Liquid Mobile Guide to: hCG and HRT 

Table of Contents

• HRT+ Injections Intro
• Liquid Mobile Program
• HRT Need to Know
• How to Store
• How to Administer Injections

Welcome to HRT with Liquid Mobile!
Congratulations on taking this step on your HRT (hormone replacement therapy) wellness journey. We are excited to support you! Be sure to include your primary care and medical teams on your HRT decisions and plan. Consultation and labs are required regularly ensure your wellness is on track. Medications are non-refundable.

There are many excellent sources of information available to assist with your learning needs including Mayo Clinic & WebMD. See below for some great insights from the Mayo Clinic.

What is testosterone?
Testosterone is a hormone produced primarily in the testicles. Testosterone helps maintain men’s:

• Bone density
• Fat distribution
• Muscle strength and mass
• Facial and body hair
• Red blood cell production
• Sex drive
• Sperm production

What happens to testosterone levels with age?
Testosterone levels generally peak during adolescence and early adulthood. As you age, your testosterone level gradually declines — typically about 1% a year after age 30 or 40. For older men, it’s important to determine if a low testosterone level is due to normal aging or if it is due to a disease (hypogonadism). Hypogonadism hampers the ability to produce normal amounts of testosterone due to a problem with the testicles or with the pituitary gland that controls the testicles. Testosterone replacement therapy, in the form of injections, pellets, patches or gels, can improve the signs and symptoms of low testosterone in these men.

Does a naturally declining testosterone level cause signs and symptoms of aging?
Not necessarily. Men can have many signs and symptoms as they age. Some of these signs and symptoms can be caused by other factors, including medication side effects, obstructive sleep apnea, thyroid problems, diabetes and depression. It’s also possible that these conditions cause low testosterone levels, so treatment might result in increase of testosterone levels.  Some that might occur as a result of lower testosterone levels can include:

• Changes in sexual function. This might include reduced sexual desire, fewer spontaneous erections — such as during sleep — and infertility.
• Physical changes. Various physical changes are possible, including increased body fat, reduced muscle bulk and strength, and decreased bone density. Swollen or tender breasts (gynecomastia) and body hair loss are possible. You might have less energy than you used to.
• Emotional changes. Low testosterone can contribute to a decrease in motivation or self-confidence. You might feel sad or depressed, or have trouble concentrating or remembering things.

A blood test is used to diagnose a low testosterone level.

Can testosterone therapy promote youth and vitality?
Testosterone therapy can help reverse the effects of hypogonadism, but it’s unclear whether testosterone therapy would benefit older men who are otherwise healthy. Although some men believe they feel younger and more vigorous if they take testosterone medications, there’s little evidence to support the use of testosterone in otherwise healthy men. Guidelines from the American College of Physicians indicate that testosterone therapy might improve sexual function somewhat in some men, but there’s little evidence that it improves other functions, such as vitality and energy. It should not be taken if wanting to remain fertile and still have children.

What are the risks of testosterone therapy for normal aging?
Testosterone therapy has various risks and should not be taken if you are still interested in remaining fertile as it can have an impact on child bearing. Additional risks include:

• Worsening sleep apnea — a potentially serious sleep disorder in which breathing repeatedly stops and starts.
• Causing acne or other skin reactions.
• Stimulating noncancerous growth of the prostate (benign prostatic hyperplasia) and growth of existing prostate cancer.
• Enlarging breasts.
• Limiting sperm production and sterility
• Testicular shrinkage
• Stimulating too much red blood cell production, which contributes to the increased risk of forming a blood clot. A clot could break loose, travel through your bloodstream and lodge in your lungs, blocking blood flow (pulmonary embolism).

Should I talk to my doctor about testosterone therapy?
If you wonder whether testosterone therapy might be right for you, talk with your primary care physician and medical team about the risks and benefits. Your doctor should always be involved in your hormone therapy plan. If you don’t have a medical condition or symptoms of declining testosterone, your doctor might suggest natural ways to boost testosterone, such as losing weight and increasing muscle mass through resistance exercise.

