T Nation

Chronic Fatigue


Hi everyone,
Long time lurker, first time poster. I am 45 and I have struggled with fatigue (mental and physical) since high school. I admit to severe over training in my past (attempting to turn pro in triathlon). I am a PT. I stopped over training at around age 30 but the fatigue never went away. I also developed waking insomnia. At around age 32 I went to my GP and he did “thorough” blood testing (sorry I don’t have them anymore) and was told everything was fine. Had multiple sleep studies that were not diffinitive. Total T was in the high 200’s but was told I was in range. Thyroid (TSH and T4) were WNL. AM cortisol was WNL.

I was told to stop exercising because I was getting old. So I stopped exercise for a few years, Of course I got worse. I then re-started exercise in a controlled manner but was even more fatigued. At age 39, I insisted on a referral to a urologist. Was put on clomid (name brand) for secondary hypogonadism. I got up to around 500 TT. I felt OK but got scared about an eye floater then d/c’d clomid. I actually felt pretty damn good for about 6 months then slid into fatigue again. Went back to the urologist about a year later and was put back on clomid. No response in 6 months (discovered I was on generic). But the urologist said it didn’t matter. Was told I could either try trt (injection) or go on with no treatment.

Agreed to the injections. Wasn’t allowed to self inject. 400 mg depo q 3 weeks. Felt AMAZING after 2 months. (Trough 450 TT, peak must have been VERY high) This lasted 2 more months. Then felt terrible as I progressed toward 6 months. Was given the choice to go off trt or try testim. Testim 2 tubes daily for 3 months and nothing (of course it was high E2 all along). Went to a different dr. New dr put me on compounded transdermal T scrotal application. Again high E2 kept me from seeing benefits but he would not treat the high E2. Then tried an hcg stim test. Results were TT of 700 but skyrocketed E2 - felt awful. Decided to go off trt. MORE AWFUL!! Went to a naturopath at Tahoe a few months later at age 42. She tested cortisol via saliva (results were “flipflopped” causing waking insomnia).

Tested neurotransmitters (perfect). Tested all thyroid parameters (I will get to that). She started by treating the cortisol. Never saw much difference for about a year. Went to a psychitrist in early 2015 and was put on lexapro 10 mg. Didn’t help much. Currently weaning off. In early 2015 talked the naturopath into trying TRT again based on never treating E2 previously. She prescribed transdermal T 6% with chrysin 6%. Limited, if any improvement. She felt I wasn’t absorbing. Added 200iu hcg 2x/wk and I felt awful. She decided I cannot tolerate hcg. At age 44 she put me on injections of T cyp. I decided to inject EOD (she prescribed 1x/wk then later 2x/wk). Initially tried without AI but ended up with a TT of 850 and E2 of 66. I tried 80mg/wk, 100mg and 126mg with between 0.5 and 1.25mg/wk anastrozole I never could get my T:E2 in a range where I felt good (always had negative side effects).

The naturopath and I feel I am an over aromitizer and no amount of AI will work. Here we are at what I am going through in real time (aka right now). I talked to the naturopath on 4/4/16. My thoughts were to stop testosterone and do a HPTA re-start with 5 to 10mg tamoxifen qd (although my testicles are very atrophied I still am not willing to try hcg again). She countered with re-reviewing my thyroid test from 2014 that we never treated for, then revisiting a HPTA restart later. My thyroid test results show normal TSH, normal free t4, but very low normal free t3, and very high normal rt3. So she wanted me to do a 3 month trial of generic cytomel to “knock” the rt3 off my receptors. Here is the crux of the issue.

I started the cytomel at 5 mg morning and afternoon on 4/6/16. I feel the worst I have ever felt fatigue and brain fog-wise. I am at 10 days post final injection of T cyp. So either I am nearing a very hypogonadal state or I cannot tolerate cytomel. I feel I am a bad science experiment, ie she is throwing things at me and seeing what sticks. I feel the naturopath put the cart before the horse. But she is by far the best dr I have worked with. So my choices are the following:

  1. Get back on trt
  2. Stop the cytomel (or decrease the dose)
  3. Beg and plead to do tamoxifen before trying to treat the thyroid issue
  4. Stop everything
  5. A combination of 1,2,3, or 4 or something I haven’t thought of
    Any thoughts, questions, etc are appreciated.


Post lab data with ranges. Including normal.

Have you read these; found here: About the T Replacement Category

  • advice for new guys
  • things that damage your hormones
  • protocol for injections
  • thyroid basis explained
  • finding a TRT doc

Over training can break one’s metabolism.

LH/FSH before TRT and while on SERM
fasting cholesterol
fasting glucose
cortisol results with time of day

What is your history of [not] using iodized salt or vitamins listing iodine+selenium?

Post your oral body temperatures as per the thyroid basis explained sticky.


Thanks for responding KSman,
I will review the stickies you mentioned. I will do my best with regards to lab work. Some labs may be lost (and I was going off memory). I will respond in a week or two as I am going out of town. I believe the over training has broken my metabolism. Triathlon can be very unhealthy mentally (OCD) and physically for some people (myself included).
I really appreciate and trust your advice as I have been following your posts for years.
Thank you,


Thanks back to you!

I have read where some ultra marathon runners have simply been broken after an event. These things are very real.

I will have limited time here for a while too.


Hello again,
KSman, I have collected old lab results per request. Also, I apologize for emailing you directly, as I was reviewing this information on my iphone and accidentally responded to you via email. Also, I have reviewed the stickies.

