T Nation

My Case - Updated with Labs at End


#1

History of Illness

Age: 37
Height: 71 inches
Weight: 255
Waist: 38 inches
BF%: 23%.
BF Distribution: all over, but mainly pecs, thighs, midsection and glutes
Body/facial hair--low levels of hair in axilla, arms, with fairly dense hair below the belt and moderate leg hair (except no hair from 3 inches above ankles and below). Moderately dense beard, but grows very slowly. Facial hair (sparse) since age 13, pubic hair since 11-12 maybe.
Health conditions: Hyperension (149-154/86-92), ADD
RX--none for a while, but was taking Lisinopril and Adderall along with Androgel. I have been off all meds for approx a month. I am taking D3(10,000 IU/day), Fish Oil (Omega 3 @ 300 mg), Super B Complex, and Zinc (100 mg/day).
Diet--whatever I want, whenever I want it, but generally the American Diet of occasional fast food (good choices), occasional chips, not nearly enough protein. I don't count macros at all.
Training: 3 days per week of strength training (45-60 mins per session with warm-up) with 2-3 conditioning sessions (conditioning may be done on lift days, maybe not--definitely not overtrained)
Morning wood: (very rarely--1-2x/month); Nocturnal erections: (same as morning wood)

As a teenager, I was very heavily muscled and lean (sub 8% bodyfat at 19 and 180 lbs, naturally). Body fat kept creaping up throughout early 20's and beyond.

First noticed approx 2000

Symptoms:
Fatigue
Irritability
Lack of motivation
Social withdrawal
Emotional outbursts
Increased weight/fat gain around chest, buttocks, inner thighs
Mental fog
Loss of libido
Absence of nocturnal or waking erections
Decreased strength of erections
Decreased volume of semen (per semen analysis Oct. 2009/Feb 2010)
Decreased sperm count/motility (see above)

Originally diagnosed as depression and prescribed various SSRI medication
Wellbutrin
Celexa

Late 2008-Early 2009
No change in symptoms (or worsening)
Blood test by PCP to check Testosterone levels (orig tests revealed test levels of 100-120 if I remember correctly)
Began regimen of 3 (weekly) 100 mg injections of Test Cyp in MD�?�¢??s office with follow-up bloodwork performed on 4th week.
Felt great initially, but crashed before follow-up injection
Follow-up blood test (taken approx 1 week following last injection showed minor
increase in testosterone level)
Weekly injections performed in MD office were not practical as I was travelling over an hour for each injection.
Loss of testicle size with concurrent aching at times.
Impractical nature of travelling for injections as well as disappointment led to stopping treatment for approx 1 year.

Late 2009-Early 2010

Switched to Urologist for fertility consult
Marginally normal findings at that time.
Repeated semen study 4 months later with little to no change

Began Androgel Application (5mg/day) (packet)
Felt better at first, then rebound symptoms
Testosterone level checked with marginal improvement (approx 30 points to 197 (range 168-146)
Time of last application to blood test was 24-25 hours.

Started 7.5 mg Androgel
First blood test revealed decrease of testosterone levels from 197 to 168 (approx)
Time between last application and blood draw was 24-25 hours again.

Changed jobs, no insurance so stopped treatment.

Jan 2011
Currently applying 7.5G/day of Androgel since Jan 5th
Current symptoms
Low libido
Weak erection
Fatigue
Slow body composition change despite training (especially in pecs, thighs, glutes)
No motivation for activities
Social withdrawal

Jan 21st blood work with blood draw 3 hours after application of 7.5G Androgel (x 3 weeks at that point).

TT: 328 (250-1100)
FT: 73.5 (35-155)
E2: 50 (13-54)
Prolactin: 7.6 (2-18.0)
TSH, 3rd Generation 1.96 (0.40-4.50)
FSH: 2.4 (1.6-8.0) **Relatively high since TRT should shut down natural production, no?***
LH: 0.7 (1.5-9.3) **Relatively high since TRT should shut down natural production, no?***

Discussed those numbers/results with the fertility doc and at first he was on board with treatment. A week later, he said "If I didn't know you were on TRT, I'd say you are perfectly normal"--My reponse to that? "You're fired" (in my best "The Donald" voice).

