Ancillaries to TRT and long-term markers to monitor

Hey guys,

I thought I’d do a post about the best ancillaries and things you should be doing if you want to maximise your TRT journey.

Once you are dialled in and feeling good, I feel like there are a number of things you can keep an eye on to ensure long term health on TRT and maximise your wellbeing even more.

If I had a dollar for every time I heard someone say “TRT isn’t a magic bullet”, I wouldn’t be doing too badly for myself. But as cliche as it is, it is true.

So in this post, I’ll address some of the things I think are important to keep an eye on when taking TRT, as well as the things you should be doing to maximise your overall health. Some of these things are markers that can move out of range due to the either upstream or downstream effects of TRT.

Blood Pressure

Testosterone seems to have differing effects in different people, but one thing that certain guys struggle with on TRT is their blood pressure. Testosterone can upregulate angiotensinogen gene expression, renin activity and AT1R expression. As you can see below, if these are increased you get more sympathetic activity and vasoconstriction as well as water and salt reabsorption, all of which increase blood pressure.

And this is definitely why some guys can have like 140/90 blood pressure chronically on TRT.

How to decrease your BP? Well, follow the steps below and you might be on the right track:

• Ensuring you are not running supraphysiological testosterone levels chronically (true TRT is not a cycle)
• Reducing salt intake, increasing potassium intake (if Pot is low)
• Lose excess bodyweight (btw, I would actually argue that all things equal a 315 lb bodybuilder at 5% bodyfat is unhealthier than a 315 lb sedentary desk jockey, but that’s a story for another time)
• Exercise regularly - cardiovascular training, reduce resting HR and turn ‘on’ AMPK
• Reduce excessive alcohol intake
• Ensure quality sleep hygiene
• Reduce stress
• Incorporate sauna bathing (can lead to significant decreases in BP)
• If all of that fails, something like an ARB (angiotensin II receptor blocker) medication or other class of BP meds may be something you need. I personally run a low dose ARB year round to ensure my BP stays under 120/80.

Blood thickness, heart health

Certainly something that can increase on TRT is both the thickness of your blood and heart size. A lot of bodybuilders who run heavy doses have thickened left ventricle walls of their heart, due to the fact that both androgen receptors in their heart muscle are chronically expressed due to the high anabolic load as well as the fact that heavy training leads to changes in heart morphology (left ventricle gets thicker to accomodate and overcome large pressures during resistance training).

Dallas McCarver for example had a heart around 3 times larger than normal on his autopsy.

Now, am I saying that will happen running 150mg/week? No. However, it is something to be mindful of.

Testosterone can also increase red blood cell production, leading to elevated Hematocrit values on your bloodwork (HCT). Often I will work with guys who have HCT levels of over 55%, which is putting you at risk of clotting and heart disease. You don’t want thick blood!

How to fix? Well, one option is to donate blood. This will drop your HCT almost immediately. However, some guys with low iron levels can crash them even more by giving blood.

So the longer term option is probably to realise that if your HCT levels are high, you might not be dialled in. If your body is creating more red blood cells than you can tolerate or is healthy, this in itself is a sign that your TRT protocol may be amiss - and I definitely have seen some fantastic reductions in HCT simply by dropping dose to a more reasonable number (200mg a week is not therapeutic TRT in like 98% of men).

Hydration is also a big part of this, and have tested myself 1 week at very low hydration levels, barely drinking before getting a blood test and having a HCT of over 55%. 2 days later having hydrated well, my HCT was at 48%.

Heart health is also a big part of this, and I feel like a lot of guys who get on TRT also have a history of heavy resistance training either bodybuilding, powerlifting or have significant amounts of muscle, so I would also recommend at least a yearly ECG/EKG and echocardiogram. This will look at how your heart is functioning and its size, shape, efficiency, structural damage etc.

Lipids

TRT can definitely lead to fluctuations in your lipids. I won’t go into the science here as it is quite complicated, but this video describes it if you are interested in why TRT can lower HDL and raise LDL.

But if you are on TRT and struggling with your lipids, you are certainly not alone! It’s tough.

Checking your HDL levels is probably the most important here, and there are definitely supplements you can take to raise it in the event that it is low - for brevity, will leave that for another post (or the comments if interested). Sometimes, (esp. for guys on heavy cycles) if your LDL is extremely high, it is worth doing a VLDL test to break the LDL value down in subfractions - to identify the subfractions of your LDL value based on the size, density, and/or electrical charge, and give a better idea about your true risk of heart disease and coronary artery atherosclerosis.

Also, adding in Apolipoprotein A1 / B + the ratio is a great idea: Apo B is a primary component of LDL, and this ratio is a very powerful predictor of heart disease risk as backed up by numerous studies. Apo B is a component of all atherogenic or potentially atherogenic particles, including small very-low-density lipoprotein (VLDL), intermediate-density lipoprotein (IDL), LDL, and lipoprotein(a) [Lp(a)], and each particle contains 1 molecule of apo B. Therefore, apo B provides a direct measure of the number of atherogenic lipoprotein particles in circulation.

Pregnenolone, DHEA-S

Both Pregnenolone and DHEA-S are neurosteroids (modulate neuronal processes within the human brain) that are higher up in the cholesterol to testosterone cascade. Some men struggle with these levels being too low once TRT is started.

LH is in control of the uptake of cholesterol into steroidgenic tissues (adrenal gland, gonads, placenta) and ablation of LH can certainly reduce circulating levels of Pregnenolone and DHEA-S. On TRT, LH levels typically fall to virtually zero, so some guys can get lower levels of Pregnenolone and DHEA-S than they had naturally, which can lead to some pretty nasty cognitive sides. Both Preg and DHEA have been implicated in cognitive function, spatial awareness and memory enhancement, so deficiency in these can be unpleasant to say the least.

Checking your levels on a blood test is a good idea as an adjunct to TRT. Both of these can be supplemented if low.

Estrogen Management

I’ve done a few longer posts on E2 so won’t go into crazy detail here, but needless to say, controlling E2 is a big one on TRT.

Testosterone can be directly aromatised into estrogen by the enzyme aromatase (original name hey), but this enzyme is highly prevalent in certain tissues including fat. So if you carry a lot of adipose (fat) tissue, you are going to potentially have higher conversion and thus higher E2 levels. Controlling this can be done via an AI, but I probably prefer to address the cause: if you are overweight dropping your bodyfat % is a great start to reduce excess aromatisation, and if your dose is too high then reducing that can also get your E2 levels back to the range where you’re going to feel the best.

Thanks as always for reading and see you in the next one!