T Nation

HPTA Restart Protocol


#1

I looked through the stickys and read a bunch of the threads here and elsewhere, but there doesn't seem to be a good consensus on the best protocol for a HPTA restart. I'm hoping we can get some of the experts to chime in and help out with an effective and sane protocol for those of us who have secondary hypogonadism and would like to try a restart.

I was going to put this into my personal thread, but I think the information on a restart would be useful to a broader audience of this forum. If this should be moved, let me know and I will do so.

Anyway, from what I have seen, the most famous restart protocol is by Scally. He uses large doses of HCG at the start (2500IU EOD for 16 days) and then a combination of clomid and tamoxifen for 30 days dropping down to just the tamoxifen for an additional 15 days. However, the hCG dose is very high and seems like it would drive up estrogen quite a bit. Also, I have heard bad things about the side effects of clomid (especially on libido). The protocol does not include anything like anastrozole or aramosin which seems like it would be a good idea to help with estrogen issues.

So I guess I have a couple of questions:
1. Is the Scally protocol good? Optimal?
2. If not, what would be a better protocol and why? Can we tap the group knowledge to develop a resource for an optimal HPTA restart protocol?
3. Any other recommendations based on the science?
4. Any other recommendations based on personal experience? Once thing I'm particularly worried about is how long one has to feel lousy before the HPTA will kick back in? What's the fastest way to get back to "normal"?


Low Libido Post PCT, Help
Low Test After Diet and Overtraining
#2

I suggested a while back that this would be a great topic for a stickie. I have muddled through a restart based on the Scally protocol, but I am having a hard time with Clomid (I think) and not sure how long I will be able to continue. I found so much conflicting info that it would be great if a pro could lay it out!


#3

Scally is bogus and because many refer to his PCT does not mean that it is correct, safe or effective. You have to watch out for bro-science. Scally is in that crowd.

Most important is understanding what you are trying to achieve and what the agents do.

High dose hCG was discredited years ago. High continued stimulation of the LH receptors by LH and/or hCG can desensitize the receptors. So when you are done, what good is your own LH when the receptors are tired of listening?

High LH and/or hCG can create very high intratesticular testosterone levels. That is turn drives high T–>E2 inside the testes. Anastrozole or any competitive AI drug cannot control that. So one can take relatively high anastrozole doses and still have high serum E2.

If you have high FSH/LH, you are primary and there is nothing to restart.

If hCG does not work, you are primary. Stop and do TRT.

If SERM does not create good LH/FSH levels, you are secondary, stop and do TRT.

You can do a restart [or PCT] with SERM or hCG then SERM. Never take multiple SERMs or SERM and hCG at the same time.

SERM’s increase E2 levels, aromatase inhibitors are needed if the SERM’s are effective.

1a) get testes physically recovered with 4-6 weeks of hCG or SERM [suggest nolvadex, not clomid]. You do not want high doses as you want the testes to be functioning on normal LH receptor stimulation. 250iu hCG SC EOD or 12.5 mg nolvadex ED.

1b)) If you start on hCG, time to switch to SERM [nolvadex]. Just stop hCG and start SERM. When using hCG, if the testes have been making decent amounts of T, then the top end of your HPTA has not been active. With the SERM, it will now be. Take SERM for two weeks, if you did 1a), you can skip this.

1c) Take 1.0 - 0.5 mg anastrozole per week in EOD divided doses. You will need a liquid product to get by-the-drop dose increments. Read about anastrozole over-responders, understand the signs and recourse.

2a) Slowly taper off of the SERM, do not stop suddenly or your HPTA may shutdown.

2b) You will want to be on 0.5 mg anastrozole and cruise on that for a few weeks, then taper.

Can you do PCT/restart without SERM? Yes, but may not be effective as the top end of your HPTA has not had a dress rehearsal. Can you do a SERM only PCT/restart? Yes. Note that some can obtain SERM’s but not hCG.

