Advice for Restarting T-Treatment?

Pharma / TRT Testosterone Replacement
1

Hey all,

Was wondering if anyone would be able to help me out with some advice as I move forward with (probably) restarting treatment for low T.

I think I have had low T for most of my life, but I never actually went and saw a doc to get an official diagnosis until early 2015 (I was 29 at the time). Anyway, these are the baselines that the endo established back then in 2015 (drawn at 8am):

Estradiol: 37pg/ml
FSH: 2.2 mIU/ml
LH: 4.49 mIU/ml
Total T: 289 ng/dl
SHBG: 39.61 nmol/l
Free T: 5.1 ng/dl
Prolactin 4.34 ng/ml
TSH: 2.57 uIU/ml ref range 0.30-5.10 [run by the GP I saw prior to the endo, drawn at 12:08]

After this we started TRT and after two years the results were non-existent, and in fact I would say that I was worse off than I was before. I started with AndroGel, which actually worked well, but we had to up the dosage to the maximum allowed after about 6 months. Then after about 4 or so more months on the max dose my insurance changed and we had to switch to injections (Cypionate) and we once again had to increase the dosage after a few months. The final level I was at before I had to switch docs due to yet another insurance change was 200mg/ml every 2 weeks. I felt quite good on AndroGel, but absolutely miserable on the injections, even on my highest dose.

The new endo I went to started me on Clomid and I felt much better and we didn’t have to increase the initial dose (1/2 tab of 50mg Clomid every other day) at all for the entire year. I don’t have my labs available, but Total T levels were always 450-500 ng/dl and Free T was much higher than it ever was while I was on either AndroGel or injections.

Well during the time I was on Clomid (2017) I had a lot of stress in my life from trying to finish a Master’s degree as well some relational stressors also. I had problems sleeping (which really started when I started AndroGel, but got worse with injections) and eventually I stopped taking Clomid when I found that doing so improved my sleep. I also noticed that when I stopped none of the low T symptoms I had earlier came back, so I figured all was well. Although since stopping Clomid my sleep issues came back.

Well I’ve since quit my job and graduated and have been doing nothing as far as work is concerned for the past 6 months in order to try to recover the past 3 years. I’ve not recovered like I expected to and went and had some new labs drawn last week by a GP (at 12:40):

Total T: 197ng/dl
Total Estrogen: 188 pg/ml
TSH: 2.84 mIU/ml
FSH: 1.9 mIU/ml
LH: 5.1 mIU/ml
Prolactin: 7 ng/ml

Those are my levels after having not been on any type of testosterone treatment for over a year now.

The GP hasn’t run any SHBG or Free T labs yet, but I’m presuming Free T isn’t good. So I’m looking for some guidance as to how to continue or what to look for this time around. From my understanding in order for Clomid to actually work everything else (GnRH, pituitary, testes) needs to work, and since Clomid did work it likely indicates a reversible cause.

So would it be worth it to check for other causes of low T? Like maybe an autoimmune disease? If so which one(s)? Any other causes worth checking into, like Hypothyroidism? I have found that switching to natural shampoos and soaps helped a bit. Adding a Magnesium supplement helped a bit also. Getting a new mattress has improved my sleep. But none of these have really brought me back to feeling normal, or at least they have not sustained the feeling of normal for me.

I did have a semen analysis done before I started TRT in 2015 and everything was fine there.

I have had issues losing weight in the past, and even when I was on low T treatment I still had issues. I presume losing weight will help T levels, but I find that it is almost impossible to do so. It seems that no matter what I do or how hard I work at the gym or at my diet it is 10x harder for me to lose any weight compared to others. When I started treatment for low T my weight was 225 lbs and it just went up and up no matter what I did. And even now that I am not on treatment it continues to go up no matter what I do (currently at 324 lbs).

Any ideas, advice, guidance, etc would be appreciated.

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While I can’t speak to the clomid (I don’t use it so know nothing about it) I can say the gels typically don’t work for people or may work in the beginning but then application spot stops absorbing. I can also say that 200mg of cypionate every 14 days is NOT a good protocol. Your highs and lows would be extreme and not feel very good. You would probably be better served at 100mg E7D (every 7 days - ie once a week) or 50mg E3.5D (every 3.5 days - ie twice a week) and that will give you much more stabile levels. You would expect to feel an initial high and then a drop for a few weeks until you stabilize around 6 weeks and then you would do bloods and figure out where you are at and how you feel.