I made an appointment with a local doc who specializes in TRT. I was supposed to see him yesterday and have all of my bloodwork done, but his office was flooded due to torrential downpours and melting snow putting the river by the office over 7 feet above flood stage.

I've rescheduled the appointment for 2 weeks from today. I'm fairly confident things will turnaround soon.


#2

Lack of HPTA shutdown indicates that you are a poor absorber of transdermal T. That is common or universal for hypothyroidism and your TSH confirms that there is a problem. Do a complete thyroid panel. Check waking body temps, record and post here.

Are you using iodized salt, eating sea food or have iodine in your vitamins?

Your E2 is very high, so while you are not absorbing well, you are converting to E2. Common for non/poor absorbers. You are very estrogen dominant which is making you feel crappy.

You need to self inject. Read the stickies, they are very useful. Start with advice for new guys then protocol for injections.

“If I didn’t know you were on TRT, I’d say you are perfectly normal” -the problem is that an endo does not have any perfectly normal patients as a reference!


#3

The doc I’m seeing in a couple of weeks is very knowledgable in the area or TRT. He is a PCP who has a niche as an “anti-aging” doc. From what I have heard, he is great. He believes in the protocol per the sticky and from what I understand the first visit will be blood work and patient education.

From a current patient on here, I received a message as to what to expect for blood work which will include everything listed in the bloodwork sticky so I’m hopeful.

Just wondering if I should order some RC anastrozole or just wait . It could be 6 weeks before I start the protocol depending upon when the results are back. I hope it is sooner than that, but not sure.


#4

RC anastrozole

in general, depends on

-willingness of doc to prescribe

-prescription drug coverage

-out of pocket costs

Otherwise liquid anastrozole is perfect for EOD dose control.


#5

He prescribes the arimidex.


#6

Some do get scripts in had then get liquids [not quite legal] because of the Rx costs and/or inability to manage dosing with pieces of tablets. All the greater a problem for anastrozole over-responders.

Arimidex is now generic and some are getting smaller dose tabs or caps, some via compounding pharmacies. Arimidex brand name is only 1mg tabs that I am aware of.


#7

Well, looks like I finally have a doc who is knowledgable. First appointment today went vey well. Bunch of blood drawn. Appt next week to go over results and hopefully start the protocol.


#8

Results are in: blood was drawn between 1130 and 1145am
I’m only going to show the significant information regarding the CBC and CMP plus all of the other stuff that we need to discuss.

CBC:
WBC 7.8 Ref: 4.0-10.5
RBC 5.28 Ref: 4.1-5.6
Hemoglobin 17.6 (High) 12.5-17.0
Hematocrit 51.4 (High) 36.0-50.0

(rest weren’t significant at all)

CMP
Glucose 88 Ref: 65-99
Cratinine 1.2 Ref: .76-1.27
Bilirubin 2.2 (High) 0-1.2 (I have a naturally high level of bilirubin–i’ve known this for years–checked with hematologist–all good.
ALT (SGPT) 63 (0-55). Not sure about this one. Don’t drink, no NSAIDS, no drugs

Lipid Panel
Cholesterol 169 Ref: 100-199
Triglycerides 188 Ref: 0-149
HDL 34 (Low) >39
LDL (calculated) 97 Ref: 0-99
LDL/HDL ratio 2.9 Ref: 0.0-3.6

Vit B12 and Folate
B12 505 Ref: 211-946
Folate 14.7 Ref: >3.0

Testosterone
TT 400 Ref: 249-836
FT 12.9 Ref: 8.7-25.1

C-Reactive Protein 0.46 Ref: 0.00-3.00

E2 14.5 7.6-42.6 (This was after 3 doses of liquidex at .25, .5 and .5 ((Mon, Thurs, Mon.)) Last blood work prior to this E2 was 50)

Hemoglobin A1c 4.6 Ref: 4.8-5.6

Prolactin 9.4 Ref: 4.0-15.2

Vit D 32.3 Ref: 32.0-100.0 (this is telling because i’ve been supplementing with 10.000 units of what appears to be a low quality product)

Hemocysteine 10.5 Ref: 0.0-15.0

Cortisol 10.5 Ref: 2.3-19.4 (blood draw at 11:45 am)

