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Thread: TRT Tips for Younger Men | Tyler Perkins

  1. #11
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    What are the causes or potential causes of decreased T for the general population?
    These are the potential causes I can think of:
    -Drugs/medications
    -Poor sleep quality/insufficient sleep
    -Obesity
    -Poor physical fitness
    -Porn addiction
    -Differences in testing methodology
    -Dietary nutrient deficiencies
    -Food additives
    -Plastics
    -Environmental pollution/pesticides
    -Oversocialization/ psychological pussification of society

  2. #12
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    Everyone whether on testosterone or not should address adequate sleep, stress reduction, adequate nutrition, and exercise. We are not always in control of how much we sleep or how much stress we have in our lives but we are in control of what I call the three pillars of health or what I usually say the trifecta of health. We are 100% in control of what we eat, if we exercise, and whether or not we optimize our hormones. Hormone optimization is simply understanding that each hormone has beneficial effects, and the goal is to simply maximize the beneficial effects of each hormone by optimizing levels. It's all about prevention of age related disease, disability, dependence, and frailty. Testosterone therapy is just that -- it's testosterone alone and it is most likely adequate for a younger man in his 20s and maybe early 30s but after the late 30s and definitely after the age of 40 it becomes about hormone optimization. Why wait until you get a deficiency or a disease that was preventable? Hormone optimization is not that different than Starting Strength and it's four main lifts. Let's say a man just wanted to do bench press only and wanted to forget about the other three lifts. He could get really strong in the bench press, and let's say he's benching over 400 pounds. I would say that's pretty impressive but when the day is done without doing the other lifts he's going to be deficient in those areas. Starting Strength makes you harder to kill and so does hormone optimization. One can choose just to do testosterone, just like one can choose to just bench press, but without the other hormones you're not as strong as you could be.

    I always ask the question, how many of you would take a pill from your family doctor if he told you it would do this: It's going to increase your lean muscle mass, strength, endurance, healing capacity, exercise tolerance, bone mineral density, energy, motivation, self-confidence, libido and sexual function. It's going to decrease your visceral body fat as well as subcutaneous body fat. It's going to decrease your fatigue and improve your cholesterol. It's going to help protect you against cardiovascular disease, insulin resistance, and diabetes. How many of us would take that pill? Well that pill is testosterone, and there is a dose/response relationship, which means the better the levels the better the response. There is a fear of testosterone that is not based on any medical literature showing harm. The problem is we as physicians were never trained on hormones we were only trained to use medications for the management of diseases and to treat symptoms. We have no training in prevention. So those of us that understand hormone optimization in its most pure sense would say that everyone should consider hormone optimization after the age of 40 because maintaining optimal levels of hormones combined with nutrition and exercise is your best defense against age related disease, disability, dependence, and frailty. Testosterone and the other hormones absolutely change lives and maximize health, but there is still such a stigma attached to it because of what occurs in the bodybuilding world, and many men simply using it only for performance enhancement at young ages.

    Quote Originally Posted by CommanderFun View Post
    Did you touch at all on going off TRT for fertility reasons and how that goes? One of the main turn-offs to TRT for me has been that I don't want to have to go off it later to have kids. It seems like dealing with losing the exogenous test while endogenous production is suppressed makes for a really bad time of it, worse than just having the low T. For now I just take clomiphene citrate and it's definitely helped. I haven't been able to kick antidepressants entirely but I have been able to drastically reduce the dosage. Also actually grew some real chest hair.
    When it comes to fertility and testosterone therapy a man has several options he can choose from. He could of course choose to never do testosterone, he could use hCG or Clomid as monotherapy which will raise testosterone levels and preserve fertility at the same time, but what I don't see them doing very well is resolving symptoms in a really symptomatic man. A man can choose to do testosterone along with hCG from the very beginning and that will maintain spermatogenesis. If a man wanted to do testosterone only he can then add hCG later when he's ready to get someone pregnant, and if that was not sufficient then you could add Clomid and or HMG. Many younger men with true hypogonadism will actually bank sperm as a failsafe. So your physician should give you all of your options and then you can choose which one best fits your lifestyle and needs.

  3. #13
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    Quote Originally Posted by J. Keith Nichols MD View Post
    When it comes to fertility and testosterone therapy a man has several options he can choose from. He could of course choose to never do testosterone, he could use hCG or Clomid as monotherapy which will raise testosterone levels and preserve fertility at the same time, but what I don't see them doing very well is resolving symptoms in a really symptomatic man. A man can choose to do testosterone along with hCG from the very beginning and that will maintain spermatogenesis. If a man wanted to do testosterone only he can then add hCG later when he's ready to get someone pregnant, and if that was not sufficient then you could add Clomid and or HMG. Many younger men with true hypogonadism will actually bank sperm as a failsafe. So your physician should give you all of your options and then you can choose which one best fits your lifestyle and needs.
    Thank you, that was actually very informative. I'll talk about this stuff with my endocrinologist. It took me a bit of hunting to find one that actually treats testosterone deficiency. I probably wouldn't have gotten treated since previously I tested in the 200s at another doctor (and was told I was "fine" and then had a fat man lecture me on my eating of eggs for breakfast because my LDL was too high, and then got the hard sell on taking a statin), but I happened to come in in the mid 100s when I got tested for this place.

