This guest post – which is one of the most epic posts on testosterone you're ever going to read – is written by my friend Jay Campbell, my guest on the epic podcast “Is Metformin Really Dangerous?, Little-Known Peptides For Muscle Gain & Fat Loss, Testosterone Replacement Therapy & Much More!“
Jay is a Champion Men’s Physique Competitor and the best selling author of both the Testosterone Optimization Bible and The Definitive Testosterone Replacement Therapy Manual: How to Optimize Your Testosterone for Lifelong Health and Happiness.
As a 17 year TRT patient, Jay is a master at manipulating and tweaking the human endocrine system to optimize performance and health. He has experience working with thousands of men and women in optimizing their nutrition, exercise, fitness and fat loss. Jay makes it his personal mission to effect positive and rapid change in each and every client who enters the mastermind program.
Warning: Jay is at the extreme cutting-edge of this stuff and knows more than most anti-aging docs or endocrinologists, so I highly recommend studying up on what he has to say in this article. Take your time, and bookmark it if necessary if you can't get through the entire article right now.
The Global Decline Of Male Testosterone Levels
Testosterone is far more than a ‘molecule’ associated with being a man. It is literally the lifeblood and the foundation of all things related to male health.
In fact, suboptimal testosterone levels are responsible for a seemingly endless list of age-related diseases:
- Heart disease
- Prostate disease
- Metabolic Disorder
- Insulin Resistance
But natural testosterone levels in men have been dramatically decreasing for nearly 3 decades across the USA and the world at large. The Hebrew University Study even goes on record to say that males will be completely infertile by 2050
Unfortunately, this decline cannot be explained by normal physiologic parameters (obesity, smoking, etc.), and the medical community is either ignoring or completely unaware of this trend.
Why Testosterone Deficiency (Hypogonadism) Is Rarely Diagnosed
Men are oftentimes embarrassed to report symptoms of a sexual nature. They are conditioned to accept them as “normal” and “unfixable” at an older age when presenting “nonspecific symptoms” (depression, lack of motivation, etc.). Surprisingly, low testosterone levels are NOT investigated as a potential source.
This is due to the lack of a definitive biochemical test for hypogonadism, or any standard “patient care model” for physicians to follow when treating the condition.
In other words, they have no approved way to diagnose it since it can’t be “seen” or touched”. This leads to doctors reaching the conclusion that testosterone deficiency is “uncommon, difficult to establish, controversial and dangerous treat due to a lack of awareness concerning the research on testosterone deficiency.
To make matters worse, most physicians are very fearful of prescribing testosterone as doing so for aging constitutes off-label use. And since they are unaware of testosterone deficiency and how to treat it, they will outright refuse to test for it.
The Endocrine Society recommends, in regards to their protocol for measuring testosterone deficiency, that male hypogonadism should only be diagnosed when measuring testosterone levels at their morning peak (highest level). Sadly, this will lead to less men meeting criteria for a diagnosis of hypogonadism (ultimately restricting the number of men who qualify for treatment).
According to Dr. Ashok Kadambi (MD, FACE), one of the members of the Endocrine Society tasked with assigning the ‘normal value’ ranges, “The number 300 sounded good.”
The Worldwide Demonization Of Testosterone
The stigma associated with the word “testosterone” is an obvious and oppressive cultural norm that first started when the United States government passed the Anabolic Steroids Control Act of 1990. It then was carried over into the world of professional sports with Ben Johnson and the Major League Baseball Drug Scandal.
To this day, most people perceive the use of testosterone as cheating, immoral, unethical and or illegal.
Mainstream opinions will debate the ethical and moral dilemmas behind using therapeutic testosterone (also known as Testosterone Optimization Therapy, or “TOT”), even with no basis in fact that said therapeutic usage is harmful to human life. We also can’t forget the current anti-masculine movement in progressive and feminist cultural circles. Being a strong, hyper-masculine or alpha male is considered “toxic” as shown in many recent modern-day ad campaigns.
But TOT is literally no different than using any other health-promoting medications like aspirin, caffeine, or antibiotics.
The fact that a naturally occurring hormone (not a drug) essential to the development of every human being is being aggressively controlled is a reflection of the incredible amount of ignorance under which society and the medical community lives. Testosterone has been successfully used since its recognition as an essential biological molecule for male health in 1939 (via the Nobel Peace Prize).
