosterone anymore and they also start decreasing their production of sperm and our fertility gets really impacted, especially if we are obviously looking forward to having another kid with your wife, your girlfriend. So, that's a concern. Many doctors wrongly make patients stop testosterone replacement when they want to have a kid, which is a horrible thing to do. Instead, we have now some data from Baylor College of Medicine, Lipshult’s team, that shows that using testosterone and hCG together can prevent not only the atrophy of the testicles, or the shrinkage of the testicles, but also improve fertility.
Lately, we have gotten some data on the fact that hCG can reactivate all the hormones that are upstream of testosterone that were shut down by testosterone replacement. Testosterone replacement is obviously a good thing to do, but it shuts down LH, FSH, pregnenolone, progesterone, even DHEA comes down in many cases. So, all those hormones upstream tend to be reactivated by the effect of hCG. I'm going to get into many details on that, because I have a video that actually I think I drew a diagram on a whiteboard that you can understand more what I am trying to say. Because, a lot of doctors say, "No, I don't prescribe hCG. I think there's no use for that," and I think after you watch that video you would be able to negotiate with your doctor about the use of hCG in a much more educated fashion.
Don’t stay behind on TRT advances.
The next commandment is don't stay behind on advances. Actually, that's the last commandment, the 10th one. And this is an evolving field, testosterone replacement and men's health in general. We don't only talk about testosterone on ExcelMale.com. We talk about thyroid hormones, about DHEA, about pregnenolone, progesterone, about supplements, about exercise, about you name it, diet, even some cognitive practices et cetera. It's really amazing how many studies are coming through every week, and even for me, and I read everything that I can every day. Even before going to bed, I print out a few papers. Even for me, it's hard to keep up, and I know that if I'm not staying current, I may be missing things that are coming through in the field and obviously will not be able to help others with my information. But don't stay behind on advances. Register on ExcelMale.com and learn more, because an educated patient pretty much gets a lot better care.