T Nation

Evitagen's Case File

I started on TRT nearly two months ago. I initially went to the doctor because I felt like a wreck with no energy, no libido, no passion, etc.

My initial blood work is as follows (my endo at the time would not order an estradiol test):

T3 uptake 33 22-35%
TSH 2.20 0.40-4.5 mIU/L
T4(thyroxine), total 6.1 4.5-12.0 mcg/dL
free T4 index (T7) 2.0 1.4-3.8 N/A
testosterone, total, LC/MS/MS 210 250-1100ng/dL
testosterone, free 28 46.0-224 pg/mL
testosterone, bioavailable 60.5 110.0-575.0 ng/dL
SHBG 29 10-50 nmol/L
albumin, serum 4.7 3.6-5.1 g/dL
LH 2.9 1.5-9.3 mIU/mL
FSH 4.7 1.6-8.0 mIU/mL
PSA, total 0.1 <= 4.0 ng/mL
prolactin 5.8 2.0-18.0 ng/mL

I was put on 100mg testosterone enanthate / week 7-8 weeks ago by the endo. I got prescriptions for HCG and anastrozole separately from my GP nearly a month ago. I dosed 33mg testosterone enanthate, 100IU HCG and ~.33mg anastrozole three times a week.

I got lab work done the day after I took my dosages. These are as follows:

testosterone, total, LC/MS/MS 925 250-1100 ng/dL
testosterone, free 185.5 46.0-224 pg/mL
testosterone, bioavailable 405.7 110.0-575.0 ng/dL
SHBG 23 10-50 nmol/L
albumin, serum 4.8 3.6-5.1 g/dL
estradiol <15 <= 39 pg/mL
LH <0.2 1.5-9.3 mIU/mL
FSH <0.7 1.6-8.0 mIU/mL
PSA, total 0.1 <= 4.0 ng/mL
prolactin 4.8 2.0-18.0 ng/mL

My interpretation: it looks like I do not have a cancer from these results. However, my estradiol is low. I do feel a lot better, but my libido is still gone. Erections occur during sleep and upon awaking, however. I do recall a couple of days where I felt amazing and had sexual desire and then came done steadily after that. This was sometime after starting the AI and HCG.

I do believe I am close to getting this dialed in, which is fortunate being that I am so new to TRT. How would you recommend I proceed? I am thinking of decreasing anastrozole, increasing HCG or the testosterone. It seems like any of those would lead to more estradiol, though increasing HCG or TE would sate my curiosity about what more testosterone would make me feel like. I appreciate any guidance.

T levels are perfect, so no need to mess with T or HCG. I would back off adex to 2x week instead of 3. That should get you where you need to be.

Thanks, VT.

I forgot to mention that I had a vitamin D test done a few weeks ago. My levels were 66ng/mL (I take 2 2000IU liquid capsules and a multi-vitamin daily). Is there any reason to take more? Some of the stuff I read says 50-70ng/mL is good but >80ng/mL is better, others say 66 is about optimal. Reference range goes up to 100ng/dL, I believe.

Probably wouldn’t hurt to increase, but also probably not a lot of benefit either.

[quote]evitagen wrote:
Thanks, VT.

I forgot to mention that I had a vitamin D test done a few weeks ago. My levels were 66ng/mL (I take 2 2000IU liquid capsules and a multi-vitamin daily). Is there any reason to take more? Some of the stuff I read says 50-70ng/mL is good but >80ng/mL is better, others say 66 is about optimal. Reference range goes up to 100ng/dL, I believe.

My levels were approximately the same (68) the first time I had bloodwork done after I found out I was low. Despite the fact I was taking 5kIU a day, I upped the dose to see if I could get into that magical “above 80” range.

I eventually did.

It didn’t make me feel any different.

Not sure what I was supposed to expect, but there wasn’t any difference between 68 and 83 for me. It won’t hurt you to raise your levels, but don’t expect anything grand. Also, be careful not to raise it too high - it is possible (though pretty difficult) to take too much Vitamin D.

I need some help with what I think is an E2 problem.

When I got my last labs done, by ankles were swelling profoundly and mood and sex drive were off. I got the above lab work a few days after, saw the low E2, and took a week off anastrozole. The bloat went away and mood improved. The next week I took a .25mg dose, only planning on taking 2*.25mgs each week, or a half of my previous dose. The bloat started to return, so I backed off again. So I decided not to take any anastrozole, and the bloat went away. Now, without any anastrozole for more than a week, I again have bloating, fatigue, sour mood, and low sex drive. I first thought I rose through the “sweet spot” in regard to E2 levels and am now with high estradiol levels on account of no aromatase inhibitor, but I am not sure.