The duration’s and timing are all flexible. Nothing is carved in stone. Everyone’s responses and problems are unique. So seeking the perfect PCT/restart can be a bit misguided.

Labs [optional]: With SERM or hCG, your T and E2 levels should be uncreased [else do TRT]. If high normal, 1.0 mg anastrozole per week. If mid range, 0.5mg

If E2 is high, LH may be high, cut SERM by 50%, anastrozole can be ineffective

With SERM, your LH/FSH numbers should be good. Else do TRT.

If your T levels are good, no real point in checking for LH/FSH, as they will be good. However, if they are high, you will need to reduce SERM dose.

Your testes need DHEA to make T. Supplementing DHEA will help if your DHEA-S levels are low [deficient]; otherwise no advantage. High DHEA supplements can drive high E2 levels in some guys.

You can tell if T levels are good, so need for labs is not always needed to know T levels or that LH/FSH levels are up. But you can’t feel high LH.

During PCT if you start feeling better for a short while, that can be from elevated E2 levels. But when taking an AI, you can get same effect from E2 levels that are too low. So you can get lost. But if your thyroid is a mess, feeling good may not be achievable.

We know that hypothyroid states can lead to low LH and low T. So the prospects of a HPTA restart may be poor in such states. There is more to sexual functioning than your T levels. Do not have T tunnel vision. Note the other health issues and causes in the advice for new guys sticky. If there is a cause for low T, you need to identify and fix that.

Testicular response to hCG or LH is age dependent. HPTA restarts for old guys is silly. HPTA restarts can work very well for younger men if there are no other complication.

Some young guys have brittle HPTA’s that just fail. Sometimes this is spontaneous and idiopathic. However, adventures with 5-alpha reductase inhibitors [hair loss drugs], or stupid cycles can cause irreversible damage. A deca only cycle is a good way to get seriously messed up. So some of these HPTA failures can be caused by drugs/gear; but in some cases these events might just be bringing a future failure forward in time. I have to throw over-training, extreme low fat diets and starvation diets into the risk pool.


HCG Nolva PCT Help?
Low T at 26, Considering a Cycle
#4

Wow. Thanks for the detailed reply, KSman! A couple of follow up questions:

  1. When “slowly tapering off the SERM”, how should that work from both a dosing and timing perspective?
    1a. Should the taper be 2 weeks? 4 weeks? More?
    1b. During the taper how to handle the doses? We are starting with 12.5 mg novalex ED. Can we go with 12.5 mg EOD to essentially cut the dose in half? Or is ED important? Is dropping the dose by half too large of a jump?

  2. Anastrozole vs aromasin? Is there any advantage to using one versus the other for E2 control? Seems like aromasin is not discussed much.

  3. Not a question, but I would agree that getting thyroid and other issues fixed is key prior to TRT. I made this mistake. On the advice of my doctor, I went on TRT while still having thyroid issues (Hashimoto’s) but didn’t feel better until I got the thyroid stuff in check. I think that was the wrong order – I believe that many of the T issues were a result of the thyroid problem and stress from personal issues.


#5

Fantastic write-up as usual, KSMAN! Mods - can we get something like this stickied?


#6

And please define old guys? Is there an age past which it is usually pointless?


#7

I second the classification of “old guys”? Apologize for putting my own question in here, but what guys are good candidates for a restart? Has anyone came back to, and stayed at middle ranges after being on TRT for let’s say 10 years. When their numbers were on the low side to begin with? Xlr8, have you done or started the restart? I’d be very interested to know what numbers yourself and others like you see a year after you’re off Everything. Hope you have good results.


#8

If you know you’re secondary, you might as well just start with the SERM. If we’re going to sticky something, it probably needs to be a bit more detailed and cover those of us that really are sure of Primary/Secondary status. When restarting a system that worked before a steriod cycle, the kitchen sink approach is probably valid. No so if you attempting diagnostic work and might need to stay on T, HCG or SERM long term.

