T Nation

HPTA Restart for TRT w/Application to Gear & PCT


#1

How to attempt HPTA restart before or after TRT.

Please do not ask about methods that you read about elsewhere that have high doses of SERMs, stacked SERMs or SERMS+hCG. There is a lot of bad bro-science that is really bad advice. The idea that more is better is totally stupid.

Objectives:
- restore form and function of testes with hCG or SERM induced normal levels of LH/FSH.
- avoid over stimulation of testicular LH receptors which can desensitize LH receptors.
- avoid over stimulation of testicular LH receptors which can cause high levels of T-->E2 inside the testes [which cannot be managed with anastrozole].
- keep E2 levels managed during and after this protocol
-- avoid E2 rebound-->shutdown, see above
- get the top end of the HPTA in the game, releasing LH/FSH

Looking for points of failure:
- if hCG does not increase T levels, testes have failed - STOP and go to TRT
- if SERM does not increase LH/FSH levels, hypothalamus/pituitary failed in this regard -STOP and go to TRT

Avoid Clomid: Clomid was the first SERM and the first born always gets more baby pictures. Many papers exploring the effect of SERMs were written and Clomid was the agent. So the literature always points to Clomid. However, Clomid creates some very nasty estrogenic side effects for some guys. Nolvadex is a SERM that does not have those bad side effects and has the same desired effects as Clomid at a the same dosing amounts. You may need to butt heads with your doctor to get from Clomid to Nolvadex.

What is a SERM: https://en.wikipedia.org/wiki/Selective_estrogen-receptor_modulator

SERMs and Aromatase inhibitors were developed to address female estrogen positive cancers. Some docs freak out because these are cancer drugs. SERMs also increase LH/FSH and are useful in fertility work, so docs can get past the cancer thing.

SERMs and fertility:
Fertility doc will give guys insane doses of SERMs because this will increase LH/FSH. The context is often very low LH/FSH and low T levels. If you give a low T guys high SERM doses, LH will go very high and E2 will typically be very high. When SERM is stopped, LH receptors can be desensitized and now things are worse and the high E2 levels can cause shutdown and/or make secondary hypogonadism worse.

Anastrozole: The prescribing info and clinical data is almost entirely in a female cancer context and the dosing is 1mg/day. The objective for female cancer patients is E2=zero. In males the objective is modulation of E2 levels and getting near E2=22pg/ml [80pmol/L] works very well for TRT guys. We see docs prescribe 1mg/day which illustrates their stupidity. Most guys on TRT need 1.0mg/week in divided doses. Anastrozole is a competitive drug, which competes for the aromatase enzyme reaction sites with free testosterone FT. That for reasons that may not be clear to you creates some very nice linear dose-response actions that are easy to utilize in dose refinement after you get E2 lab results.

There are multiple paths to the same end point. You may not have all of the drug choices to take advantage of. As long as you understand these things, you can make good choices and might be able to educate your doctor too.

First stage:
1a) Inject 250iu hCG SC EOD then do labs for TT, FT, E2 after 4-6 weeks. If things have not improved, stop and go to TRT.

1b) Now if T levels acceptable, now do Nolvadex below to get hypothalamus and pituitary in the game.

Now hypothalamus and pituitary are active.

---or

1a) 20 mg Nolvadex EOD [Clomid if only option]. Then do labs for LH/FSH, TT, FT, E2 after 4-6 weeks. If LH/FSH low, stop and go to TRT. If LH/FSH good and T levels still low, stop and go to TRT.

Now tests, hypothalamus and pituitary are active.

If you get this far, your HPTA is working. If you are stopping TRT and going back to where you were, in most cases you will not be better than before TRT.

Some younger guys with low-T can restart. Not always going to work often fails.

So this is the way that PCT should be done for those who have been doing gear or got in trouble along the way.

You need to be taking anastrozole as required to keep E2 near the 22pg/ml [80pmol/L] target. For mid range T levels during the above, 0.5mg/week in EOD dosing would be a good start. Typically this should be maintained after this process is complete to prevent estrogen rebound. So cruise on anastrozole afterwards for a few weeks then taper out. You need to have a liquid solution of anastrozole in vodka to dispense by the drop for small dose increments. Dissolve tablets 1mg/ml in a dropper bottle, count drops per ml and do the math. Always shaken, not stirred before dispensing.