This section below is when NOT on TRT or SERM but cortisol levels were under treatment via nutriceuticals (after the space is not on TRT, SERM nor cortisol treatment):
TT=317ng/dl (160-726) 8/15/2014
FT=5.5ng.dl (9.0-30) 8/14/2014
E2=<20pg/ml (ND-56) 8/14/2014
LH=2.7mIU/ml (0.8-7.6) 8/14/14
FSH=4.8mIU/m (0.7-11.1) 8/14/14

Prolactin=6.74ng/ml (2.1-17.70) 5/11/2012 (post clomid)
Prolactin=3.7ng/mL (2.1-17.70) 10/8/2009 (on clomid)

7/24/09 lab tests pre clomid (LH and FSH were not checked while on clomid):
LH=1.6mIU/mL 1.5-9.3
FSH=3.3 mIU/mL 1.4-18.1

6/24/2010 lab test ON clomid: Told I had secondary hypogonadism
Testosterone, tot= 594ng/dL 280-800
Free Testosterone=17.3pg/dL 8.7-25.1

8/15/2013 lab test on hcg stimulation test: Confirmed secondary hypogonadism
Testosterone, tot=701ng/dL 280-800

CBC: 5/11/2012 (Fasting)
Na=138 nmol/L 135-145
K=3.6 nmol/L 3.6-5.5
Chloride=104nmol/L 96-112
CO2=28nmol/L 20-33
Anion gap=6.0 0-11
glucose=103mg/dL 65-99 H
HA1c=5.6% <6
Bun=16mg/dL 8-22
Creatinine=0.83mg/dL 0.5-1.4
Calcium=9.4mg/dL 8.4-10.2
AST=28U/L 12-45
ALT=32U/L 2-50
Alkaline phosphate=48U/L 30-99
Total bilirubin=0.8md/dL 0.1-1.5
Albumin=4.4g/dL 3.2-4.9
Total protein=7.7g/dL 6-8.2
Globulin=3.3g/dL 1.9-3.5
A-G ratio=1.3g/dL no range
Hematocrit=47.8% 42-52

Fasting Cholesterol 2/19/13 (on 400mg t cyp q 3 weeks)
Cholesterol, tot=159mg/dL (100-199) (first time since tested in my life that I was below 199 total cholesterol)
Glucose=72mg/dL (65-99) (first time below 100)

Fasting Cholesterol 1/15/15 (No trt)
Cholesterol, tot=203

Fasting cortisol 9:17 am 6/14/14
5.0 ug/dL 0-23

Thyroid panel: 8/5/14
TSH=1.53uIU/mL 0.45-4.5
Free T4=1.37ng/dL 0.82-1.77
Free T3=2.8pg/mL 2-4.4
RT3=23.2ng/dL 9.2-24.1 (4/6/16 just started Cytomel 5mcg in am and titrating up slowly)

DHEAs=187ug/dL 80-560
IGF-1=193ng/mL 101-267
25-hydroxy=49ng/mL 30-100

I don’t have the most recent 24 hour cortisol test, but the NP said the results were “flipped”, meaning when the levels were low at the time of day they should be higher and vice versus.

I have taken waking temperatures on and off for 15 years. They have always been between 96.8 and 97.3 degrees. They are not consistent at the same temperature every day. Never am I at 98.6 degrees in the afternoon.

I use sea salt unfortunately - so most likely low iodine. I have been taking Metagenics brand phytomulti with iron for years (iodine 150mcg) - not enough I know). Also take metagenics epa/dha, and d3 5000.

Thank you,


hCG dose appears to be very high, inducing high T–>E2 inside the testes.

Why are you taking any supplemental iron. That is typically not needed or good for healthy males.
T3 meds should help with rT3.
Note that I recommend dosing to achieve improved body temperatures. As rT3 decreases, you may need to then reduce dose as things improve. Compounding pharmacies can produce a time release T3.
You can review the thyroid sticky for terms: rT3, adrenal fatigue, Wilson’s book, stress etc

Sometimes we see that thyroid problems cause low T. A few cases here have seen T increase with thyroid treatment. But often does not happen.
Your thyroid panel results are old.


Thanks for reviewing the labs, KSman,

Yes the HCG stim test was a VERY high dose (5000IU eod if I remember correctly).
Even at 100IU eod (last summer) I felt poor at that dose.
I will get the non-iron Phytomulti next bottle - thanks.
Yes, it is early days in the Cytomel “journey” but I am hopeful - I have a conscientious Dr.
I will ask about time release compounded T3 - thanks.
I believe I am up to date on the terms - I will check the stickies if I am unsure.

3 questions:

  1. Do you think I should try another re-start with Tamoxifen? (I am 16 days post last T cyp injection)
  2. If yes to 1) should I ask for a script now or wait 3 months to see if the Cytomel is helping (as I feel quite poor currently - hypogonadal)?
  3. Do you think generic Tamoxifen is adequate or do you believe name brand Nolvadex would be a better choice?

Thank you so much,


I would not expect to see any difference other than cost.

If thyroid problems contributed to your secondary hypogonadism, I would have doubts about a restart working under those conditions. Maybe you could manage on 10mg Nolvadex EOD while you work on your thyroid issues then make that your in-place restart foundation later on. See the HPTA restart topic.


Thank you KSman,

I will ask the Dr. about starting Tamoxifen earlier than 3 months and then continuing thereafter.

2 questions:

  1. If I am on T3 (cytomel) do you recommend an iodine supplement as well?
  2. If yes which product (kelp, etc) and how many mcg per day?

I really appreciate your advice,


There are roles for iodine and your intake should be adequate in any case.
0.5mg/day would be OK, but may need to load more if deficient.


Thanks you!!! (20 character minimum)