T Nation

New Guy Getting Up to Speed


#1

I just learned I have low T (52 yo with a TT of 284) and before I have a chance to provide the full patient history I wanted to ask a question that relates to the potential need to find a new doc. Just today my doc emailed and said he'd be happy to refer me to an endocrinologist given that hCG and AI are outside "his scope," as he says. Reading that others on this board use international pharmacies to procure hCG, I wonder if I could procure an AI that way, as well.

My doc is willing to write a script for injectable T every two weeks and show me how to inject at home. While I think I can educate him about the wisdom of a more frequent dosing schedule and get him to write a script for that, I get the vibe that he's not willing to hear me out on hCG and AI. I don't relish getting referred to an endo or anyone else, frankly. I am presuming it will be an uphill battle with anyone.

So, can I get hooked up internationally and just work on my doc to go with a more frequent schedule as well as track E levels?


KSman is Here
#2

There are 7 stickies to read, one is 'finding a TRT doc'

AI can be obtained domestically as a research chemical if needed. hCG is typically difficult to find and at best may not be always available if you find a domestic source. hCG is not a US federal schedule III drug, but many states have criminalize possession as schedule III. If you obtain from overseas and get a letter from US customs ... do you understand the implications of that?


#3

I usually agree with KS, but not on this one.

hCG is easy to find and if you get it from India or where ever, it's not expensive, either. An A.I. is a necessity and you can get that from overseas or from a research chem company. If you have a script for a certain amount of Test, then how is the doctor supposed to know how often you're injecting? You think he's going to figure out if you're also adding hCG in the mix? Not likely. Finding needles is about as hard as walking into a Walmart.

No doubt your doc will have you injecting with a needle fit for a caulking gun. Go with a 28-30 ga. 5/8" insulin needle.

Follow the protocol in the sticky. Use the blood tests that the doctor orders to get your dosing dialed in (make sure he orders estradiol as well, they usually ignore that). It's not rocket science.


#4

I am on 130 mg of Test Cyp injected weekly and have no need of an AI. Indications of a need for AI are backne, itchy nipples, and water retention.

If you want to have kids, or to keep your balls the size they are, you need hcg, as I understand it. I am only nine weeks into my journey and am suffering from no side effects other than some shrinkage, which I am okay with it. I already have kids and have no interest in having more, so hcg isn't a hassle that I want to deal with by injecting twice weekly to resolve.

Many here want you to be proactive, and that might be a good plan. Being proactive would involve an AI and hcg. A-Dex is an oral AI but hcg is injected. If I were you, I would make sure you have a good provider of TRT and let the blood tests, and how you are feeling, dictate what you take and where you go.


#5

Mythical bro-science: Indications of a need for AI are backne, itchy nipples, and water retention.


#6

Thanks for the replies, gents.

Well, after an email exchange with the practice manager in which I was led to believe that injectable T + hCG + AI is a protocol the new doc has in her arsenal, I saw this new doc today who is pushing BHRT cream and sent me home with a saliva test. Despite having insurance and learning the new doc is in the network of providers, I am being treated like an anti-aging clinic "cash" customer who will be opening up his wallet for the tests and the cream. It wasn't my best day as I didn't realize what the hell was going on until I got home. I'm a firefighter and we had been up much the previous night, so I'm giving myself a pass for not having my thinking cap on during the office visit.

In any case, I've emailed the practice manager stating I'd like the $215 they charged me for a saliva test back. That won't be a problem. What I'm interested in knowing from the folks in this fine forum is why saliva tests and "bio identical" testosterone are not optimum testing and treatment protocols. When I return the saliva test kit, as they'd like, I want to lay all that on them, in addition to the confusion about the doctor being cool with T + hCG + AI and taking my insurance. I'd like to be treated like a patient with legitimate health concerns (fatigue, low libido, ED, etc.) not someone seeking what appears to be the tonics and potions being peddled by the doctor's spa business.

