T Nation

Always Tired Again

I’m 24 years old, nearly 25, overweight at 210 pounds and 5’ 11". For as long as I can remember I have lacked energy. In high school I used to wake up and play water polo / swim from 6am to 8:30am and then sleep through every class until school was over at 2pm. I was the fattest on my team, always with love handles, despite swimming / water polo year round and strength wise I never made any progress in the weight room during off-season. I didn’t overeat either, just whatever homemade meal my mother cooked at the time. I have a baby face and have never been able to grow any facial or chest hair aside from 3 hairs protruding from a mole on my cheek and a nipple hair or two. My teammates’ legs were covered in hair and mine were bare as a baby’s bottom. My testicles have always been very small. In fact, when I was referred to a urologist he commented saying that they were abnormally small and I remarked that’s how they had always been.

Recently, my PCP informed me that I have high cholesterol. My family has a history of cardiovascular issues and I was concerned. So for 6months, I ate a strictly ketogenic diet without cheating and went from 218 pounds to 196 pounds. I also made sure to get 8 hours of sleep each night, went to bed at roughly the same time every evening, and worked out at the gym consistently either 3 or 4 days / week. With my diet, sleep, and exercise in check I hoped to eliminate the chronic tiredness I had always lived with. I didn’t. So I started googling and thought perhaps it was low testosterone. I asked the PCP to check my levels and it came back with the following:

DHEA Sulfate - 303 (85-690mcg/dL)
Progesterone - .5 (<1.4 ng/mL)
PSA - .3 (< OR = 4.0 ng/mL)
Estrogens, Total, Serum - 110.1 (60-190 pg/mL)
FSH - 24.7 (1.6-8.0 mIU/mL)
LH - 15.0 (1.5-9.3 mIU/mL)
Free Testosterone - 19.1 (35.0-155.0 pg/mL)
Testosterone, Total, LC/MS/MS - 126 (250-1100 ng/dL)
Thyroid Peroxidase Antibodies - 4 (<9 IU/mL)
TSH - 3.13 (.27-4.20 microIU/mL)
T4 Free - 1.20 (.93-1.70 ng/dL)
T3 Free - 2.9 (2.0-4.4 pg/mL)
hs-CRP - 5.9 (<5.0 mg/L)
LDL-C Direct - 121 (<100 mg/dL)
HDL-C - 37 (> OR = 40 mg/dL)

She wanted to put me on AndroGel which I refused because from my reading I believed it had low efficacy and wanted to “fix” the problem ASAP. I requested an injection and she offered 100mg E14D. I asked if I could inject 50mg E7D to maintain stable levels and she refused and referred me to a Urologist with a “Primary Hypogonadism” diagnosis.

The Urologist put me on 100mg Test Cyp E7D but each time following an injection between about 8 and 24 hours later I began to experience chest pains. After the 3rd injection I reported this to the Urologist and he asked me to stop TRT until I was cleared by a Cardiologist. Long story short, the Cardiologist ordered an echocardiogram, EKG, and a stress test and cleared me to continue. However, the Urologist no longer wanted to manage my care and referred me to an Endocrinologist. After a 4 week hiatus, I was back on TRT and (I forgot to mention earlier) I could again get through about the first 4 days of a week without feeling the need to nap a few hours after waking up. However, about 3 weeks later after a total of 8 or 9 injections total, I was beginning to feel tired again and where previously days 5, 6, and 7 were the worst, now all of the days were “the worst”–even after administering the weekly dose.

I re-read KSman’s stickies and decided to try E3D as well as subcutaneous injections to even out the peaks and valleys. I also requested an E2 reading from the endocrinologist. Below are the updated lab results:

FSH - 7.7 (1.6-8.0 mIU/mL)
LH - 4.1 (1.5-9.3 mIU/mL)
Testosterone Total LC/MS/MS - 760 (250-1100 ng/dL)
Free Testosterone 177.3 (35.0-155.0 pg/mL)
Estradiol - 76 (< OR = 39 pg/mL) Quest

I requested Aromasin because I read on a TRT wiki over on Reddit that it has no negative effect on lipids, and, being that mine are high, this is preferable. However, the endocrinologist told me he prescribes neither Arimidex nor Aromasin because those are breast cancer drugs not intended for men.

Reading through more of KSman’s stickies today, I think I might perhaps have subclinical hypothyroidism because I seem to match the criteria (feel cold easily, sparse hair at outer eyebrows), and my mother is diagnosed with hypothryroidism–perhaps it is genetic in my own case. I have not yet purchased an oral thermometer to check my morning and afternoon temps.

Going forward I am wondering if I am on the right track. Obviously I need to lower my Estradiol as well as check my oral temps and possibly begin IR. I intend also to check for adrenal fatigue at the next meeting with my doctor. But really my question is, do my labs indicate that TRT is a lifelong treatment for me and will fixing the above mentioned issues dispel the recent “tiredness” I’ve again been experiencing, primarily the Estradiol.

Finally, if anyone has any recommendations for procuring Aromasin through legitimate methods, I’m all ears. I’ve called several Low T clinics who all told me they would prescribe it but only if I would come off of TRT for a month so they could verify that my Total Testosterone is in fact below 400 ng/dL. The Endocrinologist, PCP, and Urologist all refused my request to be prescribed Aromasin. I think it’s amazing that a male with abnormally high Estrogen receives no assistance from Doctors in managing it.

Thank you for your time and any help.

I was in a similar situation where my endo prescribed 200mg E3W and refused to treat my elevated E2 even by lowering my dose, he even stated he never has seen issues with E2 just above high range and he doesn’t like prescribing aromatase inhibitors due to side effects (idiot). That’s how I knew it was time for a new endo. You’re never going to get much benefit from TRT with estrogen that high, you definitely need to find someone willing to prescribe you something to control your E2.

