HRT - Beyond the Basics

[tdsg]

Hi, I have a few questions, but med protocol and lab numbers first. Have been on HRT since September 2013. I will be looking for advice/answers regarding other labs to run that might shed further light on what is needed to feel and perform my best.

My med protocol:
60 mg testosterone cypionate, subcutaneous E3D
0.125 mg anastrozole/DIM E3D, same day as testosterone
500 IU HCG E3D, day after testosterone/anastrozole/DIM
Tadalafil: 5 mg maintenance dose daily before bedtime

My latest numbers: December 2014, Labcorp
Total T: 1013 (348-1197)
Free T: 23.1 (6.8-21.5)
PSA: 1.9 (0-4)
TSH: 1.42 (0.450-4.500)
DHEA-S: 302 (71.6-375.4) but Labcorp did serum instead of sulfate. 6-month prior was 333.6 with TT of 915 and FT of 22.1.
Estradiol: 23 (7.6-42.6)
Total Cholesterol: 181 (100-199)
Triglycerides: 55 (0-149)
HDL: 69 (>39)
LDL: 101 (0-99)

Baseline lab numbers prior to HRT: August 2013, Labcorp
Total T: 380 (348-1197)
Free T: 8.9 (6.8-21.5)
PSA: 1.2 (0-4)
TSH: 1.89 (0.450-4.500)
DHEA-S: 256 (71.6-375.4)
Estradiol: 5.9 (7.6-42.6)
LH: 5.9 (1.7-8.6)
Total Cholesterol: 226 (100-199)
Triglycerides: 70 (0-149)
HDL: 68 (>39)
LDL: 144 (0-99)

First, couple of questions/explanations/issues. I feel pretty good since starting HRT, but not great. I do exercise hard 4-5 times a week. Eat pretty healthy. Age: 48. Height: 5'11". Weight: 190 lbs. Sleep is always less than is needed. I tend to wake up early (5ish) and go to bed on average around 11. Pretty tired most of the time so may not be getting quality sleep. Seem to wake up tired.

I had previously been doing 250 IU HCG EOD but upped to 500 E3D. Testicular size seems smallish at either dosing schedule. Seems to be fluctuation in size throughout the week. Is that normal? Would a temporarily higher dose, maybe 1000, help increase testicular size by jump starting Leydig cells. If so, what would be a safe protocol?

Used to never have nighttime erections. Better since starting HRT, but I also do the 5 mg Tadalafil daily/nightly to help with this. Erection always stronger in the mornings upon waking. Erection strength and/or ability to achieve/keep one later in the day may be an issue sometimes.

Have always been on the nervous/anxious end of things. Performance anxiety has been an issue in the past. Social anxiety can be a problem too. Generally, just don't feel well enough to engage. Single for years and years. Confidence is an issue. Have done my share of SSRI's in the past with improvement in sociability. Stopped because they tend to cause/contribute to ED problems. In combination with Wellbutrin, they are not as bad. Currently, take Wellbutrin (150 mg) only in the morning. Not sure if it addresses anxiety much, but at least it is one less known to cause ED issues.

Seem to have always had memory problems. May be getting worse, but I don't know. Perhaps the anxiety contributes to this.

I am looking to optimize how I feel, how I perform, etc. No doubt I'm on the right track with HRT and my numbers look pretty good I think. Looking to run some additional labs that might shed more light on the anxiety, sometimes less strong erections, etc. I have 6-month labs coming up in June and would like to do some fine-tuning. I know there are more things that could be checked.

Back in December 2013 I had a few additional things checked.
Vitamin D, 25-Hydroxy (30-100) which came in at 46.2.
Thyroid Peroxidase (TPO) Ab (0-34) which was 12.
Triiodothyronine, Free, Serum (2-4.4) which was 3.6.

Does anyone know some additional things to check (beyond the basics) that might address anxiety and strength of erections? HRT is expensive so I'm looking to optimize.

If there is already a post that would be beneficial for me to read, please let me know.

Thank you

[BrickHead]

I highly doubt fidgeting with medications is going to give you a higher libido, testicular hypertrophy, or more energy considering your high normal T value and normal estradiol value.

