T Nation

43 y/o Fat Dad, My Story


#1

I'm 43, 5'10", and 260lbs obese. I became a father 3 years ago, and since then I've experienced significant loss of libido, ED, and weight gain. I can't have sex without viagra or cialis. About a year ago, I started seeing a personal trainer, doing a mix of weights and cardio, mostly weights, because I meet the trainer MWF for weights, and I'm supposed to do cardio on T and Th (what ends up happening is I just meet the trainer MWF and don't do any cardio!) But I've been pretty good about the training routine MWF for a year, and have been puzzled at the lack of improvement. I mean, there was an initial moderate jump in strength and muscle mass in the first month, but I've been on a plateau ever since. I'm on a low carb type diet, with variable compliance, but end result it's one year later and I gained 10 lbs. Years ago I used to be able to rip off the pounds when I low carbed it, but it's as if it's not working any more. That said, I do feel better now than I did before I started training.

So about a month ago I see a primary care physician, because I haven't seen one in over a decade, and I'm 43 and obese and people are depending on me. He runs a bunch of tests.

In summary:

I have mild hypertension. For that I'm on a low dose of quinapril (an ACE inhibitor) and I added 200 mg of CoQ10 which is also supposed to help with that.

I'm obese. The doc put me on Victoza, which is FDA approved for Type 2 Diabetes. (I don't have diabetes.) He says it will help me lose weight. It's an off label use, but so far it appears to be working. I lost 8 lbs in a month without trying especially hard, so I'll keep using it as long as it's working.

But this is the TRT forum, right? So I'll get to the meat of the story.

My total testosterone was 173 ng/dL. It was in the mid afternoon when they drew my blood, though, so the doc recommended I repeat it in the early A.M. (Testosterone levels peak in the early morning.)

I repeated it at 8:30 a.m., and it was 191 ng/dL. Still pretty low.

In the meantime I'm tearing up the internet reading everything I can find, experiencing an epiphany, as I had just discovered what ails me. Among other things I discovered the TRT forum on T-Nation. I called my doc and told him I needed Free Testosterone, Estradiol, LH, FSH, and while we're at it let's do the Total Test one more time, because I want to be sure. He says that's fine let's do the labs, but this is beyond my level of expertise and I think you should see a urologist who is the only local doc specializing in testosterone deficiency.

The latest labs with reference intervals(also early A.M.):
TT 199 ng/dL (175-781)
FT 0.69 ng/dL (0.95-4.30)
Estradiol 42.9 pg/mL (20-75)
FSH 1.97 mIu/mL (1.0-12.0)
LH 1.16 mIu/mL (1.24-8.62)

I saw the urologist today. The interesting thing is that he's on TRT himself, using Androgel, which is what he wanted to give me. I showed up hoping to persuade him to prescribe KSMan's recommended triple protocol of twice weekly injected SQ T, SQ Hcg and PO Arimidex. He was an easy going guy and listened to me, but only compromised a little. He's letting me do once weekly subQ T cyp, 100mg. And I think that's because I brought copies of the two abstracts (Greenspan, and Al-Futaisi) that supported subQ injection of T once weekly.

He thinks the Hcg is unnecesary at physiologic doses of T in a man who doesn't plan on having more children, and if I was concerned about preserving fertility, he'd be giving me Clomid and not Hcg. (The disadvantages of Hcg he brought up were cost, and the fact that it had to be injected.) And he says on Androgel himself he hasn't experienced any atrophy of the balls, and only a small fraction of his patients have had an issue with that, and again he prescribes Clomid for that purpose. So I wasn't getting anywhere with Hcg. (Why the bias against Hcg?)

With respect to Arimidex, he's familiar with it's use in this context, but he wasn't so sure my E2 should be considered high. He says we'll consider that later if my E2 levels go up, if I have symptoms related to the E2 or if I don't get the expected results from the TRT.

He drew my blood today for a prolactin level, and instructed me to start the T today (Tuesday), and to get my blood drawn for FT and TT tests on Friday (I guess a peak level), and then again on Tuesday before I inject (the trough level.) He'll discuss those results with me by phone when they come back, and he wants to see me in the office again in 3 months.

So at my Walmart pharmacy I pick up the Test-c. $20 copay. It's the 200mg/mL concentration, in a 10mL bottle. There are no needles in the bag, so I ask for 29 gauge 50IU insulin syringes as recommended elsewhere in this forum. The pharmacist is highly skeptical, because a) I shouldn't be injecting Test subQ, and b) the needle gauge is too fine and it will be too hard to draw up and inject, and I'll probably break the syringe if I try. I'm full of self-doubt, but I decide to trust in the forum, and I insist. He relents and gives me the syringes, with an exasperated look I interpret as "dumbass."

