T Nation

Help With My TRT Treatment


#1

Hello all, I have been reading and researching TRT with the help of forums such as this along with reading the different protocols of some of the most well-respected clinicians in hormone therapy. I wanted to post my situation to see if anyone with solid knowledge of hormone therapy to give me advice to my plan.
I am an athletic 34yr old male 6’2” 200lbs. About 2 years ago upon returning from deployment I began exhibiting symptoms of chronic fatigue, depression, muscle loss despite continued exercise, low to no libido, and increased abdominal fat. I wasn’t sure what was going on with me until I was turned onto TRT by fellow coworkers. I went to my PCP at the VA and she agreed to run a hormone panel. I have an extensive medical background however I did not do my due diligence to research what tests were actually needed. The only tests she ran was a CBC, B12, Vit D, and Total Testosterone. The labs are as follows.

WBC 4.07 K/uL (4.0-11.0)
RBC 5.52 M/uL
HGB 17.3 g/dL (14-18)
HCT 49.6 % (39-52.5
MCV 89.9 fL (85-102
MCH 31.3 pg (28-38)
MCHC 34.9 g/dL (32-36)
RDW-CV 11.7 % (11-14
PLT 178 K/uL (128-412)
MPV 11.6 fL (8.69-12.56)
Lymph % 34.2 % (24-39)
NEUT % 56.0 % (50-68)
MONO % 6.6 % (4.4-12)
NEUT # 2.28 K/ul (2.0-7.5
MONO # 0.27 K/ul (0.18-1.3)
LYMPH # 1.39 K/ul (1-4.3)
BASO # 0.04 K/ul (0-0.1)
EOSIN # 0.08 K/ul (0.0-0.6)
EOS % 2.0 % (0-5)
BASO % 1.0 % (0.0-1.0)
IG # 0.01 K/uL (0-0.04)
IG % 0.2 % (0-1)
CHOLESTEROL 143 mg/dL (140-200)
HDL 64 mg/dL (35-67)
LDL 71 mg/dL (<119)
TRIGLYCERIDE 48 mg/dL (35-200)
BILIRUBIN, DIRECT 0.5 High mg/dL (0-0.2)
GLUCOSE 102 mg/dL (70-109
UREA NITROGEN 17 mg/dL (8-25)
CREATININE, SERUM 1.0 mg/dL (0.7-1.3
SODIUM 138 mmol/L (136-146)
POTASSIUM 4.7 mmol/L (3.6-5.3
CHLORIDE 103 mmol/L (102-114)
CO2 28 mmol/L (24-32
CALCIUM 10.0 mg/dL (8.8-10.3)
PROTEIN, TOTAL 7.6 g/dL (5.9-7.9)
ALBUMIN 5.0 High gm/dL (3.5-4.7)
T. BILIRUBIN 3.2 High mg/dL (0.4-1.3
ALKALINE PHOSPHATASE 55 IU/L (37-108
AST (SGOT) 14 IU/L (13-33)
ALT (SGPT) 12 IU/L (7-31)
ANION GAP 12 mmol/L (8-16
PO4 3.4 mg/dL (2.2-4.3
EGFR 86 mL/min (>60)
TESTOSTERONE TOTAL 319.7 ng/dL (225-972)
TSH 1.89 uIU/mL (0.35-5.00)
B12 261 pg/mL (250-1100
FOLATE 15.6 ng/mL (2.8-20.0)
25 OH VITAMIN D 32.5 ng/mL (30-100)

My PCP would not pursue TRT since my Total T was “normal” I then went to what I now will call a “Doc in the Box” for TRT treatment. This guy used the labs above without requesting additional labs and started me on 200mg/wk. Test cyp. I was on that regiment for 4 weeks and I felt amazing however I had started to do my research and was concerned that this doctor did not care about my health at all. I found a doctor in my area that had the right credentials for TRT treatment and from what I see now follows the current treatment protocols. He ordered repeat labs as he was concerned with my current dose of test. The labs after 1 month of 200mg/wk. are as follows.

