What if I told you that many, if not most, people that are starting TRT start with the wrong dose? This could be the difference between providing you benefit from your testosterone replacement therapy or doing actually nothing. Today we're going to cover what the best starting dose is, and what that range is, and why I come up with this particular range.
Today we're going to discuss the best starting dose for testosterone replacement therapy, or TRT. We'll be examining everything from the symptoms that you have and goals that you might have to lab values, dosing schedules, etc.
Before we get into those details though, I want to give you some rough ideas on what the best TRT starting dose is. I should also note that this is based on my own clinical experience, based on my own opinion and what I do with my patients specifically. I would rather start with a low dose and increase as needed. When I'm starting someone on TRT for the first time, I typically start them at around 80 milligrams per week to 120 milligrams per week, and this may change or vary based on your labs, your symptoms, your goals, and a few other things which we're going to discuss next.
So first of all, the subjective. The best TRT starting dose does require a little bit of understanding of your personal goals. Everyone starting TRT should have some kind of symptom that you're trying to improve, or some sort of problem that you're trying to help with. Now of course there's specific symptoms and problems that are associated with hypogonadism, but there can be off label uses for it as well.
Some of the common things would be increased libido, motivation, improving energy, decreased muscle mass which you're trying to improve, or improvements in your mood or erectile function. Things like this are often associated with hypogonadism, and when you replace the testosterone you're going to see improvement in those things typically.
So these are pretty standard for most people looking to start TRT or testosterone replacement therapy. But what's not standard is your timeline. Like how long have you been dealing with these symptoms, what's your level of frustration, is there some sort of reason to speed things up or slow things down?
On the side of slowing things down, some people do have cardiovascular disease, known cardiovascular disease, meaning they've had heart attack, stroke, stent, something like that, maybe even blood clots previously. They may have blood pressure issues as well. All these things are informing us we may want to take this a little bit slower with this person, see how they respond initially.
Some other things, chronic health issues like high inflammation, autoimmune diseases. Sometimes these people are already activated from years of dealing with chronic inflammation, and they may more easily tip over into getting more anxious and activated from the testosterone replacement therapy. So it's best to go slower in situations where there's a little bit less known about what the outcome may be. So there's a lot of situations where you just want to be a little bit more cautious with your dosing, dose schedule, and how quickly you escalate the dose.
The other thing is your lab metrics. Before any dosing begins, a comprehensive review of your lab values is essential, because you want, first of all, a baseline. And this is going to include things like total and free testosterone levels, estradiol levels, and you can measure different types of estrogen as well, and other critical things like luteinizing hormone, prolactin, FSH, your red and white blood cells. All these things are essential to understand, including your PSA, and we want to get a baseline so that we can create a more precise dosing strategy.
On the scheduling of your testosterone replacement therapy, it's going to vary widely too. Some patients are going to do better with once a week, some patients are going to do better with multiple times a week. It depends what your comfort level is in terms of remembering to actually take your dose, sticking yourself with needles, and of course there's also topical gels and topical creams that you can also apply. These are going to be once daily usage, versus with injections maybe once a week or twice a week. Some clinics do every other week, but usually by the end of the first week most of that injection is going to be gone.
So you're going to notice more peaks and valleys when you're dosing less frequently, and with those higher peaks and valleys it's going to create more problems, or make it a little more difficult for your body to maintain normal levels of the byproducts of your testosterone like estrogen, DHT and various other metabolites. So when you're dosing more frequently you get a more even level of testosterone. There's still going to be some humps, but they're not going to be as sharp and there'll be less of them, and so because of that you're often going to notice less side effects as well.
Reasons to start low mainly are going to, again, mitigate the potential side effects that may come about, such as increased hematocrit, exacerbation of your sleep apnea, mood swings like anxiety, heart palpitations, even sleep issues. This lower dose will allow you to introduce the testosterone into your body slowly, let your body kind of get used to it, and then slowly you can increase it as your body is more tolerant of that, and also when your lab metrics, lab monitoring, say that perhaps you do need more.
