Body building

A Physician’s Information to Testosterone, Physique Composition, and Intercourse

Dave can not get up

Dave is a lifter. He is healthier than the average Westerner and does most things right when it comes to exercise and nutrition. Sure, he drinks a bit and emphasizes a lot. But who does not?

But last year Dave felt tired. It also lacks motivation and drive and it slowly increases in the middle. He even starts to become soft around the chest. This is quite common among men in their mid-thirties to forties, but much less common in a lifter. But what really bothers Dave is his erections. Sometimes they just do not happen and if they do, they can not be sustained.

Dave is actually a friend of mine. When he talked to me about these issues, I asked him two questions:

Do you have any kind of anabolic steroid or do you just get off? A well-known symptom of anabolic steroids is that the body has difficulty recovering its own testosterone production if it deviates from it.

When was your testosterone level last reviewed?

Dave answered "No" to the first question and "Never" to the second question. So, what's going on here and what should Dave do?

A crash course in erections

The male erection is a tightly coordinated event between the nervous system and the blood flow in and out of the penis. The brain registers a "sexually relevant" clue. This can be any number of things, and the response depends on the man. It could be that he is snuggling up with his partner or sees his partner walking around the room naked. For others, it may require direct stimulation. The point is: The brain is the hub for erections.

Assuming that the brain is sufficiently sensitized to a sexual stimulus, nerve impulses are sent to the penis. This triggers a variety of biochemical events that release chemicals such as nitric oxide (NO). These then trigger cellular cyclic GMP, which opens the blood vessels and allows more blood to flow in. The penis, which is rich in capillaries, becomes blocked, causing pressure to build up. This hydrostatic pressure causes inflation.

All of this depends on a separate set of blood vessels that drain the penis. These vessels begin to contract under increasing pressure and other biochemical events. The coordinated action of the incoming blood vessels and the building pressure allow the blood to flow in and stay in, creating an erection.

Where does testosterone contribute to this whole process? We'll talk about it soon. First, you need to know about the three Bs.

The three B's

If you're thinking about testosterone, libido, and erections, it's helpful to have a framework: brain, biochemistry, and blood flow.

1 – brain
One can imagine that the sexual brain contains sexual stimulators and sexual oppressors. Emily Nakowski, PhD, calls these "accelerators and brakes". For sexual desire to occur and sexual arousal to occur, the accelerators must be turned on while the brakes are turned on.

This is how it works: You are sitting on the couch and working hard to make a suggestion for the work. You are stressed. Your girlfriend sits down next to you and rubs against you. They register a "sexually relevant stimulus". This presses on the accelerator, but then the brain checks the context. The stress you are under brakes. The extent to which the stimulus can enhance the accelerators and the extent to which the load acts on the brakes determine the quality of the erection and response.

Many people understand it all wrong. This is where the brain works and it's not just an automatic stimulus response device. It happens much more. (By the way, women have far more sensitive brakes than men, so foreplay and context are so much more important to their sexual desire, arousal, and function.)

This is the same reason why alcohol or a first date can lead to a weak or complete erectile dysfunction despite strong desire. Every man and probably many women have experienced this phenomenon. The brain is critical and relaxation with sufficient nerve stimulation is required for the penis. Women, it has nothing to do with you. And people, that's completely normal.

To better understand this brain effect, think of "pointing and shooting". The two branches of the nervous system are P (parasympathetic) and S (sympathetic). Parasympathisch is relaxing and sympathetic is stimulating. The balance of P and S is critical. To get a boner, you need sufficient P or parasympathetic outflow. Think of P for "point" to remember. To ejaculate a sufficient sympathetic discharge is required. Think S for "shoot".

A man who ejaculates too fast and / or has weak erections has a bad parasympathetic (relaxing) discharge. Overworked, overwhelmed, alcohol, stress, mood medications, or a condition that interferes with nerve signaling can cause this, with diabetes being the most common.

A man who is unable to ejaculate or ever need to ejaculate may suffer from the opposite: a bad sympathetic discharge. This too can be caused by stress, mood medications and diabetes. This may also be an indication of the use of Viagra or another PDE5 inhibitor. For younger men who are not overweight, this is almost always a result of stress effects or medication.