[quote]KSman wrote:
Scally is bogus and because many refer to his PCT does not mean that it is correct, safe or effective. You have to watch out for bro-science. Scally is in that crowd.
[/quote]
Maybe we should add some detail to the below so that it’s not bro science as well.

What’s high dose and what’s long term? You refer to common TRT doses of HCG below. Doses that barely keep my testes at a normal size. You think the same dose is effective in jump starting adequate levels of T after being shut down? What if someone is Primary at normal LH levels but not at higher doses of HCG?

It would be good to add detail on high dose HCG being discredited and evidence of desensitization being real. I don’t have anything in my admittedly small e-library.

The key work here is ‘can’ and only an issue if you end up producing more T than you intended. How often is that going to happen on a restart and how long are we exposed?

Most restarts I’ve seen include pretty short spans with high dose HCG. The intent is jump start production and get off. So there’s a chance you could have high E2 for a few weeks if T levels were higher than needed. I’d take high E2 for a couple weeks in return for a blood work that showed my testes make more T than I needed. That would be easy to correct.

I’ve fallen into this category, but I’m not convinced this statement is 100% accurate. If you’ve been shut down for a long period of time, how long do you have to be at high normal LH/FSH for your testes to start producing adequate amounts of T? I tested after three weeks on a SERM. May not have been long enough to jump-start adequate production. Maybe I need a signal much higher than high normal LH for a few weeks? Maybe I need a signal higher than normal to produce long term. Enter high dose HCG.

Yes, but how long on HCG and how much? Even Shippen suggests higher doses to assess response. He also suggested adjusting dose to get appropriate response, not some hard fast rule like 250IU EOD. Take as much as you need, and no more than you need to get the appropriate response. What if someone needed more to produce adequate T levels? How would they every know without a high dose test phase?

Or HCG. If you can’t get your pituitary to work but your testes do work, wouldn’t HCG be worth a shot?

I just can’t rationalize why HCG and SERM at the same time is all that bad. If you are trying to restart two different systems at the same time, or keep one going while to restart the other, it seems logical. Unless you assume the first time you take an HCG shot or dose of the SERM, you’ll get the appropriate response. I’m assuming that’s not the case and the restart takes time. You’ll need many doses to get the desired response. Maybe that’s incorrect. I’d have to test LH/FSH after my first SERM dose.

How do we know 250IU HCG EOD is going to = normal LH for everyone? How do we know normal LH is enough for everyone to get to desirable T levels in 4-6 weeks if at all?

The last two sentences are key. The Scally restart assumes we started with a functioning system before a steriod cycle. It’s not the best solution if you’re trying to determine where you system is failing. We need to take a different approach if we’re trying to determine Primary or Secondary status.

Primary at normal LH levels - HCG mono might be an option, but we’d never know with the 250IU EOD protocol.
Primary at high HCG doses - Need TRT.
Secondary but not with a SERM - Long term SERM might work, or at least until you figure out why you’re secondary.
Secondary with a SERM - Need TRT

This all seems reasonable in general, but the doses you suggest of HCG and Nolva seem to be what one would end up on or cruise at if Primary or Secondary. If we’re trying to get an exaggerated response to jump start production, I think higher doses for a few weeks are a logical start with not much risk. You’ll get a definitive answer and can adjust the dose down. If you start low, you’ll either have run it for much longer and test more, or always wonder if you should have given it more time or a higher dose.

These are just the ramblings of someone that’s taken a general interest in their own health issues. I’ve not treated anyone else or been involved in any real studies. What I plan to try soon:

HCG ramp - While on T, increase HCG from 250IU to 500IU MWF for two weeks. 250IU is barely enough to keep my testes at full size. Still feel like they’re a tad smaller at that dose.

Higher dose HCG - Something in the same vein as the Scally PCT or Shippen challenge. 1000IU ED for a couple weeks and test. I know I’m E dominant so probably 6mg of Aromasin EOD like I’m doing now. If free T isn’t at a reasonable level after a couple weeks of 1000IU HCG ED, I think it’s clear I’m primary. Seems better than waiting 6 weeks or wondering if I need more than 250IU EOD.