Hundreds of thousands of reports from male patients and their TOT-prescribing doctors exist and the majority of them are overwhelmingly positive (alongside 2.3 million testosterone prescriptions in 2015). Unfortunately, there is still a major lack of large-scale, long-term studies assessing the benefits and risks of TOT. Much of this ignorance can be attributed to the promotion of extremely flawed studies that are falsely used to demonize the usage of therapeutic testosterone.
Testosterone & Heart Health
No heart attacks, strokes, or adverse effects have been reliably linked to the correct & therapeutic use (not abuse) of testosterone.
The myth about testosterone being bad for heart health started back in 2014 when expert panels urged the FDA to limit the diagnosis for prescribing TOT “to men whose low testosterone stems from an acute medical problem such as damaged testicles or thyroid disease”. The FDA then issued that all testosterone products must have a black box warning label placed on them.
What the majority of physicians don’t know is that this ruling was based on data involving men in multiple flawed studies which was then applied to the general population.
In the light of hundreds of studies demonstrating testosterone’s profound beneficial effects, this labeling is clearly false. And this inaccurate warning label further reinforces the need for TOT patients to work with highly-qualified physicians who can serve as a concerned and helpful health advocate.
Testosterone And Prostate Cancer
Contrary to popular medical consensus, prostate cancer is actually caused by low levels of testosterone.
Based on the data sets currently available, testosterone deficiency can be safely treated with TOT after successful prostate cancer treatment. More studies can be found here, here, here, here, and here. High blood levels of testosterone do not increase the risk of prostate cancer, nor does TOT itself (even amongst men who already have a high risk for prostate cancer).
Ben also discussed testosterone and prostate cancer in this podcast.
Testosterone And Cholesterol
TOT has little to no effect on plasma HDL in clinical dosages, while it often decreases LDL levels. Therapeutic dosages do NOT negatively impact cholesterol levels, as this study shows.
A foundation of proper diet and exercise should be established prior to the use of any statin medications, but ideally, they should be avoided altogether. Niacin and baby aspirin are much safer and natural alternatives.
Statin medications come with several side effects that include an increased risk for type 2 diabetes. Unfortunately, numerous prescriptions are written daily in spite of the fact that you must treat 100 people to have an effect on a single individual.
If you are using statin medications, you will have subclinical levels of testosterone and require TOT.
Testosterone And Insulin Resistance
Due to its ability to improve various health markers, TOT should be considered as a front-line treatment by informed doctors when treating diabetes, insulin resistance, and metabolic disorders.
TOT And Fertility
Don’t buy into the “bro hype” on social media and online forums: It is entirely possible to have children while on TOT through the use of highly effective medications that maintain natural reproductive function.
Primary choices include human chorionic gonadotropin (hCG), clomiphene citrate (clomid), and human menopausal gonadotropin (hMG). There are numerous accepted dosing protocols. The protocol being used will vary, based on the experience of the prescribing doctor and their patient's subjective response to treatment.
Consider getting a measured sperm count in order to understand your baseline values before undergoing TOT.
It would also be prudent, as a precautionary measure, to have your sperm frozen to be used at a later date just in case.
TOT And The Modern Medical Community
Nobody says it better than Dr. Brad Feliz, Chief of Pathology and Laboratory Medical Doctor at the Queen of the Valley Medical Center:
“I had a constant stream of ‘male hormones are bad while myself and fellow young doctors were choked with dogmatic axioms like ‘women need hormone modifications throughout their adult lives’ wherever I went from University of CA, to Harvard to Stanford.
For decades, ostensibly intelligent medical faculty would warn that any male hormone therapy would result in anti-social/criminal behavior, massive side effects and often death. The lunacy of that advice now seems on par with medical profession’s refusal to accept cigarettes as a causative agent in lung cancer.”
The Life-Changing Benefits Of Fully Optimized Testosterone Levels
The rewards of optimizing your testosterone levels via TOT are often dramatic and completely transformative.
The men who go down the route of therapeutic administration ultimately classify their lives in two different phases: Life before TOT and life after TOT.
Here’s just a sample of the ways in which testosterone can improve your mindset and outlook on life:
- Clinically proven to boost confidence levels, especially amongst potential sexual partners.
- Improves mental outlook on life and resiliency, allowing one to remain more composed and tactical in stressful situations.
- Increases assertiveness, leading to greater certainty and faster decision-making.
In short: The physiological effects of optimized blood testosterone levels can radically transform your health, your happiness, and your overall productivity.
But there are numerous physical benefits of TOT that cannot go ignored…
#1: Testosterone Decreases Body Fat
Obese individuals (+25% body fat) have increased aromatase activity, insulin resistance and excess visceral fat which naturally elevates their estrogen levels while further lowering their testosterone levels, as this study shows.