Can testosterone therapy promote youth and vitality?
Testosterone therapy can help reverse the effects of hypogonadism, but it’s unclear whether testosterone therapy would benefit older men who are otherwise healthy. Although some men believe they feel younger and more vigorous if they take testosterone medications, there’s little evidence to support the use of testosterone in otherwise healthy men. Guidelines from the American College of Physicians indicate that testosterone therapy might improve sexual function somewhat in some men, but there’s little evidence that it improves other functions, such as vitality and energy.

What are the benefits of using HRT?
It’s impossible to predict because every man is different. Many men report improvement in energy, sex drive, and quality of erections. Testosterone also increases bone density, muscle mass, and insulin sensitivity in some men. Men also often report an improvement in mood from TRT. Whether these effects are barely noticeable or a major boost depends on the person. Karen Herbst, MD, PhD, an endocrinologist, specializes in testosterone deficiency. She estimates about 1 in 10 men are “ecstatic” about their response to testosterone therapy, while about the same number “don’t notice much.” Most have generally positive but varying responses to testosterone replacement.

What is hCG?
Human chorionic gonadotropin (HCG) is a type of luteinizing hormone (LH). Although it is a naturally occurring hormone and can help men who want to raise their testosterone, they fear bioidentical hormone replacement therapy alone might cause loss of fertility or testicular atrophy. As men age, it’s common for them to experience a reduction in one of their most important hormones: testosterone. In addition to being a natural testosterone replacement therapy, HCG is an effective way of treating the loss of testosterone, helping men increase their testosterone levels back to a normal range. That can lead to erectile dysfunction, but can also cause:

• • Decreased sex drive
  • Reduced stamina
  • Depression
  • Loss of body hair

How does hCG work?
HCG instructs the testicles to produce more testosterone. During testosterone replacement therapy, the hypothalamus begins to reduce its production of gonadotropin-releasing hormone (GnRH), which in turn causes the pituitary gland to stop releasing LH. Because of the reduction in LH, the testicles begin to produce far less testosterone, and they start shrinking in size and volume. In short, because you’re augmenting your testosterone through the addition of hCG and it can also be used with testosterone replacement therapy. Sometimes your body thinks it no longer has to produce testosterone. That is when hCG reminds the testicles to continue working to produce that testosterone. By supplementing testosterone replacement therapy with hCG, men may augment the amount of testosterone in their body.

How do I store my hormones? 

• • • hCG Storage
      Store dry powder at 68°F to 77°F (20°C to 25°C) and away from heat, moisture and light. Once reconstituted keep this medicine in a refrigerator between 36°F to 46°F (2°C to 8°C). Keep all medicine out of the reach of children. Throw away any unused medicine after the beyond-use date. Do not flush unused medications or pour down a sink or drain.
    • Topical Ointment Storage
      Store in a cabinet that is maintained at room temperature. Keep all medicine out of the reach of children. Throw away any unused medicine after the beyond-use date. Do not flush unused medications or pour down a sink or drain.

Recommended Labs
It is recommended that you manage your labs directly with your primary medical provider and your medical team. Labs often recommended by primary care teams include:

Initial (Fasting) & Annually

• • • Testosterone: Total & free (LCMS)
    • SHBG
    • Estradiol & Estrone
    • DHEA-S
    • FSA & LH
    • DHT
    • PSA
    • CBC
    • Optional
      • Prolactin (impact libido)
      • Progesterone
      • TSH, fT4, fT3
      • 25 OH Vid D, Parathyroid hormone
      • CMP, Lipids
      • Insulin, hBa1C, homocysteine

Lab Test once Stimulated 24 hrs after hCG (Fasting; once symptoms are alleviated of Q3 months if symptoms are not within the normal range)

• • • Testosterone: Total & free (LCMS)
    • SHBG (will elevate if over treating)
    • Estradiol & Estrone (will elevate if over treating; low libido if too low)
    • FSA & LH  (will decrease if over treating)
    • DHT  (will elevate if over treating)
    • CBC
    • Optional
      • Prolactin (impact libido)
      • Progesterone
      • TSH, fT4, fT3  (if energy low)
      • 25 OH Vid D, Parathyroid hormone
      • CMP, Lipids
      • Insulin, hBa1C, homocysteine

Guest should always notify their primary care and all specialists of their HRT plan, related information, issues and recommendations.