I cannot get blood work done for another two weeks. What should I do in the interim? Could it not even be an E2 issue? I know it cannot be dietary, since I eat the same foods regularly. Anyway, thank you in advance for any help.

EDIT: I have another question. I heard the cruciferous vegetables such as broccoli and cauliflower lower estrogen. I eat both of these foods daily; could their impact actually drive my estradiol levels into an non-optimally low range?

You seem to be an adex overresponder. This is tricky. Perhaps the 0.25 mg dose every 4 days or so would be more appropriate. I recommend you just play around with it and see if you can come up with a workable solution.

Also could consider switching to Aromasin. I personally did better on it than with adex.

Symptoms: Fatigue, lack of sex drive, recurring edema (mainly in ankles, feet, but holding water everywhere), lack of motivation, muscle weakness, moodiness, depression. No anxiety, which seems to be a common symptom. Erections occur during the night, but are not strong.

Dosage changes from last lab test:

100mg -> 120mg/week Testosterone enanthate
1mg -> 0 mg/week Anastrozole

My latest labs from a week ago Thursday (I was able to get orders from another doctor, luckily).

Triglycerides 53 <150 mg/dL
TSH 1.99 0.40-4.50 mIU/L
T3, Reverse 36 H 11-32 ng/dL
Thyroid Panel
T3 Uptake 30 22-35%
T4, Total 4.5 4.5-12.0 mcg/dL
Free T4 Index 1.4 1.4-3.8
Thyroid Perox.
Antibodies 12 <35 IU/mL
Total 805 250-1100 ng/dL
Free 169.9 46.0-224.0 pg/mL
Bioavailable 334.6 110.0-575.0 ng//dL
SHBG 22 10-50 nmol/L
Albumin, Serum 4.3 3.6-5.4 g/dL
Pregnenolone 16 13-208 ng/dL
CBC (more information available, below are just the “red flags”)
RBC 4.13 L 4.20-5.80 Million/uL
MCV 102.4 H 80.0-100.0 fL
MCH 34.3 H 27.0-33.0 pg
Progesterone <0.5 <1.4 ng/mL
Estradiol 35 <= 39 pg/mL

My analysis:

Progesterone is very low, suggesting my HCG dose should have been higher. Since I had these labs drawn a week ago, I had increased the dosage of HCG from ~120IU to 250IU since I planned on having blood work drawn again within a month anyway, I figured this would be a good experiment. Luckily, it seems that my experiment was a good idea, since it seems my progesterone has cratered, and raising the HCG should bring this back up.

Meanwhile, I have macrocystic anemia. I do not know what is causing this. I eat 4oz beef or chicken liver everyday along with 12oz of spinach, so I think I have B-12 and folate covered. I eat 220g of mostly animal protein per day, so I believe I have iron covered as well. Previous vitamin lab work showed no deficiencies in any of these micronutrients. Perhaps I have developed an absorption issue. This could also be related to the diarrhea I have suffered from in the past few weeks. I have since cut back on the capsaicin-containing spices and late-afternoon caffeine in an attempt to remedy this problem with some results.

Estrodiol is again off the mark only this time in the opposite direction. I have not taken more anastrozole, and my feet are swelling after subsiding for a week (although I am honestly not sure if my edema is related to E2 at all). I plan on going on a 1/8 mg/week regimen seeing as I seemed to over-respond to previous dosages.

I should note that the above labs were taken 2 days after a scheduled injection of testosterone enanthate (dosed 3x weekly). I purposefully avoided taking the shot in anticipation of the blood draw, so testosterone levels should be a bit below previous values.

I should have values for free and total T3 soon. I also took a DHEA-S test today since the fatigue I am experiencing is causing me some hardship, and I want more information sooner.

My plan:

Continue on 120mg/week testosterone enanthate
Continue taking 250IU HCG 3x/week
Start 1/8mg anastrozole / week (any recommendations on how to dose this? I am not sure if I can split an 1/8th of a pill, so I might have to go 1/8 E7D). Changing two variables makes for a rather poor experiment, but I changed two variables last time I had blood drawn (+20% in testosterone enanthate and near-elimination of AI), so this would not be the first time I made a mistake.

I welcome any comments or suggestions, including what blood tests to get next. I have orders on hand for testosterone (total, free, bioavailable, SHBG, and albumin), estrogen panel (includes estradiol and estrone [doc gave me this without me asking]), progesterone, and pregnenolone, so I imagine I will get those in three weeks. I should be able to get more without any difficulty.

