Your Doctor Can't Prescribe TRT at 500 — Here's Why | Weekly Q&A

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The whole idea of a podcast is less appealing than diving out of a fucking 10-story window, so instead of that, here is a weekly question pile answered in writing with the room the camera does not give me.

So let's talk about the mechanism of growth hormone and how it's functioning in your body, how it's produced, and then how that applies to the actual goal here, which is losing body fat, okay? So we have two signals.

You have your GHRH, which is your growth hormone releasing hormone, goes from your hypothalamus to your pituitary, and signals the release of a growth hormone pulse. The second signal is ghrelin, which comes from your gut when your stomach is empty, and in my experience the hungrier a client is, the more pronounced that pulse feels in terms of the downstream effects, but I cannot point you to a study proving ghrelin is what sets the size of the pulse itself.

Growth hormone hangs around in the blood for roughly three or four hours before the picture changes.

Then when you eat, the insulin that's released from the pancreas goes into the blood, and it triggers the conversion of that growth hormone into IGF-1. I want to be careful here, because that is how I have described the sequence for years and it maps to what I see with clients, but there is no study I can hand you that shows insulin performing that conversion directly.

What is well documented is what IGF-1 does once it exists, which is shut the whole thing down. IGF-1 feeds back on the hypothalamus and the pituitary and suppresses further growth hormone release, and in human work by Bermann and colleagues that feedback runs through hypothalamic somatostatin rather than acting on the pituitary alone.

So you have a system that builds pressure when you are empty and releases that pressure when you eat.

While that growth hormone is still circulating, it activates an enzyme in your fat cells called hormone-sensitive lipase. And what this does is it basically breaks open those fat cells and then releases triglycerides, so those triglycerides can be used as a source of energy, meaning that when you're in a calorie deficit, one of the mechanisms that's influencing fat loss is the release of growth hormone, right? So we kind of have two things working for us when we're in a calorie deficit without the CJC and ivermline.

Riedel and colleagues looked at pulsatile growth hormone secretion during energy restriction in normal weight and obese men and found the metabolic regulation of those pulses differs between the two groups, which matters because the leaner you already are, the more of this machinery is running on its own before you add anything.

CJC 1295 is a GHRH analog, so you are injecting an override to the upstream signal rather than waiting for your hypothalamus to send it. Ipamorelin does something separate.

So that break on the system that gets created after IGF-1 is produced and goes back to the hypothalamus in the pituitary, we're basically turning that off temporarily with the ipermerelin.

Timing follows from that. If you inject before bed you are stacking your override on top of whatever nocturnal release your body already produces, and while the strongest natural pulse is commonly described as happening during REM sleep, no study has shown me that specific timing with the confidence people repeat it, so the practical version I use is to inject in the morning before eating and get two big ass pulses of GH rather than just the one.

Question number two, my total tea is around 500 nanograms per deciliter and my doctor says I'm fine, but should I be pushing that to 800 or 1000 with TRT or is mid range actually enough? So this is an interesting question because one of the things that we have to consider from like a medical standpoint and prescribing guidelines is typically you're not gonna get testosterone replacement prescribed from a doctor unless you're below 400 nanograms per deciliter.

And so what that means is like with the growth of the industry in telehealth companies like Apex Medical, the one that I own and others kind of stepping into the industry and taking advantage of what we'll say this gold rush of TRT prescriptions is doctors are gonna be under much more scrutiny, especially when it comes time for them to look at whether or not they wanna move testosterone off of the schedule to controlled substance list, which is something that they've discussed doing.

So that's the first thing to consider, right? Most of the time your doctor is just not gonna prescribe not because he doesn't think you need it, but more so because he literally can't from a prescribing guideline perspective.

Those prescriptions are a little bit more relaxed, but if you were looking at going gray market, we'll say, what I'll say is this, the testosterone level for men, I would say 500 is probably like at that 50th percentile.

The number on its own does not tell you how you feel. Look at free testosterone, look at SHBG, look at magnesium and vitamin D, because a guy with high SHBG and a 500 total can have less usable hormone than a guy at 420 with low binding protein. Do not marry yourself to the level.