Oh, and I continue to be on the lookout for a good TRT doc in my neck of the woods here in Washington State. Thanks, again. - Rick


#7

Valid KSMan, I regurgitate what I read, and often, that's mythical Bro Science. I'll shut my yap.


#8

Saw the endo my primary doc referred me to. She doesn’t see the need to test for FSH. What can I tell her to change her mind?

She also doesn’t see the efficacy of an AI, though she did refer me to an MD colleague who does. What educating rationale can I share with her to change her mind on this, as well, the stuff in the Estradiol sticky?

I kinda want to convert her because she has some interesting things to say about my Hashimoto’s hypothyroidism and I think I’ll schedule the blood labs with her to see what second opinion she has on my hypo.

Thanks! – Rick


#9

With all of the science and medical issues, therapeutic options etc, the biggest problem in the TRT field is the doctors. There is a ‘finding a TRT doc’ sticky.

Doctors do not need to have or evolve critical thinking or deductive reasoning to practice medicine. They are mostly robotic within their sphere of knowledge and ignorance. Listening to informed patients disturbs them.


#10

First off, thanks KSMan for your prodigious and tireless work on behalf of so many.

Ah, yes, the stickies… I’ve spent time with them all but I’m not recalling the justification for FSH testing. I really want to lay it out to the above mentioned endo because I’m seeing the need to push back, even against doctors you may not go with. I may see the endo for my thyroid issues and while I’m there I want to give her the primer on FSH and AI, her sticking points.

I did make an appointment with the MD that uses AI’s in his protocol that the endo suggested, but I was perturbed that in addition to taking my insurance he requires a $240 annual fee just to be seen. I’ll share what comes of the appointment on the 24th.

Cheers!
Rick


#11

You may not need an AI, but you will have shrinkage without HCG, and infertility if that is an issue for you…

You need to have your initial bloodwork done according to the stickies so you know your baseline numbers. I inject twice weekly, 100mg wk and don’t need an AI. TT 850 and my E2 is 20 with no AI. Below the optimum number of 22 (which is not necessarily optimum for every man)

Before TRT my TT was 250 and E2 was like 7, and because of this my FT level was still on the low side of normal. (So I am not estrogen dominant). My E2 plays nicely with my TT levels.


#12

Thanks, JDeck. Yeah, I’m operating with the understanding that I may not need an AI but I figure I should only deal with doctors who are square with the expanded protocol should I need an AI.


#13

Finally have some labs to report:

TT 274 ng/dL Range: 291-739
Free T 7.5 pg/mL : 4.3 - 30.4
LH 2.6 mIU/mL : 1.7 - 8.6
FSH 2.7 mIU/mL : 1.4 - 11.2
E2 15 pg/mL : 10 - 42
T3 2.8 pg/mL : 2.3 - 4.2
T4 1.3 ng/dL : 0.7 - 1.5
TSH 4.06 uIU/mL : 0.45 - 5.10
rT3 41. 8 ng/dL : 9.0 - 27.0
DHEA-SO4 184.0 ug/dL : 58 - 257
Dihydrotestosterone 20.0 ng/dL : 16 - 79
Thyroid Peroxidase
antibodies >900 IU/mL : 0.0 - 9.0
B12 533 pg/mL : 247- 911
Folate >24.0 ng/mL : 5.4 - 24.0
Ferritin 60 ng/mL : 11 - 450

I also had a saliva test to measure Cortisol levels and I was normal for the 6am, 4pm and 10pm samples and depressed for the 11am sample ( result of 4 with a range of 5 - 10 nM).

I’m a 52 year old firefighter of 22 years and have had a shitty quality of life the past couple years. Chronic fatigue, brain fog, shitty memory, difficulty focusing, depression and anxiety that have trended toward apathy, ED, lowered libido, cold intolerance and recent weight gain. Back in 2001 I was diagnosed with E.D.S. - Excessive Daytime Sleepiness, which is a form of narcolepsy. Prior to the E.D.S. diagnosis, a night time sleep study revealed I suffered mild sleep apnea. A tonsillectomy was performed and my sleep apnea went away. Noticing that my sleep quality had improved but that my fatigue was largely present, I had another sleep study (a daytime sleep study) that revealed the E.D.S.

