Testosterone Replacement.



How Does One Get Started With Testosterone Replacement Therapy?

The initial step is calling our office to have an exam.  During this two visit initial exam you will meet Dr. Farrah, have a physical exam, and we will do a blood draw to check your levels of total testosterone, free testosterone, prostate specific antigen, and estradiol (estrogen) to see if you are indeed a good candidate.

If you are a candidate and choose to go ahead with treatment your dose will be individualized based on age, body weight, activity level as well as your baseline blood levels.

All patients will have an additional blood draw four to six weeks following the start of treatment we verify the dosing by rechecking your serum levels, as well as other markers to ensure there has been no negative reactions.

At Midtown Medical we handle your care within a concierge model of health care.  This means we only accept a small number of patients each month to ensure personalized care.  In addition we charge a flat rate membership pricing that covers all of your interactions with Dr. Farrah and his staff.

Please Read the additional information below to begin learning about this treatment.

What Is Testosterone?

Testosterone has always been known as the male sex hormone, However, many women are surprised to find out that they too produce testosterone (in a much smaller capacity than men). 


Healthy pre-menopausal women actually have 15–20-fold higher levels of testosterone than estradiol. In addition, there are exponentially higher levels of androgen precursors.  

Testosterone is derived from cholesterol as are most of our hormones. Its chemical structure is very similar to that of cholesterol and with only minor adjustments to this base structure other hormones such as estradiol (estrogen), progesterone, cortisone, DHEA and androstenedione are also produced.


For Men the vast majority of testosterone is produced in the testicles and for women in the ovaries.  This is under the influence of a releasing hormone called Luteinizing Hormone (LH).

LH is produced in the pituitary gland and is released in a pulsatile manner where spurts of testosterone are released throughout the day.

There is typically a surge in the morning which can account for morning erections in men. The testosterone that is in our blood stream is mostly bound up by a protein called sex hormone binding globulin  (SHBG). This bound testosterone is inactive. The fraction of the testosterone that is not bound is called free testosterone. It is the free testosterone that is able to diffuse into the target tissues and exert its function. Only about 2-3 percent of the body’s testosterone is unbound and free.

Testosterone Deficiency (Low T)

A male’s testosterone is estimated to decrease 1-3% a year starting in his thirties. In women unlike the possible abrupt onset of their estrogen and progesterone decline in menopause, the decline in testosterone is much more gradual.  A male’s testosterone decline is so gradual it is difficult to delineate a specific time when we know our levels are “low”. It is estimated that in men over the age of 55 approximately 50% of them will have testosterone levels below the lowest normal range for young men. However when dealing with hormone optimization, “normal” is a relative term. It is derived for a population of a wide array of ages. An average level for all subjects tested is determined and then two standard deviations from the mean identifies the “normal” range. For testosterone the range is typically defined as 300 – 1100 ng/dL. However Optimal ranges are typically closer to 600 - 1200 ng/dL.

What Are The Symptoms Of Low T?

  • Fatigue

  • Irritability

  • Depressed mood

  • Decreased sense of well being

  • Breast development

  • Decreased libido

  • Sleep difficulties

  • Decreased morning erections

  • Joint pain/muscle aches

  • Decreased strength

  • Erectile Dysfunction

  • Weight gain/belly fat

  • Decreased mental clarity and focus

Who Should Get Treated?

In a man that has a total testosterone below 300 or a female below 15 ng/ dl there is little controversy as to whether or not their levels  are considered “low” or whether or not they should be treated. But what about the symptomatic 40 year old male that has a level of 500 that may have had a level of 950 when he was in his twenties? Should he start replacement therapy? Or, should he wait until his level drops below the magic lower limit of “normal” of 300? Testosterone Deficiency (Low T) is a clinical diagnosis based off of symptoms and there is no universally accepted lab level that makes the diagnosis. It is a syndrome that is not clearly understood by all primary care providers. It is up to the patient to make an educated decision and seek out a physician well versed in the current literature that can explain the benefits and potential risks involved with testosterone replacement therapy.

How will Testosterone Replacement Therapy Help?

The medical literature supports replacing testosterone levels to optimal physiologic levels (upper end of the normal range). It has been shown to increase energy, improve sleep, increase lean muscle mass, decrease body fat, increase libido and increase an overall sense of well-being. All of which improve a man’s quality of life. The health benefits associated with optimized testosterone levels include: decreased risk of cardiovascular disease, strokes, Alzheimer’s disease, diabetes and osteoporosis.

Why Are Testosterone Pellets The Best?

The benefit of the pellets over topical creams/gels is the improved serum levels obtained with the pellets; the steady state obtained in the levels vs. peaks and troughs; not needing to remember to apply the cream/gel daily and no need to worry about accidentally transferring any of the testosterone to your family members or pets.

Although one can achieve physiologic levels with the injectable synthetic forms of testosterone, the rollercoaster effect with peaks and troughs seen in the creams/gels is also seen with the injectable form. This roller coaster effect is due to the fact that the injectable form and transdermal forms are time released. One will get a spike in the testosterone level shortly after it is injected or applied and then the level gradually declines over time until the next application or shot. With the pellets, the absorption is not time released. Once the implants are placed under the skin, small blood vessels called capillaries surround them. The testosterone is then absorbed by these capillaries. There will be a slight delay in reaching physiologic levels compared to injections and transdermal forms as the body develops these new blood vessels surrounding the pellets. However, once the peak level is obtained a steady state remains for several months. The further release of the testosterone from the pellets is not time released as previously mentioned. Rather, it is dependent on the patient’s cardiac output. When the patient is awake and active, there is more blood flow going through the capillaries that surround the testosterone pellets. With more blood flow comes more testosterone absorbed and this mimics our natural physiology. When one sleeps there is less blood flow and less absorption of the testosterone.

Patient compliance is always a concern when having to give yourself an injection once or twice a week or to remember to apply a cream/gel daily. With the pellets, they are placed through a small incision under the skin of your buttocks and they are slowly absorbed over the next 4 – 6 months. The patient doesn’t have to remember to do anything else to achieve optimal serum testosterone levels.

How Does Testosterone Effect Estrogen Levels?

Testosterone can get converted/aromatized to estradiol (estrogen) and this conversion rate varies for each individual. Some men require an estrogen blocking medication to keep this level in the optimal range. Estradiol is important for the health of man’s brain, bones, skin and vascular system. Estradiol also has beneficial effects on the cholesterol levels as it increases HDL and decreases LDL. Too much estradiol can cause worsening moods, swollen and sore nipples, breast development (gynecomastia) and over stimulation of the prostate. If the estrogen is blocked unnecessarily and the level is too low, one can experience joint pain and less commonly one can experience irritability and aggressiveness known to some as “roid rage”. Because of this we also follow your estradiol (estrogen) levels and keep you in the optimal range.

Call us at 850.386.8282 to schedule an appt.

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