If I get a reasonable T response from HCG (doubt it, but we’ll see)…

SERM - I’ll start a SERM while tapering HCG so that T levels and stimulation remain while the SERMs do their job. I have Clomid, so I’ll start with that. If I get any sides from that, I know Torem will get me the LH response I need at 60mg ED. That put me at high normal before. 20mg of Nolva ED had me quite a bit lower on LF/FSH. Anacdotal proof not all SERM work the same for eveyone at the same dose.

I’ll test after 3 weeks on the SERM. I know that was enough time to get LH/FSH to high normal before. If T levels are still good, I’ll taper the SERM to take only as much as I need for the appropriate dose. Lower the dose a bit and test two weeks later.

So…

Week 1/2 - 500IU HCG MWF - Still on T
Week 3/4 - 1000IU HCG ED
Blood work - Continue if T levels adequate.
Week 5 - 500IU HCG MWF, SERM
Week 6 - 250IU HCG MWF, SERM
Week 7 - SERM
Blood work. If T levels adequate, taper SERM. If not, run (try taper) HCG as long as it will work.


Thoughts on Planning PCT
#9

“If SERM does not create good LH/FSH levels, you are secondary, stop and do TRT.”

Isn’t this backwards ? My understanding is that secondary is Low to low normal LH and FSH, Low Total T and Low to low Normal Free T. That’s how I was diagnosed. This indicates that the testes are most likely in good working order, and the problem lies elsewhere in the HPTA (the pituatary.) So if a SERM does not create good LH/FSH levels, wouldn’t that most likely indicate primary, not secondary ? If a guy is secondary, it seems to me that the first line of treatment should be hCG or a SERM and not TRT. Of course I am new to all of this and certainly not an expert, so I could easily have my stuff ass backwards.

This is from the NIH website :
Secondary hypogonadism

In secondary hypogonadism (hypogonadotropic hypogonadism), defects in the hypothalamus or pituitary result in low testosterone levels because of insufficient stimulation of the Leydig cells. It is also associated with low or low-normal FSH and LH levels. Patients with secondary hypogonadism can have their fertility restored by suitable hormonal stimulation, whereas those with primary hypogonadism resulting from testicular failure cannot. Secondary hypogonadism can be caused by a number of conditions (Table 3) including hypothalamic and pituitary disorders or lesions, hyperprolactinemia and Kallmann syndrome (which causes a GnRH deficiency) (16). Certain medications and illnesses can also affect the hypothalamic?pituitary system resulting in hypogonadism (17).


#10

“Scally is bogus and because many refer to his PCT does not mean that it is correct, safe or effective.
You have to watch out for bro-science. Scally is in that crowd.”

I happen to know Scally personally.
KSman, being an engineer, perhaps you should look up Scally’s credentials
before you throw around the term bro-science.

I respect your opinions for the most part, but you are out of line sir.


#11

I have done a restart and it worked well for me…for a time. Then it seemed my levels started to drop again. That was about a year ago. So I repeated it again mid spring and maybe once more after that. I mostly used 20mg nolva (tamoxifen) daily and .25mg anastrazole thrice per week (for about four weeks). In between restarts I would run with .25mg anastrazole twice a week.

Initially I was able to keep up with my bloodwork frequently because my insurance covered it all. But I changed jobs early this year and had to go more by feel, which obviously is not very scientific.

Anyway, I recently went off of everything for a few months, wanting to get my levels tested again. Actually, I was taking Rez-v and ZMA daily by Biotest (for two mos) and taking nothing Rx. Levels were low again.

Here’s my point or main questions:

  1. How do you maintain a restart?

  2. If a restart works and then subsides, is this indicative of anything?


#12

[quote]PKNY wrote:
“Scally is bogus and because many refer to his PCT does not mean that it is correct, safe or effective.
You have to watch out for bro-science. Scally is in that crowd.”