I actually believe you could likely get by with less drugs, for example: 100 mg T per week, 250 to 500 IU of HCG three times per week, and perhaps NO anti-aromatase. But I am not a doctor, and it is he will make the best judgments for you if he knows what he is doing.

One thousand IU of HCG three times per week will likely have you at supraphysiological value of T, and that's not good for TRT.

I don't mean to be a wisess by asking this, but can you seriously see or palpate minor differences in testicular size from day to day? Is this much of a concern to you, or anyone else? If it is fine, but feeling good and fertility (IF that's your concern too) are top priorities for me.

Perhaps monotherapy with HCG at super high doses will give your ball size back, as it has mine with 9000 IU per week (see my thread). I am on HCG monotherapy because I want to try for a kid soon. My libido is OUT OF CONTROL on some days with HCG.

Six hours of sleep per night is inadequate for many.

Again, I believe you MIGHT do better with less drugs and a simpler plan. Speak to your doc though.

[NeverAlone]

I fully agree on the sleep issue. Sleep dep definitely tamps down my libido. So it could be as simple that, especially since it sounds as though sleep-dep is a constant for you.

Sleep disturbances aren't uncommon with Welbutrin, and I'm surprised it benefits you as it often exacerbates anxiety. Not clear though: are you taking Welbutrin alone or still in combo with an SSRI?

Are you also taking in caffeine? Perhaps not since you're on Welbutrin, but if you are, that could be messing with your sleep as well, especially if in higher amounts or even smaller ones later in the day.

On a separate issue: do you have lab results from when you were taking 250 IU HCG EOD (all other meds being equal)? Just curious if there was any hormone differences.

[tdsg]

Hey Guys,

Appreciate the replies. Thanks for taking the time.

Attached is labsum1 and I'll add labsum2 in the next post. I still have not figured out how to add more than one image in the same post. Perhaps moderators can adjust so its all together.

I had been doing 250 IU HCG EOD up until this past December after those labs were run. In June after labs, I'll know what doing 500 IU E3D has done to my numbers. There is definitely fluctuation in testicular size throughout the week and I would not categorize it as minor. Still wondering if that is normal. Would love to hear from others on this. I actually heard of trying 1000 IU HCG from Dr. Crisler in a Super Human Radio interview. Google it if interested. That interview is long, but very good. If I understood it correctly, it is very brief - maybe just a few times at 1000. Yes, definitely feeling well is a much bigger priority than testicular size. If I understand it correctly, HCG can affect mood/well-being for reasons other than just the size issue.

Libido is decent, just wish I could get those rock hard stiffies from youth back again with less fear of losing them. I think the anxiety does seriously affect that. And yes, less than ideal sleep on a regular basis is probably a much bigger component of this than I have previously considered. Just don't know how to not wake up so early. Have tried some melatonin here and there, but I have not noticed a whole lot of improvement. Admittedly, may have not tried it (long) enough to know for sure. Memory issues are likely tied to poor sleep too. I do tend to drink my share of coffee/tea in the morning hours. Never much after noon though.

I believe the 3 drugs together (Testosterone, HCG, and anastrozole) is pretty much the recommendation on this site for those starting HRT. Not saying it is the only way, and HCG only is great if that works for you. I would not be opposed to that and may discuss with doc in June.

I am on the wellbutrin only now. And, I do know it is not the best for anxiety. The SSRIs are designed more for the anxiety I believe, but I absolutely can't go back to those again as they were insanely hard to get off of years ago. Talking about brain zaps that felt like electric current going through your brain! I had been on nothing for a few years, but due to not feeling optimal with the HRT only, I went back to the wellbutrin, the lesser of two evils.

I titled this post HRT - Beyond the Basics mainly because my numbers are good (at least the ones that have been run), but I still don't feel or perform as well as I would like. Makes me wonder if there are other labs to run and things to check. I still have more reading to do for sure, but I was hoping others might know of some things that can be overlooked that play into all this. Perhaps, I don't have the basics down just yet. Sleep is pretty darn basic and maybe I have not given that its due credit as a major contributor to how a person feels and performs.

[tdsg]

Here is the second half of those labs in the previous post.

[KSman]

More hCG is not better! Suggest EOD dosing as you are stretching the half-life. High dose can degrade LH receptors and lead to unmanageable E2 levels. Also costly. 250iu EOD is all that you should need.

