In traditional medicine, once we make the diagnosis of hypogonadism, we supplement testosterone on a continuous basis. By example, we offer testosterone daily (by gel or patch), weekly, bi-weekly, or monthly (the last 3 by injection). But we never truly cycle the patient on & off testosterone (akin to bodybuilders) aside from the peak & trough effect of the regimen.
In actuality, the human body normally produces testosterone in a diurnal fashion, reaching a peak the morning and falling to a trough by the afternoon. But when assessed over the course of a week and even longer over a month, one's testosterone level remains relatively stable. That's why I've always advocated for either daily application of gel (which minimizes peak trough variation) or weekly injections (given the 7-10 day half-life of testosterone cypionate and enanthate).
In fact, the older "style" of dosing testosterone cypionate and enanthate on a monthly basis really has no basis in physiology as I've taught many physicians. Imagine if you will one's testosterone level 7 days after an injection of cypionate or enanthate. It will be approximately 50% of the initial peak value (this is how we define half-life). A week later or 14 days after injection, one's testosterone level will be 25% of the initial peak value (50% of the previous week). At the end of the 3rd week, we're down to 12.5% and by the end of the month, we're begging for another injection because our levels are now barely 6.25% of the peak. Of course, if this is too low, we can always start out at a higher level, achieved with a larger dose. But don't forget that it's the peak that leads to side effects.
Which is why I've always suggested smaller, more frequent doses to minimize the peak:trough ratio (daily application of cream/gel being one of the most extreme examples). In essence, I'm trying to reach a steady state of feeling good. However, in a small study of 24 community dwelling 70yo men with normal testosterone levels (below 500ng/dL) randomized to weekly injections of placebo vs weekly injections of testosterone 100mg vs weekly injections of testosterone 100mg x 4 weeks alternating with 4 weeks of placebo, the authors concluded that increasing testosterone from the lower half to the upper half of the normal range in a monthly on/off cycle was just as beneficial in increasing muscle mass and decreasing fat.
I'd like to direct your attention to a couple of fascinating points in this study. First, none of these men were diagnosed as hypogonadal in a traditional sense with low levels of T. Their testosterone levels were normal, albeit in the lower half of the range. Second, they achieved benefit (reversal of sarcopenia) by increasing their testosterone into the upper half of the range. In other words, it's not necessary to go overboard and exceed the upper limit of normal (at which point, your risk for side effects increases exponentially). Third, those who cycled their testosterone supplementation demonstrated baseline testosterone levels during their month off supplementation. In other words, they maintained normal pituitary and testicular function (very important for anyone interested in maintaining future fertility). While I'm not ready to advocate this cyclic regimen for all my patients, it does make you wonder if those self-experimental bodybuilders were onto something all along?
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Any mention of an exercise component in the study?
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