T Nation

Doc is Uninformed, Probably Doing It Wrong. Help Me Correct Her


#1

Hey all,

I’ve been reading this forum for years and years and this is the place with the least nonsense bro-science BS. I’ll start with my short story first and include bloods, and other such things.

TL;DR: Always been a mousey lil biznitch, used AAS and felt awesome, got huge, injury took me out later in life, age 36 and just got TRT prescribed due to bloodwork. See bloods and questions below the novel I wrote.

In my younger years I was very slow to develop manly features and late to hit puberty at around 18. I was always the target of bullying in school and was left with using my wit to deter aggressors, which usually left me with a black eye. I didn’t have facial hair until well into my 20’s. I’ve always been what my friends call “pretty”. I’m mostly hairless across my entire body. Wrists are only 6 1/2", which looked kind of odd with 18" arms. My beard comes in patchy and up until I started lifting my friends ribbed me by calling me “Twig Arms Timmy”.

I started lifting at age 26 and got a decent trainer to help me start. I gained very slowly at first. I struggled for a few years even though my diet was decent (not perfect by any means but I wasn’t super serious then) but it was good enough to make the gains I wanted. Something was wrong and I craved more, so I got into the pro-hormones after a fair amount of research. My first go at it was with superdrol and I gained a good 10-12lbs and did an aggressive PCT. A few cycles later and I was a 215lb monstrosity at 5’11" and 8%bf. At this point my friends referred to me as “scary”.

I looked great. Felt great. But I would consistently struggle with a cervical spine injury that I couldn’t figure out. It would pop and I would be in bed for a week straight. I got regular deep tissue massages, frequented the chiropractor, and ate glucosamine/MSM tabs like tic-tacs. I also took a serious back injury from a crappy form leg press. All 600lbs came down on me like a brick house and folded me like origami. I got away with several torn muscles and a L3-4 herniation. I was careful with it and healed it pretty quickly and got back to the gym. I’ve also struggled with some weak joints… My shoulders aren’t great, and I sometimes have issues with my SC joint of all things.

Fast forward to age 34. I got married and stopped lifting seriously, but kept myself decently big with the help of some SARMS. The wife hated the thought of me doing anything illegal, but there were still some PH’s left over from previous cycles so I would sometimes do that, but my PCT’s were crap because of the state of the research chemical market at the time. I likely didn’t even PCT at all because it was probably bunk. I felt like crap mostly and my libido was floored but I kept on SARMs almost 100% of the time to feel halfway normal.

Age 35 I took another cervical spine injury that left me in so much pain that I stopped all workouts, stopped all SARM usage, and I was like this for a year until I sought out some help. I kept telling myself it would get better. It was so bad some days that I couldn’t turn my head, or get out of bed without help. It took months of xrays, mri’s, treatment plans and PT before they finally decided to give me two courses of epidural. The tests showed severe degeneration in C4-C5 and lessened degeneration in neighboring discs. I think this is due to the anthrax vax I got in the military in '98, but nobody seems to believe me. The epidural helped quite a bit temporarily. Overall the pain is much less, but it comes back and bugs me sometimes. Nowhere near the same though… for now.

So now I’m 36 (close to 37) and got back into the gym after I felt better and… well… it sucks. Somehow I feel WORSE after my gym visits. I have years of knowledge and research behind my exercises. I was trained by one of the best trainers in the world (not telling who so I won’t incriminate). My diet is impeccable. Every time I come back from the gym I’m sore for over a week. I feel like I was hit by a truck every single time. Not just the soreness, but the overwhelming amount of tired I feel afterwards needs some addressing. I lost all the fat I gained when I was on injury, but I have some fat in my midsection that refuses to leave. My body looks sort of pear-shaped… not unlike an untrained woman. So back to the doc. I knew what this was. I’m no dummy and this isn’t my first rodeo. My T is on the floor. I know the feeling from so many PCT’s. But I haven’t cycled anything in over a year. I went to my doc and played dumb. “My libido is so low and I don’t even think about sex ever. I can achieve erection but I don’t want to use it. I’m tired all the time and feel like I’m walking around in a fog.” Several key words were used here and of course my doc responded with exactly what I primed her for. “Sounds like low-t. Let’s get some blood work.”

I wanted NO ambiguity here. The last time I asked this question at age 34 my T was at around 320-ish ng/dl and the doc at the time responded with “It’s low for your age but I can’t recommend TRT at your age.”. This time I drank a few nights prior, and ate carbs prior to the test which I scheduled later in the day. I did not bother to deprive myself of sleep however. It came back at 157ng/dl. Wowzers that’s low. Even with the stuff I did to myself. Doc prescribed TRT and started me at 100mg per month. I gave her a study from the AACE which stated biweekly is preferred, which she happily accepted and allowed 100mg biweekly from the get-go. I will be slowly talking my doc into weekly injections, with dosage depending on bloodwork.

