T Nation

33 on TRT


#1


Age: 33
Height: 6'0''
Waist: 29''
Weight: 171lbs
Body: Lanky; probably ~ 12% BF (4-pack) 2xBW squat 2.8xBW DL
Facial Hair: 2 and a half year old beard. Full head of hair
Fat Storage: Waist and glutes. Legs are very lean. No obvious gynecomastia.
Rx/OTC: None, occasional excedrin for headaches/migraine

Lab Results: (what / [normal] / mine)
- TESTOSTERONE, TOTAL [332 - 896 ng/dL] 100
- Vitamin B12 EXT [145 - 915 pg/mL] 907
- TSH EXT [0.350 - 3.000 uIU/mL] 2.230
++ Complete Blood Panel
-WBC EXT [4.0 - 10.0 10³/µL] 12.4 SA=SIGNIFICANTLY ABNORMAL Result
- RBC EXT [4.5 - 6.5 10] 4.9
- HGB EXT [13.0 - 18.0 g/dL] 15.6
- Hct [40.0 - 54.0 %] 44.1
- MCV EXT [80 - 100 Æ?L] 90
- MCH EXT [27.5 - 34.7 pg] 31.6
- MCHC EXT [32.0 - 36.0 g/dL] 35.2
- RDW EXT [11.0 - 16.0 %] 11.0
- PLATELET EXT [150 - 500 10³/µL] 318
++ Metabolic Panel
- Sodium EXT [135 - 145 mEq/L] 142
- Potassium EXT [3.5 - 5.2 mEq/L] 4.2
- Chloride EXT [98 - 109 mEq/L] 103
- CO2 EXT [21 - 31 mEq/L] 30
- Glucose EXT [70 - 105 mg/dL] 75 Impaired Fasting Glucose when Fasting glucose is between 100 and 125 mg/dl
- BUN EXT [7 - 25 mg/dL] 24
- Creatinine EXT [0.70 - 1.40 mg/dL] 1.09
- eGFR EXT [>60 mL/min] >60
- eGFR, African American EXT [>60 mL/min] >60
- BUN/Creat Ratio EXT [3 - 40 Ratio] 22
- Calcium EXT [8.2 - 10.4 mg/dL] 9.9
- Total Protein EXT [6.4 - 8.9 gm/dL] 7.0
- Albumin EXT [3.5 - 5.7 gm/dL] 4.8
- Globulin EXT [2.0 - 4.0 gm/dL] 2.2
- A/G Ratio EXT [0.9 - 2.1 Ratio] 2.2
- AST (GOT) EXT [13 - 39 U/L] 22
- Alkaline phospatase EXT [34 - 104 U/L] 83
- ALT (GPT) EXT [7 - 52 U/L] 33
- Total Bili EXT [0.3 - 1.0 mg/dL] 0.4
++ Lipid Panel
- Cholesterol EXT [0 - 200 mg/dL] 167
- Triglycerides EXT [0 - 200 mg/dl] 238
- HDL Cholesterol EXT [23 - 92 mg/dL] 51
- Non-HDL EXT 116 *=Non-HDL goal: to be < 30 points above LDL goal
- Lipid panel Calc. LDL EXT [0 - 130 mg/dL] 68
++ Urinalysis
- Urine Color EXT Yellow
- Urine Appearance EXT Clear
- Urine S.G. EXT 1.020
- Urine pH EXT 6.5
- Urine Leukocyte esterase EXT Negative
- Urine Nitrite EXT Negative
- Urine Protein EXT Negative
- Urine Glucose EXT Normal
- Urine Ketones EXT Negative
- Urine Bilirubin EXT Negative
- Urine Urobilinogen EXT Trace (Normal)
- Urine blood EXT Negative
- Urine WBC EXT None
- Urine RBC EXT None
- Urine Squamous Epithelial EXT None
- Urine Bacteria EXT None

Diet: Intermittent fasting. Maintaining, averaging 2600 kcal/day, eat out 1x/wk otherwise home cooked meals. 1-3 caffeinated beverages/day. Typical day: half dozen eggs + tortillas; protein oatmeal, shake, trail mix, home cooked dinner w/family.
Training: Currently DUP, 3x/wk squat and bench, 1x/wk deadlift, 1x/wk accessory. Happy to post program but I don't think I'm overtraining.
Testes: Righty never 'grew up' and was noted by pediatrician. Lefty had a testicular cyst removed 6 years ago [non-cancerous]. Vasectomy 8 years ago.
Morning Wood: Not as hard but still frequent. Sex w/wife 3-4 times/week.