#2: TOT Is Lipolytic (i.e. fat-burning)
Visceral fat is a leading predictor of disease risk , and also found here (Heart, Cancer, Diabetes, Alzheimer's and Dementia).
#3: Testosterone Increases Muscle Mass
Testosterone’s anabolic nature allows for the improvement of muscle protein synthesis (and therefore muscle growth).
#4: Testosterone Improves Heart Health
The hysterical claims from mainstream media and online advertising state that TOT increases the risk of cardiovascular disease (heart attacks, strokes, etc).
All studies that support this belief come from compromised patient population groups of normally older men with pre-existing vascular conditions.
Newer evidence (more than 350 studies) clearly shows that testosterone is cardioprotective and optimized testosterone levels help prevent cardiovascular disease.
In other words, suffering from a testosterone deficiency increases the risk of vascular disease!
#5: Testosterone Helps Treat Depression
Testosterone assists the brain in producing more dopamine, protecting against depression while promoting a more positive and energetic outlook on life.
Men undergoing TOT experience improvements in mood and alleviation of depression-related issues (due to its antidepressant effect in patients, making it a viable SSRI alternative), also found in this study, and here.
There is a “Chicken vs. egg” riddle currently being investigated: Do low testosterone levels cause depression, or does depression cause low testosterone levels?
I don’t know the answer for sure, but I do know this:
The top hormone optimization doctors in the world go as far as to use therapeutic testosterone as a front-line treatment option for depression in lieu of psychotropic medications.
#6: Testosterone Improves Memory And Protects Against Alzheimer's
Testosterone can help improve working memory in men, which is the basis for virtually every cognitive process required for proper brain function.
Younger and older men find that testosterone helps improve visual memory, verbal memory, and spatial processing power. It can rapidly eliminate brain fog, leading to clearer thinking and an improved mood.
Newer studies even show that testosterone has neuroprotective effects against cognitive diseases such as Alzheimer’s and Dementia, as shown in this study, and also here.
#7: Testosterone Fights Chronic Inflammation
Low testosterone levels are strongly associated with various chronic inflammatory diseases. Inflammatory markers (IL-6, TNF-alpha, etc.) inhibit testosterone production via their suppressive influence on the HPTA.
Testosterone, due to its lipolytic nature, also burns visceral fat, a major cause of inflammation and various forms of cancer.
The Unexplained Causes Of Sub-optimal Testosterone Levels
What most people don’t know about male hypogonadism (low testosterone levels) is that there are actually two types:
- TYPE 1 (Primary): Results from physical defects in the gonads (i.e. testicular injury)
- TYPE 2 (Secondary): Results from pituitary defects (i.e. obesity, alcohol/opioid abuse, chemical disruption, etc.).
It is assumed that 25% of mean are classified as having type 1 or type 2 hypogonadism, and even this number is believed to be significantly underestimated and under-reported. Only 10% of men in the USA are being treated with therapeutic testosterone. In Europe and Asia, less than 2% are being evaluated and less than 1% are treated.
Secondary hypogonadism is what’s most normally associated with aging men suffering from testosterone deficiency, which remains unacknowledged by the medical community. So we have a general lack of understanding when it comes to treating suboptimal testosterone levels. But there’s another factor amongst the multitude of factors that are actively decreasing testosterone levels in men worldwide: The rapid fall in sperm counts and increase in fertility disorders that have arisen as the result of long-term exposure to endocrine disrupting chemicals (EDCs).
How Are Endocrine-Disrupting Chemicals (EDCs) Destroying Male Health?
EDCs are defined by The Endocrine Society as “An exogenous, (non-natural) chemical, or a mixture of chemicals that interferes with any aspect of hormone action”.
EDCs may act as hormone system agonists or antagonists (or both). EDCs can not only decrease testosterone production but also interfere with its signal transduction (i.e. androgen receptor binding, transcription, and translation).
The massive presence of EDCs can be attributed to urban environments, GMO foods, blue light, plastics, and various man-made products.
Significant increases in environmental pollutants, contaminants, and particulates in the air produced by industrial factories, smog, emissions from cars, and more are bombarding our biological systems and lowering testosterone levels on a global scale. EDCs also come from pesticides, herbicides, and pharmaceutical agents like cosmetics, sunscreens, & plastics. Many chemicals have yet to be tested for any EDC Activity.