WHITE BLOOD CELL COUNT 5.9 3.8-10.8 Thousand/uL
RED BLOOD CELL COUNT 5.61 4.20-5.80 Million/uL
HEMOGLOBIN 18.4 H 13.2-17.1 g/dL
HEMATOCRIT 50.5 H 38.5-50.0 %
MCV 90.1 80.0-100.0 fL
MCH 32.7 27.0-33.0 pg
MCHC 36.3 H 32.0-36.0 g/dL
RDW 13.4 11.0-15.0 %
PLATELET COUNT 180 140-400 Thousand/uL
MPV 9.0 7.5-12.5 fL
ESTRADIOL 73 H < OR = 39 pg/mL QAW
TESTOSTERONE, TOTAL, LC/MS/MS 999 250-1100 ng/dL
FREE TESTOSTERONE 186.8 H 35.0-155.0 pg/mL
HOMOCYSTEINE 11.4 umol/L
IGF 1, LC/MS 206 ng/ml
Z SCORE (MALE) 0.8
THYROID PEROXIDASE ANTIBODIES 1 IU/ml
C-REACTIVE PROTEIN 0.5 mg/l
INSULIN 2.2 uIU/ml

Based on these labs the new doctor lowered my dose of Test Cyp. To 100mg/wk. and added 1mg/wk. anastrozole. I began this protocol and then was accepted to an Endocrinologist at the VA. I also went and donated blood based on my H/H levels
Upon meeting with the ENDO at the VA he wanted me to quit the Test Cyp for 6 wks. and then get new baseline labs. I agreed as I wanted to know if I had primary or secondary hypogonadism. I went the 6wks and the crash was rough. The labs at 6wks of no Test are as follows.

ESTRADIOL 40 pg/mL (0-57)
HOMOCYSTEINE 10.2 umol/L (>< 11.4)
FSH 11.32 mIU/mL (1.27-19.26)
PROLACTIN 4.95 ng/mL (2.64-13.13 ng/mL)
TESTOSTERONE TOTAL 314.8 ng/dL (225-972)
SHBG 25.4 nmol/L (13.3-89.5)
TESTOSTERONE FREE INDEX% 43 %
LH 4.78 mIU/mL (1.24-8.62)
BILIRUBIN, DIRECT 0.3 High mg/dL (0-0.2)
CHOLESTEROL 134 Low mg/dL (140-200)
HDL 62 mg/dL (35-67
LDL- 66 mg/dL (<119)
TRIGLYCERIDE 37 mg/dL (35-200)
GLUCOSE 95 mg/dL (70-109)
UREA NITROGEN 16 mg/dL (8-25)
CREATININE, SERUM 1.1 mg/dL (0.7-1.3
SODIUM 137 mmol/L (136-146)
POTASSIUM 4.4 mmol/L (3.6-5.3)
CHLORIDE 103 mmol/L (102-114
CO2 26 mmol/L (24-32)
CALCIUM 9.9 mg/dL (8.8-10.3
PROTEIN, TOTAL 7.6 g/dL (5.9-7.9
ALBUMIN 4.6 gm/dL (3.5-4.7)
T. BILIRUBIN 1.6 High mg/dL (0.4-1.3
ALKALINE PHOSPHATASE 62 IU/L (37-108
AST (SGOT) 15 IU/L (13-33
ALT (SGPT) 12 IU/L (7-31)
ANION GAP 12 mmol/L (8-16
PO4 3.7 mg/dL (2.2-4.3)
EGFR 77 mL/min (>60)
TSH 2.20 uIU/mL (0.35-5.00)
WBC 5.06 K/uL (4.0-11.0)
RBC 5.24 M/uL (4.7-6.1)
HGB 16.4 g/dL (14-18)
HCT 46.0 % (39-52.5)
MCV 87.8 fL (85-102
MCH 31.3 pg (28-38
MCHC 35.7 g/dL (32-36
RDW-CV 11.6 % (11-14
PLT 242 K/uL (128-412
MPV 10.0 fL (8.69-12.56
Lymph % 35.0 % (24-39
NEUT % 53.9 % (50-68
MONO % 8.5 % (4.4-12
NEUT # 2.73 K/ul (2.0-7.5)
MONO # 0.43 K/ul (0.18-1.3
LYMPH # 1.77 K/ul (1-4.3
BASO # 0.04 K/ul (0-0.1)
EOSIN # 0.08 K/ul (0.0-0.6)
EOS % 1.6 % (0-5
BASO % 0.8 % (0.0-1.0)
IG # 0.01 K/uL (0-0.04)
IG % 0.2 % (0-1)

