One question I get from time to time is:
What HRT levels should I shoot for?
Men that ask this question are looking for the ideal testosterone (T) and estradiol (E2) level necessary to get them over their low testosterone symptoms. And oftentimes they ask me this question, becuase, quite frankly, their doctors seem to know very little about ths subject. Based on what I have seen in the Peak Testosterone Forum, the typical endocrinologist will tell a man that his testosterone of 300 ng/dl is just fine and maybe hand him some Cialis. They will even suggest psychotherapy or just ask the man to leave since their "hands are tied". And, unfortunately, most PCPs are just woefully ignorant in this area.
The HRT clinics, and now many urologists are getting on board, take a completely different approach. They usually have very specific HRT targets that are based, quite frankly, on the fact that they are generally effective. While it is true that going on HRT is an involved decision and isn't for everyone, the explosion of HRT clinics in the U.S. is simply because it makes most low testosterone men feel better. And I am an exmple of that.
However, one key to their success is that they have honed over the years, through trail and error, specific T and E2 levels that seem to work very well on average at least. For this reason, I want to discuss the HRT levels used by most of the HRT clinics from what I have seen. In fact, I'll use my own clinic's protocol as an example. It has been very successful, is proud of its track record of safety and operates in multiple states. (I have no affiliation with them.)
Here is how they handle things from what I have seen:
1. They do several screens to make sure a man does not have existing or past prostate cancer or any other containdications.
2. They also make sure that the man is low testosterone. For them the definition is total testosterone < 450 ng/dl.l.
3. They do weekly injections of testosterone cypionate. .
4. They target peak and trough total testosterone of 1000-1200 ng/dl and 600-800 ng/dl, respectively. Testosterone reads are done at the trough, i.e. 7 days after the shot. Peak testosterone is then assumed to be about 300 ng/dl above the trough.
5. They dose with Arimidex if necessary to bring estradiol (E2) between 20 and 30 pg/ml. Armidex, a half dose, is taken on the fourth day after the injection to coincide with the peak. A second half dose is taken two days later.
6. They regularly ask their patients about how they are doing. For example, some men will feel aggressive, overly alert and perhaps having trouble going to sleep. This is time to back off a little on their testosterone dosage. There is some tweaking that can occur in other words.
7. They test every three months for the basics (testosterone, estradiol, PSA, RBCs, etc.).
8. If a man's PSA goes over 2.5 or if the PSA increases by 1.0 within a rolling year time period (even if less than 2.5), then they will refer out to a urologist and get a urological clearance.
Again, this protocol is similar to many other HRT clinics. It is very simple and has been honed by years of trial and error. There are quite a few variables that had to be worked out, such as injection frequency, timing of Arimidex, intramuscular versus subQ and so on. But when you get the right mix, the short and medium term results - HRT on this level has not really been done long term - seem to be excellent.
At my HRT clinic, for example, they said that they do not really need to advertise: patients come mostly by word of mouth. The solid majority of their men just love HRT with this kind of protocol and wouldn't have it any other way. It is greatly helping their sex life, their relationships with women and their relationships at work. Furthermore, for some men, mirculous things often happen. I had my morning erections restored after decades of not having any. A high percentage of type II diabetics find that they no longer need insulin any more. Many men suddenly shed pounds and put on muscle like never before. And many half-dead husbands say that they are finally chasing their wives around the bedroom again and that can be good for the relationship.
CAUTION: HRT does NOT always work like this. Sometime there are multiple causes for low libido and erectile dysfunction for example. In addition, there are certain groups that generally should not use HRT, such as men with advanced kidney disease and high RBC (red blood cell counts) or existing/past prostate cancer (although the latter is controversial). If you have any medical conditions, do your homework and discuss with your doctor. If you have hypertension, discuss with your doctor as well. An occasional side effect of testosterone treatment is elevated blood pressure in men with existing hypertension.
The bottom line is that you are probably not going to do that if your doctor has you on Androgel with testosteorne of 350. Nor are you likely to see much improvement if your estradiol is 55. The HRT clinics have learned all these numbers the hard way over the edecades.
Now the above approach is quite "mechanical." However, you should be prepared that many doctors use a completely different approach. Here are a few examples:
1. Bioavailable or Free Testosterone. One of our posters stated that his doctor targeted bioavailable testosteorne and liked to see 300 or more. And with estradiol he liked teenage number between 15 and 22 pg/ml.
2. Going By Feel Only. One forum poster stated that his doctor went completely by "feel", i.e. had a complete emphasis on sympotms. Here is what he wrote:
"The HRT doctor will find out in a couple of weeks that I am on Testosterone injections because I am using his office to get the blood work done. I am using the HRT doctor to get the blood work done because my PCP doesnt want me to look at (or know) what my testosterone level is at. My pcp wants me to go by how I feel not by what number I am at. I agree with him to a point but I still want to know. Is that wrong?" 
So it's either feast or famine when it comes to symptoms I guess! Some endocrinologists could care less if you are just barely limping through life miserable with low testosterone symtpoms: they just care whether you are above or below that magic 260 ng/dl number of the range. And then you have a physicians like this who does not even trust the number for use in treatment.
NOTE: Many HRT clinics will now offer HCG to the mix for a very reasonable price. This is affectionately called "The Trifecta" by those who use the cypionate, Arimidex (anastrozole) and HCG triad. HCG does nothing for some men. However, for still others it 1) boosts mood, 2) may help with fertility in some cases and 3) reverses any testicular shrnikage. Injection levels vary widely and I will cover that on another page soon.