Did I just fry my HPTA, was I just made this way, or is this mild Cushing’s due to epidural? Sadly I don’t have any cortisol levels in my bloodwork so I’ll request it on my next test on the 5th. I honestly want to be on TRT. I always felt like I was missing something until I started using “things”, and then it all clicked into place. I felt like I should have been that way all my life. I’m not too sure I want my cortisol checked so the doc won’t deviate from my current TRT plan.

My main question is this: How can I make sure that I get optimal dosage and timing from a doc that is clearly uninformed on normal practice of TRT? She’s easily manipulated, but I worry that I’ll push too far. This also means she likely knows nothing of using AI and HCG if needed. I’ve always been able to keep gyno in check in the past, but I definitely am prone to it. Also this 100mg I just got 5 days ago feels like it totally shut me down right away and I feel like utter garbage. Feels like I’m walking through water. Extra tired. Super brain fogged.

Vitals:
BP: 120/82
RHR: 89 (I’m working on my cardio don’t judge me)
PulseOX: 99%

Bloods (nonfasted) - Cholesterol looks slightly off, but pretty good for nonfasted:
TESTOSTERONE, TOTAL 157 ng/dL 250 - 827 ng/dL
TESTOSTERONE, FREE 37.8 pg/mL 46.0 - 224.0 pg/mL
GLUCOSE 92 mg/dL 65 - 99 mg/dL
Fasting reference interval
Urea Nitrogen 14 mg/dL 7 - 25 mg/dL
Creatinine 0.98 mg/dL 0.60 - 1.35 mg/dL
eGFR, Non-AA 99 mL/min/1.73m2 > OR = 60 mL/min/1.73m2
eGFR, AA 114 mL/min/1.73m2 > OR = 60 mL/min/1.73m2
BUN/Creatinine NOT APPLICABLE (calc) 6 - 22 (calc)
SODIUM 142 mmol/L 135 - 146 mmol/L
POTASSIUM 3.8 mmol/L 3.5 - 5.3 mmol/L
CHLORIDE 108 mmol/L 98 - 110 mmol/L
CARBON DIOXIDE 24 mmol/L 20 - 31 mmol/L
CALCIUM 10.0 mg/dL 8.6 - 10.3 mg/dL
PROTEIN, TOTAL 6.8 g/dL 6.1 - 8.1 g/dL
ALBUMIN 4.7 g/dL 3.6 - 5.1 g/dL
GLOBULIN 2.1 g/dL (calc) 1.9 - 3.7 g/dL (calc)
ALBUMIN/GLOBULIN RATIO 2.2 (calc) 1.0 - 2.5 (calc)
BILIRUBIN, TOTAL 0.7 mg/dL 0.2 - 1.2 mg/dL
ALKALINE PHOSPHATASE 38 U/L 40 - 115 U/L
AST 22 U/L 10 - 40 U/L
ALT 30 U/L 9 - 46 U/L
Total Cholesterol 211 mg/dL 125 - 200 mg/dL
HDL CHOLESTEROL 63 mg/dL > OR = 40 mg/dL
TRIGLYCERIDES 70 mg/dL <150 mg/dL
LDL-CHOLESTEROL 134 mg/dL (calc) <130 mg/dL (calc)
Desirable range <100 mg/dL for patients with CHD or
diabetes and <70 mg/dL for diabetic patients with
known heart disease.
Cholesterol/HDL Ratio 3.3 (calc) < OR = 5.0 (calc)
NON-HDL CHOLESTEROL 148 mg/dL (calc) mg/dL (calc)
White Blood Cells 9.7 Thousand/uL 3.8 - 10.8 Thousand/uL
Red Blood Cells 5.64 Million/uL 4.20 - 5.80 Million/uL
HEMOGLOBIN 16.1 g/dL 13.2 - 17.1 g/dL
HEMATOCRIT 49.1 % 38.5 - 50.0 %
MCV 87.0 fL 80.0 - 100.0 fL
MCH 28.5 pg 27.0 - 33.0 pg
MCHC 32.8 g/dL 32.0 - 36.0 g/dL
RDW 13.0 % 11.0 - 15.0 %
Platelets 264 Thousand/uL 140 - 400 Thousand/uL
MPV 9.3 fL 7.5 - 12.5 fL

TSH w/ Reflex T4
TSH 1.50 mIU/L 0.40 - 4.50 mIU/L


#2

That’s how I felt after my shot last week, really tired, lower energy and shortly after it passes and I started feeling better. It takes 3-4 days after your shot for the T to peak, normally for me the peak is when I get super tired and things get better slowly. Don’t expect to start feeling better right away, it takes time for your body to reach a balance. For the past three months I was on 200mg every 3 weeks and didn’t feel much better till my new doctor lowered it to 75mg weekly. I tended to feel way worse than before I even started TRT when I was given too much testosterone, it drove up my E2 which can make you feel really terrible no matter where your T range is at!


