T Nation

Low T Since 18 Yrs Old. No Improvement on TRT. Help w/ Protocol?

Hey I’m new here so I hope I’m posting in the right area but I was hoping I could get a little help reviewing my blood work and my Dr’s protocol.
Some background information struggled with very low energy since 14 years old, had some sleep issues such as sleep apnea but since cleared of it after losing weight. Got tested at 18 for low testosterone by a DR who thought it might be the cause of my chronic fatigue and came back at 9.8nmol/l he put me on Test C shots 200mg/2 weeks but I noticed no improvements and stopped the shots after 3 months because I wasn’t uncomfortable with it at such a young age.

Now 22 years old still suffering from chronic fatigue and have went down every route and tested for what seems to be every issue possible and all my blood work comes back completely healthy, on paper I should be the healthiest person yet still suffer from extremely low energy and mental fog , and a seemly inability to put on muscle even though I force myself to work out 5 times a week and have my diet very dialed in. Went to another doctor who ran my test levels and my bloods came back at
Testosterone total : 12.8nmol/l
Progesterone: 0.9nmol/l
Estradiol: 43pmol/l
Albumin Random U: < 3 mg/l
DHEAS: 17.4 umol/l
LH: 2.3 IU/l
FSH: 2 iu/l

My doctor put me on a testosterone compounded cream 100mg/g at 1g a day applied to bicep, he also found high Reverse t3 so put me on 5mcg of cytomel.

6 Weeks after no improvement I re did my bloods and my levels came back at
Total Test: 13.5nmol/l
Free Test: 235pmol/l
DHEA: 13.8umol/l
FSH: 2 iu/l
LH: 2.8 IU/l
Estradiol: 34pmol/l

After these results my doctor said it was because I was applying the cream to my bicep ( as directed ) and not my scrotum and to try scrotum application, personally I found the cream very annoying especially since I was told not to let anyone touch my arm, cant shower or sweat/ workout for 4 hours after application and asked to go on injections instead. I self injected and on my doctors advice split in into 50mg twice a week, so 100mg of Test C a week total.

I switched to injections and while I didnt notice any major changes I noticed a slight increase in strength and muscle mass over the 4 weeks, it felt like 2 years of working out finally started to get results which was nice as well and a little more mental clarity and a better mood, more calm but nothing major. I should mention I found myself sleeping much longer up to 12 hours. I re did bloods after 4 weeks and asked my doctor to check my SHBG to be safe and my results where
Total test: 27.5noml/l
Free Test: 945pmol/l
SHBG: 11nmol/l
Progesterone: 0.3nmol/l
Estradiol: 98 pmol/l
DHEA: 7.9umol/l
And my LH and FSH were both below average due to the shots shutting down natural production.

After some research and talking to my doctor again I came to the conclusion daily injections might benefit me since the low SHBG means i might be metabolizing testosterone to quickly. My doctor agreed but said I was wrong about injections and that they were the issue and causing me to not feel any better because im “overdosing on testosterone” due to my high free testosterone levels. He said with my low SHBG (which he believes to be genetic) I will only benefit from compounded cream applied to my scrotum) so he put me on 150mg of compounded cream via scrotum application once a day.

My issues are that its been 2 weeks and I feel much worse, even less energy, sleeping longer and waking during the night, sometimes waking up sweating, weaker in the gym, feel less motivated, worse mood, and overall even worse then before I started TRT.

My main issue is my age and that I am Canadian so its hard to find a doctor that even cares about my hormones but i feel my current doctor is trying to just fit me into the optimal range even if at the lower end (since his plan is the cream will drop my levels i guess because some test will convert to DHT? at least thats how he explained it ) than treat my symptoms.

I was hoping to get some other peoples thoughts especially those who have similar issues.

my main questions are :

  1. From what ive read the levels raised by cream drop by nearly half after 16 hours, should I not be on the cream twice a day compared to once? would this help? I feel the once a day application is causing my levels to spike and drop by the next morning making me feel worse

  2. Are injections really not going to help ? Id much rather do the injections because atleast I know they are working and I find it easier. My doctor couldn’t quite explain why injections wont work for me just that the cream is what I need.

