T Nation

My Testosterone Journey... Comments Please


#1

Greetings all from a new forum user seeking opinions about TRT, primarily to remedy low T and my tendency toward overuse injury and improve recovery after injury and exercise.

My testosterone journey….
I guess first the requested #’s and history.
Age 43
Height 6’2”
Weight 194lbs
Waist 36-38”
Generally furry overall, dense beard. Minimal body fat, except maybe pinch 1.5 inches right in the front of my stomach. No smoking, no drugs, no alcohol. Good diet with plenty of carbs, fat and protein. Could do better on greens sometimes. Generally eat a lot, but burn what I eat, don’t put on weight easily, burn it off easy when I do by backing off slightly on calorie intake. Weight after high school 165lbs, slow gain mostly through adding muscle to get to current weight. I was a bean pole in high school. Still would be described as skinny by most people. Generally well hydrated and 8 to 9 hours of sleep per night (but not straight through).

Work as self employed arborist and landscape contractor. Note that work is treated as training. I don’t schedule back to back to back hard days. I build in time for recovery after the ass-kicker days.

Born missing right kidney (but have both adrenals), undescended right testicle, and with bilateral absence of the vas deferens (BAVD). Left varicocele.

Mononucleosis, fall 1992, in college. Wiped me out. Stamina never felt the same afterward. Also never had the same amount of time to train. Otherwise, very healthy, active. Infrequent colds, rare flu.

As part of fertility investigations with my wife, diagnosed in mid 2000’s with azoospermia and BAVD, and low T (two separate readings, 211 and 373). Drs at the time didn’t even comment on the T, as I was fairly asymptomatic (other than slow recovery after injury, and no sperm, the latter of which may have been more of a function of BAVD). LH and FSH in low end of normal range for both of those T readings. Total T readings since then pretty consistently in the 200-300 range. Libido is and has been fine.

Testicular cancer in early June 2014 (found a lump on self exam on a Thursday, ultrasound on Friday, left orchiectomy the following Monday). Follow up monitoring clear to date (blood markers, CT and X-Ray; no chemo or RPNLD, caught it very early, and mostly not a type that metastasizes). No more left varicocele! At least one benefit to nut’ectomy.

It turns out the testicular tumor was cranking out T, and raised my total T level to 491 (double my baseline avg), measured just before surgery. I didn’t realize what was making me feel great before I found the tumor and got the data and surgeon told me that testicular tumors can make T. Thinking back to life just before surgery, I felt great. Recovery after exercise was spectacular. Stamina was great. This data point and associated feeling is what got me interested in boosting T. I had no idea that I could feel that good again and I’d rejected out of hand the idea of hormone replacement. Life is funny (weird) sometimes. T after surgery plummeted back down to historic ranges (200-300). Interesting that my body kept T level the same with one less testicle and the undescended one (brought down as a baby) at that.

Fast forward to 2017. Finally got motivated to starting working on T in earnest. After working with a naturalpath to increase endocrine building blocks (healthy fats) and make sure my vitamin and mineral levels were appropriate, and noticing no differences after two to three months, I decided to start T treatment. Urologist I am seeing for follow up monitoring for the long gone cancer recommended Androgel based on history and accumulated data, and I reluctantly said ok I’ll try it. The feeling of 491, and the hope that I could pull out of the tendency toward overuse injuries pushed me to trying treatment.

Most recent data set below after: 2 weeks at two pumps of 1.62% Androgel applied daily to shoulders and triceps, and two weeks at three pumps applied daily. Urologist started me at two pumps and wanted to pull labs in two weeks. For reference, 3 pumps gives 425.25 mg T onto skin, at 10% abosorbed, approximately 43mg/week. Compared to the 100mg/week injection recommendation, this seems low, and I think my T numbers reflect that. T total pre TRT was 228, first two week reading was 186. After two weeks at three pumps, I occasionally notice some subtle positive effects: more energy, wake up feeling some muscle recovery and building that happened overnight, and stronger erections. Also hit some lows, testicular aching (two short episodes since starting treatment, each about 6 hours). Most recent data set at one month into treatment is posted below:
TSH 0.88
Cholesterol (total, HDL, LDL) 128, 46,73
T total 164 (302-903).
T free 25 (47-244)
T free % 1.5 (1.6-2.9)
Regrettably no E2 number
SHBG 46 (17-66)
LH and FSH readings at two weeks (2.2, 8.8) had halved from pre-treatment reading (5.5, 14.4). T dropped at first two week treatment reading, and dropped yet again at one month reading under increased dose, presumably due to drop in endogenous production from falling LH, FSH levels. Latest drop could also be due to stress as my father had a stroke 3 weeks ago and dealing with that created a sleep deficit and massive stress load (more conversion to E2?). Other miscellaneous data, from pre TRT, all collected at first visit to naturalpath (will add references ranges as I work on this post):