#3

Thanks mate. Good to hear someone else had that same issue in the beginning. I wanted this thinking I would feel better, not worse, right?

I feel a little better today. Yesterday was a waking nightmare.

If my bloods allow for it, I’d like to get in the high range >800ng/dl as long as my doc will prescribe AI to keep that E in check. I used to take it back when I “self-medicated”.

Let me say that I HATE getting bloods done. I don’t mind it so much if I’m not fasted, but if I’m fasted I pass out cold. I wake up to smelling salts and I’m a pale green and ready to barf on the nearest nurse. A nurse once monitored my BP during one of these events and it bottomed out at 60/40. I asked her if I died. You could clearly see the look of worry on her face.


#4

Your cholesterol is fine and TRT often improves.

Please provide lab ranges for TT, FT. You can directly edit your post above, look for pencil icon.

HTC=49.1 is very high relative to your T levels. TRT can be expected to make this worse. You may need to do blood donations if you can. Avoid iron fortified vitamins, breads, pasta, rice etc. RBC will increase too and that is behind high HTC.

You should have checked LH/FSH before TRT. But problem is likely to be secondary hypogonadism with your history.

Dr: Younger virile males produce around 10mg T per day, 70mg/week. If you inject 100mg T enanthate [eth] or cypionate [cyp] per week, after the ester groups are stripped off you get ~70mg T.

The peaks of injecting once a week or less frequently promotes higher HTC, driven by the peaks and E2 is similarity increased. Injecting 50mg twice a week is your best option and SC/SQ provided smoother T levels while also avoiding decades of muscle needle damage. Inject with #29 1/2" 0.5ml insulin syringes, upper leg, pinch up skin and inject into end of fold, needle parallel to muscle layers below.

Do you need to remain fertile?
250iu hCG SC EOD is a replacement dose for youthful LH levels. This will prevent shrinkage and scrotum pulling up tight, and yes, many wives GF’s do care.

You need to be testing E2 estradiol. But get on proper T delivery for a while first so labs match protocol. I typically suggest 0.5mg anastrozole at time of twice a week T injections, and then adjust to get near E2=22pg/ml.

TSH is better near 1.0
Please self-check overall thyroid function via last paragraph in this post. DO NOT think that this is trivial. If you are not using iodized salt, change that.

Please read the stickies found here: About the T Replacement Category

  • advice for new guys
  • 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.


#5

Beautiful. Great info. Let me give you some additional info, though it doesn’t cover everything.

HTC=49.1 is very high relative to your T levels. TRT can be expected to make this worse. You may need to do blood donations if you can. Avoid iron fortified vitamins, breads, pasta, rice etc. RBC will increase too and that is behind high HTC.

Agreed. I’ll reevaluate my diet accordingly and donate once my plan is dialed in if I can’t get it under control. I have some pretty deliciously healthy blood that I’m sure somebody will be glad to have.

Dr: Younger virile males produce around 10mg T per day, 70mg/week. If you inject 100mg T enanthate [eth] or cypionate [cyp] per week, after the ester groups are stripped off you get ~70mg T.

Ok. I’ll see where I end up once the bloods are in.

The peaks of injecting once a week or less frequently promotes higher HTC, driven by the peaks and E2 is similarity increased. Injecting 50mg twice a week is your best option and SC/SQ provided smoother T levels while also avoiding decades of muscle needle damage. Inject with #29 1/2" 0.5ml insulin syringes, upper leg, pinch up skin and inject into end of fold, needle parallel to muscle layers below.

The doc seemed to have an aversion to allowing me to do it myself. I’m doubting they will do subq based on their current lack of knowledge. They follow what’s on the package. If I show up once a week for a while I’m hoping they’ll just get tired of me and let me do it myself. From there I’ll move to subq.

Do you need to remain fertile?
250iu hCG SC EOD is a replacement dose for youthful LH levels. This will prevent shrinkage and scrotum pulling up tight, and yes, many wives GF’s do care.

