Common TRT Prescriptions

[01dragonslayer]

Testosterone​

There are a few different forms of testosterone for TRT. These forms can be broken down into four categories: 1) injectable oil-based testosterone, 2) testosterone gels/creams, 3) testosterone lozenges, and 4) implantable testosterone pellets. The two most common forms are injectable oil-based testosterone and testosterone gels. Testosterone may also come in transdermal patches or troches, but both forms are not used often.

Right now, there are no FDA-approved oral pill forms of testosterone in the US. In general, oral pill forms may cause liver damage and should be avoided for TRT. The only safe oral form for long-term use is testosterone undecanoate, which again is not available in the US. For men outside the US, it is marketed under several brand names including Andriol, Undestor, and Nebido among others.

Most docs will first recommend Testosterone in the following forms and generally (but not always) in this order:

Gels/Creams​

Testosterone gels deliver testosterone through daily skin applications. The gels consist of a hydro-alcoholic base medium with 1 or 1.62% active testosterone. These formulations deliver 25, 50, or 100 mg of testosterone per day. This form of testosterone is relatively new with the first testosterone gel introduced in 2000. As such, most gels are sold under a brand name only and are typically more expensive than generic injectable testosterone cypionate and enanthate. Androgel, Axiron, Fortesta, Testim, and Vogelxo. Recently, generic versions, such as Bio-T-Gel have become available.

Recently, testosterone gel usage has surpassed injectable testosterone usage for TRT. Approximately 60% of TRT users use testosterone gels, while 35% use injectable testosterone (according to Endo Pharmaceuticals FDA filing for Aveed). Gels will likely be the first recommendation by any physician. It’s important to know that the surge in their usage may be largely attributed to the heavy advertising by the pharmaceutical companies promoting these gels not the actually effectiveness of these gels.

Overall, gels mimic the natural release of the body, but many men complain that testosterone gels do not fully raise T levels back up to normal desired levels. Experience has shown that some patients may never absorb enough testosterone from gels to improve symptoms of low T.

Pros: Easy to use; dosage can be easily modified; many available gels; mimic physiological release Cons: Expensive; inconsistent dosage; can rub off on others; doesn't work well if you sweat a lot; must be applied daily; may not raise levels to desired levels.

Products: Androgel, Axiron, Bio-T-Gel, Fortesta, Testim, and Vogelxo

Dosage: 2.5-10 grams of gel spread over the application site daily

Injections​

Testosterone injections involve the injection of oil-based testosterone into the muscle (usually the thighs, glutes, or deltoids). The testosterone is then absorbed via the muscle into the blood stream over time. Intramuscular testosterone preparations have been the mainstay of testosterone replacement therapy since the 1950s, and they are one of the most popular forms of testosterone for TRT.

The two most common forms of injectable testosterone are testosterone enanthate (TE) and testosterone cypionate (TC). TE and TC are modified forms of testosterone. Specifically, they have an ester molecule attached to the T molecule. This attachment slows the absorption of testosterone and increases the half-life. Due to their long half-lives, both TE and TC provide a sustained release of testosterone into the bloodstream. The most commonly recommended dosing regimen for TRT is 100 mg to 200 mg every one to two weeks. If your doctor tells you to inject every other week, half the dose and inject every week. Lower dosages injected more frequently lower the fluctuations in testosterone levels between injections. For more info on testosterone esters, see r/steroids A Primer on Esters.

Overall, injections of testosterone enanthate and testosterone cypionate are inexpensive and safe. Since both forms have been around for so long, generic versions of these medications are available. Most men that use injectable testosterone for TRT swear by it because they get T levels back to normal and deliver results.

While injectable testosterone is safe, know about two potential drawbacks. First, T injections can cause fluctuations in T levels following administration. Following an injection of testosterone enanthate or testosterone cypionate, T levels exceed normal physiological levels for the first 2 to 3 days. They then steadily decline to levels below physiological levels just prior to the next injection. To minimize this issue, just shorten the interval between T injections and lower the dose proportionally to minimize this cyclical nature of highs and lows. (See the dosage instructions) Second, injectable testosterone increases red blood cell production more than other forms of testosterone. To address this potential side effect, just get regular check-ups with your doctor after starting TRT to monitor red blood cell levels. Then, your doctor can address any issues preemptively.

Of note, the FDA recently approved a new injectable testosterone ester (testosterone undecanoate) called Aveed by Endo Pharmaceuticals. Like testosterone enanthate and cypionate, testosterone undecanoate has an ester attached to it. Unlike testosterone enanthate and cypionate, which need to be injected every week or every other week, testosterone undecanoate needs to be injected once every 10 weeks. Studies show that testosterone injections of 750 mg Aveed maintain normal levels between 300 and 1000 ng/dL for up to 10 weeks.

Pros: Inexpensive; consistent dosage; easy to adjust dosage. Cons: Need to inject; some doctors may not want you to inject on your own; T levels may fluctuate if you inject infrequently; may experience injection site pain.

Products: Testosterone cypionate (generic); testosterone enanthate (generic); testosterone undecanoate aka Aveed (branded product by Auxilium Pharmaceuticals, Inc.)

