And we are optimizing.
We're not trying to replicate what our body has done because clearly our body is not doing
a good job.
So we are optimizing and the best effects with the least amount of side effects is going
to come from steady levels.
Welcome to the Hormones Happen podcast, a podcast designed for individuals like you
who are curious about the amazing benefits of hormonal placement therapy.
I'm your host, Jeremiah, and I'm a nurse practitioner who specializes in HRT.
I've seen firsthand the debilitating effects of hormone deficiency and have personally experienced
the benefits of optimization.
My goal is to arm you with information regarding the good, the bad, and even taboo aspects
of HRT while answering your burning questions.
Please join me for today's episode of the Hormones Happen podcast.
Ladies and gentlemen, boys and girls, men and women.
Well, you get the point.
Welcome back to the Hormones Happen podcast.
Today I want to talk to you about some of the intricacies of testosterone, but not the
symptoms of when it's low and the amazing benefits of when it's replaced, but more so
specifics as to different forms that it comes in, how to take it, and just some tips and
tricks.
Testosterone replacement therapy is incredibly versatile and comes in a variety of different
forms such as orals, creams, pellets, injections, even nasal sprays, and probably patches too,
which goes into kind of transdermals.
But I just want to touch on each of them, some of the pros and cons, and then my experiences
in prescribing them.
Starting off with the oral formulation, historically, because with an oral anabolic, it has to have
what's called a 17 alpha alkylation attached to it.
It has been harsh on the liver because that 17 alpha alkylation prolongs the amount of
time that it's in the liver, which can often show increases on some of the blood work that
we get.
There is a newer form of testosterone called testosterone undercannuate, which actually
has a very, very long ester attached to it.
And for this reason, it actually bypasses the liver and gets absorbed through lymphatic
circulation.
It's still a very expensive medication at the time, and I'm not sure if any of the compounding
pharmacies are able to actually make it.
But as it becomes more available, I think this is going to be a great option for a lot
of people who have hesitation to use injections or they have difficulty with the high maintenance
application schedule of a cream.
Topical creams are a great option for both men and women.
With men, there are some things we need to take into account, such as transferring to
other people, because this is a high dose cream in comparison to women.
So placing the cream on, let's say your forearms or the crook of your arms right behind your
elbow is not a great idea because if you go to hug your wife or your children, you're
going to pass it on.
Although with wives, I mean, women can also use a little testosterone, not horrible, but
you know, children, pets, we want to avoid it.
There is some things to take into consideration with the cream, such as how often you apply
it and where you apply it.
So what do I mean by this?
So the creams are applied twice a day.
Some people say once a day is sufficient, but for absolute steady levels, twice a day
application is apex.
Twice a day application to the scrotum.
Now that might be bad enough for some people, but now we also need to shave the scrotum.
And I'm not talking electric razor, but straight razor.
And this makes a huge difference.
It can vary the levels by up to 400 points they've seen in studies.
So application to the scrotum twice a day, once weekly shaving would be a great option.
But you also have to consider some of the skin textures.
If you have some really thick skin there, which on the scrotum, it's usually a thin,
very vascular membrane, thick skin, dry skin, not showering before.
These are all things that can also affect the levels.
The time of the year, what kind of clothing are you wearing?
Depending on the base that it's mixed in that can vary how long it takes to actually fully
absorb into the skin.
There's a lot to take into account.
And this is creams.
Now gels are different.
That's an alcohol based base essentially.
And that is something that I don't recommend placing on the scrotum.
Guys will usually apply this on the shoulders, but you cannot get a gel as strong as you
can a cream.
Creams you can compound to a much higher level and there's better absorption.
Not a huge fan of the gels at all, but definitely don't place that to the scrotum.
Just the creams.
These are specially compounded creams with safe bases that you can apply to the scrotum.
One more thing with the creams, if you're going to apply it to your testicles, your
scrotum, one thing you need to consider is sexual intercourse.
And recommendations are waiting six hours after application before engaging in sexual
intercourse.
Like I said, it's not going to be devastating if you don't, but that's just one more thing
that you need to consider with the creams.
If you've listened to the podcast before, you know I'm not a fan of pellets for a variety
of reasons.
The idea is great that you have a pellet inserted for three to four months and life is fantastic.
But the reality is that there's a guessing game in trying to determine the dosage for
this pellet and trying to realize is this dosage going to last you for three to four
months.
Oftentimes, what I'll see is someone will get benefit for three to four weeks and then
for two months, maybe three months, they're just dwindling down on that hormone to a point
to where maybe they feel even worse than they did before towards the end of the pellet's
life.
