T Nation

Anything to Track to Help My TRT Doc?

OK, so I’m 49 and have some of the symptoms of low T - I asked my GP to have it checked, he only had total T tested, but that was low. So now I’ve just done my first visit to an Endo Doc, and they pulled a bunch of blood and are going after the testing in a big way. What I’m wondering is, given how much T can vary, what are some of the factors that vary T production, are any of them things I should track to better help my Doc come to an accurate conclusion? I assume how often you have sex affects T levels, I don’t smoke, drink, or do any recreational drugs - is there anything else to track?

BTW, he’s also checking thyroid and adrenal function. I’ve read most of the FAQs and this guy came recommended by another doc, and he reportedly does a fair amount of male hormone replacement work, so I’m hoping he knows his stuff.

WRT me, here my general health issues - I’ve marked one with an asterisk that I don’t think there’s the possibility of a hormone related issue, but maybe there’s more for me to learn? Oh, and years ago I had Hepatitis A, and a bad testicular infection when I was 13.

Insonmia
Cholesterol
Fatigue, weakness
Anxiety
Memory, concentration, focus
Soreness after exercise, time to heal, hands (joints) hurting
*GI tract problems
Difficulty reaching orgasm
overweight, workout w/o results

EDITING TO ADD THE INFO SUGGESTED IN THE “PROTOTYPE” STICKIE:

I’m 6’2" 215 lbs
36"-38" waist
not very hairy
weight is almost exclusively on my gut - I’ve got a beer belly and I don’t drink. I think it’s mostly adipose and not just sc - when I’ve done lots of abs work, you can feel the muscle under the layer of sc fat, but the gut is still there. In high school I was 6’2" and 128 lbs - after H.S I worked hard physical work on Alaska commercial fishing boats, but never really muscled up like the other guys. The last 20+ years have been an office cubicle.
PSY doc has me on Wellbutrin (50mg) and Focalin XL (20 mg capsule, but I split it to 10mg)
diet is reasonably healthy with the exception that my insomnia makes it really hard to sleep on an empty stomach - I know it’s horrible to do, but I eat a snack right before going to bed.
Training - I’ve struggled to have the energy. I’ve about given up, I’m hoping trt or SOMETHING is going to help me get some energy back. It’s really sad when at the company gym, in an exercise class with older overweight women, that I’m the one that can’t keep up? My aerobic endurance is even worse than my strength.

OK, I goofed up - I went to the 2nd appointment w/o re-reading the stickies and FAQs (I was too curious to know if I really was low-t) and I wasn’t prepared (pretty much just forgot) to discuss injection protocols, E2 testing, or hCG. Doc ended up prescribing 200 mg testosterone cypionate (1ml @ 200mg/ml) injected intramuscular every 2 weeks. No hCG or anastrozole.

Any suggestions on how to get the doc to change things up to sc injections bi-weekly or EOD, and to add hCG and adex? I’m not opposed to getting this guy on board with what’s recommended here, probably easier to do that than finding a new doc unless someone knows a Houston doc that already has it figured out (if so, send me a message!!).

Question - given the problems women have encountered with HRT, is the testosterone used in trt bio-identical, or does it not matter for some reason?

It took me a couple of weeks, but I’ve gotten a copy of the test results from the office staff, this is for the first blood draw, pre any trt:

