T Nation

28 YO Male About To Begin TRT 9/30


#1

Hi all,

First off, I really appreciate all the information and guidance you all have been providing free of charge. I've been lurking here for the past few weeks, and in that very short time your opinions, analysis and experiences have proven EXTREMELY helpful in my attempts to change my life.

Short bio data - I am a 28 YO male, 5-11, and 339 lbs (down from 415 in January of this year, and 394 on July 1st of this year). I am currently following an ultra low-carb diet (<20 grams of carbs / day) to lose weight, as well as exercising 5x a week for 50-60 mins on an elliptical trainer.

Starting about 10 years ago, I began feeling totally exhausted, foggy-headed, and just "out of it" pretty consistently. My academic performance suffered greatly - once a fantastic straight-A student, I graduated college with barely a 2.7 GPA. I had no sex drive (frankly, I didn't even know what a sex drive was until this year, when my therapist asked if I'd ever had a girlfriend). I had a great group of friends that stuck by me even as I slowly withdrew from all social activities, always complaining that I was exhausted or just "not feeling up to" doing things that should have been fun and exciting for me. I took up smoking cigarettes, drinking copious amounts of coffee, and just generally chastising myself for not being able to keep up with my peers, and this turned into a variety of really negative thoughts/self-talk that I am currently in CBT to get a hold of.

Somehow, even with all this going on, I was able to push through and get a pretty good job after graduation...which lasted all of 3 years, with my mental/physical state continuously deteriorating, until I quit and proceeded to spend the next 2.5 years literally locked in my apartment, overeating and sleeping at odd hours of the day, avoiding everyone I knew (including family), and just generally being depressed and exhausted.

Jan 1st of this year I moved home in an attempt to figure out what the hell was going on with me. My thyroid/blood/blood sugar was checked (everything normal - even at 415 lbs), I was told I was depressed, and began psychotherapy and taking Wellbutrin 300mg daily in May. I also discovered I had severe sleep apnea, which is now being successfully treated with an APAP machine (according to the data the machine keeps, my sleep is now perfect, with no apnea events so long as I am sleeping with the mask on). I have been using the APAP since June 1st of this year, and although it reduced some of the daily exhaustion I have, I am still brain-fogged, unmotivated, and mostly just dog tired all the time.

On the advice of my therapist, in early September she suggested I get my testosterone levels checked, as my symptoms seemed to correlate well with low testosterone. Lo and behold, my levels were extremely low - 250 - and my GP immediately ordered more tests as well as informing me that he wanted to put me on testosterone cyprionate injections of 200 mg 2x a month. After reading up here, I asked him to order some more tests before we started with injections, thinking that it would be best to have as much information as possible before starting with such a serious program.

Below are all of the tests I've had done so far - they are all within the past month, and hopefully they will be of some assistance. Additionally, I have been taking my waking body temperatures this past week, and literally every single morning the past 7 days the value has been 96.9 F - no change day to day.

Testosterone / Other Hormone Tests

Testosterone: 2.5 (2.2-7.8 ng/ml)
Testosterone Free: 55 (30-140 pg/ml)
SHBG: 28 (13 - 90 nmol/L)
Estradiol: 38 (0-47 pg/ml)
Prolactin: 6 (0-14 ng/ml)
FSH: 3 (0-14 mIU/ml)
LH: 6 (0-14 mIU/ml)
PSA: 0.4 (0-4.00 ng/ml)

Comprehensive Metabolic Panel

A1C: 5.5% 4.0-6.0%
Sodium: 135 135 - 145 mEq/L
Potassium: 4.0 3.6 - 5.2 mEq/L
Chloride 100 98 - 108 mEq/L
Carbon Dioxide 25 22 - 32 mEq/L
Anion Gap 10 4 - 12
Glucose 82 62 - 125 mg/dL
Urea Nitrogen 12 8 - 21 mg/dL
Creatinine 0.91 0.51 - 1.18 mg/dL
Protein (Total) 7.3 6.0 - 8.2 g/dL
Albumin 4.0 3.5 - 5.2 g/dL
Bilirubin 0.4 0.2 - 1.3 mg/dL
Calcium 9.7 8.9 - 10.2 mg/dL
AST (GOT) 17 9 - 38 U/L
ALKPHOSPHATASE 74 35 - 109 U/L
ALT (GPT) 16 10 - 64 U/L