Health Conditions: Former chronic migraines extremely reduced by gluten free diet (celiac blood tests came back mixed. Did not pay for a genetic test). Spent 10 years on all kinds of drugs [anti-seizure, anti-depressant, blood pressure] prior to that for migraine pain management but have been 'clean' for 2+ years.

Symptoms: I didn't go to the doc suspecting low test, I went for a physical but with the following complaints:
- Night sweats 1-2x/month
- Brain Fog
- Verbal confusion and loss of words in conversation

Based on symptoms, both my doctor and I suspected sleep apnea. I had previously been diagnosed with apnea when sleeping on my back (low blood oxygenation) but fine on my side. Instead of a CPAP I decided to try and sleep on my side. Wife rolls me over 1-2x/week when snoring on my back. Doc thought maybe I was sleeping on my back more than we realized, but wanted to eliminate (1) thyroid (2) anemia (3) testosterone. See lab results above; test is absymally low, all other labs came back great (high WBC, recovering from cold)

This all came as a shock to me, really, because I'm a competitive powerlifter who is pretty strong and, I thought, pretty lean for my age. I have sex with my wife of 12 years 3x/week which is less than when we first married but still I think pretty good for a couple in their 30s where everything is familiar and whatnot, and with a couple pre-teen kids keeping us busy. I have a thick head of hair and a prolific beard. I coach my kids' flag football team. Basically you look at me and say 'no way' but yeah, way.

After reading more and reflecting since the diagnosis with my wife, I see the following additional symptoms that are likely related:
- Irrational irritability on occasion
- Work drive is a lot lower than it used to be
- Feel fatigued easier when stressed out about things
- Indecisive
- Fleeting interests, my wife calls them 'four day hobbies' where I get into something for a few weeks then lose interest.

I have a followup appt with doctor (internal medicine) on Monday to address some of my concerns, then we will proceed with 100 mg test injections.

My concerns:
+ Should we do a cortisol lab?
+ Should we do a LH/Prolactin test to try and figure out why?
+ High white blood cell count might not be getting over cold; could it indicative of an infection (or overtraining?) which may be causing low T?

I get it, my T is super low and needs to be treated, the human in me though is driven by stories and having a story to say why my T is low would make me feel better and let me put a bow on that chapter of my life.

Thanks for listening, anything else I should address with my doctor? Again trying to figure out 'why' is it possible the testicular cyst did something? We did ultrasounds before/after and blood flow was fine. I didn't notice an immediate effect of the surgery, but reflecting I can see that after the surgery my work drive depleted somewhat, and my desire for sex decreased to a point [I unhooked myself from a long standing porn habit easier than I thought I would have].

philip


#2

You want to check prolactin because a undetected prolactin secreting adinoma can press on your optic nerves.

Low T will lower HTC. When you do TRT, HTC should be around 48. If still low, suspect GI blood loss and do an occult blood test.

Please read these stickies:

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

AM cortisol + DHEA-S would be good for adrenal status.

You did not test estradiol E2.

During TRT you need to test:
TT
FT
E2
CBC
AST/ALT
hematocrit [HTC]

Nice job on the post! You can look forward to a huge improvement in quality of life if you can get a doc to do TRT right.
Doctors are the big problem and many are idiots.

Suggested TRT:
50mg T cyp/eth twice a week
250iu hCG SC EOD to preserve testes/fertility and prevent shrinkage and aching
.5mg anastrozole at time of injection and adjust to get near E2=22pg/ml, adjustment details in sticky
Your doc may want to wait and see what happens to E2 before Rx anastrozole. Most guys need this, some do not. And many docs will not even test E2 or Rx anastrozole unless you are above normal range. If we had pre-TRT E2 we could be a bit more intelligent about this.

Your symptoms are classic for low T. But many of those symptoms also come with low thyroid function.
TSH=2.3 is too high. Should be closer to 1.0
The range is misleading.
TSH could be elevated from not using iodized salt, which might then affect the whole family.
Please read the thyroid basics sticky.
Thyroid labs:
TSH
fT3
fT4 [please not T3, T4]


#3

Thanks KSman.

I’m still doing my crash course on TRT (diagnosis came 2 days ago) and will finish reading the stickies, along with two books I have lined up.

I do want my doc to check LH, prolactin and E2 prior to starting for reference points and to try and get a better handle on why.

My doctor seems supportive, he suggested TRT without my asking, my only concern is he doesn’t seem to have the same intellectual curiosity I have as to figure out why, he’s primarily concerned with treatment. But this is based off one email and phone call and maybe in person on Monday I’ll get a better vibe.

