All guys over 25 must read . . .

[Kruiser]

Part 1

About five months ago I was diagnosed with a somewhat common but frequently undiagnosed medical issue that is not even on the radar of most primary care physicians. Fixing that medical issue has had massive benefits to my productivity, business, and general well-being.

I feel extremely fortunate to have discovered and fixed this issue and hope that I can help others discover and fix this issue if they have it. In this post, I will share some of my own experience and provide a bit of an orientation to the issue in case it can help others. I really want to “raise awareness” (although I hate that phrase).

This post won’t have any relevance to most of you. But for the few who find it relevant, it just might change your life . . .

Intro

Around the time of my 40th birthday last spring, I noticed that I had become really unproductive. I just couldn’t focus. I felt physically exhausted for no apparent reason. I felt depressed and had serious trouble getting stuck in negative mental states. I was very indecisive.

What was wrong with me? I had no clue. I just didn’t feel like myself. It took enormous mental energy for me to focus enough to compose a short and inconsequential email. Why couldn’t I get my act together?

I was relatively healthy and should have felt great. Paleo diet. Regular heavy lifting. No alcohol. 20% body fat, which is certainly not ideal, but not “fat” either. I did a ton of work on my mindset and was doing Tony Robbins’ Hour of Power every morning. While I’d feel better while doing the Hour of Power, the conditioning was not sticking at all and I would be in an extremely low mental state for most of the day.

At the end of a day of accomplishing not too much, I was exhausted and all I could do was lay on the couch and read my phone while I yelled at my young kids to stay in bed and be quiet. What had happened to me?

Awareness

Luckily, around that time I had to see to see a doctor for a minor issue unrelated to this post. I saw a naturopath. I don’t really like seeing doctors and the visit seemed to take forever. She asked lots and lots of questions. I’d think “Why is she even asking me this? That’s not why I’m here. Where is this going?”

Eventually, she looked up from her notes and said “I think I know what’s going on with you, but I’m going to have to do a blood draw to be sure . . . “

5 Months Later . . .

About 5 months after starting treatment for this issue, my productivity is through the roof. I can focus intensely and for long periods of time. I’ve put on 7 pounds of muscle. My cholesterol is down. My blood sugar is optimal.

But by far the the biggest benefits from fixing this issue have been mental and emotional. I am always optimistic. I am calmly confident. Setbacks don’t really phase me, even serious ones. Truth be told, things in my business are not going well yet, but the challenges don’t throw me off. Six months ago I would often feel devastated in the face of even a minor setback.

Everything isn’t sunshine and rainbows and I still have down days where I need to more intentionally manage my emotionally state. The difference is that now I am able to manage my emotional state effectively, whereas six months ago I wasn’t. (@Kung Fu Steve’s coaching has also helped a lot, but that doesn’t fit cleanly into this narrative, so I won’t mention it.)

The Issue

If you haven’t guessed it yet, my medical issue was low testosterone.

When my naturopath mentioned that she suspected low testosterone was my problem, I was more than a little skeptical.

So, as I waited for my lab results, I fired up the Google. As I read through the lists of clinical symptoms for low testosterone (one is included below), I realized, to my surprise, that I had many of them.

I never really had low testosterone on my radar, even though I was decently well read in the health and fitness area. Sure, I had heard awkward radio commercials for testosterone replacement therapy (TRT) clinics, but I had thought of low testosterone as an issue for 70 year old dudes who didn’t want to accept the fact that they were 70, but wanted to feel like they were 30 again. I learned that TRT is also, at least sometimes, for 30 year olds who don’t want to feel like 70 year olds anymore.

I also learned that while our testosterone levels naturally do decline as we age, there has also been a much more precipitous drop off in testosterone levels in recent years that is most likely due to environmental factors (plastics, pollution, pesticides, etc.) that disrupt our endocrine systems.

Our grandfathers generally had much higher testosterone levels than we do. One of the two big U.S. blood-testing labs recently dropped its “normal” ranges for total testosterone by about 100 ng/dl as the blood samples they have been testing have been dropping so much.

Testosterone affects virtually every system in the body, so if your testosterone level is too low, you will not be doing well.

When I got my labs back, I found out that my total testosterone was below “normal,” my free testosterone was below “normal,” and my estrogen (also essential for male health) was so low it didn’t even register. While this is a terrible hormonal profile, I was overjoyed. I finally knew what was wrong with me and I knew that it was fixable.

Diagnosing Low Testosterone

There are two components of properly diagnosing low testosterone: 1) low lab numbers and 2) clinical symptoms. You should have both to be diagnosed with low testosterone.

