T Nation

Baseline Tests, Clomid Restart, Low Temps


#1

I’m 34, good shape at 6" 200lbs. Since I was 14 I’ve experienced major depression, and have recently been diagnosed Bipolar type 2. for the past 2 decades I’ve been on and off various antidepressants, and currently take depression and bipolar medicines. Long story short no matter what I do, I’ve spent the majority of my life feeling terrible.

This past January I went to a mens clinic hoping for some new insight. They took labs, and based on the following results prescribed weekly 200mg Cypionate. Knowing what I know now, I would have asked for more extensive labs, and would have never started such an inappropriate (for me) protocol.

1/9/17 Labcorp Lab Results:

Prolactin: 10.6 (4-15)
Ferritin: 121 (30-400)
Test Total: 256 (348-1197)
Test Free: 7.4 (9-25)

Initially I felt the best I’ve ever felt in my life. Sex, concentration, athletic ability, amazing sleep, and most important to me, for the first time in my life I had an extended period of ZERO depression/bipolar symptoms. This high last for approximately 4 weeks, but things progressively got worse. I became very irritable, bordering on irrationally angry at times, sex drive was zero, getting erections was a challenge, sleep was bad, back breaking out and very oily face etc. I was on TRT for 4.5 months before deciding to get a 2nd opinion.

After assessing the situation with my wife, we found a urologist that specializes in TRT. We met with him, he was great, but he was also pissed at the “mens clinic” for irresponsibly (his words) administering TRT. Based on my limited labs he felt we could have made healthy gains, but based on the symptoms I was exhibiting, was concerned my system could now be permanently shut down. We did a prostate exam, prostate was enlarged and approximated the size of a 50 year old. Not good. We agreed to taper down to get baseline labs to decide next steps. The lab results were:

Prolactin TSH: 1.5 (.5-5)
Prolactin: 7 (4-15)
Estradiol: 12 (8-43)
LH: 1 (2-9)
FSH: 2 (2-12)
Hemoglobin: 17 (13-18)
Hemotocrit: 52 (38-51)
Test Total: 119 (348-1197)
Test Free: 5 (9-25)
Alkaline Phosphate: 124 (39-117)

We meet with the Dr this Thursday. Obviously some of the labs are concerning. Yes, test is unacceptably low, however I’m personally more concerned about Estradiol, LH, FSH, Hemotocrit, Alkaline Phosphate, because I currently don’t understand how all the variables interact.

What concerns do you have? What questions should my wife and I ask the Dr? What should we be prepared to discuss? What do you think the expected treatment plan will be? What would be ideal?

Any comments, questions, concerns, input would be greatly appreciated!

Other pertinent info:

-age: 34
-height: 6’
-waist: 36
-weight: 200lbs

-describe body and facial hair: Average to minimal body hair. Small amount on chest & stomach, little to none on back. Facial hair is noticeable with a fair amount of stubble after not shaving for a couple of days. However, all areas besides upper lip are not thick enough to grow a full beard.

-describe where you carry fat and how changed: I carry most of my fat across my midsection and have noticeable love handles. They have been with me for life regardless of exercise and diet…

-health conditions, symptoms [history]: 5 documented concussions. Bone cancer at 26, however no chemo or radiation. Major depression and newly diagnosed Bipolar 2.

-Rx and OTC drugs, any hair loss drugs or prostate drugs ever: Zero hair loss or prostate drugs. Multiple combinations of depression meds and currently take Welbutrin, and Lamictal.
– real dangers! see this http://propeciahelp.com/overview57

-lab results with ranges: See above…will keep updated.

-describe diet [some create substantial damage with starvation diets]: Solid macro diet. All food groups between and between 1950-2250 calories depending on goal. No alcohol, tobacco, caffeine, or recreational drug use.

-describe training [some ruin there hormones by over training]: Currently lifting weights following Stronglifts 5x5.

-testes ache, ever, with a fever?: Consistent right testicle ache while on TRT, which has persisted while off to get baseline tests. No fever.

-how have morning wood and nocturnal erections changed: More often than not I don’t experience morning wood of nocturnal erections. Happens occasionally but certainly not often.


#2

Most doctors are not good at this. Most are ignorant and do not think about what they are doing.

Blood is too thick. Donate blood if you can. Avoid iron fortified supplements, flour, bread, cereals, rice etc.

On TRT HTC=52 will get worse and 200mg T was really a bad idea. On TRT monitor HTC, RBC, hemoglobin, ferritin.

E2 is low because low FT leads to low FT–>E2
So no concern re E2.

You now have secondary hypogonadism and there is no reason to think that this was different before TRT.

Your 200mg/week testosterone cypionate was too much and you felt great until FT–>E2 build up high levels of E2 in your body. This is classic. Mood problems and intolerance are typical and E2 made you a bitch.

Oily complexion is not unusual and can calm down as your body gets used to good T levels.

Fertility: Are you needing to be fertile at this point? Wife agrees?

