T Nation

Best Course of Action

Hi guys,

I am 28, tall (187cm), skinny(63kg) and always was. I have little facial hair, but everything else is pretty normal - have chest hair, had acne and oily skin which still sort of exists and also balding slowly since the age of 18. I have a large varicocelle on the left testicle since the age of 14, but I never felt it affects me in any way. I started masturbating in such an early age which I can’t even recall and felt like having a great libido all my life. Until…

When I was 24 my hairloss started to freak me out and from that age to 26 I used fin (propecia); 1.25 mg per day for the first year, and about 0.5mg in the second. I didn’t feel like having ED/libido issues before the drug, while taking it and a few months after quitting. This statement is a bit tricky, because all of the symptoms I have at the moment seemed to occur slowly after quitting, and I can’t remember any “crash”, but I can honestly say that all this time I had sex life which I can easily describe as satisfying.

On day one of propecia use I felt like something is really wrong: I got brain fog and wasn’t able to concentrate and felt poisoned, but thought I just needed some time to “get used to it”. Through the first months I felt terrible testicular pain sometimes, but I had no bad experience in the sexual area, so I ignored it. Moreover, I felt hornier as time went by. It did nothing to my hair but my scalp became less oily, and my sex drive went up, so overall, it did not feel so bad.

Over this time on fin I became more and more anxious. Because of that, I decided at some point, one year approx after starting, to cut the dosage. It didn’t help and later on, I got a panic attack. It scared me because I felt very mentally stable until that point, so I quit the drug.

During a few months after stopping I had a lot of these panic attacks and felt awful. I started a therapy (CBT), and over time managed to reduce anxiety. But as the anxiety feeling tapered off, I felt less and less sexual. At some point, I felt completely asexual and impotent, lost sensation in my genitals, felt atrophy in my balls, no sexual thoughts, no morning wood. Complete, horrible sexual silence. It was 10 months approximately after quitting propecia, but I had (and still do) a strong feeling that my problem was related to this drug, although the vast majority of propecia users that experienced sexual sides report ED and libido loss through the usage, short recovery after quitting and crashing a few weeks later. In my case, I had a gradual decline after quitting, which, again, is not typical, but there similar reports to mine do exist.

I had no clue of what’s going on and all of this bloodwork they had on the site’s checklist was unfamiliar. I took these tests and got the following results (again - 10 months after quitting 2 years of usage, age~27):

LH: 4.5 (0.57-12.07)
FSH: 13.7 (0.95-11.95)
Total Testosterone: 14.17 (6-29)
Free Testosterone: 33.84 (31-142)
Estradiol: 54 (40-161)
Free T4: 15.47 (9-19)
Total T3: 1.6 (0.89-2.44)
TSH: 0.89 (0.35-4.94)
Prolactin: 515.5 (54-380)
Vitamin D: 28.6

With a TT of an 80 years old dude, FT of a corpse and a prolactin of a pregnant woman I went to several doctors, one of them is like a well known American genius professor (endo), which all mainly shouted words like “fine”, “in range” and “psychological”.

I couldn’t bare the fact that this is happening to me. I became obsessed. I forced myself to masturbate, watched a lot of porn, read a lot of forum threads in propeciahelp - and became even more frustrated and compulsive. I felt there’s no resort, no one that really recovered, no one that really got his libido back - even not with TRT or SERMs. The stress and depression got stronger.

Besides the crap, all of these professionals (doctors / therapist) said from time to time things that actually made some sense. Endo said that FSH shows infertility and that my varicocelle is the main cause for that, so maybe its also interrupts with sexuality. One of the other doctors said the prolactin sample shouldn’t be taken early in the morning like the other hormonal stuff.

Another one said that bloodwork is crap anyways and swore that especially calculating FT is a “complete mambo jambo” and I should take SHBG test instead. He also mentioned that the fact I’m skinny affects this result in a way I couldn’t understand. My therapist said that even if I have T problem, my compulsive masturbation probably led to dopamine related issues that cause ED and libido loss and asked me to abstain from masturbation, sex and porn for a certain time.