Another concern of the brain has to do with the command and control center of metabolism. The hypothalamus is an area of ​​the brain that receives signals from other hormones and then coordinates other hormone-producing organs in the body.

The hypothalamus registers all signals from the environment (location, noise, temperature, etc.) and signals from inside the body (exogenous hormones) and adjusts the metabolism as needed, similar to a thermostat.

With respect to the testes, the hypothalamus releases gonadotropin releasing hormone (GNRH), which binds to the pituitary gland and triggers the release of luteninizing hormone. LH then migrates to the testicles, supporting sperm production and increasing testosterone production.

If this hypothalamic-pituitary gonadal communication link is compromised, it can dramatically affect testicular function and testosterone. Testosterone inhibits feedback on the hypothalamus and can also be converted to estrogen via the enzyme aromatase. This estrogen plays a role in the feedback to the pituitary, which is why the drug tamoxifen is sometimes used in men.

The estrogen effect could play an important role here. We do not have any proof yet, but many naturopaths, like myself, believe that the large increase in low testosterone levels in young men is related to the levels of estrogen in our environment. Estrogen-like compounds are ubiquitous today: our water that leaches from plastics, is sprayed onto our food as pesticides, and the accumulation of fat and milk in the animals we eat.

So when we think of "brain," we also want to think about hypothalamus. The other interesting thing is that hypothalamus and pituitary gland are also responsible for thyroid and adrenal function. These are crucial for the metabolic function: we call them the HP-Axi. HPT = hypothalamic-pituitary-thyroid-axis (HPT), hypothalamic-pituitary-adrenal axis (HPA) and hypothalamic-pituitary-gonadal axis (HPG, ie testicles and ovaries).

Because of this, some therapies, such as HCG, can be effective for men in a variety of ways. This is also the reason why low libido and low levels of testosterone emanating from the brain usually lead to fatigue, sleep disturbances, mood swings, weight gain, cold intolerance, etc. Thyroid, adrenals and gonads.

2 – Biochemistry
Remember that the nerve signals are converted into biochemical signals, including the signaling molecules cGMP and nitric oxide. This is probably how testosterone is involved in regulating the erection. When the brain sends nerve signals to the penis, nitric oxide is released and cGMP is signaled. This then expands the blood vessels and sets the erection cascade in motion, increasing blood flow and decreasing blood flow.

cGMP is degraded by the enzyme phosphodiesterase 5 (PDE5). Since PDE5 impairs cGMP activity, blood flow to the penis is slowed down and the erection is absent or incomplete.

This is how Viagra, Cialis, Levitra and other erectile dysfunction drugs work. They each act as inhibitors of PDE5, prolonging the effect of cGMP activity, enabling harder, longer-lasting erections (yay science!).

Here also a low testosterone level can occur. Testosterone treatment increases nitric oxide activity and can stimulate healthy promotion of erectile tissue. Testosterone may also play a role in PDE5 inhibition because sufficient levels of testosterone are required for these drugs to work.

Testosterone also affects the brain. It is not fully understood how testosterone promotes libido and sexual function, but one of the hallmarks of every hormone is its ability to affect many enzymes and other hormone receptors that are involved in several areas. Testosterone probably works as a primer for male sexual brain and penile function. Without this primer, the entire cascade is interrupted.

3 – blood flow
Erectile dysfunction is really a blood circulation problem. If the nervous system works well and testosterone levels are adequate but blood flow is compromised, this is no bueno for erections.

For younger men who are not overweight, circulation is probably not the main problem. However, it will always be involved, which is why erection medications work. Erectile dysfunction in older men, overweight men and those with metabolic syndrome or diabetes is almost always about blood vessel problems. High blood sugar, high blood pressure and inflammatory mechanisms severely damage the cells that line the blood vessels. These are the same cells that work on nitric oxide and cGMP.

That's why lifestyle adjustments are so important to men. Most men use testosterone and erectile dysfunction, but studies show that erections in men over the age of 80 are fully restored when the lifestyle is corrected.

Erectile dysfunction is an early warning sign of cardiovascular disease. Solving the problem at this stage requires a complete overhaul of the diet and lifestyle, including weight loss, reduced sugar and carbohydrate intake, strength training, and stress reduction. In other words, stop living and behaving like an idiot when it comes to your erections. If you want to sit on the couch to crush cola and crush Doritos, then your penis will eventually rebel!