LH 5.5
FSH 14.4
Pregnenolone 26
T total 350
T free 47.8
DHEA-S 290
E2 24
SHBG 28
PSA 0.4
Hct 45%

Questions
Do I present as clear cut primary hypogonadism? Would it be worth stopping treatment to see if HCG or Clomid or an aromatase inhibitor would stimulate T production/help retain T in my system?

Why would my LH not be up when T is low. FSH seems to respond when my T is low? Recent reading I’ve done would indicate that high FSH would facilitate the E2 pathway, driving down T, both directly through aromatization, and indirectly through negative feedback…

SHBG seems higher more recently. Any thoughts on what could be driving this relationship? Anything I can do to bring it down?

Considering that my T level is still tanked, and I have questions about primary vs secondary hypogonadism, and whether I’d respond to an increase in LH (aka HCG), would it be worth stopping treatment to let everything rebalance, grab a new complete data set, and start fresh? If yes, suggestions for stopping? Cold turkey or with something to reactivate LH/FSH?

Also looking for suggestions on how to grab the steering wheel of this bus/Dr. to go see. Anyone out there in Portland, OR. Most of the providers I’ve seen seem fairly uneducated about T treatment, endocrine dynamics, the impact of low T, and the need to gather all the relevant data, at least until a stable treatment plane is achieved. The naturalpath has taken the most holistic approach of anyone I’ve seen to date.

I recognize I’ve made some mistakes in not getting all the data from the get go. To anyone reading this who is contemplating treatment, I can’t say it enough, don’t start TRT until you have a complete baseline dataset, preferably with a couple different readings taken some time apart.

I just saw my primary Dr. yesterday to see if he had any recommendations or additional thoughts, and he said he typically starts guys at 4 pumps, and tests two months out to see if dose needs to be adjusted. He seems knowledgeable and I may switch the prescription to him if he’ll do what I want (leaning toward injection, bi-weekly to 1X per two weeks frequency would be quite tolerable; I’m not needle averse at all; like the idea of mimicking daily cycle by doing more frequent sub q).

I have more reading to do on this site and elsewhere, but any comments on any of above would be appreciated. Suspect I am headed toward injections, which sound more effective (and much less of a pain to not worry about transference, not having to do daily gel application or putting gel on while winter camping, not having to shower daily, etc, etc).

This site provides a tremendous service to those of us asking our own questions and not getting them answered by the traditional medical world.

Much thanks for any responses and apologies for the long post.


#2

You are not absorbing well, dose is too small and T–>E2 conversion is shutting you down. E2 has a much higher negative feedback effect than T. The HPTA is really mostly the same as the female HPOA blueprint and estrogens rule.

E2 can also increase if liver clearance is not good. Always good to see AST/ALT. Some meds increase E2 by competing with liver enzyme pathway capacity that clears estrogens.

Application to the thin skin, inner surfaces of forearm and upper arm will absorb better *, instructions are written to reduce opportunity to transfer during hugging etc. * this is well known from female HRT

Your work also means that you will sweat-off a lot of your dose.

Transdermal T is not working. You need TRT, end of statement.

hCG or LH/FSH induced bu a SERM [clomid, nolvadex …etc] can only flog your internal testicle. LH 5.5, FSH 14.4 with your low T means that increasing LH receptor stimulation would not get you very far. I am also worried about FSH=14.4

High FSH or high relative to LH is a hallmark of testicular cancer. In 100mg/week injected T, LH and FSH should go to zero. You should test on injected TRT and if FSH does not get near zero, you should be worried.