I thought about doing a Youtube video at this point, but talked myself out of it, so you only get the written version.

So I get home, settle into my home office and lock the door so the wife and kids can't bother me. I examine the goods. I briefly entertain backfilling the syringe, as has been suggested by someone on this forum, but decide not to. I pick a spot on my flabby belly and swab it with an alcohol swab. I pop the lid on the test-c, swab the rubber, draw the syringe to .50mL, insert the syringe into the inverted bottle, and slowly inject .50mL of air into the bottle, then draw. It's too easy, I go too fast or something, and somehow air bubbles get into the syringe. Only about .20mL of liquid drew up. So I tap the bubbles to the top, reinject the air, until only liquid remains in the syringe, then draw again as slowly as possible, this time drawing up .50 mL of liquid. I insert the needle into to my fat belly, and it hurts, much worse than I was expecting for a 29g needle (perhaps they're cheap needles?) but once I get through the skin it's not so bad, and the .50 mL is easy to inject. All done. The injection site still hurts, but I see no bruising or anything. I think that perhaps the pain was due to a cheap needle or maybe I had it angled wrong. I remind myself to pay attention to the angle of the cutting point next time.

So there you have it. Mixed bag really, but I'm glad that I got started on T, one way or another. The urologist didn't give me the triple protocol, but I got the sense he was listening (after all he did agree to weekly subQ injections which he's never prescribed before) and might add Arimidex in the future. I think I need some more resources to make a better case for Arimidex and Hcg. There's something about an academic paper that swayed him.

Comments and advice are appreciated.

I'll report back later with more information as this progresses in time.

Thanks KSman, VTBalla, and the rest of you on the forum.


#2

I'm really surprised that your doctor wants to retest in only one week's time. Typically the levels need to build up over a month or more to give an accurate reading. If he tests on a periodic basis, you will get it dialed in eventually.

Your E2 is high, and will likely go higher when on the injections. Losing weight will help, but you most likely will need an AI.

As long as you are self-injecting, I would recommend splitting up the dose into 2x/week injections.


#3

I second all of what pcdude said.

Your levels will not build up to a steady state in only a week--to take them that soon is a little strange and shows a poor grasp of half lives and buildup. But he at least seems willing to work with you.

You may be ok without arimidex for now. He seems willing to prescribe if your E2 rises further or, more likely, you don't get the expected benefits from TRT.

You should do your injections twice a week.

For SC injections, don't be a pussy with pushing the needle in. Meaning, don't half ass it. Stab it in rather forcefully and you will hardly feel it when you break the skin.

Agree with your doc that you may not need hcg. But keep an eye on testicular shrinkage. He is wrong about the negatives (cost and the fact it has to be injected)--you can get it readily cheaply from legitimate foreign pharmacies and the fact that it is injected is a moot point since you are already injecting your T.

I don't like the idea of SERM's for maintaining testicles since HCG does this quite readily. Seen a few docs recommend this though. To me, it just seems like a backdoor approach where you are manipulating your receptors in hopes that your pituitary will respond and send the signal to the testes which will also have to respond. HCG accomplishes the testicular stimulation directly. Though I suppose the SERM does have the added benefit of keeping your pituitary running.....hrmmm....


#4

I think he was somewhat skeptical of subQ T, (I'm his first subQ injecting patient)and by checking serum levels 3 days and 7 days post injection he'd be able to verify that it was at least getting distributed and making it's way to the circulation.

Of course I can switch to twice weekly injection later. But for this first injection I decided to humor him so that the first week tests would be meaningful.

It piqued my intellectual curiosity as well. I'm wondering when the true peak serum levels should occur, given that I injected Tuesday afternoon.


#5

Does drawing with the same needle as injecting blunt it? Which makes it harder to pierce the skin?

I read somewhere that you should draw with a different needle than you inject with.

BS or some merit to it?

So would it be better to back fill all your needles at once with one syringe and then just store them in the fridge? Any shelf life with prefilled needles?

A little off topic but it might help the OP.


#6

I use an insulin syringe and inject twice weekly, using the same syringe for both injects and going back into the vial for each inject. It works just as well the second time as the first. Could probably get more injects out of it, but needles are cheap and not really worth it.

Backfilling is a pain in the ass and really no need to do it. Its messy and you end up losing a lot of your product transferring it everywhere.

Test doesn't need to be refrigerated.


#7

Re: my pain on the initial stick.
If you'll look closely you'll note that all hypodermic needles have an obliquely beveled edge ending in a point. On all subsequent sticks I've taken care that the beveled edge was up, away from the skin, rather than down (which I'm pretty sure is why it hurt the first time I did it), and they've been much less painful, more like the proverbial pin prick.


