Jasen Bruce

Jasen Bruce

During the previous years large surge in testosterone prescriptions and TRT clinics there are unfortunately many men who have been misdiagnosed with low testosterone, yet placed on TRT when it may not have been needed in the first place. If you are one of these men and you are considering the discontinuation of testosterone treatments there is a protocol that can help restore your own hormone axis. You do not want to stop testosteone "cold turkey", this will lead to unecessary symptoms that could last for many months. This is an example of just one protocol, since there really is no "one way" to do it. This has proven a very effective foundational protocol for Defy, but of course every patient is different and therefore treatments are individualized as needed. A good TRT doctor will customize the approach based upon the patients response. TRT: Endogenous Restoration protocol for Men Discontinuing TRT Male patients who have been taking any form of exogenous Testosterone long term, longer than 12 weeks, will have secondary hypogonadism induced by the negative feedback response to the exogenous testosterone use. The purpose of this protocol is to stimulate the testes using HCG so that they are able to produce testosterone once again,while also preparing them to respond to endogenous LH/FSH(gonadotropins). Tamoxifen is taken beyond the HCG as it is shown, as aSERM, to stimulate the pituitaries release of LH/FSH whole suppressing the negativeeffects of excess estradiol. Clomid is also commonly used as a SERM. Estradiol can elevate in men who discontinueTRT so it is important to run the SERM for some time after discontinuing TRT to mitigate E2 rebound. Meds needed: HCG 11,000iu+mixing kit Clomiphene 50mg #30-#60 tablets Tamoxifen 20mg #30-#90 tablets Syringes and supplies for HCG Basic Protocol Begin protocol 5 days after the last T injection (Cyp/Enanth). If the patient is taking a T cream than begin the protocol one day followingthe last application of T cream. First 30 days: HCG 350iu daily sq Tamoxifen 20mg- 1 tablet POQD DHEA 50mg- 1 capsule QHS (Optional) Request Sildenafil (Viagra) or Tadalafil (Cialis) for any ED. Many patients experience ED during initial recovery. 30 day blood work follow up: Draw the following labs: Testosterone F&T; Sensitive Estradiol; CBC; CMP ** Physician can order additional labs at his/her discretion. After 30 days of HCG+Tamox After the initial 30 days of HCG+Tamox; If the total Testosterone is elevated at the follow up blood test, then it can be assumed that patient is responding well to HCG. Discontinue HCG and titrate tamoxifen dosage to 10mg after last dose of HCG. Continue the Tamoxifen 10mg for 30 more days. Add Clomid 50mg QHS for 30 days. Set lab reminder for follow uplabs 2 weeks after last dosage of Tamoxifen/Clomid. Levels should remain elevated from there. If not, at the physicians discretion the above protocol can be repeated until labs reflect a desired response. Symptomology (the study of your symptoms) must also play a role in determining desired response. Labs Needed: Testosterone Free and Total; Sensitive Estradiol; LH; CBC; CMP-14; DHEA; PSA If the Patient Does not Respond after 30-90 days of HCG+Tamox If the patient does not respond to the HCG+Tamoxifen after90 days (3 cycles), then it can be assumed there is possible primary hypogonadism. This would not have been caused by the TRT, more than likely it has developed naturally with age or has been present for a long time. In this case itis best to suggest continuing TRT so that T levels remain optimal and the patient’s life quality and health also remain optimal. Educate the patient on the importance of maintaining good levels of T, even if that means being treated with TRT. My good friend Nelson Vergel has provided great information regarding HPTA recovery after using androgens. This article also includes a study with HIV patients who cycled testosterone medications followed by a protocol designed to restore normal hormone function. You can read it here: http://www.excelmale.com/content.php?56-How-to-Stop-Testosterone-Safely-and-Possibly-Reset-Your-Hormonal-Axis
Why do I need blood work? One of the purposes behind drawing blood for analysis is to provide our physician a means to compare how you are responding to therapy with your hormone blood levels and other important indicators of your health. This information allows Dr. Saya to make appropriate adjustments to your regimen that not only improve how you are feeling but minimize any side effects and risks with treatment. The laboratory analysis of your blood will also provide a comparison with initial blood work and provide data that will aid in the development of your treatment plan.

