What is the optimal testosterone dose for a male patient currently receiving 100mg weekly injections, given his elevated total and free testosterone levels?

Testosterone Dose Reduction Required for Supraphysiologic Levels

Your current dose of 100mg weekly testosterone cypionate is producing supraphysiologic testosterone levels (993 ng/dL total, 21.3 pg/mL free) that exceed therapeutic targets and should be reduced to 50-75mg weekly to achieve mid-normal range levels of 450-600 ng/dL. 1

Critical Laboratory Findings

Your labs reveal several concerning patterns:

• Total testosterone 993 ng/dL: This is 66% above the recommended target range of 450-600 ng/dL for testosterone replacement therapy 1
• Free testosterone 21.3 pg/mL: Markedly elevated, indicating excessive bioavailable testosterone
• Hematocrit 49.0%: While not yet at the critical threshold of 54%, this represents a 7.5% increase from your previous value of 45.6% and is trending toward dangerous levels 2
• PSA 1.3 ng/mL: Stable and acceptable, though requires continued monitoring 1

Immediate Dose Adjustment Strategy

Reduce your weekly injection to 50-75mg testosterone cypionate to bring levels into the therapeutic mid-normal range of 500-600 ng/dL 1. The American College of Physicians recommends weekly dosing of 50-100mg specifically because it provides more stable levels and reduces problematic peaks and troughs 1.

Rationale for Dose Reduction

• Your current levels place you at increased risk for cardiovascular events and progressive erythrocytosis 2
• Target testosterone levels should be in the middle tertile of normal range (450-600 ng/dL), not upper limits, using the minimal dose necessary to normalize levels and improve symptoms 2
• Research demonstrates testosterone effects are dose-dependent, with physiologic replacement requiring lower doses than you're currently receiving 3

Hematocrit Management Protocol

Your rising hematocrit (45.6% → 49.0%) requires immediate attention:

• Monitor hematocrit every 4-6 weeks until stable below 48% 1
• If hematocrit rises above 54%, this represents a medical urgency requiring immediate intervention with temporary discontinuation or therapeutic phlebotomy 2, 1
• Elevated hematocrit increases blood viscosity and creates grave risk for thromboembolic events including stroke, myocardial infarction, and pulmonary embolism 2

Consider Formulation Change

If hematocrit continues rising despite dose reduction, transition to transdermal testosterone gel or patch 2. The American Urological Association recommends this because injectable testosterone is associated with substantially higher rates of erythrocytosis compared to transdermal preparations 2, 1.

Monitoring Schedule After Dose Adjustment

Following dose reduction to 50-75mg weekly:

• Recheck testosterone levels in 6-8 weeks at mid-week (3-4 days after injection) to assess trough levels 1
• Do not measure shortly after injection—patients measured at peak may appear adequate but spend most of the interval in subtherapeutic ranges 1
• Target mid-normal values of 500-600 ng/dL at trough measurement 1
• Continue monitoring hematocrit, PSA, and assess for cardiovascular symptoms 1

Cardiovascular Risk Considerations

Your concurrent laboratory findings warrant additional attention:

• Lymphocyte count decreased (33 → 22%) with absolute lymphocytes dropping from 2.1 to 1.6 K/μL
• Neutrophil percentage elevated (55% → 62%) suggesting possible inflammatory state
• Immature granulocytes present (1% with 0.1 K/μL absolute), which were previously absent

These changes, combined with supraphysiologic testosterone and rising hematocrit, increase your cardiovascular risk profile. The American Heart Association recommends counseling patients to report cardiovascular symptoms and screening for symptoms of venous thromboembolism 2.

Specific Dosing Recommendation

Start with 60mg weekly testosterone cypionate (a 40% dose reduction), administered intramuscularly:

• This dose falls within the recommended 50-100mg weekly range 1
• Weekly administration provides more stable levels than every-two-week dosing 1, 4
• Research shows 100mg weekly produces mean testosterone levels around 627 ng/dL, so 60mg should achieve your target of 500-600 ng/dL 5

If 60mg weekly produces levels below 450 ng/dL at trough measurement, increase incrementally to 75mg weekly. If clinical response is suboptimal and testosterone levels remain in the low-normal range, the dose can be increased further 1.

Common Pitfalls to Avoid

• Do not measure testosterone immediately after injection: Peak levels occur 2-5 days post-injection and often return to baseline by 10-14 days, so timing of blood draw is critical for accurate assessment 1
• Never treat to raise levels above physiologic range: Although peak levels transiently rise above normal with standard injection dosages, sustained supraphysiologic levels increase adverse effects without additional benefit 1
• Do not ignore rising hematocrit: Progressive increases require intervention before reaching 54%, not after 2

Your current regimen is producing levels that exceed therapeutic targets and place you at increased risk for hematologic and cardiovascular complications. Dose reduction is medically necessary, not optional.