To be clear, you are suggesting I should go forward with TRT but also address a potential thyroid issue? Or do I need to fully check the thyroid out before starting TRT?

I do use iodized salt fairly liberally, and consume a few dozen eggs a week, half gallon of milk/week and seafood a few times a month. I’m a salt guy as opposed to a sweet guy.

Fertility is a non-issue, I’ve had my kids and had a vasectomy, is hCG necessary so long as I/the wife can deal with smaller testicles?

Thank you again,
philip


#4

[quote]philski wrote:
Thanks KSman.

I’m still doing my crash course on TRT (diagnosis came 2 days ago) and will finish reading the stickies, along with two books I have lined up.

I do want my doc to check LH, prolactin and E2 prior to starting for reference points and to try and get a better handle on why.

My doctor seems supportive, he suggested TRT without my asking, my only concern is he doesn’t seem to have the same intellectual curiosity I have as to figure out why, he’s primarily concerned with treatment. But this is based off one email and phone call and maybe in person on Monday I’ll get a better vibe.

To be clear, you are suggesting I should go forward with TRT but also address a potential thyroid issue? Or do I need to fully check the thyroid out before starting TRT?

I do use iodized salt fairly liberally, and consume a few dozen eggs a week, half gallon of milk/week and seafood a few times a month. I’m a salt guy as opposed to a sweet guy.

Fertility is a non-issue, I’ve had my kids and had a vasectomy, is hCG necessary so long as I/the wife can deal with smaller testicles?

Thank you again,
philip[/quote]

Some cases of hypogonadism have no known cause, hence the term idiopathic hypogonadism. My case has no known cause. There was no damage to my pituitary or testicles and I never did roids before TRT.

Your doc should check FSH and LH. You likely have secondary hypogonadism. If there’s no known cause it still has to be treated.

HCG is not necessary but many feel better on it, especially with sex drive and sensitivity down there. I feel a lot better on TRT plus HCG than TRT alone. I am using HCG now for fertility.

What kind of doc are you going to? I suggest, if possible, to go to a urologist with a fellowship in andrology. That is the sort of go-to person for all this and what my doc is.

Contrary to some here, an AI is not necessary for all on TRT. Many men, including myself, feel fine with estradiol at 50 or below.


#5

[quote]BrickHead wrote:
Some cases of hypogonadism have no known cause, hence the term idiopathic hypogonadism. My case has no known cause. There was no damage to my pituitary or testicles and I never did roids before TRT.

Your doc should check FSH and LH. You likely have secondary hypogonadism. If there’s no known cause it still has to be treated.

HCG is not necessary but many feel better on it, especially with sex drive and sensitivity down there. I feel a lot better on TRT plus HCG than TRT alone. I am using HCG now for fertility.

What kind of doc are you going to? I suggest, if possible, to go to a urologist with a fellowship in andrology. That is the sort of go-to person for all this and what my doc is.

Contrary to some here, an AI is not necessary for all on TRT. Many men, including myself, feel fine with estradiol at 50 or below. [/quote]

Thanks BrickHead.

My doctor specializes in internal medicine. Initially he was willing to start treatment without additional labs (making me question whether he really wanted to understand this or just treat it), but I pushed back saying that I had questions and he said he’d be happy to talk on Monday, and that I should wait to fill the Rx until then. So he seems responsive, I’m hopeful he’ll be on board with doing a few more labs (LH/FSH/E2 for sure, maybe prostate) just to get a clean slate of blood tests for reference prior to starting treatment, even if its idiopathic.

I am excited to get treatment. This was all quite out of left field but after more thoughtful reflection with my wife we do see a number of symptoms that weren’t obvious. We have sex 3x/wk but it does take a little longer to get him up (more foreplay, but the wife likes that so she’s never complained). I compare myself to my brother who has been lifting half as long as I have but has a lot more muscle mass and upper body strength, and I definitely had a lot more drive for work 5 years ago (full time job + full time dad + full time PhD) than I do today (full time work + half ass dad because I’m so worn out).

Thanks

philip


#6

I had my followup visit with the doctor last night, he agreed we should take LH/Prolactin/PSA prior to treatment so he drew blood and then we started treatment with 200 ml of T-cyp every 3 weeks. After 3 rounds we’ll retake T/E2/blood see how my body responds and adjust as needed. I told him ultimately I’d like to be shooting weekly to avoid any rollercoaster effect and he said that’s fine but to start he prefers the lower frequency…


#7

[quote]philski wrote:
I had my followup visit with the doctor last night, he agreed we should take LH/Prolactin/PSA prior to treatment so he drew blood and then we started treatment with 200 ml of T-cyp every 3 weeks. After 3 rounds we’ll retake T/E2/blood see how my body responds and adjust as needed. I told him ultimately I’d like to be shooting weekly to avoid any rollercoaster effect and he said that’s fine but to start he prefers the lower frequency…

[/quote]

Bitter sweet. Sounds like you have an inexperienced TRT doc on your hands.