I happen to know Scally personally.
KSman, being an engineer, perhaps you should look up Scally’s credentials
before you throw around the term bro-science.

I respect your opinions for the most part, but you are out of line sir.[/quote]

His is the only restart I’ve seen with some sort of study attached to it. It obviously works for quite a few men. I’ve seen mention of an update to this protocol. Something about replacing one of the SERMs with an AI. Not sure how well you know him, but maybe you could ask him about this. I’d also be interested to know if he’s tried lower doses with poorer results. Again, if you’re trying to restart a system that’s only shut down due to a cycle, I don’t think there’s anything wrong with hitting it hard for a few weeks and not leaving anything to chance. It would just be nice to know if this is what he’s doing, or if lower doses produced different results.

It would also be interesting to get his thoughts on assessing primary vs. secondary for those of us that have be shut down for quite some time.


#13

[quote]beerman wrote:
I have done a restart and it worked well for me…for a time. Then it seemed my levels started to drop again. That was about a year ago. So I repeated it again mid spring and maybe once more after that. I mostly used 20mg nolva (tamoxifen) daily and .25mg anastrazole thrice per week (for about four weeks). In between restarts I would run with .25mg anastrazole twice a week.

Initially I was able to keep up with my bloodwork frequently because my insurance covered it all. But I changed jobs early this year and had to go more by feel, which obviously is not very scientific.

Anyway, I recently went off of everything for a few months, wanting to get my levels tested again. Actually, I was taking Rez-v and ZMA daily by Biotest (for two mos) and taking nothing Rx. Levels were low again (sorry Biotest, but your supps did nothing…). Not giving all the details as I’m not trying to hack the thread.

Here’s my point or main questions:

  1. How do you maintain a restart?

  2. If a restart works and then subsides, is this indicative of anything?[/quote]

If the SERM works you could stay on it for a longer period of time or indefinitely. I would reduce the dose for a couple weeks and retest, eventually getting to the point where you find the lowest dose that produces adequate results. For me this would free T in the upper part of the range.

Testing is cheap. Try private MD labs or lef.

One Biotest sup that appeared to work for me before I crashed even harder was AlphaMale. Hard to say how much because I was changing other things.

Baseline - normal sups plus ZMA
Total T - 327
Free T - 7.9
E2 - 41

Add AlphaMale and Adex
Total T - 531
Free T - 23
E2 - 18
DHEA-S - 335

Drop AphlaMale and ZMA. Add transdermal Magnesium - increased DHEA, which probably helped T.
Total T - 448
Free - T - 19
E2 - 20
DHEA-S - 438

For me AlphaMale appeared to increase T by at least 83 and Free T by at least 4. Could have been more if the Mag oil had been used before both tests. Mag oil appeared to raise DHEA-S by at least 100. Tests were 5 months apart and obviously only on one subject, so take it for what it’s worth. Could have been other things going on or changing. Could have had different test results the day before or after.

A SERM is cheaper if it works and you don’t mind going that route.


#14

From my understanding, you cannot take a SERM indefinitely as your body will stop responding to it. That’s why I will run it in cycles.

Also, I am always hesitant to try (and pay for) any supplement that lists its ingredients in a formula, without actually listing the amount of each.

However, maybe you bring up a point of simply continually running different programs, cycling one after another. Like a SERM, then Alpha Male, etc.


#15

Scally’s PCT was originally designed for athletes that have been on gear
for years and years, not for low T He’s written extensively about it’s short comings,
failures and successes.

He’s a very knowledgeable man, and he backs up what he writes about with
research, and admits when he’s wrong. He lost his medical license and paid
heavy fines for his work in this field.

He has a free page on FB if you look him up,. You can pose questions and he answers
free of charge.