Thyroid

TSH: 1.67 (0.4-5.000 uIU/ml)
Triiodothyronine (T3): 93 (73 - 178 ng/dL)
Thyroxine (T4) Free: 1.2 (0.6 - 1.2 ng/dL)

CBC (Hemogram)

WBC 11.08 4.3 - 10.0 THOU/uL
RBC 4.95 4.40 - 5.60 mil/uL
Hemoglobin 14.1 13.0 - 18.0 g/dL
Hematocrit 42 38 - 50 %
MCV 85 81 - 98 fL
MCH 28.5 27.3 - 33.6 pg
MCHC 33.5 32.2 - 36.5 g/dL
Platelet Count 373 150 - 400 THOU/uL
RDW-CV 15.0 11.6 - 14.4 %

Current Prescriptions / Vitamins

Wellbutrin 300 mg (Daily)
Vitamin D 5000iu (Daily)
NOW Foods Multivitamin (Daily)

There is a family history of goiter and general thyroid issues in my family (mother had a small goiter and is diagnosed hypothyroid, grandmother had a goiter, father had two small thyroid nodules). I was once a very skinny kid, and then suddenly, out of the blue, got fat around 8 years old. I have always carried most of my fat in my chest (have had manboobs since 8, they are massive now), and didn't really start growing a gut until partway through college, when I ballooned from 240 to 300 lbs. Additionally, I was a very active kid and played soccer, ran track (believe it or not, I was a hell of a sprinter even being overweight), and football, until a devastating knee injury my Junior year of high school (Posterolateral Knee Dislocation - ACL, PCL, LCL, meniscus all torn, hamstring torn from its anchor behind the knee, shattered fibula, secondary damage to the peroneal nerve resulting in foot drop that I deal with to this day).

My questions are as follows:

1) Does the treatment protocol my GP wants to start me on (200 mg Test Cyprionate Injections every 2 weeks) make sense given the above data?

2) Are my waking temperatures abnormally low? (96.9 on the dot every day the past 7 days) Should I start on Iodoral?

3) What else should I be doing diet / exercise / life-wise to get this weight off, start feeling better, and get my life back?

4) Does anything in my test results pop out at you as something to investigate (besides the low testosterone result)?

Thank you all again for all your help. I'm hoping to learn as much as I can from you, and contribute what I can to others as they join this site and I increase my knowledge.

Best,

-battleinseattle


#2

Do you and your family have a history of not using iodized salt? What is your history of that?
You need to get thyroid issues resolved to feel right and correct weight. Symptoms if hypothyroidism are largely the same as low-T.

TSH: 1.67 (0.4-5.000 uIU/ml)
Triiodothyronine (T3): 93 (73 - 178 ng/dL)
Thyroxine (T4) Free: 1.2 (0.6 - 1.2 ng/dL)

TSH should be nearer to 1.0
T3 is low, should be near mid range
fT3 is really what should be tested, it is what gets the job done
fT4 is above mid-range. Is range above correct? https://en.wikipedia.org/wiki/Thyroid_function_tests#Free_thyroxine

Please read these stickies:

  • advice for new guys
  • things that damage your hormones
  • protocol for injections
  • finding a TRT doc

Protocol:

  • self inject 120mg T cypionate per week with two 60mg injections per week. I have increased recommended due to body weight
  • inject 250iu hCG SC EOD
  • 0.5mg anastrozole at time of T injection

TRT will probably make storing/apnea worse, but that will be offset by weight loss

You need these labs:
AM cortisol
IGF-1
rT3
DHEA-S
fasting cholesterol [might be too low] - drink water, don’t be dehydrated

You are very estrogen dominant now, so anastrozole is a must for your TRT. One could argue for tinkering with E2 and thyroid and avoiding TRT, but in this case with your history, I think that TRT is the best approach.

