Liver King TRT: How a Regular Patient Would Get Access to Testosterone Therapy

What Liver King Actually Admitted to Taking

Brian Johnson built a multi-million-dollar brand on the claim that his extreme physique came entirely from eating raw animal organs, sleeping on the floor, and following his "nine ancestral tenets." That claim collapsed in December 2022.

The Leaked Email and Public Confession

A leaked email, first reported by bodybuilding content creator Derek of More Plates More Dates, showed a detailed PED protocol attributed to Johnson. The list included testosterone, HGH at 4 to 6 IU per day, insulin-like growth factor, and several other compounds. Johnson subsequently posted a YouTube video titled "I Lied" in which he confirmed he had used PEDs and expressed regret. He did not dispute the specific compounds outlined in the leaked document.

Citing that admission directly: Johnson stated in the video, "I want to come clean. I was wrong. I am as sorry as a man can be." He did not provide a complete clinical inventory of every substance, so any dose-level detail beyond what the leaked email contained should be treated as unverified inference.

Why His Physique Could Not Be Achieved Naturally

Researchers who study the upper limits of drug-free muscle mass use the Fat-Free Mass Index (FFMI). A 2019 analysis published in the journal Sports Medicine confirmed that elite natural bodybuilders rarely exceed an FFMI of 25 kg/m², a ceiling documented in earlier work by Kouri et al. [1]. Johnson's publicly available measurements place his FFMI well above that ceiling, which is consistent with the compounds described in the leaked email and with his own admission.

HGH and Anabolic Steroids: Different Drug Classes

Supraphysiologic testosterone (anabolic steroids) and recombinant human growth hormone (HGH) are separate drug classes with different receptor targets. Testosterone binds androgen receptors to increase protein synthesis and nitrogen retention [2]. Recombinant HGH, sold under brand names such as Norditropin and Genotropin, stimulates IGF-1 production in the liver and acts on GH receptors in muscle and adipose tissue [3]. Using both together, as the leaked email described, produces additive effects on lean mass that neither agent achieves alone at physiologic doses.

What Legitimate Testosterone Replacement Therapy Actually Is

TRT and supraphysiologic anabolic steroid use are not the same thing. TRT replaces a hormone that a patient's body fails to produce in adequate amounts. The goal is to restore testosterone to mid-normal physiologic range, not to exceed it.

The Endocrine Society Diagnostic Criteria

The Endocrine Society's 2018 Clinical Practice Guideline on male hypogonadism recommends offering TRT only to men with consistent symptoms of testosterone deficiency AND two separate morning fasting total testosterone measurements below 300 ng/dL [4]. The guideline states: "We recommend against making a diagnosis of androgen deficiency in men with total testosterone concentrations consistently in the normal range." Both measurements should be taken on different days to rule out laboratory error or transient suppression from illness, sleep deprivation, or recent alcohol intake.

Symptoms That Prompt a Lab Workup

Common symptoms that prompt a physician to order a testosterone panel include reduced libido, erectile dysfunction, fatigue, depressed mood, decreased muscle mass, increased body fat, and reduced bone density. A single symptom is rarely sufficient on its own. The American Urological Association recommends a structured history and physical exam before ordering labs [5].

What the Labs Actually Measure

A standard initial TRT workup includes:

• Total testosterone (drawn before 10 a.m.)
• Sex hormone-binding globulin (SHBG) to calculate free testosterone
• Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to distinguish primary from secondary hypogonadism
• Complete blood count (CBC) to establish a baseline hematocrit
• Prostate-specific antigen (PSA) in men over 40
• Comprehensive metabolic panel

Free testosterone matters because SHBG binds a large fraction of circulating testosterone, and only unbound testosterone is biologically active. A man with total testosterone at 350 ng/dL but very high SHBG may have clinically low free testosterone [4].

How a Regular Patient Gets a TRT Prescription

The process is straightforward and typically takes two to four weeks from first appointment to first dose. No lawsuit or celebrity confession is involved.