Put another way: Bisphenol-A, Phthalates, Atrazine and other toxins are increasingly pervading our water and food supplies. Exposure to phthalates (found in rubber, packaging, plastics, water bottles, etc.) blocks normal testosterone production. Listen to Ben's podcast with Anthony Jay, author of Estrogeneration, for more on this.
Endocrine Disrupting Chemicals Are Making Us Fat, Sick, & Infertile
EDCs, right here and right now, are causing widespread dysfunction and disruption of our hormonal systems due to their overwhelming presence in dangerous quantities.
Sadly, EDC disruption can take place in utero and affect male hormonal development for the rest of their lives. Men (and women) are being exposed to various hormone-suppressing phytoestrogens that the body is not designed to handle.
Male hormonal health is rapidly deteriorating, requiring proven medical therapies to solve this problem.
I highly recommend you take a look at these frightening EDC studies and resources to truly understand the effect they are having on you right now:
- Estrogenic and Anti-Androgenic Endocrine Disrupting Chemical and Their Impact on the Male Reproductive System
- Endocrine disrupting chemicals: a new and emerging public health problem?
- Endocrine Disrupting Chemicals Mediated through Binding Androgen Receptor Are Associated with Diabetes Mellitus
- Toxicological Mechanism of Endocrine Disrupting Chemicals: Is Estrogen Receptor Involved?
- New Modes of Action for Endocrine-Disrupting Chemicals
EDC exposure is so bad, in fact, that a “Type 3” hypogonadism has emerged that can ultimately be classified as “Testosterone Resistance Syndrome” (TRS). (This Type 3 classification is the theory of Dr. Scott Howell, Dr. Keith Nichols and myself and currently, Dr Howell is working on proving this in the scientific community.)
The Definition Of Testosterone Resistance Syndrome (TRS)
Testosterone Resistance Syndrome is a clinical syndrome characterized by signs and symptoms of testosterone deficiency in combination with a normal testosterone concentration.
With TRS, it is not the total or free testosterone concentrations that are responsible for the symptoms of testosterone deficiency but instead a disruption or interference with the cellular metabolism of testosterone.
Where most doctors go wrong is that they focus on total & free testosterone measurement numbers outside the cell but EDCs are affecting signal transduction inside the cell. This is causing cellular resistance to both the natural production of testosterone and the added use of therapeutic testosterone.
Due to EDCs, testosterone can’t exert its effects because of interference with androgen receptor binding, transcription and/or translation. As a result, testosterone levels are decreasing significantly and it is due to unrecognized environmental causes and their disruption of the cellular metabolism of testosterone.
This is why men present with ‘normal levels’ of testosterone yet show all the symptoms and signs of testosterone deficiency.
And as stated before, due to traditional medicine’s “anti-testosterone” stance, millions of men continue to suffer from diagnoses of normal testosterone levels and are refused the life-altering treatment of TOT.
What Can We Do To Treat TRS?
EDCs are everywhere and cellular resistance is difficult to treat, especially due to the lack of physician awareness.
It is the opinion of myself, Dr. Keith Nichols and Dr. Scott Howell that TRS is the cause of this unannounced and unrecognized epidemic. It is our theory that therapeutic testosterone is the ultimate tool and the be-all-end-all solution.
We must teach physicians to practice medicine not by using lab measurement numbers but via symptom resolution. It is imperative this disease is identified immediately so the level of global awareness increases, providing access to the millions who are currently being denied treatment.
The only way to treat TRS (for both users and non-users of therapeutic testosterone) is by outcompeting the EDCs at the androgen receptor level.
However, there are numerous misconceptions and falsely held beliefs about the proper usage and administration of therapeutic testosterone.
Therapeutic Testosterone Vs. Anabolic Steroids
It is important for the purposes of everyone reading this article that we delineate the differences between clinical dosages of testosterone (therapeutic) used to slow the aging process and fight disease, versus anabolic steroids in which supra-physiologic dosages for muscle growth and performance enhancement are used.
- Therapeutic: Using testosterone in minimum effective doses, combined with an optimal lifestyle for maximum health benefits, when treating men with type 1 and type 2 hypogonadism and various other diseases of aging (USE).
- Anabolic: Using performance-enhancing drugs at supraphysiologic doses, seeking aesthetics at the expense of health and/or performance (ABUSE).
The Truth About Bioidentical Testosterone
All testosterone used in TOT, regardless of delivery system, possesses identical molecular structure to your body’s testosterone.
The notion that “bioidentical” testosterone is better, or more natural than pharmaceutical-grade testosterone is nothing more than a myth.
