T Nation

Help Getting Dialed In

Hey all. I started on TRT one month ago through a men’s clinic. Having some initial issues and generally wanting to monitor my progress with input of veterans, so here we are.

My info-
Age: 32
Height: 5-11
Weight: 160
Pre-TRT symptoms: fatigue, weakness, treatment-resistant depression, ED

Pre-TRT labs-
TT: 601 (250-1100)
FT: 35.1 (46.0-224.0)
SHBG: 84 (10-50)
LH: 5.7 (1.5-9.3)
Estradiol: 39 (<39)

Protocol-
200mg test cyp 1x/week
1 mg anastrozole 1x/week (pre-mixed w Test)
400 IU HCG 3x/week

Like I said I have been on this protocol for 4 weeks. I know it is quite a bit too early to be seeing any results, but I have two questions.

  1. Thoughts on the protocol in general? Does this make sense for a high SHBG guy like myself?

  2. I have been experiencing extreme irritability starting from my 2nd injection of the Test/AI mix. This has coincided with a complete lack of morning erections as well as worsened ED. Before this, I would get morning erections maybe once or twice a week. The irritability has been bad enough to bring me here rather than just ride it out (I will of course be continuing my treatment). Mood is also shit in general, slightly worse than before I began TRT. Irritability seems to be lessening slightly on the last day or two before each dose, then coming back on strongly over the next couple days.

Anway, my actual question: is it possible I insta-crashed my E2?
My current plan is to stick with things as they are for the next couple of weeks and then go get bloods re-done in two weeks if this persists or gets any worse. That would be six weeks from the beginning of treatment - is that enough time for things to have stabilized somewhat? I would wait longer but A) this is actually really difficult to manage all of a sudden and B) since my AI is pre-mixed I won’t be able to make changes on the fly, so I would want to attempt to dial it in for month 3.

Thanks very much to anyone who cares to chime in. Don’t hold back if you think I am screwing anything up, my goal is to get this right.

amg

Very well could have crashed your e2. 1mg a week can be a lot for some. It crashed mine. I would talk to your doc and get prescribed cypionate not compounded with AI. They should never do that. They have no idea if you even need it or how you will respond.

At the same time though you may not responding to HCG well either. Without labs yet and you started everything at once it is hard to tell what is what.

How are your joints feeling?

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Hey, thanks for the response. Joints are fine aside from my bum knee which has been sore for a couple of years. I did notice in perusing the boards that joint pain/cracking is a telltale sign of crashed e2, so I will keep a close eye on this over the next couple of weeks.

Your E2 is fine. Even though it is top of the range that looks like a non-sensitive test? If so you can assume it is 10-15 points lower.

Your SHBG is sky high is what the problem is, so you have no free T.

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No doubt about the SHBG, that’s what made me decide to start TRT despite decent total T levels. From everything I read there is no lasting way to touch high SHBG outside of androgens. I actually tried the nettle root/boron combo, which felt like it helped for a couple of weeks and then crapped out. Thanks for the tip on reading the e2 test result.

edit - just figured out how to embed replies, my b

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Danazol will lower it, it is pretty cheap too.

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Not at all.

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aha, very good. Thanks for this.

There is a first time for everything. Were you on anything besides testosterone when you took that test? Like any AAS?

Nope, never tried anything in this world before. Just years of various antidepressants.

I think you still need to give it more time.

Not you sorry was referring to @highpull

No. Those days were long ago.

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Actually, that is very common.

The ECLIA test (aka immunoassay or IA) for E2 management is commonly used for those on TRT. It is not an incorrect test or a test for women, but simply one way to check estradiol levels. The other commonly utilized test is the LC/MS/MS method (aka liquid chromatography dual mass spectrometry, sensitive or ultrasensitive). It is the more expensive of the two. There are inherent advantages and disadvantages to each of these two methods. I have been fortunate to be able to speak with professionals who work with both methods. One is a PhD researcher for Pfizer and the other is a medical doctor at Quest. I’ll summarize their comments.

The ECLIA method is the more reliable of the two in terms of consistent results. The equipment is easier to operate thus accuracy is less reliant on the skill of the operator. If the same sample were to be tested twenty times, there would be very little, if any, difference in the results.