Second stage:
We have things working, now we need to slowly taper off of the SERM and see if the HPTA can stand on its own feet. We have E2 managed to prevent estrogen rebound. As SERM levels drop, SERM induced T-->E2 will drop. The hypothalamus will now see the estrogen levels in your blood and the hypothalamus will start to tell the pituitary what to do based on the combined negative feedback of estrogens and testosterone. After you taper off of anastrozole and a few weeks later, do your labs. Hopefully the result after few weeks is favorable.

Older guys will probably never benefit from the above, its a younger guys' game. There is no fix for age related secondary hypogonadism and with primary hypogonadism, there is nothing to restart!


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#2

Sticky, please.


#3

Great post KSman.


#4

does anyone can answer why and how clomid cause vision problems, beacuse I can't find answer on web ?


#5

No not know the mechanism. But note that the symptoms are typically as seen with female patients where dose and duration may not apply to someone in a TRT context. I do not see that Nolvadex has this problem. Nolvadex do what clomid does also without the estrogenic side effects that some have with clomid.


#6

Ksman. I'm curious as to what u think the age cutoff would be for this not being effective. Say 35 and below?


#7

Good question and in theory one could have data, averages and conclusions. But every individual case should be treated as such. If one is primary, not much is going to happen. As we age, the testes are going to be less productive even with ample LH/FSH. And restarts do not always work. The attempt to restart does provide useful diagnostic data. Some feel like its time for TRT and some are reluctant to start TRT "decades early".

A hCG challenge is simple and if that works, then a restart could be attempted and if that fails, hCG monotherapy is an option and one could also try a SERM. When trying a SERM, LH/FSH labs are the next decisive point.


#8

FWIW, there's at least one doc who thinks the vision problems come from having high estrogen:

The authors say the causal mechanism is unknown. I would differ, and suggest the cause is high estrogen induced by clomiphene stimulation. High estrogen causes a hypercoagulable state.(10,11) An aromatase inhibitor (anastrazole) prevents the high estrogen level, and therefore prevent the rare thrombotic complication, such as the retinal vein occlusion in the inherited thrombophilia male patient. (2)

^This bloc I copied from this article: http://jeffreydachmd.com/2013/04/clomiphene-clomid-adverse-side-effects-part-three/


#9

Ksman, going to try this exact protocol. 36M, just have never felt completely right on TRT and getting dialed in, exhausted from trying, my biggest issue was just a no joy attitude on trt, not depressed, not happy just a robot. I have tried all the protocols hcg,ai, dosages, just tired chasing, was diagnosed w sleep apnea as well which is now corrected and just womdering if i can restart. Off injections 1 week, HCG 500 3 times weekly right now, only reason I am a little higher on the hCG is my estrogen has been stuck a 7-9 for over a year even w test levels of 800-900 with no ai. Will test in 6 weeks and see where I am at, have nolvadex on hand for after that as clomid damn near killed me once. Concerned however i am making the situation worse with HCG so many conflicting opinions on this, after 1 week HCG, i can tell my estrogen has already rebounded not as achy horny as hell. Will repost in 6 weeks and advise.


#10

Does it make a difference being on TRT for 6 months verses a year and a half? For whether the HPTA can be restarted?

I'm currently doing a restart. HCG didn't help with the testes and I don't know what I was doing wrong with it.

Plan:

20mg tomoxifen + .5mg anastrazole / 2 weeks
then dropping the dose of tomoxifen by 1/4 the next two weeks
doing 7 drops EOD @ ~.02mg/drop (.14mg). Going to reduce by a drop every dose after that.

Will test for LH/FSH which I missed before starting TRT after that and decide if I want to continue on this journey.

Also curious on input on whether tamoxifen/anastrozol is something appropriate for someone my age to cruise on for a while or not worth risking the overstimulation of LH/FSH. Purely subjectively speaking it's working amazingly well. I feel amped and more positive. lol.


#11

3.5mg anastrozole per week does seem very high.
Test LH/FSH now or after? Sounds like after.

Will it work? Probabilities do not mean much when we get down to an individual.


#12

No no no I am doing 3.5 / 7 = 0.5 mg anastrazole a week

.14mg is 7 drops so what I'm saying is I am dosing at .14mg/day and that EOD is .14 * 3.5 = .49 aka .50mg.

Sorry I was unclear. I'm sure you engineers have a particular notation for stuff like this

Also was unclear about my tapering schedule. 1/4 off the dose E4D


#13

KS, can you provide any peer reviewed studies supporting the logic of tapering down at the end of a restart attempt? I know that it is correct to do so, but my doc wants to do the opposite and scale up after a month. He's reasonable and will change his mind if I can present him with something peer reviewed.