Then a follow up lab done at 8wks was done and here are the results

PSA (Since 6/13/98) 0.32 ng/mL (0-4.0)
TSH 1.73 uIU/mL (0.35-5.00)
ESTRADIOL 45 pg/mL (0-57)
LH 3.64 mIU/mL (1.24-8.62)
FSH 7.25 mIU/mL (1.27-19.26)
PROLACTIN 5.98 ng/mL
TESTOSTERONE TOTAL 342.8 ng/dL (225-972
SHBG 31.3 nmol/L (13.3-89.5
TESTOSTERONE FREE INDEX% 38 %
WBC 3.47 Low K/uL (4.0-11.0)
RBC 5.14 M/uL (4.7-6.1)
HGB 16.3 g/dL (14-18
HCT 45.8 % (39-52.5
MCV 89.1 fL (85-102
MCH 31.7 pg (28-38)
MCHC 35.6 g/dL (32-36)
RDW-CV 12.6 % (11-14)
PLT 212 K/uL (128-412
MPV 10.3 fL (8.69-12.56)
Lymph % 35.7 % (24-39)
NEUT % 53.6 % (50-68
MONO % 8.1 % (4.4-12
NEUT # 1.86 Low K/ul (2.0-7.5)
MONO # 0.28 K/ul (0.18-1.3)
LYMPH # 1.24 K/ul (1-4.3
BASO # 0.04 K/ul (0-0.1
EOSIN # 0.05 K/ul (0.0-0.6)
EOS % 1.4 % (0-5)
BASO % 1.2 High % (0.0-1.0
IG # 0.00 K/uL (0-0.04
IG % 0.0 % (0-1)
CHOLESTEROL 124 Low mg/dL (140-200
HDL 62 mg/dL (35-67
LDL 56 mg/dL (<119
TRIGLYCERIDE 37 mg/dL (35-200) Final
BILIRUBIN, DIRECT 0.4 High mg/dL (0-0.2)
GLUCOSE 86 mg/dL (70-109
UREA NITROGEN 14 mg/dL (8-25
CREATININE, SERUM 1.1 mg/dL (0.7-1.3
SODIUM 138 mmol/L (136-146)
POTASSIUM 4.1 mmol/L (3.6-5.3
CHLORIDE 102 mmol/L (102-114)
CO2 30 mmol/L (24-32
CALCIUM 9.7 mg/dL (8.8-10.3)
PROTEIN, TOTAL 6.9 g/dL (5.9-7.9
ALBUMIN 4.7 gm/dL (3.5-4.7)
T. BILIRUBIN 3.2 High mg/dL (0.4-1.3)
ALKALINE PHOSPHATASE 56 IU/L (37-108
AST (SGOT) 14 IU/L (13-33
ALT (SGPT) 12 IU/L (7-31)
ANION GAP 10 mmol/L (8-16
PO4 3.4 mg/dL (2.2-4.3)
EGFR 77 mL/min (>60)