  3. Is my declining DHEA normal? when I said my doctor he said lower is better and to not worry about it

  4. Could I really have been not feeling better because of an overdose of testosterone? to me I feel my issue was the twice a week injection and that daily injections of 15-20mg would make me feel the effects of trt , if anything based on my total testosterone levels I could go up in dosage let alone be “overdosed” am I wrong in my thinking?

  5. My doctor said the cream absorps very quickly via scotum application and that 3 minutes of rubbing it in and waiting 15 minutes before working out or even showering is enough, I give it an hour before work out and 2 hours before showering to be safe, my main concern with the cream is that i wont absorb it, am I being to paranoid ? is 15 minutes really all it takes to absorb the majority of the cream?

  6. Maybe this is an ignorant question but due to my low SHBG if i naturally had for example 27nmol/l of Total Testosterone wouldn’t i also naturally have high Free testosterone ? If its how my body reacts to testosterone is a high free testosterone really something to be concern about ?

One last thing is while I experienced no significant benefits on the injections I also didn’t notice a single side effect and even the long sleeping I believe may have been from another medication although it has gotten worse while switching to the cream, I’m sleeping 12 hours waking up feeling extra tired, even sleepy when usually I am fatigued not sleepy.

I realized I wrote a lot but I want to give a clear picture and I have no other place to ask these questions as when I try to ask my doctor I dont always get an answer although he does try to work with me and explain things.

I am 6 foot 1 and 180lbs if that relevant and all other blood work shows I am perfectly healthy. I also take daily vitamins like Zinc (25mg) Vitamin C (1000mg) Vitamin D (5000iu) and have eat at my maintenance calories, high protein diet, I eat very little sugar and my insulin levels are fine as well. I did lose 100lbs from 16-17 years old and have kept it off the last 6 years. I am still skeptical about TRT at my age but if its something that can help me I’d rather try it now then in 5 years. I am also on lembroxant for insomnia but its my only other medication other than TRT and thyroid 30mg (my doctor switched me to this from cytomel because the cytomel caused my t4 levels to drop ).

Any and all opinions are welcome and appreciated !

Were you getting 200mg 2x per week, 200mg once every 2 weeks, or 200mg split for twice weekly injections?

Is this the correct number? It seems extraordinarily high even for someone with low SHBG at 200mg. Thats assuming you took labs at a peak too.

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Sorry I should have been more clear, I got a single 200mg shot every two weeks so after no improvement I stopped until September 2021 when a different doctor re tested my hormones.

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Yup the reference range was 160 - 699 and mines was 945 pmol/l. Previously i tested at 235 pmol/l while on the testosterone cream applied to my bicep. I took my blood work on a Wednesday morning about 40 hours from my last shot. I split my shots into a Monday/Thursday split

Ok so when I did unit conversion I must have mad a mistake. If the range is as you said thats probably expected at your dose with low SHBG. I’m not sure what your Doc’s reasoning is for not continuing the shots. If it were me I would switch to twice weekly shots at a minimum. You could see what 100mg/wk does pinned 50mg each time. Likely still too high, but you could reduce from there. Or simply start 40mg 2x a week and go from there. Thats probably the more correct amount based on your labs.

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Also that number was at 100mg a week split into 2 shots a week , 50mg per shot, the 200mg was when i was 18 and was every 2 weeks I only added it into the post to add a full picture of how my testosterone was always on the lower side.

Ok if so … you were feeling best at 50mg 2x a week correct? Please clarify the protocol you were on when you felt ‘good’ or semi better anyway.