Will this medication interact with my other medication?
These injections may interact other medications. Be sure to consult your healthcare provider and provide a complete list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also, tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

What should I report before taking this medicine?
Your Liquid Mobile care team should be notified of any of the following conditions:

• • • Endocrine tumors (MEN 2) or if someone in your family had these tumors
    • Cancer
    • Heart disease
    • Untreated sleep apnea
    • Prostate cancer
    • Breast cancer
    • Uncontrolled heart failure, MI or strokes
    • Gallbladder disease
    • History of depression or mental health disease
    • History of pancreatitis
    • Kidney disease
    • Stomach or intestine problems
    • Suicidal thoughts, plans, or attempt; a previous suicide attempt by you or a family member
    • Thyroid cancer or if someone in your family had thyroid cancer
    • Men planning fertility
    • Men not wanting testicular shrinkage
    • Elevated PSA
    • Prostate cancer

Please note this list may not include all potential contraindications or precautions. Please consult your primary care physician or pharmacist for a list of all contraindications and precautions.

Additional Side effects that you should report to your primary care physician as soon as possible:
Testosterone topically applied can get transferred to a woman or child who comes in contact with the gel. As a result, patients are advised to cover the application site with clothing and wash the skin before having skin-to-skin contact to avoid transmission. Testosterone patches can cause skin reactions, and injectables can cause mood, energy, and libido fluctuations. In 2015, the FDA concluded a possible increased cardiovascular risk associated with testosterone use existed, requiring labeling change to inform the public. Testosterone use has been associated with erythrocytosis related to hematocrit, increasing the risk of venous thromboembolism.[21] Serum PSA levels can increase in response to testosterone treatment, so it is essential to rule out prostate cancer before starting therapy, as testosterone replacement can worsen the disease process. Patients on replacement therapy require reevaluation for prostate cancer at three months and one year after beginning treatment.[22] Testosterone has had no significant effects on lower urinary tract symptoms and BPH.[21] Clinicians need to address testosterone therapy’s risks and benefits before initiating treatment.

• • • Allergic reactions—skin rash, itching, hives, swelling of the face, lips, tongue, or throat
    • Change in vision
    • Heart palpitations—rapid, pounding, or irregular heartbeat
    • Kidney injury—decrease in the amount of urine, swelling of the ankles, hands, or feet
    • Pancreatitis—severe stomach pain that spreads to your back or gets worse after eating or when touched, fever, nausea, vomiting
    • Thoughts of suicide or self-harm, worsening mood, feelings of depression
    • Concerns for cancer – new mass or lump, pain or swelling, trouble breathing, hoarseness
    • Concerns for pancreatitis—severe stomach pain that spreads to your back or gets worse after eating or when touched, fever, nausea, vomiting

This list may not describe all possible side effects. Call your doctor for medical advice about side effects.

How will I receive my hCG medications?
You may receive your hCG injections in one of our local clinics, provided by a physician, nurse practitioner or registered nurse. Injection clinic visits are for medication administration only and are not to be used for follow-up visits. Please book an appointment in the clinic or via telehealth for follow-ups, refills, and questions regarding your response to the current HRT plan.

You may also elect to self-administer hCG or topical testosterone ointment at home. The medication will be shipped to your home.

What is my starting dosage for Topical Testosterone Ointment? 
Be sure you have the Brite app downloaded onto your phone, so you have immediate access to support, videos for applying topical testosterone ointment to your skin and other essential information. Topical testosterone ointment is only to be applied by rubbing onto the skin. This is not an injectable. Follow the titration plan communicated by your clinical team. Your prescription is unique to you and dosing is calculated to help alleviate symptoms. Dosing correctly is essential to minimize side effects such as testicular shrinkage.