Because what they may say is that your body is only going to pull from this pellet what
it wants, what it needs.
But the reality is, is in the world of optimization, we're augmenting it probably past where you
were at 20.
It's not a great science.
It sounds great.
And I will say it's safe.
If the person knows what they're doing, the application is safe.
I have seen some botched insertions where the pellets have come out.
There have been infections.
That is something you need to consider.
But I don't even hone in on that because I would just assume anyone placing a pellet
is an expert in that field and they're doing that great.
So I'm not going to harp on the application, but I am going to harp on the fact that we
do not know how long that pellet is going to last, how long that pellet is going to
provide you relief.
And if that pellet is going to give you your money's worth.
In my personal opinion, I do feel that the pellets are more of a cash grab presented
by the pharmaceutical companies to just try to basically just get money from you guys.
But I also know some people that do fantastic on them.
So it's not the same all the way across.
I do know people who had the pallets for years and they've done great.
The first year or so they kind of struggled with getting the dosage.
Once the dosage was situated, they were good to go.
Injections.
In my opinion, this is the gold standard form of application of TRT because it's very predictable.
It's very reliable.
And we know so much about its effects compared to other formulations.
So the things you have to consider when you have an injection of testosterone is you have
a small vial.
And inside that vial, you've got a couple things.
You've got the medication, which is testosterone.
But if you were just to inject the testosterone without an ester, you would get it all in
a couple minutes.
So we have to attach what's called an ester, which is essentially a chemical compound to
it that gives it its time released properties.
And so for instance, I specifically use cypionate.
It's a very commonly used ester.
There's other ones out there like proponate, enanthate, and decanoate.
There's several out there.
But cypionate is one of the more tried and true in TRT.
Now testosterone cypionate has an action of onset of about three to four days and a half
life of seven days.
So what this means is that if you're injecting every seven days for the first three to four
days, you're going to feel great.
But then right before your next injection, you're going to feel like crap.
Probably not as bad as before you started, but close.
And then let's say, let's play devil's advocate and say you did every two weeks.
At that second week, you're going to feel worse than you did when you started because
now your natural production of testosterone has turned off and we're giving you such a
low dose that your baseline testosterone, if you were to actually check this on labs,
would probably be less than when you first started.
So cypionate just gives us our time release properties.
It's very important.
And then lastly, there has to be some type of oil, a carrier oil attached to this testosterone
and ester because testosterone is what we call hydrophobic.
It doesn't like water.
So we have to attach it or we have to compound it in some type of oil.
And there's different types of oils out there.
Some of the most commercially available oils are things like cottonseed oil and sesame
seed oil.
I specifically compound all of the medications in grape seed oil because it's not as viscous,
meaning thick, but it's also not nearly as inflammatory.
So it gives us options as to how we can administer it, such as subcutaneous into the fat tissue
or intramuscular into the muscle.
One consideration with subcutaneous versus intramuscular is that when you're injecting
it into the subcutaneous tissue, it's going to absorb at a slower rate.
Intramuscular is going to be much quicker because you have greater vascular supply to
that area.
And when you're injecting testosterone, depending on the volume into the subcutaneous, you may
develop a small nodule that will dissipate over time.
You can also rub it to help it go away quicker, but that's just something to take into consideration
between the two of them.
The two most common that I often see used and I personally use for my patients is creams
and injections.
Now one big thing to consider between the two of these is with a cream, you can only
compound it so strong.
Most formulations are 200 milligrams per milliliter.
There are some that are 220 to 250 milligrams per milliliter, but it's really hard to say
at what point are you over saturating the base to where any excess is not going to be
able to be disassociated into the capillaries.
That's a possibility.
With the injections, the sky's the limit.
You want more, you inject more.
It's very simple.
With both the creams and the injections, there's a multitude of ways you can apply it.
As I said before, creams highly recommend the scrotum, shaving scrotum twice daily for
the most consistent, accurate results.
Now with injections, you have more variability here.
You can, assuming you're using grape seed oil, inject this like insulin into the fat
tissue subcutaneously, or you can inject it into the muscle.
Whether that be the side of the shoulder, the outer aspect of the thigh, some guys really
gravitate towards the glutes.
Just depending on how thin you are, depending on the size of your needle, you may not get
into the muscle.
I'm not a huge advocate for the large 23 to 25 gauge one and a half inch needles.
Those are the needles used for deep intramuscular injection.
Usually if a guy's doing once a week, twice a week, they're doing larger volumes.