I didn’t abstain, but a month later, I took another bloodwork in the morning and a separate one for prolactin later through the day. I got the following results:

FSH: 17.5 mIU/mL (1.4-18.1)
LH: 10.14 mIU/mL (1.5-9.3)
Testosterone 24.37 nmol/L (8.4-28.7)
Free Testosterone: 51.49 pmol/L (31-142)
Cortisol: 392.0 nmol/L (138-690)
Dhea-SO4: 7.0 umol/L (2.17-15.2)
Androstenedione: 2.30 ng/mL (0.3-2.63)
TSH: 1.11 mIU/L (0.55-4.78)
Free T4: 12.89 pmol/L (11.5-22.7)
Prolactin: 203.1 mIU/L (45-375)
Progesterone: 3.99 nmol/L (0.89-3.88)
17 OH-Progesterone: 25.64 nmol/L (1.81-10.3)

I couldn’t have SHBG test and still looking for a way to perform this test in Israel, where I live, but I took a sperm test and found out that I won’t have any chance to get my girlfriend pregnant ever, not even in a million years.

So with all this new data, I got very confused. My total T was really good. My free T was still zombish, but the doctors swore this result is “not serious” and to try and get SHBG result instead.
My prolactin was normal, and the high progesterone didn’t impress any doctor as well.

From that point until now, a year went by. In this year I tried to work on my stress issues and failed to abstain masturbation like the therapist asked me. If I managed to abstain for a few days, one of the two scenarios occurred: in the good one, I felt sort of a slight sexual desire (not even close to what I was before, but some) and “used” it immediately to have sex or to masturbate; the bad one: I kept on feeling nothing, got really stressed… and jacked.

Today I still have zero libido through the day, nothing at all. My penis won’t even move the whole day and it feels cold and disconnected from my brain. My erections, if they do occur, don’t last over 5 sec of non-direct stimulation and are like 70% in strength. No morning erections, although, there are sometimes when there are partial ones.

The weird thing is, I find myself hard through the night, sometimes when I wake out of a dream. Sometimes, and it happened a few times before this year, I’m waking up through the night with real libido (!) and have great sex with my girlfriend, but going back to the same state in the morning. This whole year I a can recall only one time I felt libido through daytime.

I decided to have another bloodwork soon. After whole this long story which I hope you read, I wanted to ask you for your opinion - based on my bloodwork and my story - what should be the best course of action for me? Where is the problem in your opinion? Is there a real mental factor in my case or some of the bloodwork and one year of 99% asexuality proves otherwise?

The most frustrating thing is that I DON’T KNOW where the real problem is, and how to treat it.
Say I get similar results in my next bloodwork, what would be the best course of action? I thought about having a varicocelectomy; endo recommends, urologists don’t, saying it has nothing to do with T and if it had, my left testicle would be much smaller, and as for fertility, well it’s probably lost anyway.

SERMs? After reading some data here and across the web, it seems like it might raise SHBG, and if FT is my problem it’ll probably be useless. TRT scares me… so little of success story with libido… I’d go for it, as a last resort, but I have to make sure that this is what I really need (?)

I’m a very light smoker and a very light drinker. I eat and sleep well. I have supplemented vitamin D, zinc and omega3 this past year with no success. At this point I’m supplementing vitamin D only.

Please help.

Many thanks.

Last fT4 is 13 and that is well below mid range of 17. Thyroid is not the cause of your problems. However, you would not want to have it as a compounding factor. Read the thyroid basics sticky, check your oral waking and mid-afternoon body temperatures and eval your history of using iodized salt and/or vitamins that list iodine.

Your DHEA was a bit low for your age. Can you get DHEA as a supplement? If so, try 25mg/day.

Elevated prolactin can indicate a prolactin secreting pituitary adenoma. Only good diagnostic is a MRI. A drug, cabergoline, can be used, 1/2mg per week to lower prolactin and then you can see how your body responds. If improved, then you will know that prolactin is a factor in your problem. But that would not explain everything.

Referring to this: http://en.wikipedia.org/wiki/Steroid_hormone

Your DHEA --> Androstenedione pathway seems very strong but
Androstenedione --> testosterone appears to be weak

FT is low and TT is higher because of two factors:

  • liver is making too much SHBG
  • liver is not clearing T+SHBG

Note that the liver produces SHBG mostly in response to E2 levels. Your E2 is really not that high.
referring to: http://www.unc.edu/~rowlett/units/scales/clinical_data.html
54/3.671 = 14.7 which is relatively low. You need to be accurate about things that stress you out.