DHEA-S 439.7 (high) 88.9-427.0

LH 5.7 Ref: 1.7-8.6

fT4 1.29 Ref: 0.82-1.77
fT3 3.9 Ref: 2.0-4.4
SHBG 20.7 Ref: 14.5-48.4
Iron, Serum Ref: 114 40-155

Based on these numbers, the doc suggested 120mg/wk T (split over 2 injections), 1 mg of Arimidex and 1000 units of HcG (500 x 2). He places orders through a national compounding pharmacy, but I was hoping to get my own scripts (cheaper I’m sure).

Anything jump out? I’m wondering why my DHEA-S is off the chart, but the T is low.


#9

Given your weight, 120mg T looks reasonable.

hCG half life does not cover 3.5 days. Suggest 250iu EOD. At this point hCG is keeping your testes functional and you are not trying to get your T levels up with that. Too much hCG can lead to E2 management problems and hCG is also expensive.


#10

any thoughts on the high DHEA but “low” T levels? he said every one of his patients is on DHEA except me.


#11

Any reviews of the labs? Feedback?


#12

[quote]SportsPT wrote:
Any reviews of the labs? Feedback?[/quote]

Obviously there are several factors that jump out of me like red flags here where I have seen in Dr’s patients with low T.
Vitamin D is low
b-12 is low.

If your dr does not pick up on the obvious then hes not worth going back. I see a ton of stuff that needs to be addressed.

Adex does not solve the issue it just a bandaide approach and not realistic long term solution.

More information is needed, your only getting not even 25% of the true pics.


#13

With only 3 doses of anastrozole prior to lab work and E2=50–>14.5, LH and FSH could at time of the labs be increased [seen for LH] and it may be that T levels have improved since the labs. But T injections will be the end of that. Getting off of androgel would leave a lot of artifacts, so none of this data really tells us much.

Some guys have higher DHEA than others. And low T production then consumes less of the DHEA production which would be expected to increase DHEA levels.

Your fT3 and fT4 look good, but TSH is still a concern.
I did ask "Are you using iodized salt, eating sea food or have iodine in your vitamins? "


#14

[quote]KSman wrote:
With only 3 doses of anastrozole prior to lab work and E2=50–>14.5, LH and FSH could at time of the labs be increased [seen for LH] and it may be that T levels have improved since the labs. But T injections will be the end of that. Getting off of androgel would leave a lot of artifacts, so none of this data really tells us much.

Some guys have higher DHEA than others. And low T production then consumes less of the DHEA production which would be expected to increase DHEA levels.

Your fT3 and fT4 look good, but TSH is still a concern.
I did ask "Are you using iodized salt, eating sea food or have iodine in your vitamins? "[/quote]

higher dhea would be due to potential other medicines you are taking (amphetamines, adderal, ridalin,)

also could indicate insulin resistance as I have seen it occur before, or adrenal imbalances which need to be further investigated.


#15

Forgot to update this with the protocol that was laid out by the doc.

60mg T 2x per week
500iu hCG 2x per week
0.5mg Arimidex 2x per week.

Test on M and Th
hCG and Dex on Tuesday/Friday

Plus Pregnenolone, Vit D3, Melatonin, Good B complex, Fish oil (not the Mega Red I was taking).

I’ve been doing it for a few weeks not. Overall feel better. Morning wood has returned most days, libido is good, losing some weight, more confident, better mood.

Return to MD in two weeks, but no bloodwork is scheduled.

Any thoughts on the dosages (for a reminder, I’m 252 lbs.)


#16

Reading problems? - I did ask "Are you using iodized salt, eating sea food or have iodine in your vitamins? "


#17

I have answered that question multiple times. Yes iodized salt, no seafood. No multivitamin.

How does the protocol look is my question.


#18

Are you on oral preg or TD? What brand, or is it compounded?


#19

Oral pregnalone.

Overall feeling great. Better mood, libido is through the roof, morning wood is great. Leaner. Scale weight hasn’t changed much, but clothes are getting a lot looser.

No blood work for another month or so. I may try to email the doc to see if I should get it next week, though as it has been 4 weeks since starting the program.