What is my starting dosage for hCG? 
Your prescription is unique to you. Be sure to read the front of the prescription so you understand your starting dose. Most will start with the following and only increase if advised and approved by your clinical team:

• • • 100iu injection = 10 units on an insulin syringe Q 3 days (starting dose)
    • 200iu injection = 20 units on an insulin syringe Q 3 days (only if ordered my clinical team and previous dosage was unsuccessful)
    • 300iu injection = 30 units on an insulin syringe Q 3 days (only if ordered my clinical team and previous dosage was unsuccessful)
    • 400iu injection = 40 units on an insulin syringe Q 3 days (only if ordered my clinical team and previous dosage was unsuccessful)
    • 500iu injection = 50 units on an insulin syringe Q 3 days (only if ordered my clinical team and previous dosage was unsuccessful)

How do mix (reconstitute) my hCG? 
Reconstitute your hCG with Bacteriostatic Water provided. Follow instructions below.

• • • 10,000iu vial of hCG:  Add 10mL of Bacteriostatic Water

* Refrigerate you hCG+ vial once it is reconstituted.
 Keep out of the reach of children and pets.  Once you receive it, store it in the refrigerator in-between doses. Dispose of needles in a sharps containers available at your retail pharmacy. If not assessable, place needles in a hard, closed container, such as a sealable detergent bottle. Unneeded medications should be disposed of in special ways to ensure that pets, children, and other people cannot consume them. You should not flush this medication down the toilet. Instead, the best way to dispose of your medication is through a medicine take-back program. Talk to your pharmacist or contact your local garbage/recycling department to learn about take-back programs in your community. See the FDA’s Safe Disposal of Medicines website for more information.

How do I receive refills?
It is highly encouraged that you request a refill 2 weeks in advance to your medication running out. Visit www.LiquidMobileIV.com , click Telehealth, then Refill to schedule a call for a refill or call 855.954.7843. Increases in dosages will require a telehealth visit with a provider and will only be allowed after 4 weeks of being on current dosage.

How do I draw up my hCG medicine? 
It is important to draw up your medication correctly. We recommend calling, stopping by the clinic or scheduling a telehealth visit for assistance, especially on your initial injections. If you have a friend or family member that is a clinician, they may be able to assist. Wash and clean your hands well before starting. Clean top of vial with alcohol, insert needle in the center, then turn vial upside down. Make sure the medicine covers the tip of the needle, then pull back the plunger to the line on your syringe for your dose. If bubbles are in the syringe, push the medicine back into the vial and draw out the hCG again at a slower speed. Remove the needle from the vial.

 How do I Reconstitute Video

What dose will I inject hCG?
Dosages will depend on each individual, but always start with the Starting Dose and only titrate up if advised to do so by your medical team.

How do I inject hCG? 
For subcutaneous injections, the belly can be an easy location to start. Target at least 2 inches from the belly button, laterally and inject at a 45 to 90 degree angle once site is cleaned with alcohol. See your guide or video for complete instructions.

Injecting Subcutaneous Tissue Video

1. Gather your supplies:

• • • Medication vial
    • Syringe
    • Alcohol wipe

2. Wash your hands and prepare injection site.

3. Clean the injection site with alcohol wipe, and let the skin dry.

4. Draw up medication

• • • Remove the seal on the top of the vial and wipe with alcohol
    • Remove the cap off the needle
    • Hold the syringe like you hold a pen or a dart, inserting the needle into the middle of the rubber stopper perpendicular, so the needle does not bend.
    • Together, turn the vial and syringe upside down.
    • Make sure the tip of the needle is in the liquid.
    • Pull the plunger down, past the dosage prescribed. Then, push up to the prescribed dosage, as this will remove all air bubbles.
    • Once you have the correct amount of liquid, pull the entire syringe out of the vial.

5. Inject into subcutaneous tissue. Subcutaneous injections will be very little pain because it is only injected directly under the skin. It can be injected into the stomach, thighs, and back of the upper arm.

• • • Pinch the injection site to create a firm surface. Alternate injection sites between either side of the stomach, back of the arm, or thigh.
    • Inject two inches from the belly button on either side.
    • Insert the needle into the skin between the index finger and thumb at 90 degrees.
    • Using a slow and constant pressure, push the plunger rod until it reaches the bottom.
    • Gently pull the syringe out of the skin.
    • Discard of the needle in a sharps container.

Additional Suggestions
It is recommended that you work closely with your primary physician and medical team, along with a wellness consultant, fitness trainer and nutritionist, to best round out your wellness journey and to build good habits. HRT may affect fertility and testicular size. Be sure to monitor if these are important to you.