Testosterone – pellets, shots and gels
As baby boomers age, they are fighting back against the aging process. As a result, there is a lot of buzz around the use of testosterone.
Here are some of the key facts, as I see them.
Low testosterone is part of the aging process. By age 40, most men and women are producing less testosterone on their own. It is normal. The problem with that normal decline in testosterone levels is that it can be associated with symptoms such as increases in abdominal fat, fatigue, need for increased sleep, not feeling rested in the morning, sweating at night, loss of mental clarity (mental fog or forgetfulness), poor mental outlook (negative thinking), mood changes (anxiousness or feeling down), reduced libido (sex drive) and reduced enjoyment of sex (reduced ability to orgasm, and strength of orgasm). The symptoms of “Low T” are similar in men and women.
TRT stands for Testosterone Replacement Therapy. If you are receiving testosterone (shots, pellets or topical creams & gels) your body will respond by producing less testosterone on it’s own. As a result, we really don’t supplement your testosterone, we replace it entirely.
Almost all of the clinical studies regarding the use of testosterone have been done on men. This unfortunate bias leaves a lot of Doctors thinking of Low T as a disorder primarily of men, not women. But this could not be farther from the truth, as many women in their 40’s and 50’s suffer from symptoms of Low T, and are not given the option to try TRT.
The pharmaceutical industry is primarily invested in promoting the use of testosterone in the form of FDA approved topical gels, applies to the skin. A lot of funding for clinical studies comes from pharmaceutical companies, who want to demonstrate how their products can help men. As a result, many of the recent studies deal with outcomes using topical T gels. When I review the results of these studies, I find the results are quite discouraging. Why is that? My belief is that the absorption of testosterone across the skin (trans-dermal) when testosterone gel is applied is inconsistent between people, unreliable and often quite poor. In these studies, men are often not achieving blood levels in the upper end of normal. And yet, for men to respond to TRT, being in the upper range of normal is where they feel the best.
The oldest form of prescribing testosterone is by injection. I have only seen this done in men. Most of the data showing the adverse side effects of TRT is gathered from data collected when men are given T injections. T injections are not bio-identical. They are not an exact match to what the body produces. The T has been modified for injection.
Bio-identical T (pellets, creams & gels) is often reported to be safer than shots of T. I believe the data on this is limited. In my experience, T injections are more likely to raise red blood mass in the bloodstream (Hematocrit and Hemoglobin) to unhealthy levels. Other than that, the safely profile of all forms of testosterone is likely similar.
The normal Total Testosterone level in men runs in the range of 250-1,100. When men have a Total T level of 250-400 they are often told by a doctor that “you are in the normal range” which is true. But do men at the bottom range of normal have symptoms of Low T and do they feel better when TRT is administered? My experience is that most men with Total T levels under 450 are symptomatic, and about 50% of them feel better when the Total T level is raised above 800. I also find that the lower their pre-treatment Total T level is, the more likely they are to respond to TRT. Despite this spectrum of Total T levels and symptoms, most insurance companies are not going to cover the cost of TRT for men unless their baseline number is under 250. By this criteria, most men with Low T symptoms are going to be excluded from having the cost of TRT covered by health insurance. Most of the men I see for T pellets or T injections are men who are falling between the cracks – men with Total T levels in the range of 250-450 who need TRT, but have to pay for the cost of it themselves.
The normal Total T level in women appears to be openly debated in the Wellness Community that helps women find balance to their T. If we accept that the upper range of normal in women is no more than 40 or 50, then I fear we are denying women the chance to try TRT to see if it helps them feel better. Anecdotally, most providers of testosterone pellets (myself included) find that most women feel their best when the Total T level is increased into the range of 80-120. I feel I am actually quite conservative in comparison to other providers of T pellets in the U.S. Women treated at other clinics are often pushed into the Total T range of 250 or higher! When this happens, I suspect we are no longer balancing T levels in women, we are jacking their T levels up unnaturally.
The point of TRT is wellness and quality of life. In other words, alleviating the symptoms of Low T when they occur in men and women. It is not the goal of TRT to do more harm. As with any hormone treatment, there are pros and cons that need to be discussed. If quality of life on TRT is significantly improved, then it must be compared to known risks of treatment.
What are the risk of TRT? Who should be excluded from treatment? The big concern is the answer to the question: “Does TRT increase the risk for stroke, heat disease (heart attacks) or clots in general?” The general answer has to be a “Yes”. Why is this? I suspect the main mechanism at play is the potential for TRT to increase red blood cell counts to abnormally high levels. Too many red blood cells will slow blood flow in small vessels, making circulation sluggish. As a result, it is important to monitor what we call red blood cell indices (hemoglobin, hematocrit) and when levels go above normal, ask the patient to donate blood as a means of bring the levels back down into the healthy normal range. Should a man or woman who has has a stroke or heart attack be treated with TRT? This is a complex question, that can only be answered by the patient and doctor after careful review of the risk / benefit equation.
T injections in men cause uneven levels of blood testosterone, levels that rise quickly after each injection, and then dropping back down after several days. This “up and down” in T levels is often called “the rollercoaster effect” or simply “peaks and troughs”. Men usually start receiving a T injection into the buttock muscle once every 2 weeks, and shortening the interval between shots to 10 or even 7 days apart to achieve more even blood levels.
As I stated earlier, I am not impressed that TRT by topical cream or gel works very well, in men or women. One way to try and improve absorption is to apply the patch, cream or gel to the underarm area, or the shaved scrotum on a man.
Pellets are my choice for women. I dose women conservatively, with the goal of achieving benefit (treating the symptoms of Low T), while avoiding bad flareups of acne or increases in unwanted facial hair. I am unique in my community in that I do this procedure under strict sterile technique.
Pellet therapy in men also works great, but is a bit more complicated. The average woman on TRT will likely feel great with a Total T blood test of 100. The average man who responds to TRT needs much more, and often feels best with levels that approach 1,000. That means that women feel well on 1/10 of the blood level that men often need! Obviously the dose of T pellets for men needs to be much higher, for the treatment to work. This translates to the fact that men often receive many more pellets than women.
The pellet insertion procedure may cause swelling and bruising in the buttock area, where they are placed. The risk of infection exists with any invasive procedure, and that risk increases based on the amount of injury that is incurred into the area of treatment. So you can see that a man who may receive 16 pellets is going to have more risk of bruising, pain and potential risk of infection than a women who receives only one pellet. Men typically receive a larger diameter 200mg T pellet, that requires a larger instrument (we call a trochar) to be used. The larger trochar increases the risk of pain, swelling and infection. I was initially trained in the use of the larger trochar and larger pellets in men, but I did not like the rate that men developed problems with bruising and infection.
As a result, I have tweaked the male pellet program at Omaha Med Spa. I am unique in that I use the same sized trochar for men and women! This means I am having to spend more money buying more pellets for men (pellets that have the 3mm diameter), but men appreciate the short recovery. And most importantly, I am achieving the same excellent Total T levels in men, and symptom relief, while lowering the men’s risk of infection.
By achieving hormone wellness using T pellets, following my safer protocol, men and women are getting the results they are looking for, but reducing their risk of side effects.
The last key point i wish to point out is this: Dosing of T pellets is based upon body weight. The heavier that a man or woman is, the more T he or she will need to be dosed at. I have found that most men under 250 pounds do very well with my T Pellet program. Men over 250 pounds are more likely to achieve positive results using my compounded testosterone injections that are administered in the med spa.