TRT:

  1. Self inject 50mg T cyp twice a week, subq with #29 1/2" 0.5ml insulin syringes
  2. 0.5mg anastrozole at time of T injections
  3. 250iu hCG subq EOD to preserve testes and fertility

Alternatively, you could try hCG only, trial at 300iu subq OED/E2D.

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.


#3

Thanks for taking time to reply, really appreciate it.

I have a vasectomy so no fertility concerns. However, I’ve experienced a persistent ache in my right testicle, and both have atrophied to 1/3rd their normal size. Appearance wise I feel awkward, but my wife couldn’t care less and says it no big deal to her, so it’s no big deal to me.

I will check oral temps and report back on thyroid function.

I also forgot to mention that as a teenager I had a minimum of 5 documented concussions, 3 within a 2 month period, and most likely more undocumented from from football, wrestling, other combat sports. Thinking that may be a contributing factor to the secondary vs primary hypogonadism.

I don’t even know what good feels like, just how painful it is to live this way. So excited to get my life turned around, and be healthy for myself, wife, and kids.


#4

TRT shuts down LH/FSH and testes shrink. Some guys get a low level 24x7 ache, others not.

Concussions can damage the pituitary and low-T can easily result.

Please re-read my post and look for things that you are not addressing, its all important.


#5

I met with my urologist this morning and he 100% agreed with you.

However to better understand my body he would like me to consider taking clomid prior to restarting TRT. His reasoning is that my pituitary gland is not functioning and he would like to see if we can treat the root rather than a symptom. He believes we’ll see some improvement but cautioned it also may not work. If there’s no improvement, or not enough improvement, we will begin TRT as you have prescribed.

Is there any downside to starting with clomid? He’s open to starting TRT now, but wants me to be open to trying clomid. Got to say, I think I found a great doc who knows what he’s doing, and is invested in my long term care. Feels good to have a partner dealing with all this stuff.


#6

I agree in general but was thinking that damage of concussions reduced the chances of this working.

This is easy to do, oral drug and low costs, but doctor visits are not.

Do not do high dose. 25mg every day can sometimes be too much, 25 every other day [EOD] is often adequate. Some docs think that more is better when more can create very high LH and high T–>E2 inside the testes creating high E2 in the blood, we the liver then creates high SHBG that lowers FT. And high LH can reduce sensitivity of LH receptors.

Some guys, not at all rare, cannot tolerate Clomid, they feel horrible. Docs have no idea. Nolvadex 20mg can replace 25mg Clomid and no side effects, but doctors are in a rut about Clomid. They need to thing and get there heads out of the books.

On a SERM, you need to check LH/FSH to see what its primary effect is. Also check TT, FT, E2 to evaluate downstream effects.

This will support/enhance fertility.


#7

Once again, you and my doc agree. He did mention that the concussions may render this treatment useless if the pituitary is damaged, which may very well be the case.

I don’t have the script in front of me but will post the does and frequency. Based on my experience so far, I wouldn’t be surprised if the doc prescribes exactly as you mentioned above. My only concern is the pharmacy called and said insurance needs additional info before approving the treatment…may end up back on TRT sooner than later.

Follow up labs are scheduled for 3 weeks out. Not enough time for full results, but our hope is that we’ll gather directional data that we can use to determine our next steps.


#8

The use if clomid should not be represented as fertility related as that may create a refusal.


#9

Well, my insurance denied clomid. I doubt my doc prescribed due to fertility, just assume it’s not approved for men under my insurance plan. Doc says he’s happy to follow up directly to see what he can do, or just start TRT.

I like the idea of seeing if my pituitary can be jump started. Are there any male specific meds that I could try and achieve the same results as clomid? One concern I have starting TRT is if insurance won’t cover clomid, I doubt there’d cover an AI and I don’t want to battle E2 issues and lose the benefits of test.

I’ll know more Monday.


#10

After a few rounds of negotiations between my Dr. and insurance company, I was approved to try clomid. Insurance’s position was that clomid use in men is an “off label” treatment, but somehow the doc convinced them this is the best course of treatment.

My prescription is for 25mg EOD. Based on my understanding of clomid half this this would be equivalent of 12.5mg ED, but wondering if I should start at 12.5mg EOD and see how it goes. I have no reason to doubt my Dr. as he’s great to work with…just read a lot online about guys getting BETTER results at the lower dose.

I’ve read the sticky and you’re post above, just curious if 12.5mg EOD may net the same/better results as 25mg EOD.


#11

Quick update.

I started the Clomid at 12.5mg ED, and so far so good. I understand it’s the equivalent of 25mg EOD, but wanted to make sure I could tolerate the first few doses so I erred on the side of caution.

So far so good, with no negative side effects. Honestly, and it’s probably placebo effect, but I’m feeling much better after only 4 days. Again, probably just placebo at this point, but the last two days I’ve also had a HUGE libido boost. Whatever’s happening, it’s been a fun couple of days.

I have follow up labs on 7/10 with results on 7/14. Short turn around, but doc wanted to keep a close eye on labs as we test this out. At this point in my TRT journey I’d be happy to go from 119 to 125! Every little bit counts :).