Thank you.

EDIT: I just discovered that pregnenolone is available OTC. I imagine if 250IU 3x/week doesn’t get my pregnenolone to 180 that this is something I should look into, yes?

EDIT 2: I am beginning to think most of my problems with fatigue, lack of sex drive and edema are related to the pregnenolone. I am basing this on the fact that my E2 is not far from where it ought to be and that most posts I read with guys with way higher E2 levels do not experience anywhere near the same level of symptoms I am experiencing. Meanwhile, my symptoms correspond to the lists of high pregnenolone symptoms that I’ve come across.

I got my results for DHEA-S (draw taken at 1400 last Friday):

DHEA-S 151mcg/dL 110-510mcg/dL.

It is my understanding that the optimal range for DHEA-S is upwards of 400mcg/dL. I have a gram of DHEA powder ordered along with some pregnenolone MLM. Any advice for how I should dose these hormones, if at all? I have read 50mg DHEA / 25mg pregnenolone as a starting point…

I should note that my mood, motivation, energy levels, and libido have improved since my last post, although they are far from where they ought to be. I have not been on a higher dose of HCG for very long (went from 120IU to 250IU 3x/week about two weeks ago), so that probablyhas something to do with this. Plus my edema seems to be going away, but then again it has been intermittent ever since it started.

Thanks in advance.

Your rT3 is mostly seen as a result of adrenal fatigue, which also would explain fatigue. Look for Wilson’s book ‘adrenal fatigue’ at amazon books. Low progesterone also lowers cortisol. Start with an AM cortisol test, do that at 8AM. Are there times of the day where fatigue is worse? You may need a 24 hour four sample cortisol saliva test.

Your thyroid levels are low. Do you use iodized salt or have iodine in your vitamins? Sea salt does not contain iodine unless the package states that it was added. If you are iodine deficient, that can be fixed. Do not tread iodine deficiency with Rx thyroid drugs.

RBC: Might be low from blood loss to the gut. This can be from intestinal bleeds or via the liver and bile duct. Get tested for blood in stool. Would be good to test for serum iron and ferritin.

Are you snoring? How has this changed?

Post your HemaToCrit results before and after TRT if you can. HTC is basic to TRT as it can get high.

Pregnenolone is very hydrophobic and absorption is very poor. Take with an oily food or with fish oil caps. Ditto DHEA. And/or take with alcohol if you are drinking anyways.

We see a lot of guys who come here with testosterone issues who have thyroid and/or adrenal fatigue.

Whatever your anastrozole dose needs to be, when you increased T by 20%, your anastrozole needs increased by 20%.

DHEA supports making T in the testes and other functions, but cannot support cortisol production, other than diverting some pregnenolone–>DHEA pregnenolone–>progesterone–>cortisol. Pregnenolone will support cortisol.

Low cortisol increased rT3 and rT3 blocks whatever fT3 you have, so that can make one hypothyroid symptomatic even if fT3 is optimal.

fT3 is terrible, pay attention to iodine!

You cannot us Rx T4 as that will increase T4–>rT3. One of the things to treat adrenal fatigue is Rx T3 alone, sufficient to depress T4 levels. Adrenal fatigue is not easy to fix, you cannot take a pill to get better, you need to read the book and see if it seems to be talking about you.

These problems affect the other systems in your body and each can make a different problem worse, a synergy of pathology. You have a lot of work do do and you will need to manage most of this yourself.

KSman, thanks for responding.

My local lab apparently does not offer the saliva cortisol test. The other labs in town are not covered by my insurance, so I it will be a few weeks before I can get that data. My fatigue generally gets worse as the day goes on (though see below).

I do not believe I snore, but then I am single, so there is no way for me to be sure.

My multivitamin has 75mg of iodine. I saw your other post on iodine a few weeks ago and tried to get more iodine in then. I’ll make a greater point of getting it in now. Believe me, I am not interested in starting on prescription thyroid medications.

The latest hematocrit taken with the labs above was 42.3 on a range of 38.5-50%. It was 40.4 before TRT.

My ferritin levels from a month ago (while on TRT) were not deficient, but I will post the exact value when I find it.

I should note I started taking 50mg/day of pregnenolone MLM two days ago. This morning my libido was roaring and I had more energy and strength today, so I think I am on to something there. I will continue to evaluate daily. I also started on 25mg of DHEA today (although I attempted to dissolve it in water before I read your post).