Pharmaceutical-grade testosterone is bioidentical to ‘natural’ testosterone because it is an “esterified” form of testosterone.
Esterified testosterone means that the testosterone is attached to a carrier molecule known as an ester, which is then enzymatically cleaved (broken off) in the bloodstream, leaving you with the “bioidentical” testosterone molecule.
The Myth Of Natural Testosterone Boosters
There is next to no scientific evidence supporting the claims made by supplement companies that their “testosterone-boosting” supplements satisfy their advertised claims.
In Chapter 4 of the TOTBible.com we analyze 5 of the most well known “natural” testosterone boosters and in every single one of the studies of them, it consistently shows they are ineffective and generate insignificant changes in testosterone levels at best (sometimes even reducing them).
It is important to understand that raising drive has no correlation to increasing testosterone levels. The current testosterone booster market is nearing $3 billion annually.
Testosterone booster pills stay on the market due to the lack of quality control in the supplement industry and the ignorance of the average men who fall prey to their slick but false advertising.
Pharmaceutical means (i.e. the usage of therapeutic testosterone) is the only proven scientific way to raise and optimize testosterone levels especially in our modern-day environment where endocrine systems are under siege.
Ineffective Testosterone Delivery Systems
Here is a quick break down of the various testosterone delivery systems to avoid using.
- Buccals- There is a high occurrence of negative side effects and poor absorption. Patients must avoid eating, kissing and drinking post administration.
- Patches – They often cause irritation at the place of adhesion, produce high levels of DHT & are terribly inconvenient due to the frequency of body preparation.
- Oral capsules – They are not yet FDA approved and there is no clinical data on how they work in the bloodstream. Past versions were ineffective.
- Nasal Sprays (i.e. Natesto) – It has a high frequency of negative side effects, in addition to the lack of long-term data demonstrating its effectiveness.
- Pellets – This is the most expensive testosterone delivery system and it is growing in scope due to the profit opportunity for doctors. It is highly inefficient and cannot be recommended. There is an infection risk due to the invasive surgical procedure. Testosterone is not delivered molecularly in an even fashion (due to varying patient biochemical individuality), and dosage is nearly impossible to titrate for control or adjustment without performing another invasive procedure. Please watch this recent video I did on the efficacy of testosterone pellets.
- Androgel Transdermal Testosterone – The most prescribed TOT protocol in the world, available in various testosterone concentrations (all of which are TOO LOW). It’s usually preferred as it is the “path of least resistance” (i.e. no pain felt, or need to use needles). One must avoid accidental transfer to women, children, and pets.
- Testosterone Undecanoate (i.e. Aveed or Nebido) – Undeconoate’s documented patient results (for instance, large boluses deliver uneven absorption) prove its inefficiency as an injectable delivery system due to the ester’s inability to break down in a uniform pattern in a patient’s bloodstream.
The Uses Of Injectable Testosterone Formulations
Preparations differ by the length of the testosterone ester. Enzymes in the body called ‘esterases’ are responsible for removing the ester from testosterone.
The longer the ester clings to the testosterone molecule, the longer testosterone is active in the body. The shorter the ester the faster it acts in the bloodstream and the shorter its half-life.
Each user is biochemically unique in the way his body will metabolize the testosterone ester into his bloodstream. Peak blood levels of testosterone can be effectively controlled via injection frequency.
When dosed daily or every-other-day (EOD), injectables can mimic the testosterone your body naturally produces. This is essential to minimize perturbations to your endocrine system, which are often the cause of potential side effects.
The Most Recommended Protocols for TOT
Based on my 20+ years of experience in using TOT myself, consulting with the world’s top TOT doctors and personally consulting with thousands of men in the use of TOT, here are the four most optimal TOT protocols to date:
- Transdermal: 200mg/gm Versabase Cream. 1-3 pumps applied to the scrotum applied 1-2x per day (once at morning and once at night. Dosage is to be determined by your doctor.
- Injectable Option 1A: 10-30 mg of testosterone injected daily. This dosage protocol provides the most stable testosterone levels (i.e. mimics endogenous production of testosterone).
- Injectable Option 1B: 50-70 mg of testosterone injected every other day (EOD). This is an acceptable compromise between daily and 2x/week injections.
- Injectable Option 2: 50-100 mg of testosterone injected twice weekly (preferably every 3rd day). Preferred by many patients due to the lack of injection frequency.
However, the newest evidence from patient feedback is that twice-weekly injection protocols don’t always provide peak levels like daily, EOD or daily transdermal protocols. It is for this reason that I don’t recommend it anymore.