********* Edited to add lab ranges *******************
and marked with +++ for those marked high by the lab

Quest

Test My measurement Reference Range

LIPID PANEL
CHOLESTEROL, TOTAL 183 mg/dL 125-200
HDL CHOLESTEROL 45 mg/dL >= 40
TRIGLYCERIDES 177 mg/dL <150 +++
LDL-CHOLESTEROL 103 mg/dL <130
CHOL/HDLC RATIO 4.1 <= 5.0
NON-HDL CHOLESTEROL 138 mg/dL target for non-HDL cholesterol is 30 mg/dl higher than LDL
COMPREHENSIVE METABOLIC PANEL
Glucose 100 mg/dL (I hadn’t fasted) 65-99 +++
UREA NITROGEN (BUN) 17 mg/dL 7-25
CREATININE 0.96 mg/dL 0.60-1.35
eGFR NON-AFR. AMERICAN 92 mL/min/1.73m2 >= 60 (I’m Anglo)
eGFR AFRICAN AMERICAN 107 mL/min/1.73m2 >= 60
SODIUM 143 mmol/L 135-146
POTASSIUM 4.7 mmol/L 3.5-5.3
CHLORIDE 109 mmol/L 98-110
CARBON DIOXIDE 24 mmol/L 21-33
CALCIUM 9.9 mg/dL 8.6-10.3
PROTEIN, TOTAL 7.2 g/dL 6.2-8.3
ALBUMIN 4.5 g/dL 3.6-5.1
GLOBUlIN 2.7 g/dL 2.1-3.7
ALBUMIN/GLOBULIN RATIO 1.7 1.0-2.1
BILIRUBIN TOTAL 0.5 mg/dL 0.2-1.2
ALKALINE PHOSPHATASE 61 U/L 40-115
AST 78 U/L 10-40 +++
ALT 82 U/L 9-60 +++
VITAMIN D, 25-HYDROXY
LC/MS/MS
VITAMIN D, 25-OH, TOTAL 32 ng/mL 30-100
VITAMIN D, 25-OH, D3 32 ng/mL >=30
VITAMIN D, 25-OH, D2 <4 ng/mL (no reference range given)
TSH 0.94 mIU/L 0.4-4.5
T4, FREE 1.3 ng/dL 0.8-1.8
T3, FREE 3.8 pg/mL 2.3-4.2
TESTOSTERONE, FREE AND TOTAL, LC/MS/MS
TESTOSTERONE, TOTAL, LC/MS/MS 262 ng/dL 250-110
Total Testosterone was measured by LCMSMS. The LCMSMS method
correlates well with our extraction/RIA_method.
TESTOSTERONE, FREE 51.0 pg/mL 35.0-155.0
RESULTS CONFIRMED BY REPEAT ANALYSI8.
CBC (includes DIFF/PLT)
WHITE BLOOD CELL COUNT 5.6 Thousand/uL 3.8-10.8
RED BLOOD CELL COUNT 5.51 Million/UL 4.20-5.80
HEMOGLOBIN 17.1 g/dL 13.2-17.1
HEMATOCRIT 49.9% 38.5-50
MCV 90.5 fL 80-100
MCH 31.0 pg 27.0-33.0
MCHC 34.3 g/dL 32.0-36.0
RDW 12.9% 11-15
PLATELET count 220 Thousand/uL 140-400
ABSOLUTE NEUTROPHILS 3086 cells/uL 1500-7800
ABSOLUTE LYMPHOCYTES 1786 B50-3900 cells/uL 850-3900
ABSOLUTE MONOCYTES 560 cells/uL 200-950
ABSOLUTE EDSINOPHILS 140 cells/uL 15-500
ABSOLUTE BASOPHILS 28 cells/uL 0-200
NEUTROPHILS 55.1 %
LYMPHOCYTES 31.9 %
MONOCYTES 10.0 %
EOSINOPHILS 2.5 %
BASOPHILS 0.5 % (no reference range given for previous 5 values)
CORTISOL, TOTAL 13.2 mcg/dL
Reference Range: For 8 a…m. (7-9 a .m.} Specimen: 4.0-22.0
Reference Range: For 4 p.m.(3-5 p.m.} Specimen: 3.0-l7.0
*** Please interpret above results accordingly*** (sample was taken at 9:45 AM)
FSH 4.9 mIU/ml 1.6-8.0
LH 3.6 mIU/mL 1.5-9.3
PROLACTIN 2.2 ng/ml 2.0-18.0
PSA, TOTAL 0.5 ng/mL <=4.0

Edit lsb ranges into the data above.