Unless you want the remainder of your life to be on enhancement medications (which will lose their effectiveness over time if you do not resolve the underlying problem), and you do not want to die of a heart attack or stroke Together: Eat Right and deal with stress. Taking testosterone as part of an unhealthy lifestyle is not for you.

Lifestyle, testosterone and erections

For most healthy men under fifty, the problem is probably brain or biochemical and NOT blood flow related. One of the first things you'll see with low testosterone is a lack of morning wood.

Most men will want to jump directly to testosterone replacement therapy, but not so fast. What you need to understand about hormones is that they work in context. You can not just throw testosterone into the mix and expect it to fix the problems. Hormones are like humans and behave differently depending on the environment in which they find themselves. Make sure all biochemistry is the right setup for testosterone to function properly.

The first step is to live a testosterone-supporting lifestyle. The things that trigger testosterone are:

Adequate intake of macronutrients. Take enough but not too much protein, fat and carbohydrates.
Reasonable calorie intake. Not too much and not too little.
Adequate intake of micronutrients. The three most important for testosterone can be zinc, magnesium and vitamin D. If any of these levels are low, testosterone levels will be affected. Adding these, if you already have sufficient quantities, will probably do nothing, but correcting any defects.
Strength training and intense exercise. Lifting weights reliably stimulates testosterone. Intense training – high volume and heavy loads – is best.
Enough, but not too much exercise.
Much walking as it sensitizes the body to insulin and lowers the stress hormone cortisol, which affects testosterone both indirectly and negatively.

Insulin, cortisol and testosterone

Because the hypothalamus is essentially a stress barometer, you do not want to exercise too hard, too often, or too long. You also do not want to go over extreme dietary habits by consuming too few calories and / or carbohydrates. Do enough, but not too much. Otherwise, you risk downstream negative effects of a disturbed hypothalamus, which is negatively affected by insulin resistance and excess cortisol.

Blood sugar management and insulin sensitivity are critical to testosterone. There is a hormone called SHBG (steroid hormone binding globulin) that binds VERY heavily to testosterone and effectively removes it from the usable hormone pool.

Insulin resistance and excess cortisol both increase SHBG. The end result is a reduction in usable testosterone, even if you make enough of it. Not to mention, excess cortisol and insulin have many other negative effects that interfere with metabolic function.


There are two nutritional plans that I consider standard advice for testosterone management: the 40-30-30 nutritional strategy for serious athletes and athletes, and 30-40-30 for everyone else.

These formulas determine the ratios of carbohydrate-protein-fat-macronutrients that I use to most men. If men are overweight, I suggest a calorie intake that can be multiplied by multiplying body weight by 10. For those who train hard, multiplying their body weight by 15 is a good starting point.

So, to repeat it again:

10 x body weight and 30-40-30 (carbohydrates, protein, fat) diet for overweight, less active men.
15 x body weight and 40-30-30 (carbohydrate, protein, fat) ratio for all men who exercise frequently and intensively.

All men dealing with this problem should run daily (the best insulin sensitizer and the best behavior for lowering cortisol levels) and lift weights at least three times a week (testosterone promoter). Remember, it is a mistake to regard such rules as gospel. Use these only as a starting point. Customize based on three factors:

Will your hunger, energy, desire and other hormonal feedback (such as libido and erection quality) improve?
Does your body composition reach the V-shape?
Do Your Blood Values ​​Improve – Free Testosterone, Total Testosterone and SHBG -?

If all of this is true, you are on the right track.

Tests and laboratories

Once you have taken care of diet and exercise, you want to get an overview of the labs:

Testosterone, total and free
Hemoglobin A1C (to prevent high blood sugar and diabetes)
Fasting insulin (to exclude insulin resistance)
DHEA sulfate
Vitamin D
High sensitivity estrogen (to rule out high aromatase, as some men flavor testosterone to produce estrogen)


These should be done in addition to the general screening of lipids, CBC and chem panel that a doctor will perform. Zinc and magnesium are also worth mentioning here, but with so many people in short supply, it is safe and advisable to take ZMA®.

It's worth noting that things like goat weed, Longjax, Forslean, and other herbs and compounds are poorly researched to aid their use, and I've seen them clinically essentially useless.

You can do these exercises directly in DirectLabs and CHEKD. Just google it.