Who is required to have blood work? Any patient who is on hormone replacement therapy (HRT) or testosterone restoration therapy (TRT).

How often is blood work required? Each patient at Defy Medical starts with a comprehensive blood analysis prior to beginning therapy. The first follow up is required 90 days after starting therapy. Once this review is complete, follow-up labs will be required twice per year, unless additional labs are requested by Dr Saya or the patient. In some cases, certain conditions or diseases may require additional monitoring where more blood work is required.

What blood tests am I receiving? This depends on factors such as the patient’s sex, type of therapy, and medications being prescribed. Typically our standard follow-up lab panel includes analysis of kidney, liver, and other organ function through a comprehensive metabolic panel (CMP-14). We also look at red and white blood cells; immune function; Lipids; diabetes risk; and nutritional deficiencies. Lastly, we look at key hormones such as testosterone, thyroid and pituitary function (growth hormone), Adrenal gland function, estrogens, and other sex hormones. We also have additional testing available by request, such as vitamin D3 and our cardiovascular risk panel. Follow up labs are customized to each patient depending on what program we are monitoring.

Where are the labs drawn? All blood is drawn at Defy Medical in Tampa, FL, or at a one of the Labcorp locations across the US. To find a Labcorp location near your home or office, please visit http://www.defymedical.com/services/laboratory-blood-testing

Will insurance cover my blood work? Although Defy Medical does not accept insurance, in some cases insurance does cover labs. Please let us know if you would like us to check your coverage. We also provide Claim Assistance by completing the necessary paperwork needed to submit for reimbursement from your insurance company. Claim Assistance does not guarantee reimbursement; this will be determined by your insurance company.

How do I schedule my blood work follow up? Patient Portal: You may order and schedule your lab work by logging into your patient portal and following the instructions for ordering lab work. If you have not been registered for the new online patient portal, please let any of our staff know and we will assist you in the process. Email: Send your lab request to: [email protected] Phone: Call our main number at 813-445-7342 and any of our staff can assist you with your lab order. Fax: Send your lab order request to 813-445-7340 Labs will tell us what is happening in your blood, we need you to tell us what is happening to you. How do you feel today? Are you experiencing any symptoms which you would like Dr Saya to address? As usual, you are welcome to call us at our office to schedule a consultation anytime. Our goal is to provide all patients with optimal service and medical care. If you need assistance or would like to speak with Dr Saya regarding your treatment, please let us know.

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

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 ester has a half-life of 8 days resulting in the slow metabolism of hormone once injected. Providers commonly recommend injecting cypionate once to twice per week to maintain stable hormone levels. 100mg of Testosterone Cypionate yields~68mg of actual testosterone.

 

Propionate: This is a faster acting ester which can peak in the blood within hours and be fully metabolized over 3 days. Injections are commonly administered every 2-3 days. Since it metabolizes so quickly, and needs to be administered frequently, it is easy to stabilize levels and optimizes blood-testosterone-levels quickly. 100mg of Testosterone 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.

