T Nation

HRT in NYC

Age: 31
Height: 72in (6ft 0in)
Waist: 36
Weight: 188 lbs
Body/Facial Hair: on Arms-Legs-some Back; have Full Beard-Moustache
Fat: carried mostly in belly, back, flanks, thighs, neck-jowels

Health conditions: snore at night (? sleep apnea/ never formally diagnosed); having tonsillectomy in Nov 2013 for enlarged tonsils that likely contribute to snoring

Symptoms: poor recovery from workouts; drop in libido; poor motivation/enthusiasm in personal & professional projects; occasional brain fog; poor sleep; difficult to lose fat; difficult to gain muscle (muscle- may be a diet issue?)

Additional Symptoms: have been told by multiple friends/family members recently that face/cheeks look slightly swollen

Rx/OTC drugs:
-Note: all started only recently in July 2013
-Vit D-3 5000 units daily
-Zinc 50mg daily
-Creatine 5g daily (pill form)
-no hair loss or prostate drugs ever

Diet:
-try to limit carbs (bread, pasta, bagels, etc. only sparingly)
-eat meat daily (steak, chicken, sushi)
-usually a salad with meat for dinner ~3-4x per week
-attempt to do intermittent fasting ~4-5 days/week (eat only from Noon-8pm)
-usual first meal is around noon; second around 7pm after gym workout
-whey protein shake after every workout 4x/week

Workout:
-4 days per week with personal trainer @ 1hr/workout
-warm-up with mobility exercises
-do 1 major lift per day (bench, squat, overhead press, deadlift) (5 sets x 5 reps)
-remainder of work-out spent on core conditioning (planks, lunges, assistance exercises)

Erections:
-still get both nocturnal and morning erections from time to time; possibly at a lower rate

Stress:
-about usual baseline for me
-no recent job loss, financial troubles, relationship drama
-sleep is likely less than optimal (likely due to snoring at night; which hopefully will be addressed by tonsillectomy in Nov 2013)


I have been considering going to see an HRT doctor for above symptoms as well as just simply wanting to be completely on top of my overall health (both endocrine health as well as general health.) I want to be at a peak/optimal level of health and performance; and if HRT can help me achieve that goal without major adverse risk to my overall health and well-being then I am willing to investigate further/pursue treatment.

I have researched (via Internet and phone calls to staff) many docs in my area at various price points, levels of expertise, and willingness to Rx different forms of HRT.

I will post labs below.
I am slightly concerned by my elevated cortisol and DHEA-S.
(wondering if that is contributing to the recent roundness people are percieving in my face)
(am guessing another explanation of the cheek puffiness could be bloating/water retention from creatine that was only recently started in July 2013?)

[Note: Labs were drawn at 7:45am after a full night of sleep and fasting for ~12 hours.]

Total Testosterone 504 [348-1197]
Free Testosterone 16.1 [8.7-25.1]

Estradiol 37.3 [7.6-42.6]

LH 4.6 [1.7-8.6]
FSH 3.2 [1.5-12.4]

SHBG 34.2 [16.5-55.9]
DHT 35 [30-85]
Pregnenolone 116 [<151]
Prolactin 18.1 [4.0-15.2] HIGH
Progesterone 1.5 [0.2-1.4] HIGH

IGF-1 197 [71-241]
IGF-Binding Prot 4.9 [3.5-7.0]

PSA 0.5 [0.0-4.0]

Cortisol, AM 25.0 [6.2-19.4] HIGH
DHEA-S 727.8 [138.5-475.2] HIGH

TSH 3.74 [0.45-4.5]
Total T3 113 [71-180]
Free T3 3.1 [2.0-4.4]
Free T4 1.16 [0.82-1.77]
Reverse T3 12.0 [9.2-24.1]
TPO Antibody 23 [0-34]

Total Cholesterol 170 [100-199]
Triglycerides 56 [0-149]
HDL 60 [>39]
LDL 99 [0-99]
VLDL 11 [5-40]

Vit D, 25-OH 39.6 [30.0-100.0]
Vit B12 422 [211-946]
Methylmalonic A. 91 [73-376]
Folate 13.7 [>3.0]
Vit A 59 [18-77]
Vit E 11.0 [4.6-17.8]
Nicotinamide (B3) 16.1 [5.2-72.1]
Nicotinic Acid (B3) <5.0 [0.0-5.0]

Coenzyme Q10 1.29 [0.37-2.20]

Homocysteine 10.0 [0.0-15.0]

C-reactive protein 2.9 [0.0-4.9]