#8

When I first started TRT I was drawing with an 18ga needle and changing to a 25 to inject. Now I draw with the 25 and just change to a new 25 to inject. Was doing IM at first and now do SQ. I have noticed I don't get a "spike" doing SQ like I did doing IM. Seems much better way to go.


#9

Update, and an important lesson about subQ injection of T:

Recall that I'm doing 100mg T-cyp once weekly, and my urologist wanted me to have T and free T drawn 3 days after, and 7 days after the first injection.

Anyway, the doctor was disappointed with the numbers. I believe the TT was 290 or so, 3 days post injection, over a baseline of about 190, and the FT also had a mild bump over the baseline as well. (I don't have the labs in front of me. I'll post them later.) He thought the numbers should have been higher in his experience with IM injection. He suggested that perhaps I should give up on the subQ business and inject IM.

But then we talked about how and where I injected, and may have identified the problem. My initial injection was close to my navel (the umbilicus in medical lingo), perhaps 2-3 inches to the left. I didn't put much thought into the injection site, just going after the fattest area I could find, but it turns out that you really should stay away from your bellybutton area when injecting subq. The tissue immediately around the navel drains into paraumbilical veins which enter the portal circulation and go to the liver, just like all of your gastrointestinal tract venous drainage. It's possible that much of my initial T dose was going straight to the liver and getting metabolized, in much the same way it would be if I had taken oral Testosterone, which is why they don't give T orally.

As it happens, my week 2 injection was way out on the right side of my abdomen, pretty far away from the navel. My conversation with the doc was too late to draw a peak level for that 2nd week, but I did get T and free T drawn 7 days post injection, for a trough level. He called me with that result today. T was 447 and free T was 13.6. He's OK with those numbers as a trough level, thinks the subQ is probably working, and wants me to get peak levels on Thursday after my next injection on Tuesday (week 4).


#10

Data points, for what it's worth:

Recall I'm injecting SubQ, once weekly, 100mg Testosterone Cypionate. My baseline TT was 199 ng/dL and FT 6.9 pg/mL

Recent trough levels drawn 7 days post injection, Week 2.
TT 447 ng/dL
FT 13.6 pg/mL

And I just got peak levels back, drawn approx 40 hours post injection, Week 4:
TT 636 ng/dL
FT 19.4 pg/mL

The doc hasn't been checking E2.
He likes these numbers, and scheduled me a followup clinic visit in January to see how I'm doing. I'll probably insist on him checking E2 at that point.

Honestly, most of the time I don't feel any different. I will say that erections happen easier, and I have had a couple of incidences of "morning wood". Sex still requires cialis though.

But it's only been a month.

I'm tempted to increase the dosage slightly to, say, 120mg per week. What do y'all think?

There's not a huge difference between peak and trough. Should I go to twice weekly injections without telling the doc, or is it really necessary?

I'm sure my E2 is moving up, given my bodyfat percentage. A lot of the T must be getting turned into E2. So I play along with the doc, hang on until January, persuade him to order E2 levels. They'll come back high, and hopefully I can convince him to put me on Arimidex.


#11

Your LH is LOW...that is the reason why your testosterone is so low. Also have you had your blood sugar checked/had a metabolic panel done? This could affect your SHBG which is most likely high since your free T is very low and your total T is slightly above range. Especially if you are obese you want to find out what is causing a high SHBG level.


#12

LH is low but it's not super low. My doc said it's in a range often seen in middle aged or older men. Yes, it could very likely be the reason, or part of the reason, T is low. And the LH may be low in response to estrogens being high, which is why I want my E2 monitored more than is happening.

My fasting blood glucose was normal (92). Metabolic panel was normal.

( My baseline total T, in the 190's is low, and while "slightly above range" for the given lab, it is still a low T. Laboratory reference intervals can be misleading, and in a large part depend on the patient population the statistics are derived from. Lab A may have a low range for TT of 175 ng/dl, and Lab B, 300 ng/dl, but they are likely using the exact same methodology, and if they're accredited labs, as most are, they subscribe the same proficiency testing programs, and if you sent them a divided sample they'd probably return statistically identical results. But the reference intervals may be widely different. While many labs have a much lower range for TT, men may experience symptoms of low T at levels as high as 400. )


#13

You should have tried to get your fsh and lh up first to see if your testicles responded. The people that definitely need TRT are people with their FSH and LH very high, telling the testicles to make testosterone yet they are not responding (low testosterone). Your body is NOT telling your testicles to make testosterone, yet you have low testosterone. So using something like clomid would have been the best first step...

Your E2 is definitely high for someone with low T, but being fat also increases E2 though the E2 is most likely causing a negative feed back in your case as there are plenty of fat people with normal T levels (I know quite a few myself).