=================
Dexmethylphenidate should not be used in combination with a monoamine oxidase inhibitor (MAOI) such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) that has been used in the past 14 days. Serious, life-threatening side effects can occur if dexmethylphenidate is taken with an MAOI.[citation needed]

Lab reference ranges added above^

From what you’ve written it sounds like Focalin and Deprenyl/selegiline don’t play well together. I’ll be sure to get off it before trying Deprenyl/selegiline. Given the potential it sounds like it has to address ADHD and sexual sensitivity/difficulty reaching orgasm, I’m interested to see what effect it may have. I ended up on Wellbutrin in an attempt by my PSY doc to address insomnia - surprise, he diagnosed it as depression. I’ve yet to find any PSY med that messes with serotonin that doesn’t give me a low grade headache and increased headache frequency and intensity. Wellbutrin was basically a last ditch attempt to have me on something (IMHO), I can’t say I was opposed to it given it’s reputation for helping you at least not gain weight and to help libido (as opposed to SSRIs). I didn’t see any changes to my libido until he added Focalin to the mix. I’ll happily give up both assuming I can find something that works better, as it is I’m kind of anxious with this mix - but at least I have some energy. I’ve tried using S-Adenosyl methionine (SAM-e) when I find myself still getting depressed, it helps some (it’s a serotonin precursor, and having had Hep-A I assume it doesn’t hurt that either) and doesn’t give me a headache.

Insomnia: Trazodone is very effective and a very cheap generic in the USA. Get 150mg tabs, which will split 25, 50, 75. Start with 25 and later on you will probably need 75-100. Combine with Melatonin 3-5 mg, find a time release type!

AST/ALT are elevated? Liver problem or did you have muscle soreness or injury at the time

Vit-B complex to increase HDL, 5000iu vit-D3, fish oil caps.

I have worked on several cases of insomnia where once the proper levels of neurotransmitter was corrected, majority of Dr’s patients I worked with where able to get off all sleeping drugs (success rate of >80%) . One needs to properly evaluate the potential causes then correct any other imbalances which may be present. All and all no drugs are needed. Trazadone can cause penis to get bent in some. There are far better options out there…

KSman - Having gotten frustrated with my level of exercise stamina and lack of improvement, I really hadn’t worked out in a long while, then did what should have been just a moderate workout, but ended up REALLY sore - shortly before that blood draw. That, along with having had Hep A maybe explains the liver results?

I’ll be more regular about taking my fish oil pill, what I’m taking has 500 EPA / 250 DHA.

Hardasnails: I agree, I suspect neurotransmitter wise something’s not right. Maybe a few of those concussions I had as a kid are doing me like what they’re finding with NFL players who’ve had their bell rung too many times. Melatonin helps some, but not enough. I’ve tried a lot of natural remedies with varying degrees of success, but nothing that works well enough to be a solution. I’m a bit skittish about natural remedies, show me the double blind test results please! Remeron leaves me like a trank’d elephant, haven’t tried trazadone (bent penis?! serious side effect! why can’t the side effect be that it’s bigger!? :slight_smile: ). Currently I’ll use Diphenhydramine (helps keep my nasal passages open too) sometimes adding 0.5 mg Lorazepam. If it goes on too long and I have a big sleep deficit and still think I won’t be able to sleep, I’ll take Ambian. That works well for me, but I don’t like taking it very often. Plus, my wife teases me about what I’ll do when I’m half unconscious - someday something really embarrassing could make it’s way to YouTube :slight_smile:

My next doc appointment is Mid-July, given he’s got me doing an every other week 200mg intramuscular, any suggestions when during that cycle would the blood draw for the labs he’s ordered give the best (most accurate, representative) results? Trust me, I’m going in this time ready to discuss injection protocol, measuring E2, and adding hCG. If we can’t come to an agreement, I’ll be looking for a new doc.

OK, looks like it’s time to fire this Doc. The lab results from the blood draw last week had come back with the exception of (most important of all) the testosterone numbers. He just proposed continuing the every other week 200mg injection schedule he set me up on originally.

I tried to get him to add labs to check E2 - he just blew me off saying “that’s not really a problem for people of your body type” (I’m thin, with a beer belly - and I’ve never drank) and for hCG, his response was that since I’m not planning on having children (recent vasectomy) that I didn’t need it either. I decided to not even try to argue to go to an EOD SC injection schedule. I’ll wait to post the lab results until I have the complete results, but I suspect that they won’t be really helpful because the day for the blood draw was the day before when I was due for the next once/2 weeks injection.

Anyone able to recommend a decent HRT doc in Houston? Drop me an IM if you do!

Well, just to follow up, I got the testosterone results now that I’m on TRT - 391 total from a range of 250-1100 and 108 free on a range of 35 - 155.