Additional Insights For The Elite Use of TOT
In a nutshell, here are the most important principles to remember when starting off with TOT:
- The “right mg dosage” is an individual thing due to Biochemical Individuality (BI). There is no ‘optimal range lab value’ or ‘sweet spot’ of testosterone or estrogen due to BI.
- Doctors should only treat negative side effects until symptoms resolve. Focusing on lab ranges and measurement numbers only cause psychogenic issues for the patient. Normal lab ranges are just guidelines and never to be used to regulate or reduce dosages in the absence of patient symptoms or side effects. Again why it’s crucial to work with an experienced Doctor skilled in managing endocrine systems.
- Minimum effective dosage principle (MED): Always start low and go slow.
- Testosterone in isolation is always best to determine a baseline and how it works independently of other medications/chemicals in the patients endocrine system.
- Before ever using an aromatase inhibitor (AI), reduce Testosterone dosage and increase frequency of the delivery system. Using an AI should only be for Men who genetically aromatize easily and then used in MED fashion and titrated off immediately upon symptom resolution.
- To maintain fertility while on TOT, use hCG and or hMG. Dosage strategies are diverse and listed in the TOT Bible.
- The two-fold goal of TOT is happiness & balance, ie feeling great with no side effects (i.e. testosterone and estrogen are balanced).
- Scrotal application is the most efficient area for transdermal absorption (see “Transdermal” in the previous section). It has 8x better absorption than anywhere else on the body. (Please do not use Androgel or any Gel Based Testosterone Delivery system on scrotal skin as it will burn. Only compounded VersaBase Creams are ok to use on the scrotum.)
- “SUPRA OPTIMAL” is the goal of every man. If a patient has no symptoms or side effects, a Physician should do nothing (even if the patient’s total testosterone or free testosterone readings are ‘too high’ or ‘outside the range’ based on normal lab measurement numbers)!
What Are The Side Effects Of TOT?
When TOT is done correctly under the supervision of a progressive and experienced TOT-prescribing physician, there are virtually no side effects.
In rare instances, potential side effects are minimal, easy to spot, and effortless to treat (nipple sensitivity, water retention, mild acne, imbalances between testosterone and estrogen), etc..
Hair loss (male pattern baldness or androgenic alopecia) is genetic. Therapeutic testosterone can speed the rate of loss at the follicular level.
Gynecomastia (the overdevelopment of the male breast) is very misunderstood by most Doctors and patients. It is caused due to genetic factors. Dr. Anthony Jay in his webinar with me went into great detail about this. Using SERM or AI Medications will not cure one of this condition and they are only bandaids. The only permanent solution is surgery. If you choose the surgical route, I recommend you work with a leading surgeon skilled in the removal of glandular tissue in the male breast. There is much more in Chapter 11 of The TOT Bible on gyno.
As your body evolves over time, your lifelong goal will be to achieve an optimal balance (i.e. feeling good without side effects) between testosterone and estrogen (E2).
Biological Markers To Know About When Using Testosterone Optimization Therapy
While I cover this topic extensively in The TOT Bible, here are a few important things you should know when you are reading your lab blood work (while using TOT):
#1: The Normal Range Fallacy
Normal values for testosterone levels, as established by various laboratory measurement companies, are used on declining levels that cannot be explained.
LabCorp significantly reduced normal values on the bottom and top ends in July of 2017 to accommodate a growing population that is more obese (and testosterone-deficient).
The new reference interval for men was decreased from 348-1197 ng/dL to 264-916 ng/dL. What was previously ‘low’ is now ‘normal’ depriving millions of men of attaining optimal testosterone levels (via a doctor’s prescription for therapeutic testosterone).
Blood levels alone cannot be used to qualify someone for TOT. Patients must be examined on an individual basis (there is no “standard model” for which the normal range is universally defined) and as such, symptoms trump lab numbers always.
#2: Serum (Total) Testosterone V. Free Testosterone
Serum testosterone is the total concentration of testosterone in your blood stream. Free testosterone is the small amount of testosterone floating around that the body can actually use (~2% of the testosterone found in the body is bioavailable).
Patients often have ‘normal’ total testosterone levels’, BUT they will also have low free testosterone levels. This is always a cause for treatment of a testosterone deficiency but most doctors, due to their lack of awareness regarding free testosterone symptomology, do not prescribe TOT in this instance.
Due to variations in the normal range for total testosterone levels, both over time and in between clinics, symptoms must be treated FIRST over the findings of a single lab report.
