During the last year we have had an increase in reports from men stating that they are running out of their testosterone cypionate injections before the refill date. This article will hopefully help mitigate this problem. Lets first rule out those who over-draw the testosterone into the syringe, of course we must pay attention to detail when it comes to lining up the syringe plunger with the dosage line. If we are not paying attention, or have not been instructed properly, over drawing just a small amount of testosterone at each injection can result in running out of the medication prior to your refill date. There are other factors which can cause loss of testosterone as you inject regularly. If you notice at the base of your needle, where you attach the needle to the syringe, there is empty space which can trap the testosterone even after depressing the plunger completely. There always seems to be that little bit of medication that will not leave the needle space. In addition to the testosterone being trapped in the needle, there is also a small amount left behind on the internal syringe walls. This type of loss is unavoidable when using a 3ml or syringe with larger surface area for the medication to 'stick' to'. Over the course of administering ten to twenty injections using a 10ml multi-dosed bottle that little bit of lost testosterone adds up.

One of the reasons I believe we have noticed the rise in reports of men running out early during the past year is the result of increased regulations regarding the prescribing and dispensing of testosterone. It is a controlled substance which was previously overlooked by most regulators, and patients had the convenience of refilling earlier than due. I remember being able to refill 3 weeks early on a 10ml bottle. Now, with the regulations, it is 3 days to one week prior to being due depending on the pharmacy. This means we now have to be mindful of our dosage and injection technique.

There is one thing being done by manufacturers and compounders to mitigate the loss. There is also something you can do to make your testosterone last the entire time up to your refill time.

At least one brand of testosterone cypionate and most compounded 10ml cypionates are actually overfilled to help compensate for the expected loss. Pfizer's Depot Testosterone is filled over 10ML. As of 2010, if I remember correctly, close to 10.8ml. The compounding pharmacies we use all fill the bottle to 11ml, which will help compensate the unavoidable loss. We had the opportunity to confirm this in a pharmacy setting in 2010 (APS Pharmacy, FL). During this test we also were able to observe the variations in the loss of medication between different syringes. Three commonly prescribed testosterone cypionate 200mg/ml 10ml bottles were selected, including Pfizer's Depot Testosterone, Watson's testosterone cypionate, and compounded testosterone cypionate. First, using a larger 12ml syringe we drew the entire contents of each bottle to confirm they were at least 10ml. A separate syringe was dedicated to each bottle to ensure accuracy. Next, using a new bottle of each testosterone cypionate and using ten individual 3ml syringes dedicated to each bottle, we drew 1ml into each 3ml syringe. This phase confirmed that each bottle lost an average of 1ml using ten 3ml syringes to draw 1ml versus using a 12ml syringe to draw the entire contents. You must be careful to accurately measure your dosage when injecting your testosterone using a 3ml syringe.

If you are having trouble drawing with a 3ml syringe, or if you are on a decimal dosage (such as 0.75ml), try using a 1ml Luerlock syringe. It looks similar to an "insulin" or tuberculin syringe but can be attached with any size/gauge needle. The 1ml Luerlock allows any standard needle to be secured onto the syringe. Two benefits to using a 1ml syringe: 1- You will draw your dose more accurately 2- There is less surface area on the internal syringe wall for the testosterone to adhere to when your weekly dosage is split into two injections using the 1ml Luerlock. I also find it easier to inject with proper technique when personally using a 1ml syringe.

2016 update:

I am currently working with another compounding pharmacy to perform testing including a similar test as mentioned in this article. I will post the details along with pictures/video when completed.

Jasen Bruce

Published in Defy Medical Blog
Tuesday, 14 October 2014 15:04

Different types of injectable testosterone

The most common forms of injectable testosterone in the US include Testosterone Cypionate, Testosterone Propionate, Testosterone Enanthate, or a combination of different ester types (ester blend). An 'ester' is basically a chain composed of Hydrogen, Carbon, and Oxygen atoms which are attached to the testosterone molecule which must be broken down creating a 'timed release" in the body once injected. Even though the testosterone molecule remains the same no matter the ester, each one can yield different results by the way they are metabolised in the body once injected. For testosterone replacement therapy the ester does not matter as much as the timing and frequency of injections. The ultimate goal should be to restore total testosterone to a good range, or 'optimal' range, with about 2%-4% free testosterone. You can acheive this using any ester if the injection is timed correctly. The problem with using blended esters instead of a single ester is that blends can cause testosterone levels to become unpredictable or too erratic for replacement therapy. Blended preparations using multiple testosterone esters look great on paper, and they can be easier for a compound pharmaceutical rep to sell, but they are not as easy to work with clinically. One reason a doctor might include more than one ester, for example a combination of propionate and cypionate, is to provide a more aggrssive release pattern "spike" in those men who sometimes feel better due to the way they metabolize testosterone once injected. Since everyone responds differently you want to make sure you are following up until response is established. I have tried every combination of ester available (and not available) and still prefer testosterone cypionate by itself as it is predictable for me.

Always remember that each of these forms is simply testosterone, the hormone molecule remains unchanged, and the only difference is the attached "ester" which determines the half-life within the body. 'Cypionate', 'enanthate', and 'propionate' are all esters.

Enanthate: This is metabolized in roughly 4-5 days. It can even remain in the body (in very small amounts) for 2 weeks. 100mg of Testosterone Enanthate yields ~73mg of actual testosterone, the rest is ester weight. Injections can be administered every 5 days. As we all know everyone is unique in their response to drugs but from what I have seen in my experience the approximate starting doses which may bring a patient within optimal ranges (650ng-1100ng) is 100mg-200mg IM every 5-7 days. Of course many factors come into play including the patient's baseline levels and biology.

Cypionate: This is metabolized in roughly 7-8 days. This is also considered a 'long-acting' testosterone. 100mg of Cypionate yields ~68mg of actual testosterone. A good starting dose would be similar to Enanthate, more commonly between 100mg-200mg IM every 7days.

Propionate: This is a faster acting ester which can peak in the blood within hours and metabolized over 3 days. Injections should be administered every 2-3 days. You must weigh the 'positives' with the 'negatives' before prescribing propionate. Since it metabolizes so quickly, and needs to be administered frequently, it is easy to stabilize levels and optimizes blood-testosterone-levels quickly. On the downside IM injections must be given frequently which can keep patients from remaining compliant. Also, since the levels peak faster there is also an increased chance of aromatizing the testosterone into estrogen and increased DHT conversion which can cause side effects. 100mg of Propionate yields ~93mg of testosterone.

Other Esters found in TRT medicine may include;

Aqueous Testosterone Suspension: No-Ester. Requires frequent IM injections since it remains in the body only for a few hours. (Very painful injection). The risks outweigh the benefits when it comes to Testosterone Suspension and we do not recommend prescribing this particular ester.
Published in Defy Medical Blog