Some things you might want to consider:

DHEAwhen DHEA sulfate is low. In one study, 50 mg of DHEA restored erectile function in 80% of men who were low.

Vitamin D, Low vitamin D levels have been shown to affect testosterone, and restoring vitamin D levels to levels between 50 and 100 ng / ml may raise testosterone levels to help with erections.

Citrulline malate, This is an amino acid that is a nitric oxide precursor. It can act as a weak Viagra and make sure that nitric oxide is in abundance. 1.5 g per day improved erections in men within one month.

Rhodiola, This one is controversial, but I personally have seen that it is effective. I've seen people who reported that Rhodiola increases testosterone, libido and erection quality. Given the beneficial effect of Rhodiola on the hypothalamus, this makes sense. Take 200-400 mg daily. It can also help premature ejaculation. This makes sense because it is an adaptogen that balances the parasympathetic and sympathetic nervous systems.
Hormonal approaches to increase testosterone

Let's say you have your testosterone tested. What is considered low?

Most standard reference areas are:

total testosterone normal = 300-1200 ng / dl. Many practitioners will treat if the values ​​are below 500 and you have symptoms.
Free testosterone = 5-21 ng / dl

Free testosterone below 10 and a total testosterone below 500 with testosterone-related symptoms, especially a morning erection loss, should be treated with the lifestyle changes and supplements listed above.

If there is no change after 3 months of concerted effort, consider taking testosterone replacement therapy or TRT. Note that there is a difference between replacing testosterone and improving with testosterone. When you run TRT, you want to restore the normal values ​​and NOT try to exceed them. Replacing to a normal level is not only beneficial for the symptoms but is probably one of the healthiest measures you can take.

An increase of the testosterone level by 1200 ng / dl is not required and can lead to problems. Remember, when restoring testosterone, you want to get your levels back to optimal levels and help the hypothalamic-pituitary-gonadal axis become healthier. Increasing the testosterone level to levels beyond the physiological potential counteracts this goal.

If the scores are low from the start, you have two options: HCG monotherapy (and / or Clomid) or testosterone replacement.

HCG monotherapy

Human chorionic gonadotropin (HCG) is an LH analogue. That is, it is biochemically similar enough to the LH hormone to interact with the same receptors. This means that it can be used to turn on the production of testicular equipment, sperm and testosterone.

There are reports that HCG increases ejaculation volume (which is true) and increases penis size. This is also true, but possibly only for people with hypogonadism or "micropenis". The Internet chat boards are certainly not without the reports of a slight expansion with HCG in normal men. In the two studies I found on micropenis, the gains were three-quarters of an inch in length and girth.

HCG is a great option because unlike testosterone it actually helps the hypothalamic-gonadal axis instead of suppressing it. It also appears to have less influence on estrogen, prostate mass and cardiovascular parameters than the more traditional TRT, while it is equal to or better than TRT in increasing testosterone.

This assessment is factual and comes from a well-conducted study on men between the ages of 45 and 53 years of low T-value. The study compared HCG with transdermal testosterone and two different injectable substances.

Many doctors give HCG along with their testosterone therapies, so that the hypothalamus works and the testicles do not shrink. Why are the testicles shrinking? Testosterone from the outside shuts off LH secretion of the hypothalamus, and therefore the testes no longer produce sperm and no testosterone. Because of this, the ejaculate volume and testes in men who take testosterone may shrink. This is usually not a big problem if the drug is not abused, but HCG helps to prevent it.

Apart from that, steroids do not reduce the size of the glans (ie the stem) but only the testes, and only if they are used too long in very high quantities.

Using HCG alone is a reliable promoter of testosterone and may be the safer and more natural option for starting HPG problems. This may also be the best approach for those who have long been receiving testosterone.

Based on the studies, there are some approaches here. When using TRT, 250 IU HCG is recommended as intramuscular injection (IM) daily. If you use HCG alone, the dose is 2000 IU per week, according to the above study, which compared it directly with TRT.

Most physicians do not give so high a dose of HCG for fear of excessive estrogen production and desensitization of LH receptors. Although this study has not shown this, this could be a consideration.

Limiting a once-daily dose to 500 IU or less makes sense. This means that you inject 500 IU 1-4 times a week (500 IU – 2000 IU) for HCG monotherapy.