Serum blood testing is the only legitimate option — urine (Dutch Test) is available but it is very expensive. Saliva testing has been thoroughly debunked as useless. Additionally, normal values are based on SERUM values.
#3: Hematocrit & Hemoglobin
These are essential biomarkers to pay attention to when undergoing TOT. On page 185 of The TOT Bible, we provide an in-depth biomarker cheat sheet to guide you along.
You should strive to stay under 20 g/dL (Hemoglobin) and 55% blood volume (Hematocrit). Periodic phlebotomy can fix elevated levels of either biomarker but one must be careful to not over phlebotomize dropping Iron levels too far.
TOT does NOT cause polycythemia vera (a neoplastic marrow disorder characterized by an increase in ALL blood cells, including platelets), which can cause an increase in clotting.
This is separate from erythrocytosis (blood thickening and a common reaction to injectable TOT) where ONLY hemoglobin and hematocrit are elevated (i.e. increased production of red blood cells-more oxygenated blood is beneficial). Normally, erythrocytosis requires no treatment.
It is important that men focus on becoming cardiovascular efficient via regular cardiovascular training (preferably low impact, steady-state maintaining a heart rate of between 125 and 140 BPM). There is much more about the preferred types of cardiovascular training in Chapter 16 of The TOT Bible.
The Truth About Estradiol (E2): Understanding The Role Of Estrogen In Testosterone Optimization Therapy
The conversion of testosterone into estradiol (E2) via aromatization is equally if not more important as the usage of therapeutic testosterone for a host of important biological functions.
Blocking estrogen via the usage of aromatization inhibitor Medications (AIs) is a total misunderstanding of biological processes and the science of aromatization.
Testosterone must aromatize into estradiol (estrogen) to confer protection to biological system. Estradiol is a pleiotropic hormone that has instrumental influence over numerous critical functions related to the cardiac and vascular system, bone and mineral metabolism, cognition, memory, mood, balance, age-related neurodegenerative disorders and lipolysis(burning) of fat.
When a doctor places a patient on an AI to attempt to resolve “estrogen-related symptoms” or to keep the patient in a perceived ‘narrow” or “optimal lowered range” of estrogen, a whole host of negative endocrine system reactions can and often does occur.
These negative effects can lead to a loss in bone mineral density, sexual function, brain function, joint and muscle function and a host of other downstream negative effects.
Attaining balance between your Testosterone and E2 levels is key for optimal health. The ideal ratio of testosterone to estradiol is based on the biochemical individuality (BI) of the individual patient.
There is no mythical ‘optimal range’ or ‘sweet spot’ measurement for E2 levels. If a patient is symptom and side effect free, lab numbers mean nothing and a treating physician should do nothing. There are many men who routinely have E2 levels over 100 and even higher with no noticeable side effects or symptoms.
TOT often fails to work due to poor E2 (estrogen) management, where patients suffer side effects from both low testosterone (sexual dysfunction, bone mineral density, brain fog, anxiety and joint issues, etc.) and what are perceived as high levels of estrogen (lack of erectile strength, water retention, etc.).
Suppressed E2 is often seen in patients whose Doctors start them out on an aggressive dosage of an AI with no corresponding biomarkers to justify usage.
An AI should never be used at the onset of therapeutic testosterone unless there is an indicated medical need based on blood work and symptoms.
For men who have symptoms of elevated estrogen, the optimal strategy is to first reduce the testosterone dosage and then increase the frequency of administration until the patient feels good (attaining balance between testosterone) and side effects/symptoms are eliminated.
If elevated levels of E2 (estrogen) persist and an AI is needed, follow the MED (minimum effective dose) principle: Use it in the lowest micro dosage possible until the symptoms resolve and then discontinue use altogether.
Suppressing estrogen is never a good strategy due to the overwhelming data/evidence that doing so causes multiple issues, as previously discussed. What is critically important to understand about the usage of AIs, is that even when they appear to resolve symptoms in men, they are still doing harm to multiple biological processes(especially causing bone mineral density issues) in both the short and long term.
Many men who have been prescribed AIs throughout long-term therapeutic testosterone administration have developed a belief perseverance in using them. These agents are silently doing harm and they should be discontinued under the care of a qualified optimization physician who can monitor your withdrawal.
For much more on the usage of AIs, read this article and be sure to watch the podcasts with Dr. Neal Rouzier, who is the leading voice in interpreting the research regarding the critical need of testosterone to aromatize into estradiol (E2) in men undergoing TOT.