Phosphorus 4.2 [2.5-4.5]
Magnesium 2.0 [1.6-2.6]
Copper 105 [72-166]
Zinc 103 [56-134]
Selenium 141 [79-326]

Glucose 109 [65-99] HIGH
Hemoglobin A1C 5.6 [4.8-5.6]
Insulin 11.3 [2.6-24.9]

Hematocrit 43.6 [37.5-52.0]
MCV 87 [79-97]
WBC 5.4 [3.4-10.8]
Platelets 111 [155-379] LOW

Glucose 109 [65-99] HIGH
BUN 19 [6-20]
Creatinine 0.98 [0.76-1.27]
Sodium 146 [134-144] HIGH
Potassium 3.8 [3.5-5.2]
Chloride 101 [97-108]
Carbon Dioxide 22 [19-28]

AST 17 [0-40]
ALT 19 [0-44]
Total Prot 7.5 [6.0-8.5]
Albumin 4.5 [3.5-5.5]
T Bili 0.4 [0.0-1.2]
D Bili 0.11 [0.0-0.4]
Alk Phos 58 [44-102]

Serum Iron 110 [40-155]
Iron Saturation 29% [15-55]
TIBC 382 [250-450]
UIBC 272 [150-375]
Ferritin 131 [30-400]
Transferrin 324 [200-370]


a)I would love to push my T levels higher.

b)I notice that my Estradiol may be considered high. (Some fat loss may help with this?)

c)Considering my age and desire for future ferility, I’m wondering if HCG + Aromatase Inhibitor (without T injections) might be a good place to start in order to increase T levels and lower E levels a bit? (or am I being naive and instead ought to consider T supplementation + HCG + AI right off the bat… or should I put all of this hormone supplementation off until I’m a little bit older (only 31 now) and levels drop to numbers that are considered more classically treatable?)

d)I’m extremely wary of elevated DHT levels in the future and/or with any treatment regimen, given history of male-pattern baldness in my family. Aside from monitoring DHT levels every few months, are there any other treatment protocol related-DHT caveats I should be aware about?

e)Can I cut out the Vit D-3 (5000 units) and Zinc (50mg) supplementation I do daily, given my normal levels? Or are my levels normal because I am taking these pills? (I’m guessing one answer might be: stop taking them; re-check levels in a few months and if low, then go back to supplementation)

f)I’ve stopped taking creatine in the past week, hoping that the roundness in my face is due to creatine water-retention and not elevated cortisol levels (i.e. cushingoid features/moon facies) [Of note, I do not have a buffalo hump, nor do I notice any abdominal striae. However, in addition to some roundness of the face/cheeks people have pointed out; it has been difficult to get rid of some of that persistent belly fat]
Does this sound like a reasonable course of action to take re: creatine supplementation?

g)Given my current mineral/vitamin levels, would I benefit from any additional supplementation?

f)Any other related/unrelated advice is welcome.

Thanks in advance to all the helpful guys out there willing to lend me some advice.

Were you dehydrated for the labs? Sodium was high. If not dehydrated, that might explain some bloat.

I was going to suggest 10,000iu vit-D3! Not high enough.

Your HPTA seems to function normally and it is acting the way that it is from the effects of E2 and prolactin. You need to lower both. You need to do a repeat prolactin and if still high, seek a MRI to look for a [prolatin secreting] pituitary adenoma. Also eval if you width of peripheral vision is diminished.

Prolactin can be lowered by 0.5mg/week cabergoline and E2 with 0.5mg/week anastrozole.

You are defiantly on the edge of diabetes. Lower E2 and elevated T levels are major characteristics of syndrome-x aka metabolic disorder. Correcting T and E2 improves insulin sensitivity. Drinking a lot of water? Numbness or tingling in your feet?

You can’t loose weight and have low energy if thyroid function is low. TSH is high. Read the thyroid basics sticky and come back with the specified body temperatures and iodine intake history. Many of the symptoms of low thyroid function are common to low T.

Yes, your adrenals look hyper!

Action items:

  • reduce E2 with anastrozole, you can get this yourself if need
  • retest prolactin and seek MRI if still high
    – do not do prolactin labs for a few days after orgasm or hugging puppies or babies, avoid cuddling
  • post data re temperatures and iodine then ping me again
  • do research on insulin resistance - the mechanism of type II diabetes examine lef.org
    – you might try Rx metformin while you get your metabolism straightened out
  • avoid starvation diets and deep fasting, you will train your body to be low metabolism and increase rT3
  • suggest four sample saliva cortisol test
  • test http://en.wikipedia.org/wiki/Adrenocorticotropic_hormone

Add
chromium piconolate
fish oil caps

Agree:
Drop Creatine, do not need unknown side effects, might be affecting sodium balance

Appreciate the response KSman.