Upon receipt of these labs companied by my history the Endo Doc diagnosed me with Primary Hypogonadism and prescribed Test Cyp. 100/mg/wk. And Anastrozole 1mg/wk. I began that protocol with biweekly SubQ shots and split my anastrozole into 0.5mg twice a week with both shots and pills on Mon and Thursday. I remained on this for 5weeks with little to no change and had a follow up lab done the results are as follows
TESTOSTERONE TOTAL 351.8 ng/dL (225-972)
ESTRADIOL 33 pg/ml

So, on 100mg/wk. my Total T hasn’t changed much at all, my E2 seems controlled with the 1mg Anastrozole. I really like Dr. Crislers protocols and requested possibly adding HCG to the treatment to keep the natural pathways open and contribute to testicular health also hoping maybe it would boost my test levels without much change to my test cyp. Dose. I also asked if I needed to make a dose change for the Test Cyp. As my numbers were still low. The Endo now wants me to keep my Test dose the same and wants to ad Clomid 50mg 3 times a week. I explained to him that Clomid and Testosterone are competing drugs as one is suppressing the HPTA and the other attempting to restart it. I also went into detail about how the pathways work and so on as I understand he is not super familiar with TRT therapy. He continued to say Clomid and HCG are the same, so this became a waste of an argument. At this point I have increased my Test Cyp to 140mg/wk. and was thinking of going back to the TRT doctor I trust to ask for his recommendations or prescription for Hcg. The main reason I use the VA is there is no cost to me for the meds and labs.

I apologize for the lengthy post but it seems those who post the maximum amount of data get better feedback from all of you. Any advice is greatly appreciated. Thank you.


#2

Totally understand, why not having to pay for it is nice there are other ways you will pay for it, you will pay for it in otherways, free is not always better. The VA isn’t knowledgeable in TRT, the difference between a good doctor and a excellent doctor is the difference between feeling good and feeling fantastic.

In reality the argument about clomid and HCG is the VA doesn’t cover/pay for HCG because it’s off-label meaning they still don’t understand it’s importance or relevance as their knowledge in the area of TRT/male hormones is severely lacking.

Keeping a guy within range is easy, knowing how to read biomarkers and knowing where in the range a guy is going to feel his best is like the difference good art and a picasso. The VA and HMO doctors only care whether you fall within the ranges because they only treat you when you fall outside the ranges, they could care less whether you’re 500 or 800 ng/dL as long as you’re in range.

They treat everyone the SAME, you deserve better, you deserve to be optimised and have your protocol tailored to your specific biomarkers, you doctors doesn’t understand the importance of HCG. However HCG may do nothing for you since you’re primary, it could elevate mood and sexual function.

The VA seems perfectly happy with you at 351 ng/dL, typically the VA fails at properly monitoring is patients something that’s all to common. You’re paying for it alright, you need to be in the 600-800 ranges.

I see guys getting on TRT for having your numbers and you’re on TRT.

You’re not paying for it, but you’re paying for it, you’re still in low T land! These doctors shut your HPTA down for 32 ng/dL, these doctors don’t deserve to be call doctors, they are deplorable!

Pre-TRT 319.7 ng/dL.

On TRT 351 ng/dL. What?!

Hint–> Defy Medical


#3

Hey bro

So, did you get anastrazole from the VA doc or TRT doc? (confused because I have never seen a doc prescribe anything other than test at VA)

Asking because I am also a vet and get my TRT through VA. Be careful with the VA docs, they are idiots when it comes to TRT.

Their is an older gentlemen here and his H/H was high from the injections. They completely pulled his script, without even checking his TT or any other levels. VA cut off is 827 just FYI.

I haven’t been sent to a VA Endo yet but i’m putting it off as long as possible because I fear they will do the same to me (cold turkey to see where my levels go).


#4

827 isn’t even at the top of the ranges, far from it. They tried to give a guy who’s primary hypogonadism clomid, better find a doctor who’s IO is higher than 50. When a guy shows in the 800 ranges, the VA and HMOs will cancel treatment and order labs within 90 days to make sure he’s still under 827, if you score above this they will cancel treatment for awhile.