I have 4 kids here. 1 of which are mine. Me and the wife have agreed that no more kids are necessary, barring any sudden life changes. I don’t think this wife will care about my testicles as long as I’m actually doing my kingly duties more often.

You need to be testing E2 estradiol. But get on proper T delivery for a while first so labs match protocol. I typically suggest 0.5mg anastrozole at time of twice a week T injections, and then adjust to get near E2=22pg/ml.

100% agree here. No idea why the doc didn’t order them the first time. Like I said in the subject… :confused:

TSH is better near 1.0
Please self-check overall thyroid function via last paragraph in this post. DO NOT think that this is trivial. If you are not using iodized salt, change that.

I eat seaweed to counter my lack of iodized salt. I’ll have my doc make sure to get vitamin prof on next go as well to be sure it’s doing what I think it’s doing.


#6

Get a high potency B-complex multi-vit that has trace elements including iodine[150-170mcg]+selenium[150-200mcg]

Sea weed may not be sufficient and not all are the same.

If you wait for high HTC, blood bank will detect that and reject you, then you are screwed.

If diabetics can inject insulin, why can’t you inject T?


#7

There’s something about me and high-dose B vitamins. It makes my anxiety go crazy. I’ll see about getting something to supplement my iodine. I did pick my seaweed carefully and eat an amount per ounce of seaweed that should correlate to the amount of iodine that I need. Again… Don’t take this as me knowing the gospel, but I only did this to supplement more with some whole foods rather than supplements.

I’ll try my best to get my HTC in check and monitor it closely. I essentially signed up for consistent blood draws anyway with TRT, so… I’ll keep a close eye on it.

I agree with your final statement. Maybe because its a controlled substance the office doesn’t like doing it? I’ll get my plan ironed out and see about it then. And if this doesn’t go the way it’s supposed to then I’ll just move to another doc. I have to admit… I like somebody else doing the injection. I could never figure out how to get my glute myself. That and doing it myself sometimes made me woozy. I once feinted with a needle in my leg. Horrible. That being said, I could definitely handle subq myself.


#8

Do not neglect selenium.

Where are you located?


#9

Seems I’m only getting 2.5mcg of selenium from my Amazing Grass drink daily. I’ll go and grab a supplement that contains this and Iodine but omits the super dose of B vitamins. Hopefully that exists, but I’m not seeing it yet. Looking for these two together always sends me to thyroid support vitamins which contain super doses of B complex. I’ll keep looking. I’ll take a trip to my local Vitamin Shoppe to see what they have.

I’m in the US. PA to be specific.

Today I feel incredibly different. It started off feeling pretty regular, and how I feel most days. Not particularly awake, not particularly tired. Just meh, as usual. My mood spiked to the positive side and I’m having trouble staving off a boner at work. And for some reason I feel like getting in a fight. Not looking forward to the roller coaster I just got on even if I feel awesome at the moment.

I remember my first go a while back with Sust250. It was UG and hurt like hell when it crashed in my muscle, but was fixed by adding some ethyl oleate. Smooth as butter afterwards. I remember I never felt like a roller coaster. I pinned once a week and I never felt down. I immediately felt awesome and it continued for the 12 weeks.

Why is less amount of cypionate making me feel down, then up? I get that sust has propianate and undecanoate etc. to keep levels a bit smoother, but… I really didn’t expect this horrible down feeling with cyp. I really hope this doesn’t happen every week. Why don’t doctors prescribe sust?


#10

Are you describing T rising and falling with E2 increasing so as T falls into a sea of estrogens you feel like crap? Suggested protocol is designed to avoid that. Only cases where this fails is hyper T metabolizers who need 3X the 100mg T dose and EOD injections because effective half-life also greatly reduced.


#11

Are you describing T rising and falling with E2 increasing so as T falls into a sea of estrogens you feel like crap?

If that was the case, wouldn’t I have the same effect with 5x the amount of T? At one point I was at 500mg sust per week. This was a long time ago, and I used AI probably halfway through my 12 week when I noticed some side effects of high E2. Really it was just itchiness in my nipples.

Don’t get me wrong here KSman, I’m not disagreeing with the TRT program you described. It all makes complete sense. I’m just curious why I’m feeling ups and downs on 100mg if E2 is to blame. It would make sense if I had the same effects, if not much worse, on 500mg sust, right? I don’t know… maybe there’s other variables at play here.

Hey I just picked up 200mcg tabs of Selenium and 225mcg tabs of kelp iodine. Hopefully this will get my thyroid levels in check.