Also read the ‘hormones and health’ thread. It has bearing on your weight and metabolism. Your starvation diets are wrong and elevated rT3 can be a result as well as epigenetic changes. You need to restore your metabolism, not starve to death.

Nice writeup! 4 stickies to read and one other thread.


#3

Thank you for your very detailed reply, KSMan. Below are my responses to your questions/requests.

“Do you and your family have a history of not using iodized salt? What is your history of that?”

My parents/grandparents grew up in and immigrated from a very poor, mountainous country with a known population-wide issue of goiter/iodine deficiency/thyroid issues. I was born here in the US though, and have lived here all my life. We have always used Morton Iodized Salt when cooking since I can remember (that iconic illustration of the girl with an umbrella is tough to forget), and have never shied away from using salt in general in our meals.

“fT3 is really what should be tested, it is what gets the job done”

I will request this test from my GP today.

“fT4 is above mid-range. Is range above correct?”

Yes, the range is correct…the test was performed by the University Of Washington Medical Center if that’s of any use. All of my doctors are under the UW umbrella.

The UW standard range for fT4 is listed as 0.6 - 1.2 ng/dL, and I tested at 1.2ng / dL.

"Please read these stickies:

  • advice for new guys
  • things that damage your hormones
  • protocol for injections
  • finding a TRT doc "

Will do!

“You need these labs:
AM cortisol
IGF-1
rT3
DHEA-S
fasting cholesterol [might be too low]”

I will request these labs from my GP today. My first testosterone injection is scheduled for Wednesday at 8am - most likely I won’t get the lab orders for these tests approved until Wednesday (my GP is usually a 1-1.5 Business Day turnaround for my requests). Will the injection interfere with the usefulness of the data from these tests?

“drink water, don’t be dehydrated”

I currently drink a minimum of 1 gallon of pure water every day. On warmer days, I take it up to 1.5 gallons. I don’t drink any sodas (regular OR diet), and drink 3-4 cups of coffee with heavy cream a day.

“Also read the ‘hormones and health’ thread.”

Will do!

“Your starvation diets are wrong and elevated rT3 can be a result as well as epigenetic changes.”

I should have elaborated on my current diet in my original post. I eat pretty much the same things every day (I don’t get bored of food, and the Wellbutrin has seriously reduced the “reward” aspect of the food that I do eat). I track every single thing that goes into my mouth religiously on Myfitnesspal, and have been doing so since July 17th. Below is my usual day of eating.

Breakfast:

2 oz roasted salted almonds (Blue Diamond Brand)
2 sticks Trader Joe’s full-fat string cheese
2 cups of coffee with 4 tablespoons of heavy cream (no sweetener, always hated sweets)

Lunch

*1 cup of coffee with 2 tablespoons of heavy cream
*Jimmy John’s Big John Unwich with Provolone, Mayo, Onions, Lettuce, Dijon, Tomato, Oregano (I have this maybe 2x a week maximum - eating during the day makes me extremely tired, and I am currently working with my sleep doctor to totally eliminate naps to rationalize my sleep schedule and figure out if my continued exhaustion is a circadian rhythm problem, or something else entirely. No naps for the past 2 weeks, so been successful so far, but extremely tired and I usually can’t risk eating because the urge to sleep/inability to be productive afterwards is so powerful).

Afternoon Snack

*1 cup of coffee with 2 tablespoons heavy cream

Dinner

*3 4oz servings of Chipotle Chicken OR Steak
*Extra large serving of Chipotle lettuce
*8-12 oz of Chipotle Pico De Gallo (Tomatoes + Onions + Cilantro)
*8 oz of Chipotle Guacamole (Avocado + Onions + Salt)
*EITHER 8 oz of Chipotle Sour Cream OR 6 oz of Ken’s Creamy Caesar Dressing

My total calories per day hover in the ~2500-3000 range. The lowest it gets is usually 2300, and that’s if I don’t eat almonds / cheese or switch from the caesar dressing to sour cream, etc.