There is no cure, at present, for narcolepsy, and it is treated with stimulant drugs. For about 4 years I took 200mg of the central nervous system stimulant Provigil. As I read the book “Adrenal Fatigue,” I wonder if the Provigil use didn’t start me on the path which saw me develop seasonal allergies (grass, dust, mold) which at times were virtually debilitating with fatigue, as well as see my testosterone levels tank. I went off Provigil when I saw how anxious it had made me and saw my personal life fraying.

I also have Hashimoto’s hypothyroidism. Back in about '95 I developed a goiter and I’ve been on .2mg of Levothyroxine since. I guess I could be considered a ‘downwinder’ in that I live in Washington state and attended college not far from the Hanford Nuclear Reservation. For years I’ve been taking a multi-vitamin that has an iodine supplement in it and switched back to iodized salt after reading the wisdom of KSMan. I just purchased a digital thermometer and will be tracking my body temperature.

As a firefighter I am constantly exposed to bad shit, from diesel exhaust to who knows what that is produced when stuff burns. Even if I have 100% respiratory protection, which I do not, recent studies indicate that any number of compounds, including chemicals used to make stuff fire retardant, can be absorbed through the skin. We’ve had a shocking number of recent cancer diagnoses in the department and many of them are regarded as “presumptive diseases,” meaning that it is presumed that occupational exposures have caused them.

Firefighting is highly hazardous to one’s health, I’ve come to find. Between the hazardous exposures, the mental/emotional stresses, the physical stresses of waking at all hours of the night, the constant ‘on edge’ physiological state and then taking a CNS drug for 4 years and I think I really did a number to myself. (I should say that I’ve been off the Provigil for 3 years now).

What else? Oh, I developed tinnitus about 2 weeks ago. Fuck, I’m falling apart.

My doctor said it might be worth our time to reconsider the treatment for my hypothyroidism before introducing T, but he thinks that dropping the Levothyroxine (which is a T4 therapy, if I have that right) and monkeying with T3 could be a delicate balancing act that could take some time to get right and could move me from being hypo- to hyperthyroidism. He thinks that there is a T element that could help resolve my elevated rT3 situation, and he thinks we would eventually resort to TRT anyway.

KSMan, I’ve laid a lot out there. I hope you can respond because I’m inclined to pull the plug on injections sooner than later and I told my doctor I’d wait to make a decision until I heard your opinion. He’s curious to hear what you have to say, too.

Thanks for your time!

Rick


#14

I also wanted to add that I have thinning of the outer third of my eye brows. In addition, I took my morning temp (arm pit – I re-read the sticky and note that an oral temp is recommended) and for what it’s worth it was 97.2. I’ll do a week’s worth of temp taking to make it meaningful.

And, yes, KSMan, I’m gonna blame the brain fog for my slow learning ;-).


#15

KSMan, I’m dying to know what your take on my labs is.


#16

Doc is right. Because of the adrenal fatigue related high rT3, more T4 simply makes more rT3. So you need to read Wilson’s book and do T3 only. Use body temps as dosing guide! TSH should probably go very low.

Have seen problems in the [fire] house when guys wear fire pants continuously while on duty. The fire retardants are toxic in that context.

You could have bromines in your system from fire retardants. High dose iodine will displace bromines which you then piss out. While that happens, you feel worse for a while.

Have you read the thyroid basics sticky?

Body temps soon? Ping me at the KSman is here thread.

Get on TRT asap, but your thyroid state/meds need to be right. You can’t do transdermals, try to get self-injecting and follow the protocol.
-------------------------------------^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^

Take high potency B-complex multi-vits with iodine, selenium and other trace elements
fish oil, flax oil/meal, nuts, lots of vitamin C, natural source vit-E

Adult onset allergies are not uncommon and could easily have thyroid and other hormones as factors.