Thyroid: Please check and post oral body temperatures when you first wake up AND mid-afternoon. This is the best measure of overall thyroid function. Your above mid-range fT3 should provide good body temperatures. If not, see references to rT3, stress, iodine and Wilson's book on 'Adrenal Fatigue'.

What other Rx and OTC meds, supplements? What other health issues?

Sleep: melatonin must be time release, otherwise on the other half of the half life, dropping melatonin wakes you up. I have also used trazodone, very inexpensive. Try 50mg at first, you may need 75 after a while. Get the 150mg tabs that break at 50 and 75.

Do you still have brain fog?
Energy levels?
Initiative to get things done?

FT is low. So higher SHBG suspected. Current E2 levels do not explain this. What is waist size?
You may need higher T dose to depress SHBG and increase TT, and then more anastrozole in proportion to T dose change.

[tdsg]

Thank you! I will get back to you later this evening on some of these things. I have often wondered about thyroid. I know there is a good post on this site. Got to run for now...

[tdsg]

Appreciate the earlier advice. Okay, I'll drop back to 250 on the HCG and switch back to EOD. Since my testosterone is on an E3D schedule, does that matter? E6D I'll be doing both T and HCG. That is the schedule I was on up until this past December.

I will follow through on body temps. Need a BBT thermometer. I had one a few years ago but lost it in a move. I have read differing opinions on whether to do it oral or under the arm. Is either one considered better than the other that you are aware of? (Sorry, I do still need to read the thyroid sticky) I will post results after I have accumulated some numbers. Also, from a recommendation you made in another post I did switch back to iodized salt.

Meds: The 3 for HRT, Wellbutrin 150 mg, and Tadalafil 5 mg maintenance dose.

Supplements:
DHEA 25 mg micronized
D3 4000 IU
K2 100 mcg
Krill oil 1250 mg (Viva Labs)
Pycnogenol 50 mg
Zinc 50 to 100 mg
L-arginine 1000 mg (basically taking to get rid of because much higher doses would be needed to have much/any benefit)
Ginger 550 mg
Aged garlic extract 600 mg
Alpha-lipoic acid 100 mg
Ubiquitous CoQ10 100 mg
C 6000 mg
Seeking Health multivitamin 3 capsules (daily recommendation is 8)
Had been taking some A, E, and selenium, but I believe I'm going to just start taking the full 8 capsules of the SH multivitamin.

Health issues:
Gluten intolerance
Hereditary fructose intolerance
Varicose veins, worse in left leg. Hopefully great saphenous vein treated in a few months.
Hemorrhoids - inherited that and the veins from Mom. Damn! Could have gotten something worse (bipolar) from Dad though. My brother did.
Anxiety, and to a lesser extent a little depression. Memory problems maybe tied to the anxiety.
Peyronie's disease - surgery when 18. Largely successful.
Hair loss on head and lower shins.
Less than rock hard woodies that I'm at risk of losing especially later in the day.

Good to know about the time release melatonin. That might help some with early morning waking. I'm sure what I have is not time release. I'll check out the trazodone if no help with the TR melatonin.

I have thought at times I have some brain fog. Maybe more so before HRT. My son has ADHD. Often wondered if I do too. If so, no hyperactivity. More focus related.

Energy is up a lot since HRT. I do ride my bike really hard (45 minutes/12 miles highest gear for muscle building). Lots of inclines where I do have to gear down some. Motivation is not too bad. Has been worse in the past.

FT low? I was thinking I was topped out pretty high on both the FT and TT. Yes E2 looks good. Waist size is 32. Probably will go down as I continue to ride throughout the Spring and Summer. It did last year. Still wearing a little winter fat. But not bad.

Thank you so much for taking the time, KSman!

[TexMed]

I had the same issues. HRT fixed it for a while, but it came back. I was getting my son tested for add/adhd when I relized I could respond YES to all of the questions my son was being asked! Went to my doc, took a quick test and got a script. Tried a few meds and setteled on adderall. I take 10 mg instant release. Brain fog, gone. Now a bit hyper sexual. I'm lovn that. Tiredness is not an issue. I take the instant release vs the extended release as it gives me more control.