Also, if they're using something like sesame seed or cottonseed oil, you probably wouldn't
want to try subcutaneous.
So with those, you're really having to bypass a lot of fat, get into the deep glute muscle
to inject.
But with grape seed oil, you're completely fine doing this subcutaneously, just like
you would insulin, pinch up a little belly fat, poke it right into the belly.
Now as far as frequency, as we talked about with the esters and the action of onset and
the half-lifes, I highly recommend twice weekly injections.
Because like I said before, once a week and God forbid, twice a week, you're going to
feel like crap towards the end of the life cycle of the medication.
But if we're doing twice a week, you're going to feel much more stable.
You're going to be at a much more stable level.
And some people say, I've had people tell me this, they're like, well, why are we trying
to maintain steady levels when our body doesn't naturally produce steady levels of testosterone
throughout the day?
And they're not wrong.
That is true.
But the difference is that now we are manipulating this and we are optimizing.
We're not trying to replicate what our body has done because clearly our body is not doing
a good job.
So we are optimizing.
And the best effects with the least amount of side effects is going to come from steady
levels.
That's the goal.
With any form of supplementation, we want steady levels.
That is what gives us the best results.
Now with the injections, there is one more tip I'd like to give.
When you have your vial, realize it's going to be mixed in oil.
When you're drawing it up, especially with, let's say a 27 gauge half inch needle, which
is the ones that I recommend, it's going to take some time to draw it up.
Now some people will actually switch the needle to a larger size needle, like an 18 gauge
or some people will do a 16 gauge.
Those are very large, almost harpoons.
I don't recommend it because when you access the top, the little rubber top of the vial,
you're going to cord out a little bit and there's going to be a piece of rubber sitting
in the bottom of your vial.
And I honestly do not know if this is going to cause some negative issues in the future.
I don't think there's been any studies on it or a whole lot of documentation, but I
know it exists and I have seen in some cases where people will have preloaded syringes
from another clinic and over time it'll become discolored depending on how long they have
it.
Usually over a month I see the oil almost looks discolored, which tells me the rubber
stopper inside the syringe is leaking into the medication.
Why would the rubber stopper on the vial not leak into the medication?
So I recommend drawing it up with the small needle, which is completely fine to do.
That's what we do for insulin in fact.
It's the same size needle, same size process.
One thing I can say that will make it quicker is if you just put your little vial in a warm
water bath for three to five minutes, it's going to drop probably about twice as quick,
which is going to make this a lot more manageable.
It does make a big difference.
Typically if you can get into a routine, for instance myself, I inject in the morning before
the gym.
So when I'm showering for the gym just to kind of warm everything up, I'll have my vial
sitting in the sink in some warm water.
When I get out, I'll draw it up.
It's much quicker and then I'll inject right then and there.
I used to draw my testosterone out the night before and just leave it overnight.
I don't see the point of it.
Granted, it's probably not in contact with that rubber stopper long enough to cause harm.
It doesn't take long at all if you warm up the testosterone vial.
We interrupt this program to bring you an important announcement.
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and believe that treatment cannot be a cookie cutter protocol.
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All right.
Welcome back to the Q&A section of the podcast.
Are SARMs testosterone?
Absolutely.
Unequivocally, no.
A lot of people have the misconception and have actually been told that SARMs are testosterone.
Now SARMs, which stand for selective androgen receptor modulators, it's a great idea.
It can activate specific androgen receptors while sparing others.
In theory, it sounds amazing.
It's like baking a cake and eating it too.
But some of these SARMs, and just for reference, such as RAD140, TT701, LGD3033, these are
very commonly sold over the counter with a lot of claims behind them that they're going
to boost your testosterone level, lose body fat, and there may be some truth to this to
some degree.
What I've seen time and time again is multiple men come to me on these SARMs under the idea
that they're already on TRT.
We get some blood work.
We see that their endogenous pathway, their natural production of testosterone is still
functioning, but now their testosterone is suppressed.
I don't know why.
I'm not by any means a SARM expert.
I'm just telling you what I see in my practice.
I don't know why this happens, but I don't necessarily know if there's long-term issues
with it.
I don't know.
The idea of a SARM if it was truly pharmaceutical is amazing, but the biggest issue with SARMs
is that being sold over the counter, there's no regulating body, there's no governing body
who determines if it's actually in there.
I've seen studies where they've evaluated several different SARMs that claim to have
a specific compound in it.
In actuality, it either has incredibly lower concentrations than what was stated.
It doesn't have any of the medication that was stated, or it has a completely different
medication than was stated.