#12

Just want to eliminate T and E2 ups and downs. If then you still feel that, we know what it is not.


#13

Went in for second blood test prior to second shot. I asked if I could have my E2 checked before going in and… well… I’ve heard of doctors like this, and I knew mine is uninformed but… WOW. Not sure if it’s worth it to continue at this place or move on. Do I spend the time to teach her about this or just count my losses?

“Pt is requesting further testing related to his testosterone level and fatigue. Estradiol levels are not normally tested in men for this diagnosis. (not a standard of care) Will likely not be covered by insurance and FM can not interpret results once completed.”

The nurse handed me this from the doctor. I was shocked. I told her to ask the doctor why this is not a standard of care and not normally tested. She leaves for about 2 minutes, comes back and says,“The doctor said because it’s a female hormone.”

Can this be saved? Should I just move on? I hate the thought of going through all this again. I read through all the horror stories people have gone through in the “stupid things doctors say” thread. This exact situation was in one of those posts.


#14

Please add to that thread!


#15

Happily. I just wish I knew what the hell to do next. My area doesn’t have a lot of choices. It’s tough to go running around all the time shopping for a smart doctor. I already took quite a few days off to get my cervical spine issues some attention… speaking of that; I just got a referral for a surgeon. I’m almost 37 and looking forward to spine surgery. fml.

Is there any way to fast-track the search? Do you think an office would give me their TRT treatment plan before I even go in?


#16

Did you read the Finding a TRT Doc sticky? Compounding pharmacies know what a lot of doctors are doing. Doctors should be willing to sell what they do, but hard to get them out of the billing rut.


#17

I did and looked for a compounding pharmacy in my area at one point. There’s one close by so I’ll give them a call soon. I think I looked into this prior to actually getting prescribed (which is when I was reading through the stickies), so maybe I just wasn’t there yet. The process is very confusing.

So as an update my doctor only tested Testosterone levels in my latest. This was taken at the end of week two just prior to my next injection. I am on biweekly 100mg injections, and my bloodwork here is to be expected:

Comments from the Doctor’s Office:
Looks like your test was collected too early
This reflects the effect of only one dose of testosterone.
We can repeat but should wait a bit so it is covered by your insurance

TESTOSTERONE, TOTAL 184 ng/dL 250 - 827 ng/dL
TESTOSTERONE, FREE 37.7 pg/mL 46.0 - 224.0 pg/mL

What the hell is she talking about? She thinks this stuff builds up in your system or something? How does she know if a blood test will be covered by insurance or not? Regular blood tests are not only approved by my insurance, it’s also recommended by them. ARRRGGH I friggin’ hate this lady!

I sent her this message in reply, hopefully to make her do some research rather than just read what’s on the f’ing label of the testosterone cypionate package. I was limited to a certain amount of characters in the message so… I had to truncate a bit. I hope she got the point.

I made a log of how I felt over the last 2 weeks. I felt incredibly bad the second week after my first injection. This seems to reflect the half life of the cypionate ester of 8 days, and I may do better on weekly injections rather than biweekly. Could we do 1ml (100mg) weekly and continue regular testing to evaluate serum concentration?

An evaluation of E2 levels is to ensure E2 levels do not increase as my testosterone increases. The aromatase enzyme will increase E2 in males and should be assessed when on TRT. Low E2-bone density loss, High E2-mood swings, breast tissue.

Reference:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3143915/

Edit:

Just got this back from my doctor. I want to fire her on the spot. Guess I need to find a new doc first before going in there and screaming in her face.

Tim,
I reviewed your message.
Increasing your dose to 100 mg testosterone once a week will double your dose,
So I can not authorize the increase.
Generally the biochemistry of medications, you will achieve a medication steady state on your 4th dose of medication.
Also I can not interpret the estrogen level once you have collected it
Again, if you wish to have a specific test collected outside the standard of care for family medicine please follow up with a specialist
Below is contact information for your convenience
Unfortunately the local providers do not accept your insurance.
-removed dr’s name-


#18

50% of doctors graduate in the bottom half of their class.


#19

I have a theory that GP’s all consist of the bottom 50. If they weren’t they would be specialists or surgeons. I have half a mind to let her harm me so I can sue her out of business so she doesn’t infect anybody else with her stupidity. I’d be a hero. 'Murica.


#20

Time to find a new Doc. Seems like PA should have a good selection.

Also, on the iodine supplement, look for Iodoral at 12.5 mg. I get mine at www.naturalhealthyconcepts.com
they have free shipping. Amazon has it too but they seem to be screwing up my orders lately. This place got it out right away and they have auto-ship.