#16

[quote]beerman wrote:
From my understanding, you cannot take a SERM indefinitely as your body will stop responding to it. That’s why I will run it in cycles.
[/quote]
http://www.advancedmusclesciencelab.com/2011/11/clomid-trt-alternative.html

http://www.advancedmusclesciencelab.com/2012/05/clomid-trt-alternative-part-ii.html


#17

Well, that is pretty interesting. I have only tried it with Tamoxifen and anastrazole and I had a great response. Here is my bloodwork:

Pre TRT (Quest):
TT: 380
(Unfortunately this is all I had - before I knew what to get tested)

Post TRT (6-8 weeks, 40mg T-cyp Mon and Fri IM) (Quest):
TT: 542 (250-1100)
FT: 84.8 (35-155)
DHT: 34 (16-79)
FSH: <.7 (1.6-8) one final time to ensure shut down
LH: <.2 (1.5-9.3)
Prolactin ; 6.4 (2-18)
Estradiol: 19 (<39)
PSA: .5 (<4)

Then I stopped taking TRT as I saw what I thought was some gyro forming. Read to take 2.5 mg Letrozole ED to get rid of it. This is after 2.5mg letrozole ED for six weeks, plus a taper. I then finally had some better advice to use a SERM restart protocol and ditch the letrozole. (Although I would swear I had great results for the letrozole alone. I didn’t get bloodwork done after only taking letrozole, but everything was showing very high T levels). For the last week of letro, I started the 20mg nolva. For two weeks I took it in the morning. Then for two weeks I took 10mg AM and PM. These labs are from day 27 of the nolva!

FSH: 18.8 [1.6-8.0 mIU/mL]
LH: 7.5 [1.5-9.3 mIU/mL]
E2: 27 [< 39 pg/mL]
TT: 1045 [250-1100 ng/dL]
FT: 216.3 [35-155 pg/mL]

Needless to say, I felt great!

Any research on ongoing use of tamoxifen?


#18

[quote]beerman wrote:
Well, that is pretty interesting. I have only tried it with Tamoxifen and anastrazole and I had a great response. Here is my bloodwork:

Pre TRT (Quest):
TT: 380
(Unfortunately this is all I had - before I knew what to get tested)

Post TRT (6-8 weeks, 40mg T-cyp Mon and Fri IM) (Quest):
TT: 542 (250-1100)
FT: 84.8 (35-155)
DHT: 34 (16-79)
FSH: <.7 (1.6-8) one final time to ensure shut down
LH: <.2 (1.5-9.3)
Prolactin ; 6.4 (2-18)
Estradiol: 19 (<39)
PSA: .5 (<4)

Then I stopped taking TRT as I saw what I thought was some gyro forming. Read to take 2.5 mg Letrozole ED to get rid of it. This is after 2.5mg letrozole ED for six weeks, plus a taper. I then finally had some better advice to use a SERM restart protocol and ditch the letrozole. (Although I would swear I had great results for the letrozole alone. I didn’t get bloodwork done after only taking letrozole, but everything was showing very high T levels). For the last week of letro, I started the 20mg nolva. For two weeks I took it in the morning. Then for two weeks I took 10mg AM and PM. These labs are from day 27 of the nolva!

FSH: 18.8 [1.6-8.0 mIU/mL]
LH: 7.5 [1.5-9.3 mIU/mL]
E2: 27 [< 39 pg/mL]
TT: 1045 [250-1100 ng/dL]
FT: 216.3 [35-155 pg/mL]

Needless to say, I felt great!

Any research on ongoing use of tamoxifen?[/quote]

Those are spectacular results. I would be rolling with that if I were you. No need to take it twice daily with a 5-7 day half life. Maybe try 10mg per day and see if you can hit close to the top of the range for free T. You’re essentially trying to take as little as possible while getting an appropriate response. The other option would be 20mg EOD. You could keep adding days between the dose and retesting.

It’s not that much different than clomid, so wouldn’t personally be too worried about lack of studies. You could always try clomid if it’s really a concern.


#19

This is a really interesting and informative thread guys. Not a great deal out there in the way of HTPA restarts with decent knowledge backing up what’s been written


#20

What would the correct dosage and duration be for a Clomid challenge test for HPTA restart ?