Maybe better sleep at night would help. Try TIME-RELEASE 5-6mg melatonin. Might be an issue waking with the bell.

Labs:
AM cortisol
IGF-1
occult blood test [poop smear]
CBC w HTC


#17

[quote]KSman wrote:

Get on TRT asap, but your thyroid state/meds need to be right.
[/quote]

KSMan, I’m not following. Are you saying start TRT now and concurrently ditch the T4 (Levothyroxine) therapy for T3 therapy? Or are you saying to change to T3 therapy and get the thyroid state right before getting on TRT?

You ask for additional labs, including ‘Cortisol AM.’ I thought I submitted to such a test when I collected saliva samples at five points during the day and got these results:

06:00-08:00 AM Result - 24 (normal) Range: 13-24 nM
11:00-1:00 PM Result - 4 (depressed) Range: 5-10 nM
04:00-05:00 PM Result - 4 (normal) Range: 3-8 nM
10:00-Midnight Result - 3 (normal) Range: 1-4 nM
Total Cortisol Output: 35 / 22-46 nM

My body temp was 96.4 this morning. I took a couple temps throughout the day and I’m not getting into the 97 range.

As I’ve said, my doctor is keen to learn your observations and I will be sharing them with him. We are going to go with injections, and my question is this: As I have informed him of the efficacy of a more frequent dosing schedule, what would be a dosing schedule I should start with, twice a week? Also, we add an AI as necessary as determined by a six week recheck, do I have that right.

Finally, I have read the Thyroid stick, a few times, actually, but I appreciate why you regularly make the point.

Thanks, again, for your valuable help.

Rick


#18

You need TRT, but pointing out that sometimes TRT with low thyroid function can make guys feel worse. So replace T4 with T3 as soon as possible. You can use body temperature as a dosing guide so you are not stuck with lab and doctor cycles. Need to get doc on board with you finding your own dose.

Cortisol: Do you feel that your energy levels were a mess for 11:00-1:00 PM Result - 4 (depressed) Range: 5-10 nM ?

You may need AI, 15 is not far from 22 and your T levels are so low. If you suspect that E2 is getting to be a problem, don’t wait 6 weeks. You can’t calculate a dose until you have had one lab while on anastrozole and hopefully at that time its a reportable level [not <10].

Those body temps are a mess. How fast will doc move on T3. Can he call that Rx to the pharmacy quickly?


#19

KSMan, I put in a call to my doc about your recommendation to switch to T3 therapy. Actually, it was an email and I described the dosing according to body temp approach as you advise. Two days ago he gave me a handout that speaks to using body temp as a way to arrive at the proper dose (pulse was another means to gauge things) so maybe getting him on board won’t be a tough slog.

As to my cortisol levels and feeling energized or not, I typically drag ass about the time my cortisol becomes depressed but I’ve always viewed this as related to my Excessive Daytime Sleepiness. For as long as I can remember, my most energized part of the day, and, of course, this is relative, picks up around mid-afternoon and into the evening. So the cortisol numbers are curious because even though I show within normal range later in the day everyone’s cortisol diminishes yet I feel a little more with it at, say, 8pm than I do at 8am.

Well, my T prescription is waiting to be picked up tomorrow morning, and I think I communicated to the doc my desire to go with a twice per week schedule. That’s your recommendation, right? His nurse is going to instruct me in how to administer my own shots. He wants to do labs in six weeks.

Rick


#20

If you get too much thyroid medication, your heart will race and you will feel agitated. So those are signs of too much. You do not want to forget that you took a dose and then take it a second time.

Nurse: Might be showing you how to do deep muscle injections with large needles. Please see the protocol for injections sticky for info re injecting with insulin syringes and doing SC injections [or IM].

I don’t know the half life of T3 medication. It will be shorter than T4 as T4 is a reservoir for T4–>T3 production. You will probably be taking T4 to very low levels. So there might be some implications for missed doses and level changes while asleep.

There might be some slow-release T3 products.

See https://www.google.com/search?q=t3+halflife

Interesting how fast things are moving!