You figure out your lab numbers by having a blood draw. “Normal” range for total testosterone is something between about 300 and 1100 ng/dl. Different labs have different ranges for “normal.” What is important is that, most likely, if you are under 500 ng/dl, you will likely feel like crap, even if you are within “normal” range. This is a critical point that too many physicians do not understand. If you can convince your doctor to order a testosterone test (which is itself often a challenge), you will often simply be told “you’re fine” if you have total testosterone anywhere above 300 ng/dl. But you might not be fine.

Clinical symptoms of low testosterone include “irritability or increased sadness, reduced libido, low energy, fatigue, decreased ability to concentrate on tasks, lack of morning erections, and a change in body composition with more central body fat.” This is one list, but you can find other similar lists online.

Note that some of these symptoms are the same as symptoms of depression and erectile dysfunction. Many guys with low testosterone end up getting prescribed antidepressants (which lower their testosterone even more) and Viagra. Their symptoms are treated, but the underlying cause isn’t.

There are no bright lines as to when someone has low testosterone, so you really want to be working with an experienced physician who specializes in TRT. One patient might have 400 ng/dl total testosterone and feel great and the next patient might have 400 ng/dl and feel absolutely terrible. Both are within “normal” range, but one is very much not well.

Personal Responsibility and Knowledge

Of course, we want to take personal responsibility for all aspects of our life, including our health. But it is especially important to be knowledgeable about TRT if you are considering TRT.

You simply do not want to be messing with your hormones using a bad protocol as that can make things much, much worse. I wouldn’t be comfortable undergoing TRT if I didn’t feel reasonably knowledgeable myself.

You want to be able to use your doctor as a consultant who works for you and with you, not a white-coated all-knowing demigod. I’ve included some resources below that could help get you up to speed.

“If I do have low testosterone, can’t I just increase it naturally or with supplements?”

Not really, but there are lots of folks who will be happy to sell you a “testosterone booster” that will not help. Note that certain supplements WILL increase libido without actually increasing testosterone levels. And, yeah, there are certain things you can do to temporarily boost your testosterone (heavy squats, cold showers, etc.), but if you have seriously low levels, those temporary boosts won’t change anything for you.

On further thought, I guess I need to qualify the above statements. I am assuming that you are already living a healthy lifestyle; managed stress, decent sleep, healthy weight, good diet, weight training, no substance abuse issues, etc. If you are 100 pounds overweight, never exercise, abuse alcohol or sugar, start there. Guys with a crappy lifestyle can actually massively increase their testosterone by optimizing their lifestyle factors.

But if you have these lifestyle factors dialed and you still have low testosterone, you are going to need TRT if you want meaningful improvement in your testosterone levels.

Also, sometimes apparent testosterone issues are actually thyroid issues. A good TRT doc should be looking for thyroid issues and getting them resolved first.

What should you do if you suspect you have low testosterone?

If your lifestyle factors are already dialed in and if you read through the list of clinical low testosterone symptoms (from the list above or from another list you find through Google) and suspect that low testosterone may be an issue for you, the next step is to get a blood draw.

You can try to convince your primary care physician to order one. From what I’ve read in online forums, that can be a real challenge. Another option is to approach a TRT clinic in your area. However, initial intake appointments at TRT clinics can be really expensive. Mine wasn’t, but some are.

A third option is to just order your own blood test. There is a company called discountedlabs.com that allows you to order whatever blood test you want and you pay for it out of pocket. You want to get your total testosterone and free testosterone numbers. Here is a link to the test you want TESTOSTERONE Total and Free (Regular) | Discounted Labs . It is on sale for $30 now, but that could change by the time you read this. You basically pick the test and schedule a blood draw at one of their many locations. Then you go in for your blood draw and they’ll email your results a few days later. Testosterone levels vary throughout the day, but generally peak mid-morning, so try to have your draw between 8 and 11 a.m. for the most accurate results.

If your total testosterone is under 500 ng/dl or if your free testosterone is at the lower end of the “normal” range, I would consider purchasing the Testosterone Optimization Therapy Bible by Jay Campbell (best and most comprehensive TRT resource I’ve found), reading it cover to cover, and then starting to look for a reputable TRT clinic in your area.

 

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[Kruiser]

Part 2

Finding the Right Doctor

You only want to work with someone who really knows what they are doing. You will only know if the doctor knows what he/she is doing if YOU yourself have a decent understanding of TRT.

The right doctor is almost certainly not your primary care physician. It is probably not the endocrinologist your primary care physician might (but probably won’t) refer you to.

TRT simply isn’t taught to most MDs and is not on their radar. Why is this? A variety of reasons. But one reason is this: most doctors’ post med school education primarily comes from pharmaceutical reps. A month’s supply of testosterone costs about $20 and testosterone is not patentable. There is no money in TRT for pharmaceutical companies.