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Yes, well I did feel quite miserable on the injections. Even on the lowest dose I felt awful, but I figured it was because the dose wasn’t high enough and that upping the dose would make me feel better. We did eventually increase it from the lowest dose, eventually up to 200mg every 2 weeks, and my levels went up and I felt somewhat better at that point (I had more energy overall and better concentration), but I still didn’t feel good and still had problems losing weight.

I updated the OP with my initial TSH levels that my GP ran in 2015 before I saw the endo. After doing some quick research it appears that hypothyroidism could be the cause [my mom has thyroid issues also]. I don’t have any labs that have any T3 or T4 levels, so no idea what those are, but I don’t remember it being discussed or investigated by the endo or GP.

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There’s your problem, no wonder you feel so miserable. These are the worst protocols and always set a man on a path to misery and is a strong indication that your doctor doesn’t specialize in TRT and is just reading the labeling on the packaging on the Test cypionate which is 200mg every 2-3 weeks. A doctor that knows what they are doing will be able to read your blood biomarkers to determine the best protocol for you.

The protocols that seem to have a better chance of working are 100mg once weekly, 50mg twice weekly and others need more frequent injections do to metabolizing testosterone at much faster rates. Your SHBG is high in relation to your Total T, the higher the SHBG, the more Total T you will need to have adequate Free T.

You don’t really have any thyroid hormone testing, TSH is a stimulating hormones which is secreted by the pituitary gland and stimulates the thyroid gland, if you wish to know how the thyroid gland is performing, then you need to check Free T4, Free T3, Reverse T3 and antibodies.

The reference ranges for TSH are invalid, anything >2.5 is indicating a problem. Thyroid labs can sometimes not show thyroid problems because your thyroid could be fine for most of the day and act up at certain times.

Hormone profiles after intramuscular injection of 200mg testosterone enanthate every 2 weeks in patients with hypogonadism

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Interesting paper, thanks for sharing. Definitely matches my experiences.

I follow up with the GP today and will insist on getting my thyroid checked either by her or the endo if she refers me. Once I know what’s what and have some blood work results I’ll post them.

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I always felt a crash on day 6 of a 200mg injection, coworker would ask me if I was sick.

The evidence for a narrower thyrotropin reference range is compelling.

It has become clear that previously accepted reference ranges are no longer valid as a result of both the development of more highly sensitive TSH assays and the appreciation that reference populations previously considered normal were contaminated with individuals with various degrees of thyroid dysfunction that served to increase mean TSH levels for the group. Recent laboratory guidelines from the National Academy of Clinical Biochemistry indicate that more than 95% of normal individuals have TSH levels below 2.5 mU/liter.

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Ok, so I finally got the results from my labs. They were drawn 1/23 @9:40a

T4
Total: 8.7 mcg/dl (4.9-10.5 mcg/dL)
Free: 1.3 ng/dl (0.8-1.8 ng/dL)

T3
Total: 130 ng/dl (76-181 ng/dL)
Free: 3.6 pg/ml (2.3-4.2 pg/mL)

TSH (drawn on 1/8) was 2.84 mIU/ml (0.40-4.50 mIU/L)

So far as I understand things my TSH is above the optimal level, but the FT3 and FT4 are about where you want them to be. So it doesn’t appear as though the thyroid is something to worry about at this point. My mom, dad, and 1st cousin all have hypothyroidism though and are on medication for it.

Since making this thread I did start eating more, specifically more protein, and it seems to have helped noticeably with energy levels, concentration, libido, etc. However, I have had to scale back the last couple of days due to feeling nauseous, but I plan to keep gradually increasing my intake as much as my stomach can handle.

Could the low testosterone be as simple as me not eating enough? I’m not opposed to doing testosterone treatment again, but I had a really bad experience when I was on it last time and I want to avoid doing it again if I can.

For reference purposes I was eating about 20g-30g of protein per meal (6 a day) for a total of 120g-180g a day. Total calories came in around 1800-2000, which I considered to be inline with my goals of fat loss and was enough to maintain my muscles through 4x a week lifting sessions. After doing some research however I found someone recommended 255g of protein a day for someone who was at my level of activity (about 40g-50g per meal if you do 6/day). That seemed quite high, but I figured it couldn’t hurt to try it for a few days and see what happened. Well I tried it, and it worked quite well, but I wasn’t able to sustain it, so I am working on increasing my food intake as my stomach can handle it until I can consistently consume this level of protein/day.

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One blood draw may not be enough to caught the thyroid in the act, thyroid hormone may be fine at the time of the blood draw and drop low hours later, I would expect to see increased TSH in these patients.