T Nation

40 Y/O New to TRT + HGH, Concerns About Prolactin & Liver Enzymes

In your case/thread opening post:
40 Y/O
6’ 1”
33” waist
190 lbs
Slender build, bit soft in the middle
Low and falling T (~300 total last test before TRT begun), long-standing fatigue issues

Fairly recently decided to give HGH a try to address fatigue and aging. Pre-HGH TSH level was in range (no other thyroid values available pre-HGH). Started taking 3.3 IU jintropin daily, but no significant impact on energy or physique. A few weeks in, bloods came back with below-range T4 (4.3 ug/dL), normal TSH (2.260 uIU/mL), normal T3 uptake (27%) and normal free thyroxine index (1.2). In response, started taking T4 (Thyroxine sodium) 100 mcg. More complete thyroid bloods pending (going to order FT3, FT4, rT3). Not sure HGH is doing much of anything (may have increased shoe size by 0.5)

Even more recently found a doc (urologist) willing to give TRT a go.

Doc (urologist) first prescribed Arimidex alone to raise T (from low 400s). Prescribed 0.5mg EOD. Went well at first (started feeling less lethargy), but within a few weeks my joints were so achy I felt 100 years old. Suspected too-low E2, ran my own bloods (in connection with HGH testing) and got back well-below-range Estradiol level of 5.9 pg/mL.

Complained to doc, who instructed me to stop Arimidex, and prescribed high-dosage progesterone cream (?) from compounding pharmacy. Applied nightly for one month, never felt much effect on lethargy, joints got slowly achy (not as bad). Follow-up bloodwork by doc showed total T falling to ~300. Doc prescribed 100 mg Test-Cyp 1x week, 500 mL HCG 2x week.

Happy to have Rx, and feeling a bit frustrated with the slow pace, I over-indulged and ran 125 mg Test-cyp 2x week (250 mg weekly) with the 500 mL HCG 2x weekly for the first three weeks. Also added Proviron (mesterolone) 50mg / daily to increase free-T and hopefully keep E2 in-range. Started feeling better, gaining weight (180-190, not noticably fatter, though - suspect water weight). Ran my own bloods, got out of range (> 1500) total test (expected closer to 1100, cutting back to prescribed dosage in anticipation of Dr.-ordered bloodwork), elevated out-of-range prolactin (~17 ng/mL), very high free T (~45 pg/mL - hooray Proviron!), and sky-high estradiol (~90 pg/mL). In response to high E2, resuming the .5mg Arimidex EOD.

My concerns are:

1- Where did the elevated prolactin come from? Doesn’t seem high enough to be a prolactinoma (this is my first prolactin test, in response to hearing the doc indicate that prolactin could be an issue we’d test for some day if the T didn’t help — I’m impatient and couldn’t wait to test). Does it rise with exogenous Test? Don’t think I pet any puppies or had any orgasm the day before the test.

2- Lab results for liver enzymes were very high: AST ~170 IU/L, ALT ~140 IU/L (reference ranges 0-40 and 0-44, respectively). This could arise from a few things, according to what I’ve read: liver damage (I hadn’t cut back on my 2-3 alcoholic drinks a day, but prior to HGH and TRT, my AST and ALT were within range at this level of drinking; Proviron/mesterolone is not 17a-alkylated, supposed to have low hepatoxicity; had been taking a single dose of NSAIDs every day for back pain), or possibly vigorous exercise causing muscle breakdown/repair (I’ve been lifting, but at a beginner stronglift 5x5 level, nothing impressive or even close to overtraining). In response to these numbers, I’ve cut out alcohol and NSAIDs for now, and dropped the Proviron (just in case). Will run these bloods again after taking a few days off of exercise to see what happens.

3- not too concerning, but other lab values out of range were platelets (high @ ~410 x10E3 /uL), Bun/creatinine ratio (low @ 8, Bun in-range @ 9, Creatinine in range @ 1.16 mg/dL), potassium serium (high @ 5.4 mmol/L), in case these are relevant.

Grateful for any input from the community on these issues (prolactin, liver enzymes) and suggestions for what other tests might be worth pursing (currently planning on getting a thyroid panel with free&total T3&T4, rT3 and TSH) and probably another lipid panel (have always been right at the very top of the total cholesterol range, a little above range on LDL).