Your pregnenolone --> progesterone pathway is strong, indicating that your pregnenolone production must be good. Progesterone is consumed to make cortisol levels which appear to be strong and that makes sense. You need to report the time of day for the cortisol lab work. We have AM cortisol labs here and one needs to do the lab work close to 8AM.

progesterone --> 17 OH-Progesterone appears to be very strong and this is a pathway to Androstenedione --> testosterone

All of this suggests that the testes are not working well, something that FSH has suggested already.

Please read the advice for new guys sticky and note the focus on causes and not just low T.


Is a steroid hormone and that is the problem, note chemical structure vs testosterone and other steroid hormones.

UPDATE - please help

Summary:

34 y/o, dealing with this crap for 8 years now, but only recently diagnosed with “initial, primary and relative hypogonadism” (so said endo)
Skinny guy, tall, testicular failure, infertility, 2 years on fin in the past, varicocele
Mid-low TT, low Free-T, high E2, high SHBG, Anemia with no clear source - iron, b12 and folic acid are all in range
Low libido, some ED, weakness, low muscle-mass, some cognitive sides
Never tried any treatment, no special diet, supplement iron only

WBC: 3.7 10 * 3/micl (4.5-11)
RBC: 4.55 10 * 6/micl (4.5-5.5)
Hemoglobin 13.3 g/dl (13.5-18)
Hematocrit 39.2 % (41-53)
FSH: IU/I 25.8 (1.4-18.1)
Estradiol: 147 pmol/l (0-146)
Testosterone Total: 16.2 nmol/l (2-26)
SHBG: 54.2 nmol/L (15-96)
Free Testosterone calculated: 0.241 (0.105-0.512) nmol/L
DHEA-S: 6.29 micmol/l (0.9-15)
Androstenedione: 0.85 ng/ml (0.4-2.6)

As time went by I tried to avoid obsessing over my problems and just focused on improving my mental health and mood. It took me some time but eventually I managed to do so pretty successfully. I used to take annual bloodwork of my total T – just to make sure things do not worsen, and then, in the last 2 tests, I asked for a more thorough bloodwork, and found out that my Estraiol had spiked.

What - if any - treatment should I consider starting? Don’t care about the infertility, I mainly interested in improving my quality of life, energy and sex drive, and avoiding any risks of having elevated E.

TRT is the end game, one or two injection per week unless estrogen becomes a problem which I’m pretty sure will be the case, then more frequent smaller injections will be necessary.

Surprised you didn’t start TRT sooner.

Thanks -

  1. What are the risks - in my situation - between having TRT and not?
  2. T injections only? no AI? Amounts? Could you be more specific?
  3. A lot of people who used finasteride claim that TRT did not help them for a long term - is there any reason to believe that ex-fin users have less chance for success with TRT than others?

It’s pretty dire without TRT, cardiovascular disease, heart disease, alzheimer’s disease, dementia, osteoporosis, diabetes and metabolic syndrome all of which TRT prevents and treats.

Let’s start with TRT in isolation and attempt to make it work without an AI, if one is needed then we’ll go there. Frequent injections is the name of the game if you want to lower estrogen, smaller doses daily or EOD if necessary using insulin syringes.

Your symptoms may be do to lower testosterone and therefore DHT, not PFS. You had varicocele on top of low testosterone, that’s enough to numb up your testicles and sexuality.

Even if you had PFS, you still need healthy testosterone.

You have an E2 problem. You stated that your “Folic Acid is in range”. They don’t test for that, they test for folate, which can be bad and show up good because of Folic Acid in your system. Folic Acid is synthetic and some people can’t process it. Your anemia could very easily be related to this. What are you Magnesium and Zinc levels? Have you tries supplementing either one of those?
Chances are you will exacerbate your problem by using testosterone at this point. It doesn’t fix everything and not everyone needs it. And listen to our therapist, you are ignoring some good advice because you don’t see the connection to it helping your situation. You should also consider something for dopamine, like mucuna pruriens or tyrosine.