If I need it, I can take a 1/2 tab in the afternoon & still sleep. I'm sure it's not for everyone, but in my case, it's greatly improved my life. I get shit done. I enguage with coworkers. BTW I'm 41. Low tes and add/adhd have simular symptoms (on the surface). You can take a test online to see if you wish to look into it. Hope this helps. Oh, & my memery is better as well. Work is much improved. I've always had sleep issues. I take temazepam or benadryl. The adderall totally knocks out any hangover.

[tdsg]

Thank you! Appreciate the information. I may schedule a visit with my regular doc and ask for the instant release too. I have a friend who is on that and she prefers that because of having more control as well. Glad you have found some side benefits - that sure couldn't hurt me assuming I would have the same benefit. Wonder if I should try to wean down on the Wellbutrin first. I may at least go back to splitting a 150 mg tab. That is what I used to do anyway.

I tell you... the memory, anxiety, and possible focus issues all came together for me once in college. I had to give a presentation, (something I have learned to manage over the years by being VERY prepared) and at the start my brain actually stopped working and there was an awkward silence for what felt like forever. In reality, it was probably no more than 10 seconds. I finally snapped out of it and just began to speak and eventually normal brain function returned and I was able to think again and speak "off the cuff". I wonder if those with ADD/ADHD have difficulty with public speaking. I would think so.

[TexMed]

I just relized you said you son has it. I missed that. See, now how crazy is that?! lol

[tdsg]

Yeah, son does have ADHD complete with some hyperactivity too. I have an apt scheduled with doc next week to discuss ADD med. Just did first temperature reading this morning at 4:30 AM (yeah I woke early again! But I did go to bed around 9). Temp was 96.43 so if that continues I may be discussing thyroid too. Dead tired.

[KSman]

Benadryl half life can be a problem and not get you through the night. May seem good at first but effectiveness wears off.

[tdsg]

Canceling ADHD appointment with GP doc. I feel it would be crazy to discuss anything thyroid with him as well. Read the thyroid sticky. Tapering off the Wellbutrin too as it does little for anxiety.

Additional symptoms I failed to mention earlier are dry skin especially on my scalp and on my legs below the knees. Usually, when the humidity increases, it is not as bad. Have had some other skin issues over the years - rashes on arms, occasionally a weird dry patch and/or bumps on my penis. No itching ever with any of these. Also, I get these red patches on the back of my head/neck that will not go away. I do shave my head due to having lost most of my hair anyway, but I do not feel as if it is razor burn as most everything on the internet suggest. The red patches are not raised and do not itch. Had been thinking the skin and hair issues were all gluten related, but not so sure now. I mostly never eat it except for the rare temptation that gets the better of me. Some of this could be lichen plants - supposedly I have this which also causes ridges in the nails. That is what a dermatologist told me several years ago anyway. A different dermatologist told me the raised bumps on my arms were folliculitis. I disagree. They could come up overnight and disappear just as fast. I still get them occasionally. No itching, basically flesh colored.

Have also had what I think are heart palpitations for some time now. If that is what it is, that does not correlate with low body temps, I don't think. Unless the thyroid issues are possibly hashimoto related. Not even sure then.

Temps so far are as follows:

4/30/2015 4:30 AM 96.43
4/30/2015 12:00 PM 98.40
4/30/2015 7:00 PM 98.69
5/1/2015 5:20 AM 96.89
5/1/2005 10:40 AM 98.38
5/1/2005 2:45 PM 98.31
5/2/2015 6:35 AM 97.10
5/2/2015 3:50 PM 98.34

How many days of temps are needed in order to feel confident about them? I have not taken the afternoon/evening temps at the same time. Just whenever I think to do it. I also wake up early at varying times.

Labs coming up in about a month. I have asked for pretty much everything on the stop the thyroid madness site. Maybe overkill, I don't know. Also feel like I should hold off on a iodine replenishment regiment until after labs. Hopefully, learn more that way.

Regarding the adrenal cortisol saliva test. I need to learn more about that. Is it a kit where you take samples throughout the day? Someone mentioned that to me. Also, would I do it on the same day that I get all my other labs done? Need to read more. Just thought I would ask and see if anyone has done it.