For 8 weeks I felt like I was all over the place on how I was feeling, it wasn’t until 10 weeks that I started feeling better. You can’t keep changing your protocol without giving your body a chance to stabilize. It could take you longer to start feeling better because you’ve been low for a long time.

This is most likely Klinefelter syndrome.

Small testies and high fsh/lh with lack of hair and virilization.

What i would do to get the aromataze inhibitor prescribed is ask for a karyotype test.

If its positive nobody will question your need for testosterone replacement and everything should be easier to get prescribed

There are different problems of that nature. The body shape might not be a perfect fit for that. This is clearly a case of primary hypogonadism which is a hallmark of Klinefelter’s, the testes do no work and that requires TRT unless there is bilateral testicular vascular abnormalities that can be surgically corrected. Given history, that seems remote.

Suggest that you get semen analysis to see if you have any fertility to protect.

E2 seems a bit high VS FT level.

TSH should be closer to 1.0 and you have not discussed your history of using iodized salt or selenium or posted oral body temperatures. This could be a major factor in your low metabolic rate, fatigue and tendency to get fat.

fT3 is the active hormone and is well below mid-range. fT4 is a bit low too.

Do not even think about IR without first addressing selenium history and supplementation.

CRP is a generalized inflammatory marker. Anything sore or inflamed?

You probably would not have absorbed androgel.

Your problem is doctors. There is a sticky for that.

Where are you located?

Labs on TRT: How long on that protocol for the labs?
If protocol is effected, we expect LH/FSH–>zero.
So something is not right. Hypothalamus seems to be telling pituitary to produce LH/FSH when it should not. Seems stuck. Monitor in future. In this state, you do not need any hCG. May need an MRI to resolve if this persists.

E2 is horrible. You need a different doc who is not ignorant. You are at risk if gyno and this is also hard on your brain, mood, prostate and arteries.

Use anastrozole. It has no direct negative effects on lipids. When you read about such things it is in the context of doses that produce very low estrogen levels and we are not doing that, we are modulating E2 levels to a more favorable normal level. It is very low estrogen levels that are the risk, not anastrozole itself.

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.


Thank you very much for taking the time to look over my issues and respond to my post in such detail.

I purchased an oral thermometer and took my temp prior to getting out of bed each day for the last five days. The temperatures were (all in Fahrenheit): 96.8, 96.6, 96.8, 97.0, 97.2

Regarding Selenium intake: I’ve been taking a multivitamin daily since October minus about a month and a half which contains 70mcg Selenium but no iodine (apparently 100% RDI). I switched a few days ago to another multivitamin, also taken daily, which contains 150mcg iodine (apparently 100% RDI) and 45mcg Selenium (64% RDI). To make up for the Selenium deficit I make sure to eat at least 3 eggs daily because it looks like they contain ~28% RDI Selenium.

I also take supplements daily consisting of 400mg Spirulina, 200mcg Vitamin K2, Vitamin D3 7000IU, Fish Oil 1200mg.

Does this indicate that IR would be a safe bet?

Labs on TRT: I was on 100mg/once a week for 3 weeks and experienced chest pain. The Urologist asked me to stop treatment until a cardiologist cleared me. Following a stress test, EKG, and echo I was cleared by the Cardiologist with no issues and his only recommendation was to drink a lot of water but to continue TRT. It took 3 weeks for these labs to be complete and get clearance from the Cardiologist. As a result, I was off of TRT for 3 weeks. Then I started again under the care of an Endocrinologist that the Urologist referred me to. I continued the protocol for 4 weeks and had labs done and come back with those results. So, 3 weeks on -> 3 weeks off -> 4 weeks on -> Labs on the fourth day following injection as per Endo’s instruction.

I’m located in Houston, TX. I looked around online and found others on other forums who recommended Dr. Lipschultz at the Medical Center. I verified that he does prescribe Anastrozole for men on TRT with elevated E2 and have an upcoming appointment in a few days. I also scheduled another appointment just in case with a doctor who specializes in Low T, Dr. Cornell located in Downtown Houston. Aside from that, I will also use the compounding pharmacy method outlined in the Finding a TRT Doc sticky.

About me: In my first post it looks like I forgot to include a few things about diet and such. I lift weights at the gym as a beginner EOD and will occasionally, once or twice a week, go in for a 20minute HIIT cardio session on a bike. I have continued this routine since October with a 3 month hiatus from March till June of this year.

Being that I’m about 30lbs overweight, I eat at about a 10-20% caloric deficit—smaller deficit on the days that I lift weights. I always make sure to get at least .8g/lb of protein and .4g/lb of fat, and fill the rest of the gaps in with carbohydrates. I’ve incorporated intermittent fasting into my eating schedule. In my case, this means 16hours fasting overnight followed by eating within an 8hour timeslot, everyday. Not sure if this IF protocol plus the caloric deficit is what you’ve referred to as a starvation diet.

When I began TRT my testes did have a dull ache from time to time but that has long since subsided. It only really lasted the first three weeks. Though they have shrunk significantly. No fever. Morning wood and erections have not changed; I’m still able to have sex 3-4 times daily.

Thanks to everyone for their help. I know we all lead busy lives and I’m truly grateful that you would take time out of your day to help a stranger!

Your shrinking testes are a possible path to infertility. You need hCG 250iu subq EOD.

Selenium looks good. Body temperatures are low, an indication that your metabolism is weakened by low thyroid function. Do read all of the thyroid basics sticky if you have not already done so.

Yo seem to be taking control and doing a great job so far.

You can do genetic testing and fertility testing if you want to know.