Thanks.


#14

Sometimes seeking a peer reviewed source is a sign of lack of fundamental knowledge.

These points are all made in the opening post.
- higher doses of SERMs or hCG:
-- can lead to high T-->E2 inside the testes [that a competitive AI cannot manage] [this was my deduction]
-- E2 levels can be high
-- stopping SERM suddenly exposes T and E2 receptors to residual E2 that can cause HPTA shutdown before is starts again
-- exposing LH receptors to high LH levels then exposing them to much lower LH [restart] levels sends the opposite message to what is needed
-- high LH levels also is thought to be able to desensitize the teste. It is known that a high constant [non pulsatile] LH exposure will do that.

Part of the problem is that many lump AI's and SERM's under "anti-estrogens" which signifies that they do not understand either. The idea that SERM's can lead to high E2 is over their heads.

So he wants a peer review of clinical research on the HPTA restart outcomes that are clearly stupid. Doc needs a dose of deductive reasoning. Doctors are typically not trained or capable of deductive reasoning.

Docs can find references to success of high dose SERM's to get sperm counts increased when guys have a fertility problem. But what happens after the pregnancy? Who tracked T, FT, E2 and libido issues after that?

A lot of knowledgeable body builders doing cycles understand the need to taper off of SERM's. They got some reasons right , but probably never contemplated the effects of what signal the testes are getting when high LH levels drop to normal or low normal levels. That community also has knowledge of the LH receptor desensitization threat.

You doc wants you to have high E2 and LH levels, then stop the SERM suddenly and expose the HPTA to the estrogens as the SERM washes out. The hypothalamus sees the accelerating estrogens and causes the pituitary to release low levels of LH. The testes then see the signal to slow down and then they have to respond to lower LH levels by reducing testicular function and the LH receptors may have reduces ability to respond to that LH there is. If a HPTA restart is the goal, that is all wrong.


#15

Alright boys and girls, 5 weeks into a restart. To recap been on TRT for about 2 years, no hcg no arimidex, some benefits for sure but felt depressed and emotionally flat, also struggled big time with low estrogen, yes you read that right, stuck at 7-8 for a year, even at 800 level TT still could not get over 15. Been on HCG 500 EOD for 5 weeks. Labs read to exactly what I started with baseline and was secondary, both LH and FSH levels read as such now, TT 387, estrogen is now at 21. Free at 9.4.

Basically these labs look identical to baseline 2 years ago I have all copies. I also have diagnosed sleep apnea that is now being treated, hoping this was one of the main causes to begin with. Balls are back to full size, ejaculate volume is back, libido is not great but no terrible either, never had any ED even when I crashed once before and I know for a fact I had to be in the 100 range of TT at one point so lucky my boy functions independent of hormone levels, obviously libido is a different story.

Will go to Nolvadex EOD for a couple months retest and see if the HPTA will kick in. Will report back then and see if I have a complete restart. Im 36 years old so don't expect to be in the 800-900 range. If i can get back in the 500-600 range naturally i consider this a complete success. Feel free to comment or ask any questions. Have lost a little weight and strength nothing crazy tho.


#16

KS,

What dosage and frequency would you recommend for tapering down after 4 weeks of 25mg clomid every other day for 4 weeks?

I'm scheduled for labs to see where things are from the 4 weeks of clomid, but I feel much improved.


#17

Your labs should include:
TT
FT
E2
LH/FSH

You can go to 12.4mg EOD for 2 weeks then 12.5mg E3D for a week then done. But really should be on the low dose anastrozole safety net.


#18

Thanks KS,

I couldn't get the doc to come around on the AI. Fortunately I haven't felt any of the typical estrogenic sides, so I lucked out.


#19

I sure haven't lucked out. Although clomid for me is a 10 on the i wanna shoot myself in the face type of drug, nova is about a 7. Was hoping I would react different.. felt better at baseline w no nova. Going to drop in a week and give it two more months and see where I am at.


#20

Thanks KSman

I am getting close to the end of my restart. Before starting "restart" I was taking Test, HCG, Anastrazole

6 weeks after stopping above. At time of testing 5mg Nolvadex ED and .25 Anastrazole EOD.

TT: 473
FT: 72
E2: 31
LH/FSH: 5.8/3.0

I am now continuing my taper. Almost done with the Nolvadex.

Interesting notes on labs:

Vitamin D was 15.6 out 25-100 (I have been prescribed D3 50,000 weekly for 2 months)