I have been doing much more research since the last posting as well as some much needed introspection.
I’d definitely appreciate some additional feedback (from any of you guys.)

Here is what I am proposing to do:

Supplements

-Increase Vit D-3 intake to 10,000 units once daily (up from 5,000)
-Add Vitamin K2, Menatetrenone 5mg once daily
-Start Methylcobalamin (methyl B12) 5,000 mcg lozenge once daily
-Start ZMA once daily (Vit B6 15mg / Magnesium Aspartate 450mg / Zinc L-methionine 30mg)
-Start Iodoral 12.5mg once daily (5mg Iodine + 7.5 mg Potassium Iodide)

Diet

-Increase intake of fish (sashimi) and seafood (i.e. shrimp, oysters, etc.)
-Increase intake of cruciferous vegetables (i.e. broccoli, bok choy, etc.)
-Limit any type of starvation/fasting diet

Testosterone

I have also visited with a local HRT doc; who it seems is willing to allow me to concoct my own HRT formulation.
His usual Rx cocktail includes Testosterone injection, Anastrozole, HCG, and Clomiphene.
[No HGH unfortunately]
He had suggested a 12-wk program consisting of 10-wks on Test + AI (no HCG); followed by 2 wks of no Test, with HCG + clomiphene.
However, given my background and display of more-than-novice knowledge of the subject he is willing to allow me to tailor my therapy.

I’d be interested to hear comments, and more importantly advice from you guys, as to how to precisely and ideally tailor the start of my TRT.
My personal proposal right now is:
-Testosterone Cypionate 50mg subQ every 3 days
-hCG 250iu subQ every other day
-Anastrozole 0.25mg every other day

I don’t see the benefit of a 10-week on Test / 2-week off Test protocol, and instead am leaning towards simply staying On Testosterone indefinitely.
As there will be no Off Testosterone period, I don’t see the need for Clomiphene. Does that sound about right?

My plan would be to get bloodwork done after being on a HRT protocol for 4 weeks, and then make necessary adjustments to Test and AI dosage at that time. (Not sure what, if any labs, could help guide adjustments necessary to the hCG dosage.)

Lingering HRT questions:
-what ester of Testosterone should I opt for? (cypionate, enanthate, propionate … knowing that prop may be complicated by PIP)
-should i opt for a brand name AI (i.e. Arimidex) instead of generic AI (i.e. anastrozole)?
-what types of syringes and needles should i request an Rx be written for?
-should i adjust Testosterone dosage to every other day so as to allow for easier coordination with concurrent hCG dosing? (i.e. being able to remember all injections on the same day instead of overlapping pattern)

Eagerly await thoughts regarding my plans for Supplements, Diet, and Testosterone.

Yes, there is a benefit to doing T, AI and hCG all at the same time.

Your doc has some strange ideas. But he is trying to keep the top end of the HPTA working. Perhaps the thinking that is helps keep the hypothalamus and pituitary in a better state of general fitness. Does that have merit? DO not know.

But would not work if one had primary and would not work if one was not SERM responsive.

As for " HCG + clomiphene" that is a bad idea for two reasons. Some guys have nasty estrogenic side effects from clomid. And HCG + clomiphene can overload the LH receptors with LH+hCG. That can have two effects, one is desensitization of the LH receptors that can spoil the game. The other is that there can be high amounts of T–>E2 inside the testes, serum E2 levels can be high and cannot be controlled because anastrozole does not work inside the testes where T levels are very high and its action of a competitive drug are overwhelmed.

Your advice regarding the Clomiphene is understandable; I think I would do best to avoid it given what I now further understand from what you said.

If you wouldn’t mind a brief response to the following questions, I’d really appreciate it as well. Plus thanks for the already great advice above.

-what ester of Testosterone should I opt for? (cypionate, enanthate, propionate … knowing that prop may be complicated by PIP; and that some have attributed some bloating to cypionate … I’m leaning towards Enanthate)

-should i opt for a brand name AI (i.e. Arimidex) instead of generic AI (i.e. anastrozole)?

-what types of syringes and needles should i request an Rx be written for?
(someone had suggested: BD Ultra-Fine II U-100 Insulin Syringes Short Needle 31g 3/10cc 5/16in)

-should i adjust Testosterone dosage to every other day so as to allow for easier coordination with concurrent hCG dosing? (i.e. being able to remember all injections on the same day instead of overlapping pattern)

T cyp and eth are interchangeable. Eth delivers more T. Availability varies by country where one may be generic and the other not.