Were you able to change the injection protocol? Even 100mg weekly would be better. I was ok on Mon and Fri injections IM.

Any changes in sleep or is this still a major problem? Poor sleep can really mess you up (as you already know). I struggled with insomnia and it turned out to be separate from my low T. Way too much stress and bad habits. Never liked sleeping aids either so I really attacked it from a physical stand point with more activity in the morning and creating a solid bed time pattern. Managed stress through “owning” less at work. that took some practice but really paid off. I never thought I was the type that would be affected mentally by bullshit “grown-up” problems, but it worked. When I got my sleep under control I felt tremendously better. Still not quite normal, but way better.

Still eating at night before bed? What do you eat?

[quote]Bearcat77070 wrote:
Well, just to follow up, I got the testosterone results now that I’m TRT - 391 total from a range of 250-1100 and 108 free on a range of 35 - 155.[/quote]

If you need assistance on neurotransmitters …PM me

On my own I’ve swapped over to a 20mg EOD SC injection schedule, but I just started this week to it’s kind of soon to notice any differences. I haven’t fired the guy yet (it looks like maybe my GP might be willing to step up, I’m seeing him next week. He does sports med and is branching out into anti-aging) but he’s saying no need to see him until December, so I don’t have any labs scheduled anytime soon to tell me with hard facts what’s going on.

The lack of hCG is definitely causing testicular atrophy - reassure me, it is reversible right - especially since I’ve not been on TRT long? My libido is up slightly, but never was an issue, but sexual sensitivity/difficulty reaching orgasm continues despite my T levels being closer to where they should be.

Sleep continues to be an issue - I’d thought I that by using Diphenhydramine 25mg at bedtime (my sinuses stop up at night) that I was using a “lighter” hammer than Lorazepam or Ambien, but when I asked my pharmacist she gave me hell about it, that long term usage isn’t good. Just some quick research shows she’s right, although I’d much rather not be on anything of course, as I’m not convinced anything is completely benign.

I really need to do more research and determine what out there has the least side effects - I find I don’t need much to get me under the “sleep” barrier. If I drank (religious reasons) probably just a 1/2 glass of wine at night would do it. (I realize alcohol is just another drug, but that’s the way I was brought up, and breaking that conditioning would be harder and have more side effects (guilt, etc.) than either heavier drugs of just suffering with not enough sleep).

Hardasnails, I’ll PM’d you on neurotransmitters - really interested to hear what you can help me understand, I suspect that’s the base of my issue, at the very least a big part.

Yes, I’m still eating at night - I feel guilty admitting what I eat given how dedicated most here are with their diets. I’ll drink a glass of lactose free 2% milk (GI docs thinks lactose contributes to my GI tract issues - but it’s not everything. I suspect stress is a factor, and there may be other yet to be identified organic factors) and eat a pastry from the local bakery. Damn that baker!! It’s a really bad habit, but I have about a 1x increase in insomnia without something in my stomach - it’s pastry only because they’re so good.

I don’t have a fixed exercise schedule - I’m working out 3-4 times a week. Some are mixed cardio - weight training classes offered at work. They’re intense enough that I’m dripping sweat and a little stiff and sore, but not the soreness I develop when I do a good solid strength session on fixed machines. I usually manage a minimum 1 strength session per week sometimes 2, and then a couple of classes. Is the time of day I exercise a big factor?

And a HUGE thank you for your continued attention and help!!

Hardasnails - I’ve tried to IM you, no luck, it’s as if the system doesn’t know your IM address. I’ve IM’d with KSman without problem, but in reply to an IM originally from him. Can you send me an IM so I can try if that will work? I’m interested in hearing what you have to say about neurotransmitters.

Thanks!

Diphenhydramine has a stated half life that does not seem to deliver as one would expect. You will start to wake up during the night as its effect wears off. And some will find that their eyes and nose get dried out.

Doxylamine is longer acting and will get you through the night. I did use it long term and it may have led to some other problems. Probably great for those who need a sleep aid occasionally.

Melatonin belongs in your body.

