Guidelines for male hypogonadism!

http://www.uroweb.org/gls/pdf/16_Mal...sm_LR%20II.pdf


If you suffer from low testosterone, above study may give you some answers. It explains different forms of hypogonadism (primary, secondary), possible causes, treatments etc...

Also good reads:
About different treatment options:
The Androgen-Deficient Aging Male: Current Treatment Options


Thread about SERM restart protocol (using clomiphene in this thread):
Clomid For Men With Low Testosterone by Jeffrey Dach MD

Adrenal gland and hormone terapy: thread with few links: Adrenal Fatigue and Hormone Therapy by Dr Lam

Thread with some info on HCG, SHBG, AI and TRT in general:
TRT

Dr Shippen chart, for rough calculations of free testosterone (using tot. testosterone and SHBG)
Attachment 1078


Desirable level of some hormones (just for basic guide, in practice it varies a lot):
Attachment 1077




Effect on various hormones on each other:
Attachment 1076


Hormone conversion chart
Fowkes chart- made to easy understand hormonal conversions:
http://www.projectwellbeing.com/wp-c...9/wb-tree2.pdf

How long does testosterone take to show effects on TRT?

A review of studies attempted to determine, from published studies, the time-course of the effects induced by testosterone replacement therapy from their first manifestation until maximum effects are attained.
This review found that:

· Effects on sexual interest appear after 3 weeks plateauing at 6 weeks, no further increments beyond.
· Changes in erections/ejaculations may require up to 6 months.

· Effects on quality of life manifest within 3-4 weeks, but maximum benefits take longer.
· Effects on depressive mood appear after 3-6 weeks with a maximum after 18-30 weeks.

· First effects on erythropoiesis (increased red blood cells) after 3 months, peaking at 9-12 months.

· Prostate specific antigen and volume rise, marginally, plateauing at 12 months; further increase related to aging rather than therapy.
· Effects on lipids appear after 4 weeks, maximal after 6-12 months. I
. Insulin sensitivity may improve within few days, but effects on glycemic control become evident only after 3-12 months.

· Changes in fat mass, lean body mass and muscle strength occur within 12-16 weeks, stabilize at 6-12 months, but marginally continue to improve over years. Effects on inflammation occur within 3 to 12 weeks.

· Effects on bone detectable after 6 months but continue at least for 3 years.

Full text: http://www.eje-online.org/content/ea...-0221.full.pdf

Some info on HCG:

What is HCG?[/B]
Human chorionic gonadotropin (HCG) is a hormone that supports the normal development of an egg in a woman's ovary, and stimulates the release of the egg during ovulation. HCG is used to cause ovulation and to treat infertility in women, and to attempt to normalize sperm count and testicular size in men. HCG is also used in young boys when their testicles have not dropped down into the scrotum normally. This can be caused by a pituitary gland disorder. HCG may also be used in some cases along with testosterone replacement in men with testosterone deficiency to prevent and reverse testicular atrophy. Note: HCG is not to be confused with HGH (human growth hormone).

Mixing Reconstitution Instructions:

Use a large syringe provided with the product to inject 11ml of bacteriostatic water to the vial containing the HCG dry powder, aiming against the glass vial wall. Swirl the vial with a gentle rotary motion until contents are dissolved- DO NOT SHAKE.

Suggested syringe size for injection under the skin: 30 Gauge needle of 5/16 inches in length containing 1 milliliter (30G 5/16x1ML). Note: ml = cc

How much HCG to draw depends on the dose to be used (follow physicians recommendations):
For example, for 1,000iu per dose = draw 1ml= 100 on the syringe
500iu per dose = draw 0.5ml= 50 on the syringe
250iu per dose = draw 0.25ml= 25 on the syringe

You can divide all of the above numbers by half if you use 5.5 ml of bacteriostatic water to reconstitute instead of 11 ml. NOTE: Discard all used syringes in a sharps waste container.



Human Chorionic Gonadotropin (From the book Testosterone: A Mans Guide, amazon.com)

Human chorionic gonadotropin (HCG) (not to be confused with human growth hormone, or HGH) is a glycoprotein hormone that mimics LH (luteinizing hormone), produced in pregnancy by the developing embryo soon after conception, and later by part of the placenta. Its role is to prevent the disintegration of the corpus luteum of the ovary and to maintain the progesterone production critical for pregnancy in women. It supports the normal development of an egg in a womans ovary, and stimulates the release of the egg during ovulation. HCG is used to cause ovulation and to treat infertility in women.
Youre probably asking yourself why you should care about this. But in men, HCG is also used in young boys when their testicles have not dropped down into the scrotum normally. Additionally, HCG is used to increase testicular size after long-term testosterone or anabolic steroid use.
As mentioned at the beginning of the book, testosterone replacement therapy triggers the hypothalamus to shut down its production of GnRH (gonadotropin releasing hormone). Without GnRH, the pituitary gland stops releasing LH. Without LH the testes (testicles or gonads) shut down their production of testosterone. For males HCG closely resembles LH. If the testicles have shrunken after long-term testosterone use, they will likely begin to enlarge and start their testosterone production shortly after HCG therapy is instituted. HCG jump-starts your testes to produce testosterone and to increase their size.
HCG can be extracted from pregnant womens urine or through genetic modification. The product is available by prescription under the brand names Pregnyl, Follutein, Profasi, and Novarel. Novire is another brand but it is a product of recombinant DNA. Compounding pharmacies can also make HCG by prescription in different vial sizes. Brand names of HCG in regular pharmacies cost over $100 per 10,000 IUs. The same amount of IUs cost around $50 in compounding pharmacies. Many insurance policies do not pay for HCG since they consider its use for testicular atrophy while on TRT an off label use. So, most men using it pay for it themselves and get it from compounding pharmacies that sell it a lot cheaper.