Sub-Q versus intramuscular comes down to blood flow at the injection site, and once you see that, everything else follows. And because testosterone is inside of a carrier oil, which is typically kind of thick and viscous, it's gonna create a depot inside of that muscle or inside of that fat that you injected into, and it's gonna take time for it to kind of dissolve and release into your blood.

Muscle is highly vascular, so that depot clears faster. Fat is not, so it clears slower.

Testosterone cypionate has a half-life of six days, and a once weekly intramuscular shot on top of that half-life gives you a shape you can predict. So what that means is I'm going to inject it, and typically within the first 24 hours of that injection, I'm gonna absorb a lot of that testosterone, my test levels are gonna spike, I'm gonna convert a lot of that to estrogen, and then over the next six days, it's gonna kinda taper off and drop back down.

That is why I push people injecting intramuscularly toward more frequent, smaller doses.

Subcutaneous flattens the curve on its own because of the slower release, but the same slow release is what creates the downside, since a large weekly volume sitting in low blood flow tissue means a pocket of oil hanging around long enough to build scar tissue and discomfort for some people. A ten unit daily sub-Q dose does not have that problem. I personally do daily intramuscular in the ventral glute, side delt, or glute, first thing in the morning, alongside growth hormone, and the difference in where your levels end up is small enough that comfort should decide it.

On cancer history and peptides, I am not a doctor, and what I can do is distill the research. So this is important to understand, okay? Now, if I was going to explain the cancer concern in the way that I have in the past and previous videos, what I would say is that something like IGF-1, which is typically the big problem, or even BPC, in some cases, people have concerns with that, things that trigger growth or healing pathways, consider those peptides or at least the, we'll say end result of using those peptides like IGF-1 as the fertilizer, not the seed.

Basically, what I'm saying is, is if you have something that's pre-existing, especially with IGF-1, what this is doing is it's signaling the proliferation of cells. Your body does not discriminate between cells you want more of and cells you do not.

What are my other peptide options for fat loss? When it comes to the nausea related to GLP-1s, what I can tell you is a lot of times, for most people, it may be just a side effect that you get that's specific to you, but always make sure that you're properly hydrated and more importantly, you're also not malnourished.

Most of the time, nausea can be caused for a lot of people because they don't have the micronutrients that they need for their body to function when we're introducing these things and or they just don't have enough food, right? So GLP-1s are probably creating a bigger problem for you which is what creates that nausea.

There is a lot more of this inside the free community, and it is genuinely free, so if you want somewhere to ask the follow-up question the men's group is here: https://www.skool.com/jh-iron-forge-brotherhood/about

Research: Bermann et al., J Clin Invest 1994; Riedel et al., Metabolism 1995.

References:

Kang ES, Betts D, Fain JN et al.. Chronic exposure of rat fat cells to insulin enhances lipolysis and activation of partially purified hormone-sensitive lipase. Diabetes. 1993. https://pubmed.ncbi.nlm.nih.gov/8397127/

Obál F Jr, Kapás L, Gardi J et al.. Insulin-like growth factor-1 (IGF-1)-induced inhibition of growth hormone secretion is associated with sleep suppression. Brain Res. 1999. https://pubmed.ncbi.nlm.nih.gov/10082812/

Bermann M, Jaffe CA, Tsai W et al.. Negative feedback regulation of pulsatile growth hormone secretion by insulin-like growth factor I. Involvement of hypothalamic somatostatin. J Clin Invest. 1994. https://pubmed.ncbi.nlm.nih.gov/7913710/

Wilson ME, Chikazawa K, Fisher J et al.. Reduced growth hormone secretion prolongs puberty but does not delay the developmental increase in luteinizing hormone in the absence of gonadal negative feedback. Biol Reprod. 2004. https://pubmed.ncbi.nlm.nih.gov/15115727/

Riedel M, Hoeft B, Blum WF et al.. Pulsatile growth hormone secretion in normal-weight and obese men: differential metabolic regulation during energy restriction. Metabolism. 1995. https://pubmed.ncbi.nlm.nih.gov/7752908/