Testosterone over Time
In both men and women, testosterone decreases with aging. Male patients primarily report decreased muscle mass, weight gain, and erectile dysfunction. Female patients typically note decreased libido, low energy, and less interest in making plans to see friends. Bioidentical hormone replacement therapy with testosterone may help restore vitality.
Effective Ways to Increase Testosterone
- Oral DHEA
- Topical cream, gel, or suppository
- Injection into muscle or fat
- Pellet insertion under the skin into the fat
- Growth hormone peptides
Women: DHEA is the precursor hormone before it becomes converted into estrogen and testosterone. A lab check on DHEA-S, the activated form of DHEA, will let us know if DHEA is low. Because the testosterone level in women is so much lower than men’s, I have found that many female patients do well with just supplementation of 5-10 mg of DHEA once a day in the morning. Oral supplementation raises testosterone in women but doesn’t make a significant difference in estrogen levels. 7-keto DHEA if recommended if side effects of acne or facial hair occur. For convenience, DHEA can be added to estrogen and progesterone creams if they are also being used.
Men: I have found that DHEA does not significantly increase testosterone levels in men, and so we focus on testosterone replacement instead to alleviate symptoms.
Women: After supplementing with DHEA, some women continue to have symptoms of testosterone deficiency. 0.5-1 mg of testosterone cream may be applied once a day on the body or, if libido is a primary concern, in the genital area. Testosterone cream may be combined with estrogen and progesterone cream if desired.
Men: Androgel is a prescription topical testosterone that can be applied to the body in the morning. 50-100 mg is the typical dosing. If Androgel is not covered by insurance, a compounding pharmacy to supply it at a reduced out-of-pocket expense. Men typically begin noticing benefits from topical testosterone about 4-6 weeks after beginning. This time lag and inconvenience of daily application convince many male patients to choose weekly injection or pellet insertion 3 times per year.
Women: I don’t use testosterone injection with women because of undesired side effects of increased facial hair and acne.
Men: Testosterone cypionate is often chosen because men start feeling better within a couple of days and only need weekly injections rather than daily applications. 100-200 mg once a week is the typical dosing. Benefits peak around 6 weeks as levels continue to increase with each injection. After 6 weeks, levels and blood pressure are checked and dosing may be changed. Weekly dosing prevents the spikes and drops of testosterone levels caused by every other week injections. Injections can be in the fat just under the skin or it can be deeper in the muscle. Patients can self-inject in the abdomen or thigh. Of note, unlike testosterone cream or pellets, testosterone cypionate is not bioidentical.
Growth Hormone Peptides
While it is known that growth hormone increases testosterone, testosterone also increases growth hormone. Growth hormone cannot be used for anti-aging purposes, but growth hormone peptides can increase the amount of growth hormone that your body already produces. Sometimes, patients find that they’re not feeling like themselves even after testosterone has been optimized. These patients may find that peptides can address their symptoms.
What is the cost of testosterone replacement?
$200/visit every 3 months until stable, then every 6 months
Cost of testosterone: You can take your prescription to any pharmacy, typically $100/month for injectable; $200/month for pellet insertion
Labwork not included.
Can I get my labwork done before making a first visit? Yes, you can if you are paying out-of-pocket or are having another doctor order the labwork.
Refills: Testosterone is a controlled Schedule 3 medication, which allows maximum 5 refills of 30 days each.
What is anastrozole? Anastrozole blocks testosterone from being converted into estrogen, which can cause nipple sensitivity/pain, breast tissue growth (bitch tits) or excessive emotionality. High testosterone can be treated by decreasing testosterone or by taking anastrazole to prevent the conversion by the aromatase enzyme.
Why don’t you recommend oral testosterone? I don’t recommend oral testosterone because of the toxic metabolites that are produced when the liver clears it out.
How do you know how much testosterone I need? Testosterone level is not well correlated with symptoms. I’ve had male patients who were doing just fine with numbers in the 200’s. Other people feel better in the 600’s. Generally, we stay within normal on the upper side around the 800’s, where men were when they were younger and felt their best. It can be normal to drop down to the 400’s by middle-age and to the 200’s after that.
Will insurance pay for testosterone replacement? Not likely. Some insurances might, but usually they won’t because natural aging is not considered an illness. Some insurances will pay when the levels are below 200 and may require testing twice before 10 AM.
What tests do you order?
–Complete blood count (CBC): Testosterone stimulates the bone marrow to produce more red blood cells. I check the hemoglobin and hematocrit to make sure that they are within normal to decrease the risk to stroke or heart attack. Some patients may need to decrease their dosing and/or donate blood until the labs normalize.
–Follicle Stimulating Hormone (FSH)/Luteinizing Hormone (LH): It’s important to know if testosterone is low because of lack to stimulation from the brain or lack of stimulation from below the waist.
–Lipid panel: Testosterone can temporarily increase cholesterol, so it’s important to get a baseline.
–Total and free testosterone: Free is more accurate and is what is available to the body to use, but it more expensive. Once we see that they match, we can just order the total from then on.
–Sex hormone binding globulin (SHBG): This protein is made by liver and binds testosterone and other hormones to make them present (total level) but not yet available (free). Issues with the liver, gallbladder, and gut may cause SHBG to increase.
–Complete metabolic panel (CMP): This checks the liver, gallbladder, kidneys, and electrolytes.
–DHT: Testosterone converts into DHT, which causes hair loss. We want to avoid male-patterned baldness.
–IGF-1: Growth hormone can be low. This can be a target once testosterone is optimized.
–Estradiol: Testosterone converts into estrogen. If high, anastrozole can be used added to the regimen.
–Progesterone: The balance of all of the sex hormones are important to avoid relative deficiencies or relative excesses. Progesterone blocks the conversion of testosterone to DHT. Progesterone also helps with sleep, stress, anxiety, depression, inflammation, and bone loss.
–TSH, free T4, free T3, AM cortisol: An imbalance in thyroid and adrenal hormone can cause many of the same symptoms as low testosterone.
–A1C: Diabetes can cause fatigue similar to low testosterone.
–PSA: Preventive medicine is important in checking prostate health which is related to testosterone level.