[quote]Bearcat77070 wrote:
Remeron leaves me like a trank’d elephant, haven’t tried trazadone (bent penis?! serious side effect! why can’t the side effect be that it’s bigger!? :slight_smile: ). [/quote]

I’m on Remeron currently for sleep but have also used Trazadone. As KSMan said it’s cheap and effective. I was splitting the thirds of the tab (50mg) into approximately 25mg pieces and sleeping like a log for 8 to 9 hours. However, if you have allergy issues, you do have to start and titrate the dose slowly as the histamine release mechanism of trazadone can cause allergy flareups. That’s the only reason I no longer use it as I have bad allergies.

It releases histamine?

Mechanism of trazodone as a low dose hypnotic

Trazodone is approved as a high dose antidepressant but is more commonly used ?off label? as a low dose hypnotic.9,23 In fact, prescribing low dose trazodone as a hypnotic may be the most frequent off label use of a drug in all of psychopharmacology.23 Off label use does not mean that such prescribing is a bad thing, despite what some formularies or critics say. It just means that the Food and Drug Administration has not approved this therapeutic use. The FDA regulates the sale of medicine, not the practice of medicine, and does not proscribe the use of trazodone as a hypnotic. The practice of medicine is set instead by community standards of care, experts, and guidelines, and in clinical practice trazodone has become accepted as perhaps the most popular hypnotic in the United States.23

Since trazodone is most potent in blocking 5-HT2A receptors, one might think that this action alone could account for its low dose hypnotic efficacy. Indeed, the selective 5-HT2A antagonist eplivanserin has been shown to have therapeutic actions on sleep maintenance and the approval of eplivanserin for this use is pending in several markets at the present time.24 However, eplivanserin does not appear to have robust actions in causing sleep onset.24 By contrast, trazodone does promote sleep onset as well as sleep maintenance, but at doses considerably higher than those necessary to saturate 5-HT2A receptors.

Roughly half of brain 5-HT2A receptors are blocked by 1 mg of trazodone (ie, at Kd; see Figure 2, top dotted line), and essentially all 5-HT2A receptors are saturated at 10 mg of trazodone (ie, at 10x Kd), but the clinically effective hypnotic doses of trazodone are in the 25?100 mg range (Figure 2, second from the top dotted line). Thus, it appears that doses higher than those that cause selective 5-HT2A antagonist actions are necessary for the hypnotic actions of trazodone. The receptor binding profile of trazodone shows that increasing the dose beyond saturation of 5-HT2A receptors recruits additional pharmacologic actions, specifically blockade of a1 adrenergic receptors and H1 histamine receptors as well. This makes low dose trazodone a multifunctional drug with 5-HT2A, a1 adrenergic and H1 histamine antagonist properties (Figure 3B).

Such a profile should indeed create an effective hypnotic on theoretical grounds, since arousal mechanisms are known to involve the actions of several neurotransmitter systems in addition to serotonin, including norepinephrine, dopamine, acetylcholine, and histamine.5,9,25 Blocking several of these systems simultaneously can impair arousal and induce sleep. In fact, selective blockade of the histamine system alone can be enough for robust hypnotic actions as was discussed in a companion article in this series on multifunctional drugs with H1 antihistamine properties.5 Adding additional antagonist actions at a1 adrenergic and 5-HT2A receptors should enhance this sleep inducing effect of H1 blockade.5,9,25

Thus, the hypnotic dose of trazodone is sufficient to saturate all 5-HT2A receptors (>10x Kd), and to block half or more of H1, and a1 receptors (~1x Kd for these receptors) (Figure 2). Blocking half of these receptors definitely contributes to hypnotic activity.26 While SERT is also blocked by about 50% at hypnotic doses of trazodone (ie, at 1x Kd for SERT in Figure 2), this is not sufficient for antidepressant actions. In fact, many studies have shown that the SSRIs/SNRIs must be dosed so that SERT is nearly completely saturated in order to attain antidepressant actions in depressed patients.9 Hypnotic doses are insufficient for this degree of action at SERT, which is why they are too low for antidepressant effects.

In summary, 5-HT2A antagonism plus H1 antihistamine and a1 adrenergic antagonism theoretically explain the therapeutic actions of trazodone as a hypnotic in the 25?150 mg dose range (Figures 2 and 3B). Combine this with the fact that trazodone does not cause dependence and has a relatively short half life, and in many ways, you have an ideal hypnotic agent.