Testosterone Replacement (TRT) Side Effect Management

Problem

Solution and Comments

Acne/oily skin

Caused by Dihydrotestosterone (DHT) effect on

increased oil production

· Accutane– a powerful prescription item - 40 mg/day for one week sometimes stops acne if started at the first sign or as directed by your doctor. Accutane is potentially highly liver toxic and can lower testosterone. Do not use unless as last resort.
· Sporanox – Effective for some acne-like eruptions that are caused by fungi. Some doctors also prescribe antibiotics, like tetracycline, for acne with good results.
. Minocycline
. Shower with Nizoral shampoo· Anti-bacterial soaps - Use a scrubbing brush and wash twice a day, especially after sweating during a workout.
· UV light or sunlight with moderation.
. Zinc/copper supplements or zinc soaps may help some men with acne.
. Other options: How to treat and prevent acne

Hair loss

Caused by DHT effect on hair follicles

· Nizoral shampoo– Available by prescription and over-the-counter as a lower dose product.
· Rogaine – Available over the counter
· Propecia (finasteride) - Available by prescription. A few males experience decreased erections with finasteride. Do not use.

Increased sex drive

· A problem? Sex drive is part of quality-of-life. This is not necessarily a bad side effect. Enjoy it.

Unresolved erectile function

· ED Drugs– Available by prescription; enables robust erections. If you have sinus congestion or headaches/backaches take non-drowsy allergy medication and ibuprofen. ED drugs can be combined with alpha-blockers and/or nitric oxide precursor amino acids (arginine or citrulline)
· Yohimbine (Yocon) - Available by prescription; increases sex organ sensitivity. Can increase heart rate and blood pressure
· Muse - Available by prescription; pellet inserted into the urethra to produce an erection. Unpopular
· Trimix – Available by prescription from compounding pharmacies. The best and cheapest formula for injection into the penis for lasting erections.
· Caverject - Available by prescription. An injection into the penis that produces an erection that can last 1 to 2 hours. Be careful with injecting too much since it can produce dangerously ling erections that need to be treated in emergency rooms! Follow instructions from your urologist.
· Papaverine – An older injectable medication, less expensive than Caverject.
· Wellbutrin – Prescription at 300 to 450 mg/day; increases dopamine.
· Human chorionic gonadotropin (HCG) – First dose is 2,000 IU, then 250-500 IU twice or three times a week. No protocol has been proven in controlled studies yet.

Insomnia

Usually, this is caused by dosages that are too high. Find the least amount that gives you a good result.

· Sleeping medications – e.g. Ambien, Sonata, Lunesta, Restoril
· Melatonin- 1 to 3 mg before bedtime. If you wake up groggy after 6 hours your dose should be lower.
· Avoid working out too close to bedtime.
· Limit caffeine, especially after 3 pm.
· You may want to try a sleep formula with tryptophan, melatonin, and magnesium. Nutrients do not work as well as drugs, but they can help some people.
Article: How to protect your circadian rhythm

Sleep Apnea

· Have your doctor prescribe a sleep study if you snore and wake up tired even after 7 hours of sleep. Some people may have to wear a C-PAP machine to breathe at night. Visit Home - SleepApnea.org for more information. There are also oral devices for those people who fail CPAP. Fatigue- When Testosterone Is Not Enough

Testicular atrophy

· Human Chorionic Gonadotropin (hCG)– One 2,000 unit injection per week for 2 weeks, followed by maintenance of 350-500 IU twice a week. For men who want to remain fertile while on TRT, 500 IU every other day has been studied. Watch this video on hCG and men

Enhanced assertiveness or reactivity.

· Make sure you are getting enough sleep.
. Count until 10 and be aware of your interaction with others.
· Decrease caffeine.
· Meditation, mindfulness, yoga, breathe from your belly for a few minutes when overreacting.
· The testosterone dosage may be too high.
· Ask yourself: Do I need to always be right?
. Vent extra energy at the gym, sex, and sharing with your buddies at www.excelmale.com

High blood pressure:

Can be caused by sodium retention, high hematocrit, being overweight, and other factors

· Blood pressure medications - Elevated blood pressure may be transient or not. Try ACE or ARBs since they seem to have fewer sexual dysfunction related effects. 
· Magnesium (600 mg/day); vitamin B6 (100 to 200 mg/day); may help reduce water retention.
· Water - Drink extra water every day to help flush the kidneys.
. Make sure you are doing cardio exercise at least 3 times a week for 30 min. Sweat and lower your salt intake since TRT increases sodium retention in some men.

Gynecomastia- RARE in TRT (male breast development)

Caused by overproduction of estrogen in the presence of low testosterone and high IGF-1

· Arimidex Inhibits estrogen production. Available by prescription. 0.5 mg/week max. Ensure that your estradiol is never under 20 pg/ml (by sensitive test) since it is needed for bone, skin, brain, lipids, libido, good lipids and hair health. Only 0.3-0.4% of testosterone is aromatized to estradiol. Current lab ranges were derived from men not on TRT. Most men on TRT do not need anastrozole. Be careful not to crash your estradiol.
· Nolvadex (tamoxifen)– Competes with estrogen for receptors. Available by prescription, 10 to 20 mg/day. Use of Nolvadex during a steroid cycle may reduce the net anabolic effect, as it decreases the production of GH and IGF-1. 
. Severe cases may require removal of the breast tissue by surgery.
· DHT cream- Some people have obtained great results by rubbing a 10% DHT cream on their nipples. Not available in the US but some people order it online from Germany
. Read about medications/foods to avoid if you have gynecomastia.
. Those who do know to respond to the above, check other reasons

Watch this video about estradiol in men

Check your estradiol with the right sensitive test.