#12

Another quick update.

I met with my general practitioner this afternoon and went over all results with him. He thinks it’s fine that the urologist wants to try clomid, however said he didn’t think it would work and we’re headed to full TRT soon.

He mentioned that my pituitary may have other issues than we know. I take meds to increase dopamine production, and apparently the increased level of dopamine can lead to a reduction in prolactin. Since my prolactin is in the normal range it may be artificially low due to the meds and I may be on the high end signaling something else going on.

He would like me to get an MRI to find out for sure. His thought is if the pituitary is fine, producing appropriate levels of prolactin which is shows now, he’s more inclined to think I may be primary and treatment would be different.

I have to read up on all this. I’m not against the MRI, plan on doing it, but want to know how to intelligently discuss the results etc. If anyone has experience with a pituitary/brain MRI I’d love to know how it went, what you looked at, and how your results impacted your future treatment.


Long Term TRT Success Stories?
#13

A few more updates.

First, I went ahead with the MRI and it came back perfect. No issues with the pituitary or anything else brain related. Exactly what was expected, but still great news.

Second, I just got off the phone with my Dr. and after about 2 weeks on 25mg EOD clomid my testosterone increased from 119 to 426 (348-1197), free testosterone jumped from 5 to 13.2 (8.7-25.1), but Estradiol is up to 33 (8-43). We meet this afternoon to discuss full results, but it looks like I’ll get on an AI. So far the results seem promising.

If I stay on clomid can I assume my T levels will continue to increase or will they stay about the same? I feel much better and have zero side effects just wondering what I can expect. I assume too that with the AI I’ll probably feel even better at the same T levels.

Thanks for your time, and I hope all is well.


#14

TT improved, but FT unknown.

Good if LH/FSH to see what the pituitary is doing. If low, increase clomid dose. Need to avoid high LH/FSH.

Given your mid-range TT, 0.25mg anastrozole twice a week would be a good start. If E2 resists management, that suggests possible high LH.


#15

Well, like the idiot that I’m known to be from time to time, I forgot to get a copy of labs…

Based on the conversation we were both happy with the results, but opted to not introduce an AI at this time. The Dr. would like to stay the course and draw labs in 6-8 weeks then reassess.

We did talk about the potential of increasing the dose from 25mg EOD to 25mg ED. He didn’t think increasing the dose would result in a meaningful increase in T, but could have negative side effects like increase E2. He’s open to me increasing on my own, but just made clear not to expect any miracles.

So again, the current plan is to stay the course and reassess in a few months.


#16

FT = Free Testosterone?


#17

Just a quick update.

I think clomid has been a good option for me. Sometimes I wish I were on injections to get my T levels up further, but I feel so much better at 400 than 120, that I’m afraid to mess with anything. However, I can’t help but think how I would feel around a controlled 800.

The positives so far have been a full return of testicle size which gives me some confidence, and enhanced sex life. I don’t feel like an 18 year old, but I’m definitely performing like I did around 28. My wife and I are back to having sex every other day, when before it was maybe one a week. Brain fog seems to have improved, and over all fatigue has gotten better. I’m feeling much better than before.

A few negatives. I definitely don’t have the high end energy I did when taking shots. I really enjoyed that feeling, I was ultra motivated, focused, really felt strong…before I crashed using a shitty protocol. On shots I was able to drop body fat, build muscle, and now on clomid I’ve noticed I’ve lost the gains I achieved. Overall I’m weaker on lifts, and most noticeably I’ve lost some mass on my chest which sucks. I also think I’m starting to have some E2 side effects such as waking up in a sweat, increased emotional (positive) reaction to playing with my kids or hearing a song that makes me think of them etc. I’m gonna let things run the course a bit to see if it’s in my head, but anticipate asking for an AI.

My next set of labs are still 6 weeks out, but hopeful I’m on a positive track.


#18

FT = free testosterone
Such things are described in the advice for new guys sticky.
You really need to read the stickies.

Did you ever check your oral body temperatures? Yes is matters.

You can do T+SERM and have high T levels and useful LH/FSH at the same time and you can test LH/FSH.


#19

Sorry, your “FT unknown” response confused me as it was included in post. Apparently you didn’t see it, but it’s there.

Yep, took oral temps. Based on reading the stickies and other posts everything checked out well.

The thing is I’m not sure I want to mess with a good thing. I’m feeling stable, much better than I did before, and not sure the potential pros of going from 400 to 800 outweigh potential cons of making a change at this time. I’m coming from the absolute cellar (119) so anything above that is a huge quality of life improvement. Just not sure…I’ve learned the hard way that the grass is not always greener on the other side, and more of a good thing is not always a good thing, so maybe I’m a little gun shy.


#20

You have the options outlined if you want them.

FT unknown, I thought that you were saying that you did not understand FT…

Get the AI ASAP. If it crashes you, stop for 6 days and resume at 1/4th of that dose. Takes a week to really feel the changes.

There are benefits to higher T levels.