My net carbs per day hover in the 20-40g range, depending again on almond intake, gucamole intake, sour cream vs caesar dressing, etc.

My total protein per day hovers in the 140-170g range.

My total fat per day is almost always 200g+.

The exercise that I do (50-60 mins on the elliptical 5x a week) burns anywhere from 750 calories to 900 calories per session according to the machine (it asks for my weight and age, I assume it has some sort of algorithm that adjusts its estimates of calories burned based on that information). The variation in calories burned is due to variations in the length of my sessions + variations in resistance levels that I set the machine at.

Regarding my GP (he’s the one running the TRT show for me), he seems receptive to alternative viewpoints, new information, etc. (he hasn’t fought me in the least on all the tests I requested after the low total testosterone result). However, when I met with him last week, I mentioned Arimidex and doing injections at 100 mg/week instead of 200mg/every two weeks, and he resisted pretty strongly. I wasn’t confident enough to challenge him then (and frankly was happy just to have someone willing to do injections) - do you have any tips on how to overcome his objections? Below is a summary of what he said to me.

Injection Protocol

*“We will necrotize your fat tissue and cause an abscess if we inject any more often than 1x every 2 weeks”
*“I only inject in the buttocks” (This is after I asked if we could do thigh injections)

Arimidex/Anastrazole

*Why do you need that? We don’t want to close that pathway (??? Lol)
*Of course your Estrogen will rise when we inject testosterone, that’s to be expected (when I asked about the potential of feeling even worse than before with a post-T injection spike in E…mind you this is all before I got back my Estradiol test results)
*Well, what we’ll do is inject every two weeks until your weight gets down to around 280, and then we’ll take you off it and see how you do (When I asked what the plans for treatment were moving forwards, how we’ll tweak stuff, regularly scheduled labs, etc.)

OK, I think I’ve bombarded you with enough information and questions for now. Again, I am truly very thankful for the time that you’ve put into helping me with all this. Time to request these labs and re-read the stickies you mentioned!

Best,

battleinseattle


#4

That iconic illustration of the girl with an umbrella is tough to forget
BUT, moron non-iodized salt has the same packaging that can be be misleading.

T injection will not affect those labs.

Pure water? Do not drink RO water, you need the minerals. Carbon filtered is good.

We often refer to docs like yours as idiots.

You can read this: https://tnation.T-Nation.com/free_online_forum/sports_training_performance_bodybuilding_trt/stupid_things_that_docs_do_and_say

I wonder if someone printed that and presented to their doc …


#5

Thank you again for your reply KSMan. Your help is invaluable.

Below are my responses to your questions/comments

“That iconic illustration of the girl with an umbrella is tough to forget
BUT, moron non-iodized salt has the same packaging that can be be misleading.”

I checked our cupboard last night, and we do use the iodized salt. Also checked with my parents about whether they’ve ever bought/used any different salt from that - my mom says she was instructed specifically to only use iodized salt by her doctor ~20 years ago, and hasn’t ever changed it up.

“T injection will not affect those labs.”

Good to know. Thank you.

“Pure water? Do not drink RO water, you need the minerals. Carbon filtered is good.”

Ah, my fault here. I meant I don’t add any flavorings, carbonate it, etc. Its straight up unfiltered Pacific Northwest tap water that I’m drinking.

LOL at the link you posted. Wow, I’m counting myself lucky just to have a doctor that’s OK with injecting T and not a total egotistical blowhard…

Again, thanks for your help. I’ll keep you posted on what my GP says about the changes I want to make to his planned TRT approach.

Best,

battleinseattle


#6

“my mom says she was instructed specifically to only use iodized salt by her doctor ~20 years ago”

OK, finally and first report of a doctor dealing with the iodine question!


#7

Hey KSMan,

I had my first testosterone shot of 200 mg Testosterone Cyprionate this past Wednesday (9/30). I haven’t really felt any different yet - is there a semi-standard timeframe for when guys starting therapy begin to feel the effects?