I am not saying you don't have low total T just because it is in range, I am saying that your free T is 'lower' than your TT in respect to the range, therefore you may have high SHBG. In your next labs I would test for that though using testosterone may affect those levels. Age also increases SHBG as well as obesity so those are both possibilities.


#14

I think that approach would have a logical way to proceed, i.e. T is low because LH is low, so correct LH. That didn't seem to be the what my urologist wanted to do, though, for what it's worth. And, for lack of reasonable alternatives, I think I'm more or less committed to following through with my urologist.

But if you did take that approach, i.e. correct the LH first, how do you do that?

A) You can substitute for LH with an LH analog, hcg. That might work. My urologist seems to have an aversion, though, to using hcg at the present.

B) As you suggest, there is Clomid. Now my understanding is that Clomid is an estrogen receptor blocker. It would trick the hypothalamus into thinking E is too low, causing release of GnRH which would act on the pituitary to release LH and FSH. That might do the job. Are there any downsides to Clomid? Side effects? Seems a powerful, blunt weapon.

Are there any other approaches to correcting a low LH?

My plan going forward is to insist that the urologist check E2 as well as TT and FT at our January appointment. If, as I suspect, E2 is high, I hope he'll be amenable to prescribing arimidex.

On a related note, I'm curious, of you fat, middle aged guys out there with low T, how many of you also had mildly low LH, and mildly elevated E2?


#15

I think that you're right, that you can infer that I have high SHBG. But is there anything I can do with that knowledge? How does it change the treatment approach, given that we're already monitoring TT and FT?


#16

January 2012 Update...

Recall that I am taking 100mg of T in T Cyp, injected subQ once per week.
I can definitely tell a difference now. I am stronger, have added muscle mass, experience firmer erections, and occasionally I notice "morning wood." Before I started T replacement, sex required viagra or cialis, without question. Recently I have been able to perform without those drugs, but only sometimes, and to be 100% sure of my ability to perform, I still take cialis. I'd like to get past that.

So I had my January 3 month follow-up appointment. I told the urologist the facts above.
He had some labs drawn.
Lab results:
Total T: 594 ng/dL (348-1197)
Free T: 13.0 pg/mL (6.8 - 21.5)
E2: 64.5 pg/mL (7.6 - 42.6) ELEVATED...

The labs were drawn in the morning on the same day I give myself the weekly subQ T in the evening, so the TT and FT should be considered "trough" values.

So the T is good. E2 is significantly elevated.

And the doc offered to prescribe me Arimidex (yee ha!). I said yeah, let's try that.
He prescribed 1mg per day. Now everything I've read on this board suggests that that's way too high. KSMan recommends a starting dose of 1mg per week, dosed EOD.

I didn't argue with the doc, though. I was just happy he wrote me the script.

The 1mg tablets of generic Arimidex (anastrazole) that I got at the Walmart pharmacy were round and easily cut into quarters with a razor blade. Given that I'm moderately obese (fat = aromatase ), and I know I have an significantly elevated E2 already, I rationalized a somewhat higher starting dose than KSman's but still much less than what the doc ordered. I decided to take 0.25mg daily, which equates to 1.75mg per week. I know Arimidex has a 48 hour half life and I could take 0.5 mg EOD, but the truth is I'll have an easier time remembering to take it if I take it every night, so, in my case 0.25 daily will work better than 0.5 EOD.

If I experience any adverse effects, I'll adjust the dosage.

The doc wants to see me again in a month, when I expect he'll draw more labs. I will update this thread at that time.

Comments are appreciated. Thanks!


#17

Your adex dose is probably going to be too high, but dosing every day should allow you to feel when you are falling through the sweet spot and bottoming out. Be cognizant of this--it will happen within the week if you rae taking too much.

You will also help your aromatization by injecting more frequently. At least twice a week.


#18

partial good news... glad you are seeing some progress.

50mg injected every three days should lower your aromatase.

you really should also be testing and monitoring your TSH levels while on HRT due to the strain HRT can place on adrenals and your thyroid.


#19

OK. Y'all are right. I told myself I'd take the T weekly until my 3 month followup. And now my doc has prescribed 1mg A'dex daily, which I'm ignoring and taking 0.25mg instead, so now I might as well go full rogue and start taking my T twice a week instead of weekly.

So from here on out I'll be taking 50mg T SubQ, twice a week, on Tuesday evening, and Saturday morning.

So, if indeed my Arimidex dosing is still too high, what symptoms will I experience as I pass through the sweet spot, and then crash?

Thanks!


#20

aching joints, moods swings, erection issues, libido issues, etc. etc.