#5

Thanks guys for the help. As far as the VA goes I was able to get into the Endo there since my wife works there and was able to talk to the doctor. He is a nice guy but definitely has no clue on current TRT treatments. I was happy to get the true baseline numbers after going cold turkey but his diagnosis of primary seems off with normal to low LH FSH numbers.

Also to answer the question, yes the VA Endo Dr was able to get me the AI through the VA. He is clueless on how clomid works in conjunction with Testosterone. My issue now is that with 200mg/wk I was in the 1000 range of free T and elevated E2 at 100mg/wk I have barely any change in my baseline total T. So now I am stuck as to whether I am secondary or primary and should I try Clomid as a standalone and stop the Test? or increase the test slightly and attempt to get Hcg from the TRT doc.


#6

Looking at my labs again I think all my Estradiol test were not the sensitive assay. I am concerned that maybe I shouldn’t even be taking the AI. Is it possible that the reason I am not feeling the positive effects is that my true E2 is low?


#7

Clomid rarely ever works and once you’re past 30 years old the odds aren’t in your favor, but unicorns do exist. Together with the best progressive doctors odds are less than 20%, even less with the doctors you have access to who just don’t understand male hormones.

By now you’re more informed than most doctors and sure you can get a script for testosterone, but who is going to balance your hormones or manage side effects when they present? Most inexperienced doctor cancel treatment at the first sign of a problem because they don’t know how to deal with it.

alphagunner has good reason to be worried about his future treatment being pulled do to inexperience. The moment you’re assigned a new doctor and it will happen at some point the shit will hit the fan and you’ll end up right back at square one.


#8

apparently VA doesn’t even have the LC/MS ultrasensitive, at least where Im at in California. I asked specifically and looked through the available labs with the doc.

What if you did a compromise and went with like 150 a week?

Are you having high E2 symptoms? Acne, Limp dick, no morning woods, emo, bloating?

Low e2 symptoms SUCK : Dry lips/skin/joints/eyes, headache, fatigue, eyes FEEL dry, low libido, decreased vascularity


#9

I was thinking 140 to 150/wk and hold there until my next labs in a couple months then reevaluate. As far the E2 symptoms, I am low libido, and fatigued. Sucks that I don’t have a sensitive e2 assay to go off of. I am going to stop the AI and if I don’t feel any high e2 symptoms I’ll stay off until my next labs and pay for a lc/ms/ms estradiol to get an accurate reading.


#10

After messing with an AI for my first year of TRT, I decided to completely drop it and all E2 control and to see where my e2 went.

On 100 a week (split into 2 doses) my TT on trough day was 1200, so too high (at least for Va standards), good thing I used my non VA provider to check my labs (they cant take my test away if its to high).

My e2 on the non sensitive test was only 30, and then I decreased to 80 a week and my TT is now 900 on trough days and my E2 is around 28-29 on non sensitive test. I feel great.

Still don’t use any AI or e2 control.

So I think there is some relevance to the Non sensitive e2 test. When I was low, it would show it as 17, and I was for sure low. When you were on 200 a week, it showed as 70. So, I think it is somewhat accurate, but not enough for precise dosing for an AI.

You can always order that lab on your own through a private lab website.

Also, tag me in your responses so I can get a notification. Lots of posts. Interested to see where you go with this.


#11

Low cholesterol is a health risk and undermines the whole cholesterol-pregnenolone-DHEA-testosterone cascade. https://en.wikipedia.org/wiki/Steroid_hormone

Get DHEA-S tested to eval DHEA status. Do not test DHEA directly.

And you also need cholesterol to support cortisol and ViT-D3

Are you on an extreme low fat diet?
You need healthy fats and EFA’s.
Some simply have unexplained low cholesterol.

Your TSH is too high and is “normal” only because thyroid hormone ranges are stupid.

Most here have thyroid issues and most of the time as a result of not using iodized salt.

Please eval overall thyroid function via oral body temperatures - see below.