Dosage: 100 – 200 mg every one to two weeks. If your doctor tells you to inject every other week, half the dose and inject every week. Lower dosages injected more frequently lower the fluctuations in testosterone levels between injections. For injecting info, see r/steroids Safe Injecting Technique

• Testosterone Cypionate - FDA AccessData
• Testosterone Enanthate - FDA AccessData
• Aveed Full Prescribing Information - Endo Pharmaceuticals Inc.

Pellets​

Testosterone pellets are implanted underneath the skin in the subdermal fat layer by a physician. The pellets slowly release a steady infusion of hormone into the body testosterone as they dissolve over the course of three to six months.

Pros: Easy to use; need to administer very infrequently; no risk of transfer. Cons: Needs to be surgically inserted and removed; may extrude/push out of your skin on their own; difficult to adjust dosage once implanted.

Products: Testopel (branded product by Auxilium Pharmaceuticals, Inc.)

Dosage: 6-8 pellets implanted every 3-6 months

• Testopel Full Prescribing Information - Auxilium Pharmaceuticals Inc.

Nasal Gel​

Testosterone nasal gel is administered into each nostril three times a day every day.

Pros: Convenience; ease of use

Cons: Must be taken three times per day, every day, preferably at the same time each day. Additionally, it failed to restore testosterone levels to normal in 10% of men in the phase 3 clinical trial.

Products: Natesto ((branded product by Endo Pharmaceuticals, Inc.)

Dosage: One spray in each nostril three times per day (5.5 mg per spray; 33 mg per day)

• Natesto by Endo Pharmaceuticals
• Natesto Full Prescribing Information

Lozenges​

Transbuccal testosterone lozenges are placed under the tongue or against the surface of your gums. The lozenges release testosterone, which is then absorbed through the mucous membranes of the mouth. The lozenge lasts for 12 hours after which time it must be replaced with another lozenge for a total of two lozenges per day.

Pros: Less liver toxicity than oral forms because it is absorbed through the gums not swallowed. Cons: Must be kept in the mouth all day; may aggravate gums.

Products: Striant (branded product by Auxilium Pharmaceuticals, Inc.)

Dosage: 2 lozenges per day

• Striant Full Prescribing Information - Auxilium Pharmaceuticals Inc.
• FDA Patient Insert on Striant

If you can get injections, do it. Everybody on /r/steroids will recommend the same. When the doc recommends the gel/cream you can mention that you're worried about it getting on your girlfriend or kids and they'll usually understand. You may also want to mention that you tend to sweat a lot or that you hear it's less effective and more expensive than injections. For /injection locations and information, see the Wiki.

HCG/HMG​

HCG is injected either intra-muscularly or subcutaneously. It can be used alone or in conjunction with Testosterone. Dosage varies, but it typically comes in a 5000iu vial of lyophilized power which needs to be mixed with bacteriostatic water. (NOTE: hCG typically comes with a sodium chloride solution, intended for a single injection; not bacteriostatic water) Mixing 2ml bacteriostatic water in a 5000iu vial of hCG will provide twenty 250iu doses. Each tenth of a cc/ml will be 250iu.

HMG is very similar to HCG, the key difference being that HCG acts as a synthetic LH (luteinizing hormone). hMG mimics both of the two key hormones produced by the testes to stimulate spermatogenesis: LH and FSH, making it more effective in maintaining fertility. However, hMG is often significantly more expensive than HCG.

As of March 23, 2021 the FDA has deemed hCG a biologic product and compounding pharmacies will no longer be allowed to provide this service

Testosterone vs. HCG​

Testosterone is the most common, but has the potential to cause infertility and testicular atrophy during TRT use. HCG can be used in it's place or in conjunction at low doses to maintain fertility and testicular size. Whereas testosterone directly puts exogenous testosterone into your blood stream, HCG tells your body to create more endogenous testosterone.

Clomid​

Clomiphene is sometimes used in place of testosterone/HCG. It is sometimes used in an attempt to restart HPTA, as well. Like HCG, it helps TRT-users maintain fertility. However, it can sometimes have unwanted side effects. It comes in an oral form and dosage can be 25-50mg ED, but may be tapered down based off BW.

Aromatase Inhibitors (AIs)​

Testosterone can be converted in estrogen via the aromatase enzyme. Consequently, taking testosterone via TRT may increase estradiol levels. Most men on TRT dosages will not experience high estradiol levels. However, some genetically susceptible men may experience high levels. These high estradiol levels may lead to symptoms of high estrogen such as fluid retention and gynecomastia. As such, it is important to routinely test estradiol levels during TRT.

If estradiol levels are found to be too high, the most common treatment is Anastrozole (Arimidex) or Aromasin. Arimidex inhibits the aromatase enzyme, and thus it inhibits the conversion of testosterone to estrogen. Common medication and doses are 0.25-0.5mg Arimidex E3-7D or 12.5-25mg Aromasin E3-7D (depending on estrogen levels and response).

Normal estrogen range is about 7-42 pg/mL. Most users on this sub report that they feel best when they're at 20-30. However, many on this sub also feel that an AI isn't needed until/unless you notice symptoms of high estrogen.