Even though I am extremely grateful to my naturopath for flagging my testosterone issue for me, I decided to work with someone else to fix it. TRT wasn’t really a focus of her practice and the treatment plan she recommended was problematic.

If you are in the U.S., see what TRT clinics are in your area, ask around, read Google reviews, interview the physicians. I was really lucky because there is an awesome and reasonably priced TRT clinic in my city staffed with doctors who are holistic and know what they are doing. But a different clinic in my city appears to try to lock patients into expensive long term contracts for treatment BEFORE their testosterone levels are even checked. Not good. See Beware of Testosterone Replacement Mills | T Nation for a good discussion of “testosterone mills.”

There are also some TRT clinics that operate telemedicine practices. That is, they’ll treat people anywhere in the country. This can be a great option for guys who live in rural areas. I think legal regulations might require you to do the initial visit in person, but I’m not completely sure of that.

I heard on a TRT podcast that if you are outside the U.S., it is difficult to get decent TRT. I could be wrong on this, so if someone else has more knowledge, please share it.

Cost

There is a cost associated with undergoing TRT. In general, you are going to be paying out of pocket. My understanding is that most insurance companies require three separate blood draws each of which must be below the very low “normal” ranges. Most men with a true medical need for TRT will not satisfy this test and will not have TRT covered by their insurance.

My cost is $200/month. That includes the pharmaceuticals, blood draws, appointments with doctors who know what they are doing, etc. I think that might be on the low end, but I’m not sure. This cost is absolutely nothing compared to the benefit it has provided me.

“If I am diagnosed with low testosterone and start TRT, what can I expect? What is it like?”

If you have a bad doctor, expect a discussion of testosterone creams or pills. If you have a good doctor, expect a discussion of intramuscular or subcutaneous injections. I’m joking. Sort of.

Injections are the gold standard. I used to hate needles so much that I would never even consider getting a flu shot because, frankly, I would rather spend a week in bed with the flu than get a shot. I almost passed out the first time I gave myself a testosterone shot because needles just freaked me out. Now, I gladly inject myself multiple times a week, because I know the shots help me feel my best. I guess we can condition ourselves to do anything . . .

TRT protocols vary with the needs of the patient and the preferences of the physician, but my current one is fairly typical. Here it is, so you have a sense of what TRT might involve for you. This is NOT a recommendation, but an example.

• Weekly, two self-administered intramuscular shots of testosterone, two self-administered shots of hCG (discussed below in Fertility section), and two small doses of anastrozole (an aromatase inhibitor, discussed below) in pill form.

• I have a blood draw and face to face doctor’s appointment about every two months. A few days after that blood draw, I have a conversation with the doctor via telephone to discuss the lab results and to see if any adjustments are needed.

• Also, I need to donate blood about once a quarter. Intramuscular testosterone shots tend to increase hematocrit levels (ratio of red blood cells to total blood volume). Some smart doctors think that is dangerous if left unchecked (excessive blood thickening could lead to strokes and cardiac events), so TRT patients should donate blood occasionally. Other smart doctors say elevated hematocrit doesn’t matter (e.g., pretty much everyone in Denver has elevated hematocrit because of elevation and they are fine). I stay on the safe side and donate (and my TRT clinic requires it).

“If I am diagnosed with low testosterone and begin TRT, what will my results be like?”

Obviously, results vary, but in general it is important to know that TRT takes weeks and months to take full effect. It is not like having a headache, taking an aspirin, and feeling better 30 minutes later.

If you want to know a general timeline for when the effects of TRT kick in, here’s an academic article on the subject: Onset of effects of testosterone treatment and time span until maximum effects are achieved Just read the “Results” section of the abstract on page 1.

For me, the changes caused by TRT were slow and almost imperceptible from day to day.

I didn’t really realize how much TRT had helped me until my two month follow up appointment. My doctor reviewed with me my survey answers from my intake appointment. “Ok, you said your energy was at a 2 on a scale of 1-10. Where is it now?” “8, maybe 9.” “Ok, you said your ability to concentrate was at a 1. Where is it now?” “10.” “Ok, you said your libido was . . . you said your libido was 0 on a scale of 1-10. Where is it now?” “9, no 10.” And on and on it went, just like that, question after question.

I couldn’t believe the pathetic (but completely true) answers I had given a mere two months earlier.

“What can go wrong with TRT?”

From all I’ve read, the main challenges seem to be 1) uninformed doctors prescribing massive and infrequent testosterone injections (e.g., one huge injection every two weeks) and 2) improperly managed estrogen. Most bad experiences regarding TRT are a result of one of these two things.

The large infrequent injections cause a hormone rollercoaster: massively spiked testosterone right after the injection which then crashes to very low levels before the next injection.