  4. #14
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    If I wanted to ask my GP for bloods, what specifically am I asking to be tested.

    There is zero chance of a GP doing anything and high priced clinics exist here but I am tempted to go down this path as a 46 year old with a view to increasing my personal QOL.

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    Quote Originally Posted by Mark Rippetoe View Post
    The second link says SS recommends Wittmer Rejuvenation Clinic, however on there website they write:

    “Treatment of High Estrogen

    If necessary, clinicians may prescribe medications or assist you in making dietary changes to treat elevated estrogen or imbalances. Providers may also modify your dose or prescribe an aromatase inhibitor if diet alone isn’t adequate to control elevated estrogen levels while on testosterone replacement therapy. The most common prescription is anastrozole (Arimidex), which prevents testosterone from being converted into estrogen by the enzyme aromatase. If estradiol is excessively high, anastrozole with TRT at 0.1mg per week is commonly prescribed. Anastrozole is an oral tablet that inhibits the enzyme aromatase. Men’s diets could be tweaked slightly to normalize estrogen aromatization. Natural phytochemical herbs derived from vegetable extracts can also be used to jumpstart the metabolization of estrogen levels.”

    1. If estrogen is high pre-trt, we need to identify the reason why and not just take medication to lower it. Especially because we don’t know if the estrogen is produced as a protective measure.
    2. The increase in estrogen on trt, even well above range, is normal and responsible for many of the desirable and cardioprotective effects. It is an integral part of testosterone therapy.
    3. Looking at blood values for estrogens or estradiol is not desirable as it is produced locally in the tissues through aromatization, unlike testosterone which circulates to reach AR receptors (or enzymes) in the tissues.

  7. #17
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    Quote Originally Posted by Roy Thomas View Post
    I believe that the use of plastic is one factor in the stew of many that is contributing to the overall decline in testosterone. It's one of the many reasons I despise the stuff but we've set up modern society to run on it so I'm really not sure what to do about it. Generally avoid microwaving foods in plastic containers (Even "Microwave Safe" ones)
    On average we invest micro plastics that when combined would be about the size of a credit card per week. The largest source of this seems to be from what we drink, so a small investment in say a reverse osmosis system would be a very good investment to minimize this.

    Quote Originally Posted by CommanderFun View Post
    Jesus, he went in there with a 185 ng/dl result and the doctor accused him of abusing steroids? People like this should be shot.
    I think Rip is right. You don’t pay for this shit. Even though they take payment up front, you need to tell these incompetent fools right in the middle of the visit when crazy things like this are said that, “I’m not paying for this visit, I want my money refunded. You clearly do not know what you are taking about with regards to this.” Then walk out of the exam room to then get your refund. This is like paying for a pizza and getting it home with a few dead flies on it. You’d go back and get a refund right.

  8. #18
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    Quote Originally Posted by Kletsy View Post
    The second link says SS recommends Wittmer Rejuvenation Clinic, however on there website they write:

    “Treatment of High Estrogen

    If necessary, clinicians may prescribe medications or assist you in making dietary changes to treat elevated estrogen or imbalances. Providers may also modify your dose or prescribe an aromatase inhibitor if diet alone isn’t adequate to control elevated estrogen levels while on testosterone replacement therapy. The most common prescription is anastrozole (Arimidex), which prevents testosterone from being converted into estrogen by the enzyme aromatase. If estradiol is excessively high, anastrozole with TRT at 0.1mg per week is commonly prescribed. Anastrozole is an oral tablet that inhibits the enzyme aromatase. Men’s diets could be tweaked slightly to normalize estrogen aromatization. Natural phytochemical herbs derived from vegetable extracts can also be used to jumpstart the metabolization of estrogen levels.”

    1. If estrogen is high pre-trt, we need to identify the reason why and not just take medication to lower it. Especially because we don’t know if the estrogen is produced as a protective measure.
    2. The increase in estrogen on trt, even well above range, is normal and responsible for many of the desirable and cardioprotective effects. It is an integral part of testosterone therapy.
    3. Looking at blood values for estrogens or estradiol is not desirable as it is produced locally in the tissues through aromatization, unlike testosterone which circulates to reach AR receptors (or enzymes) in the tissues.
    I was afraid that I may have to address something like this and it's exactly why I did the podcast...to address the 3 continued myths concerning testosterone therapy. When we discussed the androgen hypothesis you see how the misinterpretation of a study led to men being deprived of testosterone therapy for decades. So the medical literature did not support testosterone causing prostate cancer but instead just the opposite -- it has a protective effect, but yet physicians even today still think that it causes prostate cancer or increases a man's risk of getting prostate cancer. The same holds true for testosterone causing thick blood predisposing to heart attacks, strokes, or blood clots, as well as to estrogen management. The most common side effect of testosterone therapy is a secondary erythrocytosis, and it has never been shown to cause harm. The same secondary erythrocytosis occurs with people that live at high altitude.