HCG is dispensed as a powder contained in vials of 3,500 IUs, 5, 000 IUs or 10,000 IUs or more. You can call compounding pharmacies and have them make vials for you with different IU amounts, though. These are usually accompanied by another vial of 1 mL (or cc) of bacteriostatic water to reconstitute the powder into a liquid solution.


What is an IU? When measuring testosterone we spoke in weights of grams and milligrams. HCG is measured not by weight but in IUs, or international units. IU is not about weight but refers to the amount of a sub- stance that produces a particular biologic effect that has been agreed upon as in international standard. The IU from one substance to the next does not mean they have equivalent weights (for example, 1, 000 IU of vitamin C might have a different weight than 1,000 IU of vitamin A). Again, IU is not a weight measuring unit.


Bacteriostatic water (water with a preservative that is provided with the prescription) is mixed in with the powder to reconstitute, or dissolve, it before injection. This type of water can preserve the solution for up to 6 weeks when refrigerated. Some patients do not use the 1 mL water vials that come with the commercially (non compounded) available product and instead get their doctors to prescribe 30 cc bottles of bacteriostatic water so that they can dilute the HCG down to a more workable concentration that is more practical for men using lower doses of HCG weekly.

HCG is given as an injection under the skin or intramuscularly (there is still debate on which method is best). The number of IUs per injection will depend on how much bacteriostatic water you add to the dry powder vial. If you add 1 mL to a 5,000 IU powder vial, then you will have 5,000 IUs per mL, so 0.1 mL would be 500 IUs. If you add 2 mL to the 5,000 IU dry powder vial, then you will have 2,500 IUs/mL; 0.1 ml (or cc) in an insulin syringe will equal 250 IUs. If you need to inject 500 IUs, then you inject 0.2 ccs of this mixture. Table 3 provides dilution volumes at different HCG powder/water proportions.

Ultra-fine needle insulin syringes are used to inject HCG under the skin, making this very easy to take even for the needle-phobic. Typical sizes are:

1 ml, 12.7 mm long, 30 gauge and
0.5 ml, 8 mm, 31 gauge syringes.


Syringes require a separate prescription. Some compounding pharmacies will automatically include them with the shipment, but do not forget to ask them. Never use the syringe that you used for injecting the bacteriostatic water into the powder for injecting yourself; the needle will be dull (I usually use a regular 23 gauge, 1 inch, 3 ml syringe to load up the water). Remember that you also need alcohol pads to clean the injection area and the tip of the vial. Typical injection sites are the abdominal area close to the navel or in the pubic fat pad. Pinch a little of fat on your abdominals and inject into that pinched area, then massage with an alcohol pad. Discard syringes into the sharps container that can be provided by your pharmacy.

As I mentioned before, compounded HCG is a lot cheaper than the commercially available pharmaceutical products. Sometimes it is difficult to find commercially available HCG in regular pharmacies.

A review of the literature reveals a wide range of doses of HCG used and that there is very little agreement among physicians. For male infertility, doses range from 1250 IU three times weekly to 3000 IU twice weekly (these studies did not include men on testosterone replacement).

How long does the boost in testosterone last after an injection of HCG? A study looked into that and also tried to determine if high doses would be more effective at sustaining that boost. The profiles of plasma testosterone and HCG in normal adult men were studied after the administration of 6000 IU HCG under two different protocols. In the first protocol, seven subjects received a single intramuscular injection. Plasma testosterone increased sharply (1.6 0.1-fold) within 4 hours. Then testosterone decreased slightly and remained at a plateau level for at least 24 hours. A delayed peak of testosterone (2.4 0.3-fold) was seen between 7296 hours. Thereafter, testosterone declined and reached the initial levels at 144 hours. In the second protocol, six subjects received two intravenous (IV) injections of HCG (5-8 times the dose given by injection to the first group) at 24-hour intervals. The initial increment of plasma testosterone after the first injection was similar to that seen in the first protocol despite the fact that plasma HCG levels were 58 times higher in this case. At 24 hours, testosterone levels were again lower than those observed at 24 hours and a second IV injection of HCG did not induce a significant increase. The delayed peak of plasma testosterone (2.2 0.2-fold of control) was seen about 24 hour later than that in the first protocol. So, this study shows that more is not better when dosing HCG. In fact, high doses may desensitize Leydig cells in the testicles. It also showed that testosterone blood levels peak not once but twice after HCG injections. I wish they had studied a lower dose than 6000 IU since very few physicians prescribe this high dose.