It's really so variable in the manufacturing process that that's why I am not really a
huge fan of SARMs.
I think they're relatively safe, but I don't think they're very efficacious.
It is by no means anything like testosterone.
If someone's on testosterone, which like I said, I've had guys come to me on SARMs that
get on TRT, they will tell you it is a night and day difference.
It is completely two different games here.
I'm 27 years old, just started on TRT through an online clinic.
Should I be concerned about ROID rage?
That's a great question and one that I get very, very commonly.
ROID rage, what is it?
It's the idea that someone gets testosterone, exogenous forms of testosterone, and now their
anger level increases, their aggression increases.
Well, I can tell you firsthand, your aggression, your directable aggression will increase.
It's going to give you this assertiveness.
It's going to give you this aura about you that makes you more assertive.
It will happen, but will it make you essentially a juiced up asshole?
No, absolutely not.
Now this is the thing.
If you were an asshole to begin with, you're probably going to be a bigger one.
It's going to augment you from your base state.
In reality, oftentimes what I see is men will actually relax.
The anxiety that we don't even know is building up inside of us oftentimes causes a lot of
this tension.
And when we can actually decrease it through testosterone's ability to increase serotonin
and re-uptake transporters, which is essentially a natural antidepressant, you would be amazed.
These men chill.
They calm down.
I noticed it the first couple of times I took it.
I felt almost tired.
I could just go to sleep.
I felt very relaxed.
And this is the majority of men that I treat.
They feel just absolutely calmer.
And so this whole ROID rage premise, I mean, you have to realize that when they've done
these stereotypical things about it, these are usually top performing athletes that are
on multiple substances other than testosterone.
And yeah, sure, it can augment that aggression to the point of being out of control.
But depending on their baseline state of health, their baseline mental health is really what
depends on.
So testosterone is not inherently going to give you ROID rage or make you this aggressive
animal.
It's going to increase your aggressiveness, but it's going to be a controllable, directable,
very productive aggressiveness.
It's not just going to make you throw things and hurt the people that are closest to you.
I'm 35 years old.
I've been on TRT for five years and I recently increased my dosage.
I feel amazing.
No one has ever treated me to this level before.
However, I'm experiencing back knee.
And for those of you that don't know what back knee is, it's essentially just a term
that says back acne.
Okay.
Now, TRT testosterone is going to cause increased acne.
It does this because of five alpha reductase type one, increasing the conversion of testosterone
to DHT, which then causes epithelial cells to release sebum, which clog pores.
And a real indicator is if you had really bad acne when you were a child and adolescent,
you're probably going to have some acne with TRT, maybe not to the same effect.
And there are ways that you can mitigate this such as dosing protocols and what so on and
so forth.
But when you do start experiencing this back knee or the acne on your chest or on the face,
it can be very distracting and it could be debilitating.
And some men get it to a severe point to where they develop cystic acne.
That's almost unmanageable.
I haven't seen that in my practice.
I personally have experienced some acne on my back and my chest.
One thing I do recommend, there's a couple of things you can do.
First and foremost, skin hygiene is huge.
Make sure you're showering, you know, twice, three times a day.
Make sure you're using an antibacterial soap.
Make sure that you're scrubbing your skin.
If you need to, you can always dilute a little bit of apple cider vinegar and some water
and use that to rub over the little lesions.
But one thing that I have found to work really well is just getting a basic back scrubber
from Walmart.
They're cheap, maybe like three bucks, three, four dollars.
Get some antibacterial soap, just squirt it on there and just really vigorously go to
town on your back, your chest, wherever you're having the acne and, you know, even other
areas.
You know, we're prone to break out on our arms, our shoulders, our chest, sometimes
our abdomen.
It can really come anywhere.
And then just a washcloth for the face.
But if you're maintaining this skin schedule, just keeping your skin clean, we're going
to prevent the blocking of those pores and the development of this acne.
Sometimes can be really hard when it gets pretty significant and now you're trying
to catch up.
So prevention is the best cure for this one.
But once again, like I said, there are ways to mitigate it through dosing.
But acne is just something that we kind of have to to some degree expect.
And there are some men who are just genetically blessed.
They don't have any problem with this.
I want to thank everyone for listening to today's episode of the Hormones Happen podcast
and hope that you were able to find some value in the information that was provided today.
If you have any questions that you would like to have discussed on the podcast, please send
them to the email listed below or message us on the StillCity HRT and Weight Loss Facebook
page.
Remember, you are not alone in the war on hormones.
Stay optimized.