In fact, there are ZERO studies in the medical literature that show blocking estrogen is beneficial. Dr. Robert Kominiarek is doing a presentation on the dangers of inhibiting estrogen in men at the AMMG Conference in Miami on April 12th.
How Can I Get Started With Using Testosterone Optimization Therapy?
On top of reading The TOT Bible, there are other actions I strongly recommend you take:
#1: Choose the right TOT-prescribing physician
You MUST work with a progressive doctor who has an experiential-based practice of optimizing men and women.
Ideally, this same physician is also using TOT while simultaneously practicing what they preach (BE WARY of any Doctor who is also not using therapeutic testosterone on themselves).
As a patient, it is critical that you ask your doctor several questions to see if they are qualified to treat you and ultimately optimize your testosterone levels (baseline questions for vetting your TOT doctor are provided in The TOT Bible).
While most physicians will have practice-based preferences, they should be open to being a partner in managing your health. Knowledge is real power! If you read The TOT Bible and educate yourself, you’ll likely be able to find the ‘right doctor’.
#2: Understand the costs of using TOT when done correctly
The top preventative medicine clinics can charge $250–$1,250 for an initial consultation(depending on if lab work is included), plus a $150–$500 monthly fee for the physician to manage your endocrine system.
Costs vary depending on prescribed medications, supplements, additional testing and nutrition/fitness counseling.
Tele-medicine is here now but nebulous especially from state to state. It will eventually allow for medical treatments and consultations to be reliably offered via webcam, phone, and email.
And do not expect to use Insurance (i.e. a PPO or HMO Doctor) to become optimized. Hormone optimization is way outside the confines of their expertise.
There are far too many patients who have used poorly trained or inexperienced ‘insurance doctors’ and ended up worse off than when they started.
Managing a patient’s endocrine system is a highly nuanced and skilled expertise, so don’t put your long term health in the hands of an untrained doctor. Utilizing the services of a progressive-minded cash-pay doctor with an experiential-based practice is a MUST!
#3: Start optimizing all facets of your lifestyle immediately
Here’s what that means for you:
DO NOT be fat: EDCs sit in fat tissue, and visceral is the greatest disease risk.
Minimize alcohol consumption: Regular drinking decreases androgen levels via stimulation of cortisol, catecholamines, prolactin and free fatty acids (FFAs), which leads to alteration of biological processes and tissue damage. Alcohol is a nerve toxin and you should eliminate it altogether where possible.
Reduce Stress via meditation and/or silencing the mind via Yoga, Tai Chi, contemplation, Earthing and various other mind-body relaxation techniques.
Use Metformin (to lower insulin signal), Tadalafil (Cialis) and zinc (both offer inhibition of aromatase, meaning less conversion to visceral fat): Metformin and Cialis also improve endothelial function minimizing disease risk.
Avoid using psychotropic medications: This includes SSRIs, Benzamides, Ketoconazole and Aminoglutethimide.
Eat a diet high in protein and essential fatty acids: Reduce carbohydrate levels to only support your activity/training levels (minimizing the risk of insulin-mediated inflammation).
Do not eat vegetarian or vegan diets that are low in fat and protein. They lower Free Testosterone and increase sex hormone binding globulin (SHBG) levels.
As a man, your health (and your testosterone levels) are in your hands!
Don’t be like the millions of men worldwide who are doomed to a life of low testosterone levels and sub-optimal living.
You now have all the tools, resources and knowledge necessary to take control of your health and to take action and seek support from progressive, experienced physicians who have your best interests and long-term health as their top priority!
Want more from Jay?
Be sure to check out his Guaranteed Shredded program (one of the most unique approaches to fat loss and fasting that I've ever read) and also his Men's Health Optimization Bundle and Ultimate Fat Loss Bundle.
And of course, if you want to take an even deeper dive into testosterone, grab his Testosterone Optimization Bible and The Definitive Testosterone Replacement Therapy Manual: How to Optimize Your Testosterone for Lifelong Health and Happiness.
Upon meeting Jay two weeks ago, I personally read every single resource I just linked to above and am far, far more informed about the entire sector of testosterone and fat loss. I'd recommend you grab his stuff and do the same. It is well worth it.
And be sure to tune into my podcast with Jay entitled “Is Metformin Really Dangerous?, Little-Known Peptides For Muscle Gain & Fat Loss, Testosterone Replacement Therapy & Much More!“
Finally, if you have questions, comments or feedback for Jay or I about anything you've just read, leave your comments below and one of us will reply!