50mg 2x a week , i didnt notice any significant improvement but it would be what i felt the “best” on. I read some guys with low shbg only really benefited from daily or every other day shots so i thought that might be why I wasn’t noticing any real changes yet atleast with my energy but after my doctor saw my free testosterone levels he became convinced only cream would work for me. I was hoping to try 15mg a day to see if I had any notice improvements after 6 weeks but he shut the idea down. Is cream really better for those with low shbg?

I don’t really have much experience with cream. I’ve always viewed it as a second tier treatment to injections. But there are a ton of guys on here with low SHBG. Some take ed to eod injections and feel better. I would bet the majority of guys do fine 2x a week though or even 1x a week. We only see the guys with issues and most guys A) Don’t know or care what their SHBG is B) Are on weekly to bi-weekly injections and feel just fine.

For you, I would plead/beg the doc to let you try frequent injections. Inform him you only felt improvement on injections and as long as he doesn’t see harm, ask if you can try low dose ED injections. Don’t “tell him” what to do… ask him politely if you can try this as other things have failed and make sure to stress ‘whats the harm in trying’.

Just going to chime in, that sometimes being over range feels better. My sleep and anxiety are better with more Test. I haven’t slept like I have on blast on any protocol or before TRT (except as a teenager).

That doesn’t mean it is a sustainable protocol though.

I would question if the cream was defective (missing testosterone). Your LH improved on Test cream, and your Testosterone stayed about the same. That doesn’t make any sense.

I would have liked to try the 2x a week shots longer to since I imagine 4 weeks isn’t enough to fully feel the effects sadly my doctor really is pushing the cream after seeing the free test so high. I appreciate your reply , it confirms my own thoughts and I will definitely try talking to him about switching back to injections in the next appointment, I dont have anything against the cream but so far Ive only ever felt worse on it. like you said whats the harm in trying. Do you know if my free testosterone levels on the shots are anything to be concerned about?

Did my levels seem too high? My main goal especially with my young age is to find the minimum amount that gives me the maximum benefits and like you said is sustainable. I figured I probably wasn’t absorbing the cream at all which is probably why my doctor wanted me to switch to scrotal application, maybe I am over thinking things but I imagine if i couldn’t absorb the cream at all through bicep application even with scrotal application I may have issues with absorption. I never thought about the possibility the cream could be defective, it was compounded at a reputable pharmacy though but mistakes can always be made.

Dialing in on injections may take a few tries to get it right. Also finding the right injections frequency for you may take additional time. I will tell you I have low SHBG (15) and did feel my best on daily injections, even better than EOD and the effectiveness of TRT got worse as I moved injections further apart.

When your levels do stabilize it can take 1-3 months to start feeling better because hormones take time to affect tissue, hormones are unlike drugs which affect you almost immediately.

Onset of effects of testosterone treatment and time span until maximum effects are achieved - PubMed.

Protocol changes induce hormonal swings leading up to reach a steady state, and is when 4-6 things start to notice changes. So by now stopping the cream cause your T levels to plummet and the cypionate (T) is still building up in your system and is more than likely very low.

Too little or too much T may cause issues with some men.

T influences hematocrit and hemoglobin levels.

Hey thank you for the response!

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I should have mentioned my CBC was all normal and didn’t change during my time on TRT, actually funny enough my hemoglobin dropped by 1 when my Free test was 945pmol/l as compared to 235pmol/l. As well I never experienced any of the even common side effects like acne so I assumed if my body is not negatively reacting to the slightly higher levels of free testosterone as long as I get frequently blood work done I shouldn’t make it a concern unless it becomes one. My only issue is my doctor seems to be very off put by it but I couldn’t get a reasoning to why.

Thank you ! I didn’t know this , when I asked my doctor said I would adapt fine and didn’t inform me I might feel worse for the first few weeks. My situation is the opposite, I’ve stopped injections and started cream but I imagine it is the same. Since I am feeling worse do you think it would be worth getting my levels rechecked now or by week 3 or is it something I really should give a full 4-6 weeks before rechecking my levels? My main concern is that I am wasting time feeling worse for no reason when if I had continued the injections and switched to daily I might have started to feel better instead of worse.