[tdsg]

Full set of temps below. I am starting iodine replenishment. Going to build up and use kelp, at least until it becomes too many pills to take. May take a little longer than using other iodine supplements.

Basal Temps
4/30/2015 4:30 AM 96.43
4/30/2015 12:00 PM 98.40
4/30/2015 7:00 PM 98.69
5/1/2015 5:20 AM 96.89
5/1/2005 10:40 AM 98.38
5/1/2005 2:45 PM 98.31
5/2/2015 6:35 AM 97.10
5/2/2015 3:50 PM 98.34
5/2/2015 9:00 PM 98.26
5/3/2015 4:45 AM 97.04
5/3/2015 5:30 AM 96.96
5/3/2015 11:50 AM 98.15
5/4/2015 5:30 AM 97.18
5/4/2015 1:00 PM 98.88
5/4/2015 9:40 PM 97.82
5/5/2015 5:30 AM 96.86
5/5/2015 2:15 AM 98.76
5/6/2015 4:40 AM 96.79
5/6/2015 1:45 AM 98.37

Hope to feel better soon. Will report back later.

[TexMed]

tdsg wrote:
Canceling ADHD appointment with GP doc. I feel it would be crazy to discuss anything thyroid with him as well. Read the thyroid sticky. Tapering off the Wellbutrin too as it does little for anxiety.

Additional symptoms I failed to mention earlier are dry skin especially on my scalp and on my legs below the knees. Usually, when the humidity increases, it is not as bad. Have had some other skin issues over the years - rashes on arms, occasionally a weird dry patch and/or bumps on my penis. No itching ever with any of these. Also, I get these red patches on the back of my head/neck that will not go away. I do shave my head due to having lost most of my hair anyway, but I do not feel as if it is razor burn as most everything on the internet suggest. The red patches are not raised and do not itch. Had been thinking the skin and hair issues were all gluten related, but not so sure now. I mostly never eat it except for the rare temptation that gets the better of me. Some of this could be lichen plants - supposedly I have this which also causes ridges in the nails. That is what a dermatologist told me several years ago anyway. A different dermatologist told me the raised bumps on my arms were folliculitis. I disagree. They could come up overnight and disappear just as fast. I still get them occasionally. No itching, basically flesh colored.

Have also had what I think are heart palpitations for some time now. If that is what it is, that does not correlate with low body temps, I don't think. Unless the thyroid issues are possibly hashimoto related. Not even sure then.

Temps so far are as follows:

4/30/2015 4:30 AM 96.43
4/30/2015 12:00 PM 98.40
4/30/2015 7:00 PM 98.69
5/1/2015 5:20 AM 96.89
5/1/2005 10:40 AM 98.38
5/1/2005 2:45 PM 98.31
5/2/2015 6:35 AM 97.10
5/2/2015 3:50 PM 98.34

How many days of temps are needed in order to feel confident about them? I have not taken the afternoon/evening temps at the same time. Just whenever I think to do it. I also wake up early at varying times.

Labs coming up in about a month. I have asked for pretty much everything on the stop the thyroid madness site. Maybe overkill, I don't know. Also feel like I should hold off on a iodine replenishment regiment until after labs. Hopefully, learn more that way.

Regarding the adrenal cortisol saliva test. I need to learn more about that. Is it a kit where you take samples throughout the day? Someone mentioned that to me. Also, would I do it on the same day that I get all my other labs done? Need to read more. Just thought I would ask and see if anyone has done it.

I thought the adderall might increase my anxiety as well, but just the opposit. To much will, hence start with 10mg. Topical skin issues could be a recurring fungal. You could try an over the counter anti fungal. Youll know pretty quickly if its the issue, also doxycyclin is a good cheap antibiotic commonly used for skin. My daughter has the raised bumps on her arms, derm told her it was psortsis. I dont know if i agree with that. Anyway, just my 2 cents here. I know my view is more medication'ish, but that is my backround. You may very well find relief with what the others have mentioned as well. Good luck buddy

[KSman]

Your body is cool in the morning, but warms up well and quickly, that is a good sign.

4 sample cortisol need not be on any particular day.
I would get through your iodine replenishment then be stable on your iodine maintenance intake before doing this and more thyroid labs.

