Testosterone for Men
1. Diagnosis
Assess the patient for symptoms of testosterone deficiency with the pre-appointment form, with his
chief complaints and with directed questioning. Order a total and free testosterone blood test and
inform the patient that the blood should be drawn before 9am when levels are highest. The ranges are
determined with morning levels. If a man has the typical symptoms and a free testosterone in the lower
half of the broad range he will most likely benefit from testosterone optimization. Remember that the
ranges include 95% of the male population of his age who were not screened for testosterone deficiency
symptoms. So a level near the bottom of the range means that 90% or more of men his age have higher
testosterone levels.
2. For young men: HCG, inject 250 to 500 units subcutaneously each morning
Human chorionic gonadotropin works like LH to stimulate testicular testosterone production and
maintains some sperm production. It is preferred for younger men and for men who desire fertility. HCG
does not work as reliably as testosterone injections. Start with 250 units daily and adjust dose as needed
to produce a 12 hr. free testosterone level in the upper part of the 20-30 year old reference range (e.g.
around 20pg/ml with a range of 9-26.5pg/ml). Higher free testosterone levels are usually not necessary
for very good benefits, but some men may be relatively androgen-resistant and need high-in-range or
slightly high levels to eliminate androgen deficiency symptoms.
3. For middle-aged and older men: Testosterone cypionate 200mg/ml, inject 0.2ml subcutaneously
each week and increase by 0.1ml weekly up to 0.5ml weekly
Compared to gels or creams testosterone injections are more effective, more physiological (normal DHT
and estradiol levels), less expensive and without the problem of skin-to-skin transfer. The patient will
inject T subcutaneously. A 1ml syringe with 3/8”, 26g needle is most comfortable and accurate. For
friction fit needles, the patient must jam the needle onto the syringe hard before using. Do a
demonstration injection with 0.2ml in the office. The patient should inject into the upper outer thigh
while seated or the abdomen while seated or standing. Assess testosterone levels after 8 weeks on the
full dose. Do the blood test 5 full days after usual weekly injection (e.g. if injecting on Saturday
mornings, have blood drawn on Thursday). Explain the need for proper timing of the test and always
include these instructions on the lab slip. As with HCG, aim for a high-in-range free testosterone at day
5—which is half-way between the 3 day peak and 7 day trough. Do repeat levels every 3 months in the
first year or two as testicular production gradually declines and levels will fall over time. After testing,
dose adjustments are usually made in 0.05 to 0.1ml increments. Avoid making larger dose changes as
the effects can be greater than one anticipates.
4. Add-on HCG for testicular size, fertility
With testosterone injections or gels, LH and FSH are suppressed and the testicles shrink to half their
original size. Fertility is also greatly reduced. If a male patient desires to maintain testicular size and
some fertility, he can add HCG injections of 250units twice weekly—on days 5 and 6 after his weekly
injection. This will raise levels on the trough days of the week. The dose can be adjusted as needed.
Lower testosterone doses may suffice with using HCG in addition.
5. Erectile Function
Testosterone optimization generally improves libido and erectile function. Some men will still complain
of erectile dysfunction during intercourse. If he can have perfectly hard erections under some
circumstances—with spontaneous erections or masturbation, then the nerves and blood vessels must
be healthy and his performance problem is probably psychological. Knowing this is important and he can
try various techniques to deal with it. If men cannot overcome the psychological issues or do have
nerve/vascular problems, they should try L-arginine 350mg twice daily, or will need a PDE-5 inhibitor,
taken 60 mins prior to intercourse.
6. Troubleshooting testosterone supplementation
Higher testosterone levels do not promote blood clotting (DVT’s, heart attacks, strokes). However a
sudden rise in testosterone levels may temporarily increase clotting tendency. The first doses of
testosterone essentially add to endogenous testosterone levels, and can produce superphysiological
levels. Therefore I prefer to increase the testosterone dose gradually over several weeks to the
maintenance dose.
Fluid retention can be seen in older men with an excessively fast dose increase or excessive dose. This is
due to the rise in estradiol. Lower the dose and increase more slowly. Some men are quite susceptible
to acne, especially initially if their levels have been low for a long time. Again, lower the dose until the
problem clears up, then consider raising the dose again.
I assess hemoglobin and hematocrit prior to starting testosterone supplementation and at every blood
test. Higher testosterone levels stimulate more red blood cell formation. H&H will rise above the lab’s
ranges only if the man has some oxygenation problem. The most common is undiagnosed sleep apnea.
Other lung disorders and smoking will also raise the H&H. A high H&H on testosterone is erythrocytosis.
It can be called polycythemia, but it is not polycythemia vera, as some physicians may assume. A high
H&H does not increase blood clotting tendency, but only blood viscosity. There is no evidence that a
high H&H with testosterone supplementation causes strokes or heart attacks. However, I think it
prudent to keep the Hct at 53% or lower. The best remedy is to correct the sleep apnea. If this is not
effective then either lower the T dose or advise the man to give blood every 2 months. Men who do this
consistently will require a regular ferritin assessment and should be given iron supplementation as
needed to keep the ferritin above 50ng/ml.