Despite sky-high total and free T, didn’t feel much more energy than before. Maybe due to high E2?

This shotgun approach will always end in failure, more T is not always better. High E2 inhibits T’s effect on the body making you feel right back to low T symptoms. Where are all your pre-TRT labs?

The reason for your suffering has not to do with TRT but with your doctor, his is treating you like a guinea pig. The AI dose he had you on indicates he is clueless when it comes to TRT, man you’re all over the place. These TRT protocols are uncommon, unless you are a hyper T matabiliser 200mg weekly is wrong.

Standard starting dose is 100mg weekly split twice weekly unless you have high SHBG, AI aren’t usually prescribed unless there’s a need for one, this is where pre-TRT labs help. So let’s start out with labs including ranges. TSH should be closer to 1.0, most progressive doctors begin treating thyroid at 2.5.

TSH level before any intervention (tested because I complained of fatigue) was 2.85 uIU/mL.
TSH three or four weeks after starting HGH protocol was 2.26

Pre-TRT labs for test were all dr.-ordered and included only total T
April ‘17: ~400 (before beginning any intervention)
Nov ‘17: ~680 (based on Arimidex-only, but coupled with low E2 of 5.9 pg/mL, as above)
Jan ‘18: >1500 (based on 250mg Test-C weekly, in 2x 125mg injections, but coupled with high E2 of ~90, per above, based on no Arimidex)

Only SHBG data point is Jan ‘18, post-testosterone protocol, of 36 nmol/L (range 16-56)

Wasn’t a fan of the guinea-pig approach, but I’m glad to have finally found a doc amenable to writing a testosterone scrip (went through several doctors trying to find such a one), even if I had to let him try a few nonsensical approaches first.

In fairness to the doc, he ordered 100mg per week (as one 1.0mL injection of Test-C 200), the elevated rate is per my misplaced enthusiasm. Proviron is my own doing, not his Rx.

T4 (4.3 ug/dL), normal
TSH (2.260 uIU/mL), normal
T3 uptake (27%) and normal
free thyroxine index (1.2).

Anastrozole should have been 0.5mg per week maximum. Your doc does not really know enough. E2=5.9pg/ml was totally a known outcome of that dose.

Prolactin = ~17 +?range

Prolactin can be elevated from recent orgasm or cuddling {babies | puppies | kittens} - avoid for labs! Can also be high from some gear or meds [list].

You seem to be someone who does and has access to gear.

AST/ALT can be high from some liver conditions, some gear, sore or injured muscles - avoid training and have muscles fully recovered and test again.

What is your history with oral testosterone drugs or boosters? [liver]

Dehydrated for labs?

With perfect levels of sex hormones, thyroid will pull you low!

High E2 takes away energy, makes guys moody and bitchy, in part because it tanks libido. Target is E2=22pg/ml
Better to have labs in list format, easier to work with labs in list format, not buried in prose.

You can eval overall thyroid function via oral body temperatures as directed below. Also good for adjusting thyroid med doses.

Thyroid labs should be:
skip uptake and indexes which are now obsolete.

Fat gain and low energy easily explained by thyroid.

Post your oral body temperatures.

Thyroid problem could be from not using iodized salt or not using multi-vits that list 150mcg iodine + 200mcg selenium<–very important.

Post history of using above iodine sources.

Inject T twice a week to get reasonably steady T levels for anastrozole to work against and to allow lab results to be meaningful.

Take anastrozole at time of T injections, 1mg/week per 100mg T per week. So if injecting 50mg T twice a week, take 0.5mg anastrozole at that time.

Inject hGH subq, not IM and you will get better IGF-1 results.

250iu hCG subq EOD to preserve your testes.

Please read the stickies found here: About the T Replacement Category

  • advice for new guys - need more info about you
  • things that damage your hormones
  • protocol for injections
  • finding a TRT doc

Evaluate your overall thyroid function by checking oral body temperatures as per the thyroid basics sticky. Thyroid hormone fT3 is what gets the job done and it regulates mitochondrial activity, the source of ATP which is the universal currency of cellular energy. This is part of the body’s temperature control loop. This can get messed up if you are iodine deficient. In many countries, you need to be using iodized salt. Other countries add iodine to dairy or bread.