The ECLIA method is not as “sensitive” in that it will not pick up E2 levels below 15pg/mL. If your E2 level with this test is 1-14pg/mL, the reported result will be “<15”. Because of this, it is not recommended for menopausal women, men in whom very low levels of E2 are suspected, or children. In other words, if your levels are below 15pg/mL, and it is important to know if the level is 1 or 14pg/mL, you do not want this test. For us, this is likely moot, since if you are experiencing low E2 symptoms and your test comes back at <15, you have your answer. For a woman being treated with anti-estrogen therapy for breast cancer, it may be necessary to know if the E2 level is zero or fourteen because therapeutically, they want zero estrogen.

A disadvantage to IA testing is that it may pick up other steroid metabolites, which in men would be very low levels, but still could alter the result. Another potential disadvantage is that elevated levels of C-reactive protein (CRP) may elevate the result. CRP is elevated in serious infections, cancer, auto-immune diseases, like rheumatoid arthritis and other rheumatoid diseases, cardiovascular disease and morbid obesity. Even birth control pills could increase CRP. A normal CRP level is 0-5 to 10mg/L. In the referenced illnesses, CRP can go over 100, or even over 200mg/L. Unless battling one of these serious conditions, CRP interference is unlikely.

The LC/MS/MS method will pick up lower E2 levels and would be indicated in menopausal women and some men if very low E2 levels are suspected and it is desired to know exactly how low, children and the previously mentioned women on anti-estrogen therapy. It will not be influenced by elevated CRP levels or other steroid metabolites.

While some may believe the ECLIA test is for women, on the contrary, as it pertains to women on anti-estrogen therapy, such as breast cancer patients, the LC/MS/MS is the test for women as CRP levels are a consideration and it is necessary to know if the treatment has achieved an estrogen level of zero.
On the other side of the coin, LC/MS/MS equipment is “temperamental” (as stated by the PhD who operates both) and results are more likely to be inconsistent. Because of this, researchers will often run the same sample multiple times.

It is not clear if FDA approval is significant, but this appears on Quest’s lab reports: This test was developed, and its analytical performance characteristics have been determined by Quest Diagnostics Nichols Institute San Juan Capistrano. It has not been cleared or approved by FDA. This assay has been validated pursuant to the CLIA regulations and is used for clinical purposes. This statement is on LabCorp’s results: This test was developed and its performance characteristics determined by LabCorp. It has not been cleared by the Food and Drug Administration.

It is unlikely that any difference in the same sample run through both methods will be clinically significant. Estradiol must be evaluated, and it should be checked initially and ongoing after starting TRT. It obviously makes sense to use the same method throughout. Most important are previous history and symptoms related to low or high E2. Those are correlated with before and after lab results. Any estradiol management should not be utilized without symptoms confirmed by lab results.

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Not sure how your literature relates to the point you’re making? @highpull

It actually supports exactly what I said.

“A disadvantage to IA testing is that it may pick up other steroid metabolites, which in men would be very low levels, but still could alter the result.”

I’ve read the literature. I’ve also looked at over 100 tests with both methods checked concurrently. Most of the time they are within 20%, and when there was a greater than 20% difference, it was always clinically insignificant. Plus, when there was a difference of greater than 20%, the LC/MS/MS methodology was higher three times as often.

The MD at Quest, when pressed, would still not recommend one test over the other. The accountants at Quest, however, would most certainly recommend the “sensitive” test.

Simply acknowledging a possibility. It’s rare and, in men, likely clinically insignificant.

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My thing here is not sure this guy needs any more anastrozole, and that usually, you can assume it is a lower on the sensitive test. Which is why the literature you posted explains a non sensitive can have a tendency to give you a high reading.

But if he is like you, maybe his E2 is high and he needs more anastrozole, but I would usually never recommend anyone go over 1mg without a really solid reason.

The OP was worried he crashed his E2, which we can tell that is def not the case.

Again, rarely the case and when it happens, look to the conditions mentioned as the cause.

I believe you were referring to his pre TRT level. We do not know how his E2 responded to anastrozole without follow-up labs.

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