Elevated E2 is increasing SHBG and lowering FT while SHBG+T, which is not bio-availalbe is inflating TT, so T status is worse than TT labs now suggest.

Self-injected T is most effective, 100% absorption and least cost, with lowest T–>E2 potential.

Your doc not testing E2 shows that he really does not have a good grasp of these things. Urologists simple have been shown to not be very good at these things. You will have to drive the bus and cannot be passive. If you can’t get this doc on the bus, find another wing-man. Passive does not work.

You are off to a good start and have been doing your homework.

I suggest this all of the time:

  • self-inject 50mg T cyp/eth twice a week, subq, #29 1/2" 0.5ml insulin syringes
  • pinch up fold of skin over upper leg, inject into end of fold with needle parallel to underlying muscles
  • 0.5mg anastrozole at time of injects, adjusting to get near E2=22pg/ml
  • hCG: you do not need it, but might find a mood improvement, 250iu subq EOD

pregnenolone and DHEA may decrease, hCG might oppose

TRT will LH/FSH–>zero

Cholesterol is way too low. <160 is associated with increased all-cause mortality. Some simply have low cholesterol. Cholesterol is the foundation for the whole steroid hormone cascade, including Vit-D3 and cortisol. Your DHEA-S indicates that things are ticking along nicely despite your low cholesterol.

Please read the stickies found here: About the T Replacement Category

  • advice for new guys - need more info about you
  • things that damage your hormones
  • protocol for injections
  • finding a TRT doc

Evaluate your overall thyroid function by checking oral body temperatures as per the thyroid basics sticky. Thyroid hormone fT3 is what gets the job done and it regulates mitochondrial activity, the source of ATP which is the universal currency of cellular energy. This is part of the body’s temperature control loop. This can get messed up if you are iodine deficient. In many countries, you need to be using iodized salt. Other countries add iodine to dairy or bread.


#3

Thanks for the thoughts KSman. Will keep this thread going as I move things along. If helpful for the group, I can start plugging references I’ve come across into my posts. I have been working through the forum stickies, which are very helpful.

I don’t suspect a thyroid problem, don’t get cold easily, and plenty of iodine in my diet. But, I’ll start taking morning temps to see where I’m at…good suggestion.

Interesting that you think cholesterol is low, will have to do some more reading on that. There might be something there, with pregnenolone low pre TRT. More red meat! With my activity, I haven’t ever worried about high cholesterol, but no one has ever said it was low. My previous readings, cholesterol total 152 in Dec 2016, and 147 in Dec 2015. I can look back in my medical record and see if I have some really old data points for comparison. Maybe my activity level is just burning it up.

I don’t know what sort of hormone draw my kidney is pulling, but it would be worth looking at that side of the endocrine system to see if it, or the adrenals, are hogging the pregnenolone. Kidney function as measured by creatinine has been fine, checked often as part of the CT scan protocol for follow up cancer monitoring. Worth checking aldosterone?

Suspect that LH/FSH are on their way to bottoming out, but that transdermal T is just not getting in, so they are still responding to low T signal. Confounding things, it is also possible that because I’ve been low T for so long (data going back to 2005), all cells in my body have increased density of T receptors and T just gets sucked out of circulation to where it can be used. It strikes me that it might take a while to balance things out because of this. I have read that high FSH can be an indicator of primary testicular failure. It isn’t always just high LH that indicates primary hypogonadism. I just had a round of cancer monitoring in March, so not worried about that. Blood markers all normal, CT and chest X-ray normal as well. I hate to get all that radiation, and have pushed Drs. for increased monitoring intervals as appropriate. Also have found some good research papers looking at effects of cancer monitoring, and the radiation statistically is taking a few days off my life. Not finding a very treatable cancer if it ever came back could take off years…so we keep monitoring. My antioxidant and vitamin levels are very good, and I supplement them around the imaging times to help keep any oxidative damage to a minimum.

Anyone ever use the 23andMe service to look for snips in the genetic encoding of the endocrine chain? It sounds like there are a few mapped issues that it might be worth ruling out, esp cytochrome p450 defects. I am thinking about coughing up the $200 clams to get the analysis done. Anyway, thank you for your comments, will add information to the thread as I get it.


#4

Liver values, taken on 12/15/2016–AST 21 (10-40) ALT 19 (9-46)