KSman is simply a regular member on this site. Nothing more other than highly active.

I can be a bit abrupt in my replies and recommendations. I have a lot of ground to cover as this forum has become much more active in the last two years. I can’t follow threads that go deep over time. You need to respond to all of my points and requests as soon as possible before you fall off of my radar. The worse problems are guys who ignore issues re thyroid, body temperatures, history of iodized salt. Please do not piss people off saying that lab results are normal, we need lab number and ranges.

The value that you get out of this process and forum depends on your effort and performance. The bulk of your learning is reading/studying the suggested stickies.

Thank you very much for the thorough response.

I’ll try to address your questions in order:

Prolactin of ~17 was just above a lab-specified range of 4.0-15.2. Other than what’s specified in the OP, no other Rx (at least not recently, I have a history of imitrex for migraines, but no longer need it very often) or gear (never used any before except what’s specified above). Certainly no deca / tren or other such gear known for prolactin elevation (my familiarity with these comes from my recent research into T and other hormones, but haven’t ever used them). Only Test-C and Proviron (and HGH + T4).

My concern with the elevated AST/ALT values stems from my expectation that Proviron (the only gear or booster I have ever done, and only recently begun) was among the safer oral steroids (not being 17a-alkylated), and my expectation that I couldn’t have caused these highly-elevated levels from my level of excercise, given how pathetic my workouts must seem to someone who doesn’t struggle with constant fatigue (as in, squatting ~150lb 5x5). I have been struggling with some shoulder pain (I kept trying to workout as my E2 levels had fallen, and in November suffered some shoulder injury doing low-weight bench pressing, that at first made rolling over in bed really painful, and which has healed so slowly that I still can’t do a single chin-up, and still frequenctly, but not always, find bench press too painful to perform) — hadn’t thought of the connection before you mentioned “injury” in addition to fatigue — would something like this (impingement, maybe) explain levels that high, do you think?

How long would you recommend avoiding the gym prior to giving blood to remove this factor (exercise-induced muscle damage) from the liver testing? Is one week sufficient?

Blood-specific test results:

11/17 (before test-C, post-HGH)
RBC 5.23 (range 4.14 - 5.80 x 10E6 / uL)
Hematocrit 45.3 (range 37.5 - 51 %)
Platelet 307 (range 150 - 379 x10E3 /uL)

1/18 (post test-C & post-HGH)
RBC 5.20
Hematocrit 45.4
Platelet 414

I honestly can’t say whether I would have been dehydrated for labs. I live in a dry climate, and probably don’t drink enough water, so it’s possible. Which values would dehydration impact?

Regarding iodine, I’ve added a kelp supplement (133 mcg) to my daily multivitamin routine (also includes D3, B6, B12, C and milk thistle, plus melatonin at night). Have purchased some lugol’s 2% and some selenium supplement in response to some reading from the stickies here.

Although the doc prescribed one shot a week, I had by then learned enough to know that would be a bumpy ride with the cypionate ester, so have been doing 3.5 days spacing (Thurs morning and Sunday evening), althoguh at my sua-sponte elevated dosage (which I have stopped, and am letting ramp down to an amount expected by the doc for official bloodwork, per the halflife calculations available at steroidcalc.com).

Appreciate the dosage suggestions for HCG and Arimidex. How long would you expect I’d need to maintain that proposed Arimidex dosage before E2 is stable enough to retest (to see if I need to adjust)?

I’ve been doing my HCG sub-q, despite Dr. instrucitons, based on what I’d read online about preferred route of administration. I note that your suggested dosage (250 EOD) is less (summing to 875 / week) than the Dr. dosage (500 2x weekly summing to 1000 / week) although adminstered with greater frequency. Although unlikely to conceive again, I’m all about keeping the boys functioning (pregnelone, etc.) and aesthetically pleasing (well, to the extent a ball-sack can be) — is the half-life on HCG really that short when admininstered sub-q?

Oral temperature first thing this morning was 96.9 — last night before bed was 98.3