Per your recommendations on an injection protocol, my GP was actually fairly receptive to my concerns about biweekly injections of 200mg being a hormonal roller coaster ride, and was also receptive to my explanation of why Arimidex is especially necessary in my case (high levels of estrogen, large amount of body fat, historically collected fat in my chest + gyno since I was ~ 8 years old). However, he wasn’t comfortable prescribing the Arimidex to me, because he’s never prescribed it to anyone else that he’s put on testosterone - so he ended up giving me a referral to an endocrinologist in the UW Medicine system, and I should be hearing back from them on Monday about when I can get in for an appointment. Additionally, so long as the endocrinologist gives him the OK, he’s willing to go to weekly injections of 120mg Test Cyprionate, as well as adding HCG to the protocol. I didn’t ask about self injecting - he’s been very easy to work with thus far, and I figure I should let things progress as they are for at least a few weeks before broaching that subject with him.

As far as the additional tests you recommended (AM cortisol, IGF-1, rT3, DHEA-S, fasting cholesterol), I’ll be hearing back sometime this week about whether my GP was able to get them approved by my insurance. If not, I’ll go ahead and pay out of pocket - but I figure its better to see if I can get them on the hook for it first!

In the meantime, if you’ve got any other recommendations, I’m all ears. Really excited to get things moving over here.

Best,

battleinseattle


#8

In some cases, out of pocket costs for labs are cheaper than the co-pay on inflated labs costs.


#9

KSMan,

Fantastic news! I just had an appointment yesterday with an endocrinologist (I was referred to him by my GP after asking about changing the treatment protocol, adding Arimidex, etc.), and he will now be taking over my TRT.

He is fully on board with me going to weekly injections of 100mg Test Cyprionate (my GP had me on 200mg every 2 weeks), is more than willing to prescribe Arimidex if my lab values come back 2-3 weeks from now with elevated Estradiol, and is going to see if he can work with my insurance to get me on HCG injections. Additionally, he ordered a pituitary MRI for me because of my young age, slightly low FSH, and what he called “catastrophically low testosterone”, lol. He was amazed at my gym routine and just general ability to force myself to get things done given my current levels, and I think it helped him to take me seriously because I’ve lost so much weight in the past several months (415 Jan 1 of this year, ~400 June 1st, now 323 lbs).

The best news is, he actually recommended that I begin self injecting - and this was without me asking. He literally said “you’ll probably be on this for life, and there’s no way I’m going to force you to waste 2 hours a week getting to the doctor’s office for something you can do yourself.” He prescribed me testosterone along with the necessary needles, etc., and I’ve got an appointment with a nurse in his office next Wednesday (Oct 28th) to learn how to self-inject, and to do my first self-injection of 100mg test cyprionate (I’ve had 2 200mg injections thus far, on Sept 30 and Oct 14th, so this will be the beginning of the new protocol).

Additionally, when we do a lab midweek after my first 100mg injection, he’s willing to adjust the dosage upwards if the levels aren’t where we want them, or if my symptoms don’t continue to improve (your recommended protocol was 120mg/week given my current weight and levels of body fat). I told him I’m shooting for total T of at least 700, given the average T levels of a man my age, and he was completely OK with that. On top of all this, per symptoms, if the weekly dose still causes the “hormonal roller coaster effect”, he’s perfectly happy with me going to an E3D protocol, and will prescribe more needles so I can do that.

As far as how things are going so far, my performance in the gym has markedly improved in just the past couple of weeks after only 2 200mg injections. I started weightlifting in the evenings on Oct. 1st (in addition to the morning elliptical trainer sessions I’ve been doing for the past several months), and just as an example, after only 6 upper body sessions so far, my 8-rep chest press has gone from an unbelievably low 75 pounds to 150 pounds. I’ve got some intermittent morning wood (never had that before), and its definitely getting easier to focus and do intellectual tasks by the day. This stuff is definitely working!