Step 1: Initial Consultation

A patient schedules an appointment with a primary care physician, urologist, endocrinologist, or a telehealth TRT clinic. The physician takes a detailed history, reviews current medications, and assesses contraindications. Contraindications include prostate cancer, breast cancer, untreated severe sleep apnea, hematocrit above 54%, and active desire for fertility in the near term [4].

Step 2: Laboratory Testing

The clinic orders the labs listed above. Most standard insurance plans cover a testosterone panel when ordered with appropriate clinical documentation. Out-of-pocket cost at direct-pay labs typically runs $40, $120 for the full panel.

Step 3: Physician Review and Diagnosis

If both morning testosterone values fall below 300 ng/dL and symptoms are present, a physician may diagnose hypogonadism and discuss treatment options. The physician reviews the full lab picture, not just total testosterone in isolation.

Step 4: Prescription and Formulation Choice

FDA-approved testosterone formulations include [6]:

• Testosterone cypionate or enanthate (injectable): Typically 100 to 200 mg IM every 7 to 14 days. Self-injection is common and can be done at home after brief training.
• Testosterone gel (AndroGel 1%, 1.62%; Testim; Vogelxo): Applied daily to shoulders or upper arms. Transfer risk to partners and children requires careful handling.
• Testosterone patch (Androderm): Applied nightly, delivers 2 to 4 mg per 24 hours.
• Testosterone pellets (Testopel): Inserted subcutaneously every 3 to 6 months in a brief in-office procedure.
• Testosterone nasal gel (Natesto): Applied to nasal mucosa three times daily; lower suppression of LH/FSH than other forms, which may partially preserve fertility.
• Testosterone undecanoate oral (Jatenzo, Tlando): Taken twice daily with food; requires dose titration.
• Testosterone undecanoate injectable (Aveed): 750 mg IM at baseline, 4 weeks, then every 10 weeks; requires in-office administration due to pulmonary oil microembolism risk.

Testosterone cypionate IM is the most commonly prescribed form in the United States due to low cost, predictable pharmacokinetics, and patient familiarity [7].

Step 5: Monitoring

The Endocrine Society guideline recommends follow-up labs at 3 months after starting TRT, then annually [4]. Monitoring includes:

• Total testosterone (target mid-normal range, roughly 400 to 700 ng/dL)
• Hematocrit (withhold or reduce dose if above 54%)
• PSA (discontinue if significant rise suggests prostate pathology)
• Symptom reassessment using a validated questionnaire such as the AMS or IIEF-5

What Supraphysiologic Use Looks Like Versus Therapeutic Use

The distinction between Liver King's admitted regimen and a legitimate TRT protocol is not subtle. The table below illustrates key differences.

| Parameter | Legitimate TRT | Supraphysiologic (Anabolic) Use | |---|---|---| | Testosterone dose | 100 to 200 mg/week | 500 to 1,000+ mg/week (common in competitive bodybuilding) | | Goal serum level | Mid-normal (400 to 700 ng/dL) | Often 1,500 to 5,000+ ng/dL | | HGH co-administration | Not standard; used only in documented GH deficiency | Frequently stacked at 4 to 10 IU/day | | Physician oversight | Required for legal prescription | Typically self-administered without monitoring | | Hematocrit monitoring | Required per guideline | Rarely formalized | | Cardiovascular risk acknowledgment | Discussed at consent | Often minimized in online communities |

Research published in the Journal of the American Heart Association (2023) found that men using supraphysiologic androgen doses had significantly higher rates of left ventricular hypertrophy and diastolic dysfunction compared to both age-matched non-users and men on therapeutic TRT [8]. The risks do not map cleanly from anabolic steroid use onto appropriately dosed TRT.