A good rule of thumb with most medications, most things that you're introducing to the body, even supplements, is to start slow, go low, but make sure you go all the way, meaning make sure you get the full benefit out of that substance that you're using while causing the least amount of side effects.
On the other end, it would be starting a little bit higher when your quality of life is significantly impacted by the low testosterone. It doesn't necessarily mean you're going to blast somebody with the testosterone, but maybe starting on a little bit higher side. Some reasons would be where the symptoms are more severe and you're sure that this is like the main thing going on. You can certainly be a little more aggressive with the testosterone, but then you're also going to want to be more aggressive with the lab monitoring, meaning you're going to have a quicker turnaround time when you get those follow-up labs.
And then the last thing I wanted to cover on this topic of the best TRT starting dose is testing, testing, testing, testing. Regular testing of your lab metrics is a non-negotiable thing when you're on testosterone replacement therapy. Initial dosing of that is almost never going to be quite perfect, and it's going to require adjustments and fine-tuning initially, and then sometimes six months, nine months, twelve months later, another set of adjustments. If you're not testing, you're never going to know what's going on.
And you always want to make sure that you're actually on the therapy when you're actually testing, otherwise you're just testing some random time when you're not actually on it, and it's not really going to help you to know what those lab values are, unless you're looking to actually stop taking it. So you want to correspond your testing with while you're on the testosterone.
Regular testing is going to make sure that you're on the right track: that one, it's actually helping; two, it's in the right ranges; and three, that you're not having any side effects or problems that you may not actually feel but are present through high hematocrit, changes in your PSA, etc.
Your follow-up lab metrics are going to be things like total and free testosterone, estradiol, PSA and your hematocrit. Those are kind of the non-negotiables. Sometimes we'll also do things like DHT if you're worried about some of the side effects from DHT like hair loss, and there may sometimes be things going on with your cardiovascular system as well that may require more frequent or careful monitoring.
Another thing we should know with regard to the starting dose is that some people actually start out with the wrong amount of testosterone and overshoot where their sweet spot is. We've discussed in previous videos how there's kind of a sweet spot for a lot of things in our body, where too much is going to cause a problem, not enough is going to cause a problem too, and so you want to kind of be in that middle of the bell curve. Everyone's bell curve is going to be slightly different, but if you start with a really high dose you're sometimes going to miss that sweet spot, and you actually won't feel any better, or you actually will feel worse.
So that's another reason why it's better to start low and gradually increase than start high and potentially think about going higher. Most people don't think, well, this looks too high, let me reduce the dose. Instead they say, I'm not feeling anything, maybe I need more, maybe the estrogen's off, things like this. And certainly you can have those situations as well, but there's also the case where too much testosterone actually makes you feel worse. So you don't want to miss that sweet spot.
The people that tend to have the lower end sweet spots are going to be those people that maybe have a little bit more anxiety, maybe higher stress type individuals. I've had this happen with several patients coming from different clinics, where they seem to be on a fairly high dose of testosterone and we look at their labs and it looks a bit high, they say they're not getting much benefit from it, we lower it, and suddenly they feel much better.
Sometimes what will happen is you start to feel better when you initially go on it, week one, maybe week two, week three, week four, week five, and then as your body continues to get bombarded by those high doses you start to take a turn in the other direction. Instead of lowering the dose, a lot of clinics will then raise the dose.
And again, this gets back to testing, testing, testing, because if you're not testing when your testosterone, estrogen and other metabolites are at their peak, instead you're injecting on Monday and then you come in for your blood test on the following Monday, you're not capturing those high levels. You're not capturing what your body is going through as that testosterone is in your system throughout the week.
So you want to test in the middle, day three to five. That is the optimal time to test to know what's actually happening. Now of course you could do it on day seven, you could do it on day one as well, but if you're just going to do it one time, right in the middle is going to give your best indicator. But generally speaking, the more testing the better.
Wondering if your current dose is dialed in? Run your numbers through my free TRT Lab Analyzer for a personalized read on your labs and symptoms. Or schedule an appointment and we can fine-tune it together.
Topics: TRT, Testosterone Replacement Therapy, TRT Dosing, Low Testosterone, Hormone Therapy, Estradiol, Lab Testing