HCG may not only boost testosterone but also increase the number of Leydig cells in the testicles. It is well known that Leydig cell clusters in adult testes enlarge considerably under treatment with HCG. However, it has been uncertain in the past whether this expansion involves an increase in the number of Leydig cells or merely an enlargement of the individual cells. A study was performed in which adult male Sprague-Dawley rats were injected subcutaneously daily with 100 IU HCG for up to 5 weeks. The volume of Leydig cell clusters increased by a factor of 4.7 during the 5 weeks of HCG treatment. The number of Leydig cells (initially averaging 18.6 x 106/cm3 testis) increased to 3 times the control value by 5 weeks of treatment (P<0.001), while the average volume of individual Leydig cells (initially ~2200 m3) enlarged only 1.6 times. They concluded that chronic treatment with HCG increases the number of Leydig cells in the testes of adult rats. We do not know if these results can be extrapolated to men.

Currently there are no HCG guidelines for men who need to be on testosterone replacement therapy and want to maintain normal testicular size. A study that used 200 mg per week of testosterone enanthate injections with HCG at doses of 125, 250, or 500 IU every other day in healthy younger men showed that the 250 IU dose every other day preserved normal testicular function (no testicular size measurements were taken, however). Whether this dose is effective in older men is yet to be proven. Also, there are no long-term studies using HCG for more than 2 years.

Due to its effect on testosterone, HCG use can also increase estradiol and DHT, although I have not seen data that shows if this increase is proportional to the dose used.

So, the best dose of HCG to sustain normal testicular function while keeping estradiol and DHT conversion to a minimum has not been established.

Some doctors are recommending using 200-500 IUs twice or three times a week for men who are concerned about testicular size or who want to preserve fertility while on testosterone replacement. Higher doses, such as 1,0005,000 IUs twice a week, have been used but I believe that these higher doses could cause more estrogen and DHT-related side effects, and possibly desensitize the testicles for HCG in the long term. Some doctors check estradiol levels a month after this protocol is started to determine whether the use of the estrogen receptor modulators tamoxifen (brand name: Nolvadex) or anastrozole (brand name: Arimidex), is needed to counteract any increases in estradiol levels. High estradiol can cause breast enlargement and water retention in men but it is important at the right blood levels to maintain bone and brain health.

Dr Lipshultz in Houston did an interesting study in men usings gels or injections to see if every other day injections of HCG at 500 IU preserved their fertility while on TRT. He found that most men did indeed remain fertile with good sperm quality and count.

For men using testosterone gels, the same dose every third day has anecdotally helps to preserve testicular size (the dose of the gel has to be adjusted after a month of HCG to compensate for the increased testosterone caused by HCG).

Some doctors believe that stopping TRT for a few weeks in which only 1000- 2000 IU HCG weekly is used provides a good way to stimulate testicular function without having to use HCG continuously. I have not seen any data to support this approach. Others believe that cycling HCG on and off while maintaining TRT may prevent any desentization of testicular Leydig cells to HCG. Again, no data or reports have been published on this approach.

Some men have asked me why we cannot use HCG solely to make our own testicles produce testosterone without the use of TRT along with it. Using HCG as sole testosterone replacement option may not bring the same subjective benefit on sexual function as pure testosterone delivery systems doeven when similar serum androgen levels are produced from comparable baseline values. However, supplementing the more traditional transdermal, or injected options, testosterone with the correct doses of HCG stabilizes blood levels, prevents testicular atrophy, helps rebalance expression of other hormones, and brings reports of greatly increased sense of well-being and libido. But in excess, HCG can cause acne, water retention, moodiness, and gynecomastia (breast enlargement in men).

Many men have complained that their doctors do not know about HCG and how to use it (I do not blame doctors for being confused!). Some spend a lot of time trying to find doctors to feel comfortable prescribing it. One good way to find out what doctor in your area may be currently prescribing it is to call your local compounding pharmacies to ask them what doctors call them for their patients prescriptions.

After reading this information, you probably agree with me that using HCG requires a lot of discipline since you have to remember to inject it weekly in addition to your weekly or bi-weekly testosterone injection. But I know of many men who have that type of commitment since they do not want testicular size reduction. And many of us may just be fine with our reduced testicular size as long as testosterone is actually doing its job in improving our sex drive. And some lucky men do not get testicular atrophy at all on testosterone (those with large testicles to start with usually do not seem to complain about shrinkage as much as men starting with smaller testicular size before TRT). So it is a personal decision at the end!

Nelson Vergel's "Testosterone and Erectile Function Lecture Handout" (download): menshealthnov2012.pdf - Google Drive


Citrulline can treat erectile dysfunction: Citrulline Cures Erectile Dysfunction

Good thread by Freepressright: Citrulline Malate and Agmatine Sulfate: An inside look by Freepressright

Big bump for lots of good information.

How can I get to 1500 on that testosterone chart naturally? Lol. I'd be a beast!