The Future of Personalized Medicine | Shaun Noorian

Noorian's clinical framework: get baseline values, prescribe the appropriate treatment, have the patient return every 3-6 months for lab review, and modify the treatment accordingly. Estradiol monitoring is especially important in men who do not want to take an aromatase inhibitor prophylactically — the lab result tells you whether aromatization is clinically significant for that individual patient.

Noorian uses this protocol personally — he injects testosterone enanthate using a 30-gauge insulin syringe. He contrasts this directly with commercial cypionate: if you were to try to draw testosterone cypionate through a 30-gauge for the commercial product, you'd be there till next year. The subcutaneous route is particularly appealing for female patients receiving micro-doses.

Noorian describes patients who report that they can achieve orgasm faster or they can achieve orgasm at all using this compounded libido cream. He frames it as filling a massive clinical gap — two FDA-approved drugs for female sexual dysfunction exist (flibanserin/Addyi; bremelanotide/Vyleesi), but they target serotonin/melanocortin pathways rather than local vascular insufficiency. The compounded cream targets the vasodilatory mechanism, which is the same physiology that PDE5 inhibitors exploit in men.

Noorian describes HCG as one of the most popular medications in the compounding pharmacy's male health portfolio. Many fertility specialists prefer the TRT + HCG combination protocol because it maintains the intratesticular testosterone gradient (roughly 50-100x higher than serum) that supports Sertoli cell function.

Noorian explains that Empower Pharmacy was the primary advocate before the FDA PCAC for enclomiphene's inclusion in the 503B bulk drug substance list. The committee ruled that insufficient evidence differentiated enclomiphene from clomiphene. Compounders can still make enclomiphene citrate currently, but this will likely be phased out within 1-2 years.

Noorian frames this against the statin example: statins reduce testosterone precursors and cause muscle damage. Lyon's parallel point: we prescribe medications to make people less obese without controversy, but prescribing medications to make people more muscular triggers moral panic — even though muscle is a longevity organ and low muscle mass is the more dangerous metabolic condition for most aging patients.

Lyon is emphatic about oral finasteride risks: severe depression and brain chemistry changes that become very difficult to rectify even once the drug is stopped. Noorian gives patients who prioritize hair the best possible option: a topical preparation that largely eliminates the systemic risk while still addressing follicular DHT.

Noorian: there is no estrogen pellet on the market, so the only way a patient could get this therapy is through a compounding pharmacy or outsourcing facility. Lyon describes a specific patient who failed branded patch, generic patch, cream, and injectable before achieving adequate estrogen levels via compounded injectable from Empower — pellets offer yet another alternative in the escalation ladder.

Noorian cites the documentary Bigger Stronger Faster (2008, Chris and Mark Bell) as the key piece of public education that changed his own internalized stigma after he had already been on testosterone therapy himself. His argument: estrogen, progesterone, and corticosteroids — all potent hormones with documented long-term adverse effects — are not controlled substances, while testosterone, which is endogenous, is scheduled alongside narcotics purely because of sports optics. He hopes Congress will revisit the scheduling, noting that the DEA, AMA, and FDA have never changed their underlying position that the scheduling was inappropriate.

Noorian's clinical pattern: postmenopausal women present with vaginal atrophy, decreased libido, and sexual dysfunction. Their male partners often simultaneously start TRT and see dramatic libido improvement. Treating only one partner becomes a relationship problem; Noorian argues for co-treatment of couples where both partners qualify. Women require roughly 1/10 the dose of men — the compounding pharmacy creates the micro-dose injectable or high-concentration transdermal that no commercial product provides.

Noorian explains the axis: testosterone injections supply exogenous testosterone, pituitary detects high serum T, suppresses LH and FSH, Leydig cells stop producing testosterone, Sertoli cells stop producing sperm. The intranasal route avoids this by mimicking the diurnal testosterone pulse — it rises quickly and then falls. Three doses per day produce three mini-peaks, and the troughs between allow the pituitary to resume partial LH/FSH signaling. The patient gets the mood, energy, and body composition benefits of testosterone while preserving some residual spermatogenesis. For cases where intranasal alone is insufficient, HCG can be added as adjunctive therapy to continue stimulating Leydig cells.

Nandrolone is classified as a Schedule III controlled substance alongside testosterone. Compounding pharmacies can legally compound it because it was previously an FDA-approved drug and because it appears on the USP/NF compendial list. Lyon describes a patient scenario where she had exhausted approved therapies and needed nandrolone for muscle mass — she initially feared DEA consequences for prescribing it. Noorian's reassurance: prescribers who use anabolics responsibly, with appropriate patient indication and biomarker monitoring, face essentially no enforcement risk. The risk is reserved for physicians who divert controlled substances to bodybuilder networks.

Empower Pharmacy operates as both a 503a compounding pharmacy and a 503b Outsourcing Facility. The newly acquired 503b facility in New Jersey is projected to produce 50 million vials per year. Noorian frames this as future-proofing access: if a single 503a pharmacy can no longer make a medication, having large-scale 503b capacity in the system means no patient loses supply.

Oral finasteride inhibits 5-alpha reductase type II, reducing serum DHT by ~65%. Because DHT is a neurosteroid (GABA-A receptor modulator), its global suppression affects brain chemistry — the post-finasteride syndrome documented in literature includes persistent depression, anhedonia, and sexual dysfunction even after drug cessation. A topical micro-dose applied to the scalp targets only follicular 5-AR, with minimal systemic DHT reduction.