Trust me, the very last thing I want is TRT, especially after reading about the emotional and physical roller coaster ride that ensues. However, I have a lifestyle, a job and a wife that require a certain level of performance, so I may have no choice.
I’ve been on TRT for five years and no roller coaster ride of any kind.
I’m with highpull, just over 2.5 years and no roller coaster. Sure E2 can get high maybe prolactin and your nipples might get a little sensitive or ichy. You could get a bit sensitive to something sad on TV but its not that bad. Crash your E2 and you joins click a bit you might have some ED problems. But its fixed as soon as you get re-dialed in.
Now we are talking TRT levels not running gear.
A testosterone level of 1000 at every single minute of the week (weekly average is what I was discussing) is absolutely not normal. Someone who peaks at the very top of the normal range naturally is going to have a daily circadian fluctuation meaning that he’s going to average 700-800 ng/dl. On top of that, people with high test levels usually have rather normal SHBG, so their free T isn’t that high.
On a “TRT” that gets you at or above 4 digits average your free T is most definitely above the normal range 24/7. That’s gaming the system. TRT isn’t raising SHBG, which contributes to the higher degree of aromatization some seem to experience. And more DHT too, people feel better but the stronger androgen load can become a problem over time. Maybe all you had to do was to use an AI instead of more T? (and an AI?)
What I was saying on E2 is assuming a rather middle of the range degree of aromatization, meaning a normal-high SHBG. Secondary hypo patients definitely seem to have consistently low SHBG which goes well with glucose intolerance / high fasted insulin. So indeed maybe too much individual variability to make E2 a good indicator. Let’s stick to free T.
Just some food for thought: what’s optimal naturally? T in the 800-1200 ng/dl. Free T in the 2-3%. Free T = E2. It’s not that hard, but it’s all assuming normal SHBG levels, therefore a proper glucose metabolism. And that, in the land of fat and grains, is the ultimate challenge.
I’m sorry I missed the part where your doc diagnosed you as a primary hypogonadal. It seems to me that those base levels of T aren’t bad, you just had e2 a bit high, which leads to less T through negative feedback. What were your LH&FSH?
It could be as simple as losing some fat, improving digestion for a better insulin sensitivity / nutrient partitioning, and not resorting to something that is suppressive (HCG) but instead try to get less negative feedback from the E2, yielding a higher T.
By the way insulin and ferritin…
ferritin concentration in Impaired Glucose… subjects of nonobese already significantly increased when compared with Normal Glucose subjects of nonobesity
Just an idea though. I wouldn’t bother too much with iron unless you’re abusing red meat, idk.
As a matter of fact, your T/E ratio improved on HCG. This gives me a bit of hope. Fix the glucose metabolism playing with the macros. I recommend a low fat diet, but a low carb diet may do the trick if your metabolism is very bad. That’s up to you to gauge your reaction to tubers and whole fruits (rather than non-soaked non-sprouted grains and juices). The Randle cycle blames fats for insulin resistance FYI
https://www.researchgate.net/publication/6519769_Free_fatty_acids_and_insulin_resistance
As per my post right above, the rather low total T and natty high e2 makes me think you may want to lose some aromatization, either through weight loss, improving fasted insulin levels, bumping SHBG up… Clomid does the latter by the way, but don’t do it forever since you may be left with low free T. It’s a tricky balance with insulin sensitivity and carbs, nobody said it’s easy though 
There’s more to a SERM than the HPTA action.
What kinds of problems?
What’s the logic behind the high ratio and Clomid recommendation? Without seeing LH numbers ?
Broad question!
Everything that is tied to the metabolic syndrome, which is poor glucose metabolism, rather insidious and can’t be felt anyway. It’s a long term process.
Of course, if you’re fine with popping pills for every symptom of chronic inflammation that is surfacing (high prolactin among others), then you do you. Understand that it’s absolutely not fine to tell people to jump straight to TRT. You’re not a doctor, and you should understand why they don’t massively prescribe T injections for all. Just a tiny bit of devil’s advocate. Suffering is a big word you’ve been using. The doctor does their job, although I agree they could be better at explaining the strong correlations we see everywhere in research. That plus “classic” biochemistry, health professionals should connect more dots more often.