No need for brand name anastrozole.

In many jurisdictions, you do not need Rx for insulin syringes. Find out. 5/16 may work, but I expect not so well. Pass on #31 with T, but you can try and report. I get Walmart’s Relion house brand, 100 for $13USD

I always suggest EOD to make T+hCG+AI work well.

Posting an update of labs, vitals, results.
[Note: Did not start any TRT. Only some lifestyle, diet, supp changes so far.]

Labs were drawn in early morning, fasted, upon awakening.
I have included as an attachment.

Vitals

6ft 0in
Dropped weight from 188 lbs to 173 lbs currently.
Bodyfat from 23% to 16% currently. (Measured with calipers.)

Sleep

-Had tonsils removed. Snoring eliminated.
-Blackout blinds installed.
-10,000 lux light therapy in the mornings.
-Installed f.lux on computer.

Diet

-Started tracking intake religiously using MyFitnessPal app.
-Average 2500 cals per day.
-No fasting.
-Caloric breakdown is 40% protein 40% fat <20% carbs.
-Averaging less than 100g carbs per day. Those carbs are purely from veggies (mostly cruciferous type) and non-wheat/bread/grain carb sources; as I have eliminated those from my diet.
-Very limited (if any at all) fruit; trying to avoid the sugar.
-Averaging ~200 grams of protein per day. (Need a few low-carb Whey and/or BCAA protein shakes during the day to hit this goal.)
-Usual breakfast is 4 eggs over easy. Usual lunch is something protein based (sashimi, beef brisket, chicken, etc…) Usual dinner is also mostly just protein (chicken, steak, lamb, etc…)

Supplements

-Vit D3 15,000 units daily (up from 5,000)
-Vit K2, Menatetrenone 5mg once daily
-Vit B12 5,000 mcg lozenge once daily
-ZMA once daily (Vit B6 15mg / Magnesium Aspartate 450mg / Zinc L-methionine 30mg)

-Apple Cider Vinegar 2 tablespoons daily

-Whey Protein ~100-120 grams daily
-Branched Chain Amino Acids 10-20 grams prior to workout

-Did not start Iodine replacement. (My shipment was lost in mail. Plus read some things on Web that made me wary of I-replacement. Regardless, TSH has improved since last test.)

Note: am running low on Vit D3 supps. Any advice on reputable brands? Preferably something that has high dosage in single pill as I’d like to reduce overall pill burden (i.e. not have to take three 5,000 unit pills everyday.) I am wondering if I should even go up to 20,000 units daily (current value: 62.2 [30-100 = normal range]).

Testosterone/Hormones

-Adrenals still seem to be working a little overtime

-Thyroid function seems improved (TSH down to 3.01)

-Glucose homeostasis appears better (lower insulin, lower fasting glucose)
-Inadvertently left out Hemoglobin A1C off current set of labs

-Total T did not change (504 --> 492)
-Estradiol came down nicely (37 --> 25); likely due to drop in body fat %
-Was happy to see that IGF-1 level (264)
-Estrone is elevated (not sure what to make of that)
-Pregnenolone is also elevated (not educated enough to know why)


As Total T did not change despite making some solid gains in Vitals, other labs, etc.; I am now once again considering starting some T replacement.

Considering:
-T cypionate 50mg EOD subcutaneous injection
-hCG 250 units EOD subcutaneous injection
-anastrozole 0.25mg EOD

Questions/Concerns:
-I am OCD about labs … especially if I’m going to start mixing in TRT
-If I start, I plan to check levels after 4 weeks
-When is the best day of the week (with regards to injection schedule) to get labs drawn to be best reflective of whats going on?
-I am afraid of elevated estradiol and estrogenic side effects (esp Gyno)
-I am afraid of elevated DHT and don’t want to run into early development of male-pattern baldness

My goals for next few months are:
-continue to optimize health
-continue cutting body fat to get closer to 10-12% BF
-continue lifting at gym 4+ days per week with a personal trainer to put on some big muscle (note: I am a recovering weak skinnyfat guy… despite having been ‘working out’ for several months-years.)

Hoping to get feedback to see if this protocol sounds reasonable, given my current profile.
Also hoping for feedback regarding my labs in general, diet, supps, and other hormones.
Appreciated in advance.

Bump.
Hoping for some feedback from anyone.
Appreciated in advance.

Interval Bump.
Hoping for any comments.