Clomid is another option. Clomid blocks estrogen hormone feedback in the hypothalamus. This increases natural LH production, which then stimulates testosterone production.

The Clomid dose of 25 mg per day or 50 mg every other day has proven to be effective and very safe in restoring the HPG axis. In one study at least, Clomid outperformed TRT without long-term adverse drug reactions (up to 40 months) compared to TRT.

In patients with a secondary testosterone deficiency, starting from the hypothalamic-pituitary axis, which is usually the case in younger men, HCG and Clomid may be superior to TRT. In addition, the cost of Clomid compared to TRT significantly cheaper.

Testosterone Replacement Therapy (TRT)

First of all, steroids are not the same as testosterone. Many assume that they take testosterone when they take anabolic steroids. This is not the case and an important difference.

Anabolic steroids can be testosterone or androgen derivatives. Medications like Anavar, Trenbolone, Winstrol, Primobolan etc. have similar anabolic and androgenic effects to testosterone, but are not testosterone. This means that they are NOT suitable for TRT. Such drugs are also often the culprit for erectile dysfunction and low testosterone levels, especially after they have been stopped.

These "non-testosterone steroids" adjust the body's own production of testosterone like any other steroid, but can not replace the full effect of testosterone in the body. These are best left to bodybuilding circles.

Another consideration concerns the creams, gels and orals of the pharmaceutical world. You can not patent testosterone. In order to earn money with therapy, pharmaceutical companies are working on different delivery systems. These approaches are far inferior to injectable testosterone, and I would only use them if you totally reject injections.

The main medications to consider:

Testosterone Cypionate
Testosterone Enanthate
Testosterone propionate

There are two more: testosterone suspension and sustanon. The testosterone suspension consists of 100% testosterone, while the three testosterones mentioned above are linked to esters, which extend the half-life of the drug and result in slower absorption.

Suspension is rarely used due to the need for daily dosage and the rapid spikes and falls that occur during use. Also Sustanon is rarely used in medical circles, especially because it is not so widespread. It's a mix of different testosterones and a great option if you can find them.

The various compounds bound to the testosterone determine its half-life and thus the dosage frequency. Cypionate is usually dosed 1-2 times a week (50-100 mg), as is Enanthate (50-100 mg once or twice a week). The propionate dosage is 25-100 mg per day every other day.

Everyone has their favorites. For my taste I like Propionate> Enanthogenate> Cypionate. For some reason, Propionate causes me to hold less water and only gives me a "cleaner look" and smoother effects. But that is very individual.

Estrogen, DHT and hair loss

Of course, the biochemical pathways associated with testosterone therapy should be considered. Testosterone can be converted to estrogen via the enzyme aromatase. The use of aromatase inhibitors is advantageous in this regard, which is why many people use Arimidex (anastrozole) along with their TRT.

Testosterone can also be converted to DHT, which can lead to some side effects such as hair loss and acne. However, DHT can be a major libido enhancer. This is done via the enzyme 5-alpha reductase, which is why finasteride is often used in TRT.

The herbal world is filled with great aromatase and 5-alpha reductase inhibitors, which often have both effects in one herb. I found the use of products containing nettles, saw palmetto, pygeumchrysin and DIM a reliable way to control these two biochemical pathways without drugs.

Exam and health

With TRT we want to make sure that we do not increase the risk of prostate cancer, cardiovascular disease or other complications. You can consider PSA monitoring. This is a test that is becoming increasingly controversial, but still the best we have to judge the changes in the prostate over time.

You should also ensure that the hemoglobin and hematocrit levels do not increase during therapy. This can increase the risk of blood clots.

Finally, look for the levels of estrogen and liver enzymes ALT and AST to make sure you are not over-flavoring and the liver is performing the therapy.

Always take a close look at the free (direct) and total testosterone levels. If you get things right, you should see favorable changes in your blood labs on TRT. As a rule, cholesterol, triglycerides, blood sugar and anti-inflammatories decrease.

Obviously, testosterone is a prerequisite for male health, and a proper TRT should improve energy, mood, libido, erections, and body composition while making you healthier.

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Late onset hypogonadism: the benefits of treatment with human chorionic gonadotropin instead of testosterone. Aging man. 2016; 19 (1): 34-9
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