That said, I sometimes interact with Doctors who say “diet has no relationship with acne, it’s junk science”. So we’re far from getting there. The figure 2 of the following PDF explains some androgen-related issues quite well (the whole paper focuses on alopecia):
https://www.cidjournal.com/article/S0738-081X(17)30166-9/pdf
Higher than normal Androgens is usually caused in natural people by high fatty acids / glucose intolerance / insulin resistance (of which low T is a consequence). In normal people however this state doesn’t seem to last too long (speaking averages), as glucose intolerance leads to high fasted insulin which hammers down SHBG.
OP’s SHBG is tested twice averaging 37.5 ish, in a range that is nothing but statistics in a sick population. So, he’s not really up there, and again that’s fasted in the morning. Not good. The logics would be that his levels would keep sliding down slowly if his glucose metabolism doesn’t improve.
But we don’t have fasted insulin levels, so it’s mostly deductions, based on what I can read. I wouldn’t be surprised if he comes back higher than the optimal, which Dr. Attia gauges around 4-5 iu/liter. Again, the norm, which means absolute jack shit, is 2-24 iu/L. Double digits is very suspicious already. Look up HOMA-IR, which although imperfect, should be absolutely standard in every blood test. We lose time trying to figure out how far from the optimal of 22.5 we wanna be cool with. Every patient should have a score on hand, nice and clear. Or maybe that’s because there’s no money to be made on better diets and eventually Metformine/Berberine. Who knows. What we see quite often is how persistently high insulin seems to trigger virtually everything under the sun in the metabolic syndrome.
A faulty glucose metabolism would yield low SHBG thus low T, compensated by DHT and e2 (both with high free hormone levels) and a host of problems grouped under the metabolic syndrome, from acne to prostate cancer to alopecia to vascular dysfunction to diabetes and so on.
I would be extremely surprised that OP’s LH/FSH come back abnormal. I don’t believe in this epidemic of low T people. I do believe his glucose metabolism may have lead to an insufficient SHBG (for him). Ergo a T/E ratio of 9.
His ratio on HCG was a bit better, but numbers were too low. So the problem may be at the liver. Neither HCG nor TRT will improve it, more like the contrary with regards to cholesterol metabolism, at least for the latter. He is FAR from broken, and anything suppressive is IMHO a mistake. Basically he did it like tons of people do online: he jumped straight to the injectoin when he was barely out of whack.
Anyways. Clomid looks like a potentially good choice since it is estrogenic at the liver, raises SHBG, yielding more total T, and usually (as per all the studies) an improved T/E ratio.
Also more SHBG means less free e2, that’s a standard process that leads to a better HPTA response (less negative feedback). Clomid is quick to be overdosed though. Doctors like Dr. Crisler and others say 25mg MWF is plenty, sometimes as low as e5d. Clomid seems to consistently plateau at the 4 week mark, after which it should be tapered off, and an AI may be required at all times.
My TT 400, E2 was undetectable on regular test, 8-11 on sensitive. SHBG 20-29. LH 6. Dr. Saya thought that Clomid would not would for me, although he is known to prefer to try Clomid first.
Blood glucose peaks at 160 (2 hour glucose load home test) which seems to be fine. Fasting Inlusing is 4.2 uIU/mL. Never did any insulin response test since LabCorp doesn’t have it (with glucose load).
Every case is specific. That LH of 6 for those hormones isn’t great. Even if I understand Dr Saya’s interpretation of those bloods, I would have tried to raise that SHBG. And SERMs do just that. Plus you would have had higher T and e2… actually one of the rare guys who wouldn’t mind Clomid’s estrogenic isomer. I’m actually confused with the approach. He knows better. I’m only bringing up arguments to have a more horizontal discussion with the Doctor.
A fasted insulin of 4.2 (optimal or so it seems) with SHBG in the 20s (lower end) isn’t expected. One should correlate negatively with the other. I’d have needed a very detailed diet, training and lifestyle recap leading to those tests.