Cardiovascular and Hematologic Risks of TRT

Cardiovascular risk from TRT has been debated for over a decade. The TRAVERSE trial (N=5,246), published in the New England Journal of Medicine in 2023, was the first large randomized controlled trial powered to assess cardiovascular safety of TRT specifically in middle-aged and older men with hypogonadism and elevated cardiovascular risk [9]. The trial found that testosterone replacement was non-inferior to placebo for the composite MACE endpoint (cardiovascular death, nonfatal MI, nonfatal stroke) over a median follow-up of 33 months. The trial did find a higher rate of atrial fibrillation (3.5% vs. 2.4%), pulmonary embolism (0.9% vs. 0.5%), and acute kidney injury in the testosterone group, which are findings physicians now routinely discuss during TRT consent.

Hematocrit Elevation

Testosterone stimulates erythropoiesis. About 18 to 21% of men on TRT develop hematocrit above 50%, and a smaller fraction exceed 54%, the threshold at which most guidelines recommend dose reduction or temporary cessation [4]. Men with pre-existing sleep apnea are at higher risk. Baseline and periodic CBC monitoring catches this before it becomes clinically significant.

Prostate Health

The TRAVERSE trial also reported a higher rate of acute urinary retention and prostate biopsy in the testosterone group, though prostate cancer incidence did not differ significantly between arms [9]. Current evidence does not support TRT as a cause of de novo prostate cancer, but active or suspected prostate cancer remains a contraindication [10].

The Role of Telehealth in TRT Access

Since 2020, telehealth TRT clinics have substantially shortened the time between symptom onset and first prescription. A patient can complete an asynchronous intake form, order at-home lab kits, and receive a physician review within days rather than waiting weeks for a specialist appointment.

What Telehealth TRT Requires

A legitimate telehealth TRT provider must still require the same diagnostic steps a brick-and-mortar clinic uses: two low testosterone measurements, symptom documentation, and a prescribing physician licensed in the patient's state. Providers that skip labs or guarantee prescriptions without clinical review are operating outside FDA guidance and standard of care.

Cost Considerations

Cash-pay telehealth TRT programs typically run $150, $300 per month, covering medication, shipping, and follow-up labs. Generic testosterone cypionate without a subscription costs approximately $30, $60 for a 10 mL vial (200 mg/mL) at most retail pharmacies, making the medication itself affordable even without insurance.

What About HGH for Non-Celebrity Patients?

Recombinant HGH (somatropin) is FDA-approved for adult growth hormone deficiency, short bowel syndrome, HIV-associated wasting, and several pediatric indications [3]. It is not approved for anti-aging, body composition improvement in healthy adults, or athletic enhancement. Prescribing it for those purposes is off-label and, when done without a legitimate diagnosis, may violate federal law under the Anti-Drug Abuse Act of 1988 as amended.

A diagnosis of adult GH deficiency requires an insulin tolerance test or a GHRH-arginine stimulation test with a peak GH response below defined thresholds, plus clinical context (prior pituitary surgery, radiation, or a known pituitary disorder) [11]. The vast majority of adults seeking HGH for physique purposes do not meet these criteria. Clinics that prescribe HGH without a documented stimulation test are operating outside FDA guidance.

Practical Takeaways for Someone Considering TRT

Getting evaluated for hypogonadism is a routine medical process. The steps are not complicated:

1. Find a physician, urologist, endocrinologist, or licensed telehealth TRT provider.
2. Complete two fasting morning testosterone panels drawn before 10 a.m. On separate days.
3. Review results with the prescribing physician alongside a symptom assessment.
4. If diagnosed, discuss formulation options, risks including cardiovascular considerations from TRAVERSE, and monitoring schedule.
5. Return for follow-up labs at 3 months and annually thereafter.

Liver King's physique was not the product of TRT. It was the product of doses and drug combinations that sit far outside what any legitimate clinic prescribes, which his own admission confirmed. The clinical pathway for a patient with documented hypogonadism is evidence-based, monitored, and nothing like what a leaked email from a social media personality described.

The Endocrine Society's 2018 guideline is the most widely cited authority on this process in the United States, and it recommends offering TRT only when "the potential benefits outweigh the potential risks" after a confirmed biochemical diagnosis [4]. That standard, and not a bodybuilding protocol, is what governs legitimate prescribing.