    Applying our management of polycythemia vera which is a completely different condition to how we treat the secondary erythrocytosis from testosterone is not supported by the medical literature. We also don't expect people that live at high altitude to donate blood to lower their hematocrit. Testosterone is a pro hormone and once it reaches target tissues it is converted into its active metabolites DHT or estradiol. In every study to date showing benefits with testosterone therapy not a single one of those studies used an aromatase inhibitor. When we use testosterone in morbidly obese men, men with pre diabetes, and men with diabetes (where it reversed Type 2 diabetes), none of those studies used an aromatase inhibitor. The use of aromatase inhibitors is not based on the medical literature.

    Let me repeat: the majority of testosterone's beneficial effects are through its aromatization into estradiol. The normal range for estradiol is for men with low testosterone levels and if we only got estradiol levels from men with great testosterone levels then the estradiol range would be higher. What I did not get to talk about, but what many practitioners are utilizing now with testosterone therapy, is oral estradiol in men who have dyslipidemia -- they are seeing dramatic improvements in their lipid profile and no adverse effects. The estradiol that we measure in the serum is mainly what is produced peripherally by the adipocytes, not what is produced at the tissue level. It is a paracrine hormone, not an endocrine hormone. When you take an aromatase inhibitor you are literally blocking the beneficial effects of testosterone at the tissue level.

    I honestly believe most of my men have the most optimal levels they could imagine, and not a single man has estrogen symptoms. So you can probably sense my frustration in the fact that the majority of clinics out there are still providing non-evidence-based medicine. Testosterone does not cause prostate cancer. Testosterone does not lead to thick blood, predisposing to heart attacks, strokes, and blood clots. Testosterone's many beneficial effects come from its active metabolites DHT and estradiol, and when you block estradiol you block the beneficial effects of testosterone at the tissue level. There are your three big myths.

    As I discussed about the misinterpretation of the study involving metastatic prostate cancer, the estrogen management is from the misinterpretation of baseline studies in men with high estradiol levels that are not on testosterone. These men have a higher incidence of heart attacks and strokes, and we have to ask ourselves, why is that? Well of course it's the high estradiol that is causing the heart attacks and strokes, right? Well no, of course it isn't the estradiol. It's the obesity and the increased visceral fat that leads to heart attacks and strokes, not the estradiol. Estradiol is just a passive bystander that gets blamed. What happens when we take a man with morbid obesity and give him testosterone, therefore raising his estradiol levels? Well, we decrease his visceral body fat, we reverse insulin resistance or significantly decrease it, and we decrease his risk of heart attacks and strokes. These baseline observations of estradiol in men that are not on testosterone should not be extrapolated to men who take testosterone and therefore raise estradiol.

  9. #19
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    Is it reasonable to say that TOT is basically in a nutshell: take as much testosterone as you need for symptom resolution and improvement of health without limiting yourself to reference ranges of testosterone, estradiol and dht?

  10. #20
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    Default Testosterone therapy and the reference range

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    Quote Originally Posted by Kletsy View Post
    Is it reasonable to say that TOT is basically in a nutshell: take as much testosterone as you need for symptom resolution and improvement of health without limiting yourself to reference ranges of testosterone, estradiol and dht?
    I. It's understanding that testosterone has significant beneficial effects, and when you optimize levels you maximize those beneficial effects. The so-called reference range is just a population average and it is now an average of men that are producing less testosterone than ever. The reference range has nothing to do with health. Even Dr. Travison, who wrote the paper on the normal range, stated that it should not be used for clinical decision making. Hormone optimization is, once again, understanding that the better the levels of your hormones then the more beneficial effects you get from the hormone. With testosterone there is a dose response relationship. I am not talking about bodybuilders and abusing testosterone, but what I am talking about is the range in between not having enough testosterone and abusing it.

    II. There is this perceived harm with levels outside of the normal range. The so-called" supraphysiologic" levels. Every parameter of health that I can measure improves with a supraphysiologic level, essentially defined as between 1000 and 2000 for most men. Some run lower than that and some may run a tad higher in order to get their free testosterone where it needs to be. But generally speaking, between 1000 and 2000 and there is no harm at all in having those levels. In 2006 a paper was written discussing the normal range for 25 labs, and the upper end of normal for some of those labs was 1593 ng/dL. Whenever I was first misdiagnosed the upper limit of the normal range for the lab that I went to was 1500 ng/dL. The normal range in 2017 was 1197 ng/dL at LabCorp. So levels that were healthy then are now all of a sudden unhealthy and dangerous? Of course they aren't. The problem is the new normal range is for a group of unhealthy men that are producing less testosterone than ever. And to specifically answer your question, yes, you are raising testosterone to resolve symptoms and improve health even if that number is above 916 ng/dL, which is the new upper range of normal. As I discussed in the podcast, the serum levels of DHT and estradiol do not reflect the tissue levels. It is a paracrine hormone and what you measure in the serum has no effect at the tissue level. Testosterone enters the cell and is converted to DHT and estradiol. The estradiol and DHT that are circulating in the serum is what is produced peripherally and it has no effect at the tissue level.

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