#8

[quote]Davinci.v2 wrote:

[quote]philski wrote:
I had my followup visit with the doctor last night, he agreed we should take LH/Prolactin/PSA prior to treatment so he drew blood and then we started treatment with 200 ml of T-cyp every 3 weeks. After 3 rounds we’ll retake T/E2/blood see how my body responds and adjust as needed. I told him ultimately I’d like to be shooting weekly to avoid any rollercoaster effect and he said that’s fine but to start he prefers the lower frequency…

[/quote]

Bitter sweet. Sounds like you have an inexperienced TRT doc on your hands.
[/quote]

Because of the 3 week cycle?


#9

Partially.

Also, did you mention if he would provide an AI if needed?

Some need an AI and some don’t. You may not because you don’t have much fat on you. The problem if you do start to aromatize T to e2 is with an every three week injection, you’ll drown in estrogen when your T starts to fall which will make you feel worse than just having low T alone.

Also, was he willing to prodide hCG? Better to use at the forefront before atrophy sets in. Our testes provide additional functions aside from spermatogenesis.

Also, injecting every three weeks is idiotic. You’ll respond the same way as everyone else; you’ll feel great initially, probably for the first week. The second week you’ll feel like your old self and the third you’ll feel shitty. This doesnt vary on a person by person basis because we all respond similarly to test cyp and eth, with the exception of hyper metabolizers who have it much worse and need more at an increased frequency.

You need to convince him for weekly injections (ideally twice per week will provide the most stable levels), get your e2 checked after some time on TRT to see if an AI is needed and also press for hCG before your testes atrophy.


#10

[quote]Davinci.v2 wrote:
Partially.

Also, did you mention if he would provide an AI if needed?

Some need an AI and some don’t. You may not because you don’t have much fat on you. The problem if you do start to aromatize T to e2 is with an every three week injection, you’ll drown in estrogen when your T starts to fall which will make you feel worse than just having low T alone.

Also, was he willing to prodide hCG? Better to use at the forefront before atrophy sets in. Our testes provide additional functions aside from spermatogenesis.

Also, injecting every three weeks is idiotic. You’ll respond the same way as everyone else; you’ll feel great initially, probably for the first week. The second week you’ll feel like your old self and the third you’ll feel shitty. This doesnt vary on a person by person basis because we all respond similarly to test cyp and eth, with the exception of hyper metabolizers who have it much worse and need more at an increased frequency.

You need to convince him for weekly injections (ideally twice per week will provide the most stable levels), get your e2 checked after some time on TRT to see if an AI is needed and also press for hCG before your testes atrophy.[/quote]

After 9 weeks we take a blood panel/T/E2 levels and will start AI if required. Based on leanness and lack of gyno he said he’d wait for 9wk labs to make that call and that it may very well not be needed.

hCG is an option. I still need to learn more on why its important if I’m not planning on having more kids and I’m psychologically OK with shrinkage (Right testicle never grew up and has always been small, never bothered me).

I get the 3wk dosing is crap and I’m 100% with you, I’d rather do it weekly and I plan on pushing back on it as soon as I start feeling shitty. He said he has no problem increasing frequency if sides dictate it. I am logging daily and hope to be able to convince him sooner rather than later. (Once we get down to a round dose every week or every other week its easy, I think, to take half twice as often.)

TL;DR: I have a good relationship with the doc, experience dealing with docs and chronic conditions (had dealt with chronic migraines for 10+ years) and I’m willing to give him the benefit of the doubt for now but will not hesitate to switch docs if he isn’t accommodating to evidence.

philip


#11

UPDATE: Additional Testing prior to TRT:
PSA EXT 0.00 - 4.00 ng/mL 0.53
Prolactin 1.6 - 18.8 ng/mL 8.1
LH 1.7 - 8.6 mIU/mL 3.4

Labs updated online and my doc office isnt open yet; but seeing as Prolactin/LH are in range its probably secondary?

philip


#12

LH varies a lot over time. FSH is steadier and it a better indicator of LH status than LH itself. LH and FSH should be done together. It seems that you are secondary and prolactin is not the cause. You did not test E2 to see if that is a factor in your secondary hypothyroidism.