Do you need TRT? A Guide to your Decision

Hey guys,

If you’ve followed me for a while, you know I want to provide the best quality, science-based care to men across the world, as I believe a large majority of (not all) doctors simply lack the education around hormones and men’s health. I want to keep as many of you safe, healthy and happy throughout my career, and leave a positive impact on the world of hormones/men’s health. I don’t think any man should suffer through low testosterone or hormonal issues simply due a lack of quality care available. Anyway, enough about me…

Quick disclaimer (usual stuff): I'm not a doctor yet, so anything below is just my opinion. All relevant TRT protocol information/decisions should be discussed with your individual medical practitioner.

With that out of the way, I thought I’d do a quick blog post to answer the following question: do you actually need TRT?

I see so many guys (both my clients and others) hop on TRT because they want to see what it feels like, some with no bloodwork at all. That’s not actually ‘replacement’ therapy at all, because you have no idea where your T levels are at, and could be shutting down your HPTA for no good reason, leading to months, if not years, of pain to recover your HPT axis through PCT.

So here is what I think are the big ticket items to target if you are thinking about TRT and want to make the best-informed decision you can.

Symptoms

Really sit with yourself here. What are your symptoms? Not just ‘oh I used to bench 315 and now I can only bench 225', but you haven't trained in like 5 years. I like putting the symptoms first, as a simple Testosterone number/level on paper can bring vastly different symptoms between different people, so I like to work to the symptoms as a primary indicator, with bloodwork to confirm.

Symptoms like the following may be indicative of doing further investigatory bloodwork:

• Severe lack of interest in sex with a noticeable drop-off: have you experienced a lack of interest that is significantly different from 5, 10, 15 years ago? Stress and lifestyle factors of course can muddy the waters here, but I think most guys ‘know’ how horny they were, and if that level is miles away from where you are now, it could warrant further investigation.

• Loss of muscle mass or difficulty recovering despite eating, training, sleeping the same and doing everything ‘right’: it’s important that you’ve kept everything the same, and seem some big drop-offs in performance whether in the gym, sport or general life.

• Lack of energy, especially worse at night: given natural endogenous testosterone peaks early in the morning and drops at night (diurnal rhythm), if you are already hypogonadal in the morning, you can expect that number to be anywhere between 20-40% lower by the evening. If you are experiencing big crashes later in the day in terms of mood, libido and energy, it could be indicative that your testosterone levels are low.

• Erectile issues/ED, especially loss of morning wood: if you’ve noticed a loss of morning wood where you’ve had it for a number of years (especially when you were younger), it could be indicative of low testosterone. Kind of relating to the loss of libido, but if you are also struggling to get it up in the bedroom, it could be a symptom of low T.

• Depression/low mood: there are some studies to show a link between testosterone levels and serotonin, where dysfunction via low testosterone levels can be expressed in very low mood/depressive disorders.

• Significant increase in BF% despite eating the same: again, I sound like a broken record, but keeping everything the same is so vital to assessing symptoms - if you are eating just like normal, or are indeed adjusting for a slowing metabolic rate with age/lifestyle, and know this objectively (via food tracking), and are struggling to keep the weight off (especially bodyfat), it could be a reason to check testosterone levels. Also, keep in mind for the bigger guys, the aromatase enzyme (testosterone to estradiol converting enzyme) is highly prevalent in adipose tissue (fat tissue), which I will address in the next section.

• Loss of body hair/beard growth: DHT as one of the strongest androgens in the male body (converted from testosterone by the 5-alpha-reductase enzyme) is critical in body hair and beard growth. In particular, beard follicles require DHT to develop/mature, and lower levels of testosterone = lower levels of DHT = less signalling to these follicles. If you’re struggling to grow a beard, or barely have any body hair, this could be a reason to do further investigations. However, keep in mind this symptom is probably the most variable from man to man - and just because you have little body hair doesn’t automatically mean your T is low - genetics of hair coverage/expression is the driving factor here. This final symptom (loss of body hair/beard growth) could be the ‘icing on the cake’, so to speak.

Lifestyle factors

I’m thinking of making a separate post on how to optimise your lifestyle factors if you’re borderline low T, but the main ones that can either directly or indirectly lower testosterone are:

• Are you chronically stressed? Stress whether oxidative or chronic can absolutely affect gonadotropin (LH/FSH) signalling from the pituitary.