Since our SHBG’s are quite similar have you ever tried compounded cream before? did it work at all for you? reading about your experience gives me a little hope since so far TRT has been a bit of a bust for me but i know it can take a while to have the desired effects. I appreciate the study, I think I may have been a little impatient when it came to the results I was expecting at only 4 weeks but reading your and the other peoples replies has really gotten me thinking my original thought process of smaller dosage every day injections for 2-3 months would be a good start. My only issue is convincing my doctor. Do you know if there are any studies on injection frequency and low SHBG?

Well you were only at 4 weeks too, right? Cream can work great (I’m trying that out now) if you take enough of it, often enough, and in the right place. I’m not wild about rubbing my balls twice a day, but it’s working so far.

So it sounds like you’ve tried a few different things but in not great ways. Anything can work with low or high SHBG, just have to adjust.

Thanks for the reply! Yeah I guess in my mind I was expecting more changes since I had been on TRT for 10 weeks total but the first 6 weeks I was on the cream via bicep application and I wasn’t absorbing the cream since my levels stayed the same more or less. So the 4 weeks on injections would have been to short to expect results, I would have liked to continue the injections but switch to everyday at the same weekly dosage (100mg) but my doctor said only cream would work with my low SHBG. Yeah as funny as it sounds it seems much easier to just stab myself with a needle once a day then have to rub my balls twice a day lol . Have you tried cream once a day? I feel like that might be where my issues could be coming from as my doctor has me on cream once per 24 hours and ive read the cream has a much shorter duration. Do you apply the cream every 12 hours? Do you mind if i ask your dosage and levels? just so I have some comparison for when I do my blood work soon. It good to know the cream is working for you if my doctor refuses to let me try injections again maybe I will be able to find a cream dosage that works for me. Have you noticed any difference being on the cream versus injections ? any experiences or input is really appreciate !

Well, I blast and cruise, and like the feeling of high testosterone. I used to work with a clinic, but do my own thing now. So you likely can’t get away with what I’m doing unless you cheat the system.

For me it comes down to risk vs reward. I’d love to run a gram of test year round if it was consequence free, but it’s not. I spend most of my time at a bit above range in total testosterone and free. About 25 precent above. For a few months a year I’m way above (like 5-6x above the top of the range). For me that’s a good balance for a few years. But I’m not going to do that forever. Maybe 3-4 years total, than just above range past that.

This is the price you pay for being on TRT, drawing labs before 6 weeks is not recommended because if you test at 3 weeks, the weeks leading up to a steady state your levels will change and you will not know where your levels are, only where they were.

It’s not true that low SHBG men excrete testosterone faster, it comes down to individual metabolism of T. I have seen high SHBG men excrete very quickly therefore needing very frequent injections.

I tried Empowers 20%/200mg cream, but I never absorb well enough through the skin, I feel the effects immediately after application, but 3 hours later levels crashed and I could feel it, So I would have had to apply the cream every 3 hours to benefit.

Not very practical. I’m on Jatenzo now, an oral T capsule 237mg twice daily and reach a steady state in 7 days (!) at which point levels are tested and adjusted if necessary. There has been an oral T capsule available in Canada for years under a different name. I can’t remember of the name.

My levels are peak at 2 hours 988, 715 @ 4 hours and 287 @ 12 hours. This does drive up my hematocrit to 57% and hemoglobin 19.2. I’m do for another therapeutic phlebotomy.

It seems like there’s always a new oral T treatments coming out from new companies every so often, so expect this to be the go to treatment for TRT in the future, that is only when it becomes more affordable.

Current costs are in the thousands and can only imagine what my insurance company is paying.

Right now I’m playing with dosing, 2 clicks AM 1 PM, 3 clicks AM 1 PM, 2 and 2, first few days felt off but today I feel really amped up, it’s getting harder to sleep, so I may try just once per day. I assumed with my low SHBG I would need it more often.