Do you feel cold easily?
Outer eyebrows sparse?
Gain fat easily? Can’t loose fat?

What is waist size?

With your TSH, even if TRT is optimal, would expect you to feel rather down in many ways at the symptoms of low thyroid function are mostly the same as low T.

Vit-D: Find 5000iu Vit-D3, tiny oil filled capsules, take 1 per day, 25,000iu for first 5 days.

You are mixed primary and secondary.
Any blows to the head? - can damage pituitary

Anastrozole is a competitive drug that as expected needs to match T levels. Split dose and take at time of T injections. Once a week is bad news.

Optimal for most guys is E2=22pg/ml.

50mg clomid 3x per week is absolutely horrible, typical stupidity.

Self inject T twice a week and take anastrozole at that time. Take hCG then or better, 250iu subq EOD.

hCG to avoid loss of fertility

You typically will not learn anything useful from doctors and often such info is dead wrong or stupid.


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

  • advice for new guys - need more info about you
  • 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.

KSman is simply a regular member on this site. Nothing more other than highly active.

I can be a bit abrupt in my replies and recommendations. I have a lot of ground to cover as this forum has become much more active in the last two years. I can’t follow threads that go deep over time. You need to respond to all of my points and requests as soon as possible before you fall off of my radar. The worse problems are guys who ignore issues re thyroid, body temperatures, history of iodized salt. Please do not piss people off saying that lab results are normal, we need lab number and ranges.

The value that you get out of this process and forum depends on your effort and performance. The bulk of your learning is reading/studying the suggested stickies.


#12

@KSman @alphagunner , thank you for taking a look. My older labs were on a plant based diet, my most recent are on a paleo diet however I do eat fiberish cereal in the morning. I don’t each much unhealthy fats and usually eat lean meats and no dairy. I had my thyroid tested in 2014 which show tsh 2.1 and a fT4 of 0.9 and a TPO of 1. However no FT3 has ever been done.
For temp issues I seem to be hot more than cold and my hand and feet are cold
Most of the time. . My eyebrows are fine but I do have problems losing fat and will gain easily if my diet is not correct.
My waist at my belly button is 30”
As far as my dosing has been I was taking 100mg/wk in split doses on mon and Thur along with .5mg of anastrozole at shot time. With a result of only a 10 point increase in total T and a standard E2 lab of 33.
I can trace back feeling great on 200mg/wk of Test Cyp and no AI but once I started the AI I have not felt any improvements from TRT therapy at 100mg/wk. so now I’m at a point where I need some help with my protocol.


#13

Some simply metabolize T faster than others. We see some needing 300mg to get where others are at 100mg. And the hypermetabolizers have shorter effective half-lives and thus more frequent injections will be needed, sometimes EOD.

TSH should be closer to 1.0
Thyroid lab ranges are stupid. A 11:1 or 10:1 range ratio is insane.
T3, T4, fT3, fT3 should be near mid-range or a bit higher.
fT3 is the active hormone and should be tested. There is no T4 receptor.

Need those oral body temperatures.
One’s perception of warm cold can be deceiving.

You did not explain your history of using iodized salt.

If not drinking milk, what is your source of Vit-D3?
Sun exposure?
Supplements?

Do not take these oil based supplements with high fiber foods.
fish oil
Vit-D3
DHEA


#14

Thank you for your continued help. For oral body temperature when is the recommended time to take it? When getting vitals done my oral temp is typically right at 98.6 give or take .1 degree.

I do not intake any iodinized salts we only have sea salt at home and I use that sparingly. (I can see that I may have low iodine levels I will try to get labs to see).

I take 5000iu vit d3 daily along with a multivitamin and 1000mcg b12.


#15

Forget about those hospital digital thermometers, you need the glass thermometer. The difference between a degree or 2 is make or break for hypothyroidism. Take temp before you get out of bed and at 12 noon. Ideal waking temp is 97.7 and noon 98.6.

Sea salt has NO iodine in it, replace with iodine salt.