• Is your diet containing enough healthy fats (in particular cholesterol). Given the precursor molecule to testosterone is cholesterol, if you are in the middle of an extreme cut, this can absolutely be a reason why test is low - natural bodybuilders often have extremely low testosterone levels on prep. Other things to consider for testosterone would be micronutrient intake: zinc and magnesium both have roles in the enzymatic processes involved in the entire cholesterol to testosterone pathway, so ensuring adequate intake of these would be the ‘low hanging fruit’ here.

• Do you exercise and resistance train - evidence on both sides of the spectrum here, but probably more that resistance training can boost testosterone levels.

• Do you have high BF% levels - spoken about above, but having a high bodyfat will predispose you to increased levels of aromatization (from testosterone to estrogen)

• What is your sleep like? Certainly, chronic sleep deprivation has been proven in multiple studies to crash testosterone as much as 40%

Confirmation with bloodwork

Okay, so you’ve gone through all the above, and both have the symptoms despite trying to optimise everything. Where to next?

The next step would be to get bloodwork. The specific tests I won’t go into here, as I made a detailed post about what tests to get here.

But, a few points on the blood test:

Firstly, confirm with 2-3 separate tests at around 7 or 8 am in the morning. If you are repeatedly low in both total and free T, check why. Is it a central issue (i.e. signalling from the brain), and LH/FSH are low? Or is it a testicular issue (i.e. LH/FSH are normal or high and the testicles just aren’t responding). Rule out any pituitary tumours, genetic abnormalities (like Kallmann’s), iron overload, hyperprolactinemia, hypopituitarism, OSA or medications like opioids and to some extent SSRIs. What I’m trying to say here, is interpreting your bloodwork is more nuanced than simply saying: “yep, testosterone is low”.

Some guys even have very low free T but adequate total testosterone: in other words, the ‘reservoir’ of testosterone is fine, but the unbound/free testosterone is low. This in itself is not an indication of TRT, and you can absolutely do things to raise free T without immediately jumping on TRT.

Once the bloodwork is done and you’ve ruled out any of the above, and in combination with symptoms, and you and your medical provider make the decision to start TRT, that leaves us with one final step, step 4:

Preparations for a potential life on TRT

Guys come to me all the time: “I’ve started TRT but regret it, and I stuck on it for life?”

The answer is nuanced, as you’ve probably gathered most things are relating to TRT now, BUT, what I will say is this: there is always a chance that once you start TRT, your HPT axis never fully recovers. This is especially important for the guys who start ‘TRT’ despite having like 800 ng/dL testosterone levels - there’s a 99.99% chance you don’t need it. Be careful with testosterone - there is no point stopping a perfectly functioning HPT axis to simply replicate testosterone levels your body was perfectly capable of producing endogenously.

However, for the guys who do move forward with TRT, there are just a few pointers I would recommend:

1. If you’re young and still want to have children, store your sperm. Of course, there’s a very good likelihood that with hCG you will be able to conceive, but, testosterone does shut down sperm production, so freezing some just in case before you start is what I recommend.
   
2. Get educated on pharmacokinetics. So often I find doctors blindly prescribing like 150mg/month protocols (on the one spectrum) OR a huge bolus dose of 200mg once per week (the other extreme). Both of these protocols don’t take into account 2 factors: the pharmacokinetics of massive bolus testosterone doses will be a rollercoaster ride, and secondly, your body doesn’t have a constant bleed of hormone. Natural testosterone production is diurnal, so getting educated about esters, kinetics and how the body processes testosterone is key - I will make another post about the doses I recommend for each ester at a later date.
   
3. Finally, keep yourself strict. TRT isn’t just a panacea or magic bullet, all the other stuff still applies: eating clean, training, sleep hygiene, recovery. A lot of guys who come to me have wanted to use TRT to out-supplement poor habits, but it doesn’t work like that. So keep yourself honest, and you’ll be in the best spot to make TRT a huge positive factor in your life.

There you have it guys! Those are some of my thoughts on the information you need to take into account to make the best decision about starting TRT treatment. I know it can be a scary time for a lot of you, but I’ve walked that path, and if I can help in any way I can to help you guys avoid my mistakes, that is what brings me happiness.

From my previous posts I’ve been flooded with messages and message requests - just a quick note to say I will respond very soon to each of you, I’ve just been super busy at the moment.

Thanks so much for reading, until next time.

-The Fitness Doc.