The male body converts a certain amount of testosterone to estrogen via an enzyme called aromatase. Fun fact: although some think of estrogen as the “female hormone that makes women emotional,” males also need a certain amount of estrogen for optimal health (though at a much lower level than women).

Oddly, symptoms of low estrogen in males are very similar to symptoms of low testosterone. If your doctor doesn’t know what he/she is doing and puts you on a TRT regimen that crashes your estrogen, you will feel TERRIBLE.

Certain men, particularly those with too much fat, will convert an excessive amount of testosterone into estrogen. This high estrogen causes a host of problems, but can be relatively easily controlled by 1) losing weight, 2) reducing the testosterone dosage 3) preventing the aromatization of testosterone to estrogen by using an aromatase inhibitor (oral pill).

Really, if you are dealing with a doctor who is competent and experienced, you shouldn’t have any issues. Or if you do, you won’t have them for long as appropriate adjustments to your protocol will be made.

“How long will I be on TRT before the problem is fixed and I don’t need shots anymore?”

TRT is for life. You are directly replacing the testosterone your body should be producing but isn’t. But these injections don’t actually fix the reason your body isn’t producing enough testosterone. It is roughly analogous to a Type 1 diabetic using insulin. The diabetic needs the insulin because his body isn’t making it, but taking insulin via injection isn’t going to help his pancreas to start making it.

“Isn’t TRT just using steroids?”

No. Low testosterone is a legitimate medical condition. You are replacing testosterone your body isn’t producing but needs.

“Enhanced” lifters using testosterone will inject enough testosterone to boost their levels to 2,000 ng/dl or more which is way more than any human body could naturally produce. Doctors treating low testosterone generally will not let your levels get above 1,200 ng/dl (which is about the max a human body could produce naturally).

“I would never do TRT because I don’t want to rely on outside testosterone.”

If your body is not producing enough testosterone itself, you are already relying on outside testosterone to feel your best. You just aren’t getting it. You are living your life in testosterone withdrawal.

“I heard that TRT increases the risk of heart attacks and strokes.”

A single study of guys over 65 who already had serious mobility issues did find that they had increased cardiac events when undergoing TRT. Later and more comprehensive studies found testosterone replacement therapy to be cardioprotective.

“I’m only 25, can this really be an issue for me?”

Possibly. Here are a couple of links to stories of guys under thirty using TRT. The Iron and Tweed series of articles is particularly informative and well-written.

An Intro to Testosterone and TRT

What Happens After 6 Months of TRT - TOT Revolution


Maintaining Fertility while on TRT

While you are taking exogenous testosterone, your own testosterone manufacturing process will slow down or shut down and you will lose your fertility, unless you are taking something in addition to testosterone. That “something” is hCG, human chorionic gonadotropin. Basically, it will stimulate your testes to manufacture enough intratesticular testosterone to maintain your fertility.

Some doctors will not start younger men (under 30) on testosterone shots until they have tried other therapies aimed to increase their natural testosterone production (and that pose little risk to fertility).

Obviously, fertility is not a minor issue. I don’t want to get too much into the weeds here, but the resources I’ve listed below give a lot more detail. The bottom line is that it is easy to maintain fertility while on TRT or to regain it (if one has lost if by choosing to pursue TRT without hCG). But the risks to fertility, while small and manageable, are not zero.

Resources/Additional Reading

These are the best resources I have come across regarding TRT.

• Testosterone Optimization Therapy Bible, by Jay Campbell (on Amazon)
  
  
• Testosterone Replacement Therapy: A Recipe for Success, by Dr. John Crisler (on Amazon)
  
  
• TNation’s T Replacement forum : About the T Replacement Category
  
  
• Iron and Tweed’s articles on TRT:
  
  
• An Intro to Testosterone and TRT

Conclusion

Thanks for reading this ridiculously long post! As long as it’s been, I’ve actually left out a lot (free testosterone, SHBG, etc.). This is a complicated subject. My goal has been mainly to raise awareness and to provide some initial direction to anyone who might benefit from TRT.

A lot of this probably reads like I am just talking out of my a@@. I considered adding links and citations for everything I’m saying, but that would have made the post unreadable. Definitely do your own research!

I’m not a doctor. I’m just a guy who has read a few books, spent a lot of time reading threads in various TRT forums, and has had his life really turned around by discovering TRT. I also know that I am not the only guy on the forum who has benefitted from TRT and probably not the most knowledgeable guy either (@MidwestLandlord).

If I you have any questions, please ask them, and I will do my best to answer them, although I am not an expert. Thanks!

 

[Matt Dassel]

Oh my god!!

Low testosterone? Please god save me from it

Happy to hear you're doing good

Keep it up

Always a tiger