[tdsg]

It has been a while since I visited this site. I suppose I have not felt my best. Thank you to all who have provided insights so far. I am still battling low energy levels and general fatigue. Sleep is decent, just never enough due to waking early every day around 4-5 am. I typically go to bed around 10-11 pm and generally do not have too much trouble falling asleep. For a few months now, I guess I would add muscle fatigue and soreness and what seems like slow muscle recovery to my list of ailments. To refresh, my exercise routine is riding my bike. Last year after starting on HRT, I felt good, could almost ride hard everyday, and was able to recover much faster. Fastest time on about a 12 mile ride was 42 minutes. This year, dropping back to a ride about every 3 days, my muscles stay sore, and I feel tired and not as strong, and I seem to be holding onto some water. My stomach seems bloated. The same bike ride takes me almost 8-10 minutes longer in spite of switching to smooth tires from knobby trail tires. Libido and erection quality is about the same - decent but could always be better.

My HRT med schedule up until recently was 60 mg t cyp e3d subq, 250 iu hcg eod subq, and 0.125 mg anastrozole e3d. Due to smallish testicular size, I tried a few months of 500 iu hcg, but dropped back to 250 per advice on this site/thread and lack of improvement with the higher dose. I will post all/new labs that are the result of this schedule at the end of this post.

Based on the new labs run back in mid-June, my new med protocol is 100 mg t cyp e3d, 150 iu hcg ed, and 0.25 mg anastrozole e3d. I have noticed some improvement in testicular size by doing hcg at a lower daily dose, but every day. No improvement thus far in energy levels, sleep pattern, and I still have muscle soreness and fatigue, and slower ride times. I am no longer taking Wellbutrin and I feel good about that. No noticeable change yet in libido or erection quality.

As refresher, I did try IR for a few weeks due to low morning body temps averaging around 96.9. There was no improvement in temps. I stopped all iodine for about two weeks prior to blood work. I did have quite a few thyroid and other labs run this time to try to pinpoint what is making me feel and perform so poorly. I seem to stay tired.

My doc wanted me to add 50 mg pregnenolone nightly just before bed. I'm cautious over this and started with 10 mg, now up to 20 mg for just a few days. No noticeable change in anything yet. I may continue to increase this slowly and monitor symptoms and side effects. Seems like some people can experience some heart palps if the dosage is too high. I also take 25 mg DHEA daily. Pregnenolone labs were 37 mg/dL and the labcorp range says <151 so I do not know if mine is low or not. I did also have 24 hour salivary cortisol test run. Due to my early waking which was especially bad on this day (3:30 am), I did my first saliva collection at 3:45 am. Then, 10:30 am, 3:30 pm, and 9:30 pm before bed. Results say normal and were 0.024, 0.124, 0.266, and 0.045 respectively. I had all other labs run on this same day with a blood draw at about 8 am.

I do not know how to interpret the cortisol test, but I believe they are the reason the doc added pregnenolone. I know cortisol is supposed to be highest in the morning, but my 3:45 am timing of the first one makes me think that it should be low then because I should be asleep! Any insights are welcomed. My highest reading was at 3:30 pm which seems whack too.

I won't write the results here, but a few things out of range, borderline, or that made me question them are high bun/creatinine ratio, high a/g ratio, high total cholesterol, high ldl cholesterol, maybe low iron binding cap (TIBC), low UIBC, high iron saturation, high DHEA sulphate, low prolactin, low reverse t3, high free t, low vitamin K1, and low ferritin. Some of these may be beneficial like the DHEA, but I don't know. Several of these like the iron ones I don't know enough about them to really spot a problem. Hoping some of you lab geeks are able to identify definite problems that I cannot.

I am not sure I agree with increasing my t cyp. Total t had dropped to 892 (348-1197), but free t is at 29 (6.8-21.5). I am worried that I have other issues like adrenal problems unrelated to this and that increasing the dose only cost me more money and could cause unwanted side effects. Opinions? I am about a month and a half into the new med schedule with no improvement in how I feel thus far.

That's about it for now. I look forward to anything anyone knows that may help. I am considering stopping all caffeine because of the cortisol labs. Possibly cutting way down on carbs to try to lose a few pounds. I am up about 10-15 lbs from last year.

Thanks all

[tdsg]

Labs page 2

[tdsg]

Labs page 3