Wednesday, 01 October 2014 14:25

Subcutaneous administration of testosterone

Commonly prescribed injectable testosterone includes testosterone cypionate, enanthate, and propionate. All three are oil based injectables which have typically been administered by intramuscular injection (IM) using a 1” to 1.5” needle. Click here for more information on the different injectable testosterone esters. For a long time it was thought that these oil based testosterone medications could only be administered intramuscularly, however a few physicians who specialized in prescribing testosterone therapies noticed that testosterone levels appeared to be the same, even more stable, when patients administered their testosterone subcutaneously using a much smaller needle versus an IM injection. Over the years there have been more observations and studies supporting the subq administration of injectable testosterone, including the pilot study below. Normally when testosterone is administered by IM injection the entire weekly dosage is taken at one time, sometimes causing a peak in serum testosterone levels followed by a trough as the hormone metabolizes. When injecting testosterone by subcutaneous injection the dosage can be split into half, administering two smaller injections typically every 3 days (or twice per week). For many patients this method reduces the “peak and trough” effect and can keep serum testosterone levels more stable throughout the week. If you would like more information or direction on how to administer your testosterone subcutaneously please do not hesitate to contact the Defy Medical team for assistance. Subcutaneous administration of testosterone. A pilot study report. Al-Futaisi AM, Al-Zakwani IS, Almahrezi AM, Morris D. Source Department of Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman. [email protected] Abstract OBJECTIVE: To investigate the effect of low doses of subcutaneous testosterone in hypogonadal men since the intramuscular route, which is the most widely used form of testosterone replacement therapy, is inconvenient to many patients. METHODS: All men with primary and secondary hypogonadism attending the reproductive endocrine clinic at Royal Victoria Hospital, Monteral, Quebec, Canada, were invited to participate in the study. Subjects were enrolled from January 2002 till December 2002. Patients were asked to self-administer weekly low doses of testosterone enanthate using 0.5 ml insulin syringe. RESULTS: A total of 22 patients were enrolled in the study. The mean trough was 14.48 +/- 3.14 nmol/L and peak total testosterone was 21.65 +/- 7.32 nmol/L. For the free testosterone the average trough was 59.94 +/- 20.60 pmol/L and the peak was 85.17 +/- 32.88 pmol/L. All of the patients delivered testosterone with ease and no local reactions were reported. CONCLUSION: Therapy with weekly subcutaneous testosterone produced serum levels that were within the normal range in 100% of patients for both peak and trough levels. This is the first report, which demonstrated the efficacy of delivering weekly testosterone using this cheap, safe, and less painful subcutaneous route.

UPDATE: Self-Administered Testosterone Injection Meets Main Goal In Late-Stage Study. Reuters (2/26/2015, Grover) reports that an experimental once-weekly testosterone injection, testosterone enanthate that is to be marketed as QuickShot Testosterone, met its primary goal in the ongoing late-stage study. The study involves 150 patients with less than 300 nanograms of testosterone per deciliter of blood. QuickShot is the only self-administered, subcutaneous treatment currently in late-stage
Monday, 29 September 2014 16:36

TESTOSTERONE DOES NOT CAUSE HEART ATTACKS

TESTOSTERONE DOES NOT CAUSE HEART ATTACKS

It is shocking that the recent study which claimed that testosterone causes heart attacks has found its reach within certain medical circles, then to the masses, considering the obvious flaws within the study itself. Not surprising are the attorney's looking to make a buck off anything they can spin to their benefit. They are using this flawed study to generate lawsuits against Big Pharma producers of testosterone medications. The problems within this study include: Lack of testing and monitoring estradiol conversion, which can happen in aging men and easy to manage with proper treatment. Lack of testing and monitoring Hematocrit/red blood cells which can become elevated in men given testosterone. This is also easily manageable and preventable when properly monitored.

Lastly they did not even provide proper dosing of testosterone to the men within the study. More on the study flaws can be found here: TESTOSTERONE DOES NOT CAUSE HEART ATTACKS. Soon enough this study will be knocked to the ground and these attorney's will have nothing to stand on. Fact is, maintaining good levels of testosterone actually reduced heart attack risk.

Here are two videos which discuss how to manage estrogen and red blood cells in men taking testosterone. The lack of these levels being monitored is a major oversight within the study.

Dr. Saya discussing how to manage elevated red blood cells in men taking TRT: http://www.defymedical.com/video-education/134

Dr Justin Saya discusses managing high estrogen in men on TRT: http://www.defymedical.com/resources/135

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