KSMan, I can’t thank you enough for all your help. The knowledge you shared allowed me to ask the right “leading questions” that got me the responses and the treatment necessary, and allowed me to feel much more confident in advocating for myself throughout this process. Please let me know if you have any additional questions, advice, etc. given what I’ve shared thus far - again, you’ve been immeasurably helpful, and frankly, we should be paying you for your hard work.

Alright, hope you’re doing well.

Best,

-battleinseattle


#10

You need to be injecting with a #29 0.5ml [50iu] 1/2" insulin syringe.

Doctor’s office will probably use something huge.

At Walmart/Sam’s for ~$14 you can get a box of 100 insulin syringes, their Relion house brand [that appears to be made by BD]

Did you read?
Please read these stickies:

  • advice for new guys
  • things that damage your hormones
  • protocol for injections

Review my prior posts and thyroid related, suggested labs etc.

What did you do re iodine?

still need fT3, rT3 data
Your low body temperatures indicate a thyroid function problem


#11

Hi KSMan,

First off, I want to apologize for the delay in getting back to you. My previously operated on left knee decided to go absolutely haywire the day after your message (severe pain, swelling, locking, etc.), and I’ve just now managed to get the pain under control and will be going in for an MRI this Friday to see what’s going on (ultrasound and x-rays showed only mild osteoarthiritis in the joint, which is right on schedule given that the knee was operated on ~12 years ago, but the length and severity of the pain/swelling don’t look like a typical OA flare to my ortho doctor) Currently taking 75mg indomethacin daily to bring the pain/swelling under control, and it finally seems to be working.

Below are my responses to your questions…

“You need to be injecting with a #29 0.5ml [50iu] 1/2” insulin syringe."

My doctor prescribed me #21 1" needles for injections - I self-injected last week in my thigh and again today with no issues…I haven’t felt any “roller coaster” effect since going to weekly 100mg injections, so am OK with sticking with this for now. I’ve got a blood draw scheduled for this weekend to check my levels at the midpoint between injections, and my doctor is OK with me moving to E3D or a higher dosage if levels come back lower than we want them.

"Please read these stickies:

  • advice for new guys
  • things that damage your hormones
  • protocol for injections "

Have read all three - actually saved to my desktop and use them as reference guides when dealing with my endocrinologist!

“Review my prior posts and thyroid related, suggested labs etc.”

I requested the labs you recommended (IGF-1, rt3, Free T3, AM cortisol, fasting cholesterol). My endocrinologist messaged me yesterday shooting down my request - he said that he is happy to discuss further, but doesn’t think that they’re medically necessary. However, he approved adding estradiol to my upcoming blood draw to check midpoint T levels, and doesn’t have any problem prescribing an AI if those values come back high. Not sure where to go from here - I’m going to use your stickies + other research that’s out there on cortisol, IGF-1, etc. to try and put together a case, but I also don’t wan’t to risk messing up a pretty good relationship with this endo given the horror stories I’ve heard about others…But hey, you’re the expert here, so any advice you have here would be much appreciated.

Additionally, I had a brain MRI w/contrast done last Thursday, and the results came back negative for any sort of pituitary tumor or other weirdness going on there. Just thought you’d want to know.

“What did you do re iodine?”

I’ve got a bottle of 90 Iodoral tablets sitting on my desk as I type this. I held off on starting on it, wanting to get as many labs done as possible & see how the T replacement went, but since I’ve met resistance from my endo, I’m seriously considering beginning the iodine protocol you’ve outlined in your stickies. Let me know if you think this is a good idea…

“still need fT3, rT3 data
Your low body temperatures indicate a thyroid function problem”

Yeah, need to work on putting together a case for getting those labs approved by my endo (addressed above).

OK, so that’s where things stand. Again, I really appreciate your help, and I’m sorry for the delay. Hope all is well with you.

Best,

battleinseattle


#12

You can order your own labs on the WWW and pay out of pocket.

#21 is insane when the muscle damage/scaring can be mostly avoided.


#13

If you have troubles getting an anastrazole prescription and don’t want to order them online PM me if you need a doctor recommendation