T Nation

Started TRT 13 Days Ago. Questions About Protocol and Primary Diagnosis


#1

I have been reading this forum for a while now and finally joined to make this post now that I have started TRT.

I am a 33 yo IT professional with two young children (3 year old son and 3 month old baby daughter). The last few years I have struggled with (what I now think to be) low testosterone symptoms. Low energy. No drive. Nonexistent libido. Fuzzy logic and inability to make important decisions. Weight gain. Declining gym performance. All of it. When I needed it most, my sense of manhood quite literally disappeared. My relationship with my fiance is hanging on by a thread. I recently lost my job. Worst of all, I can’t keep up with my kids, and instead of enjoying them as I should be, caring for them has become an energy zapping ordeal that I often find myself dreading. Hard to admit this, but it’s true. Even the most enjoyable parts of life can become a chore when your energy level is in the toilet.

I am 6’-0" and weigh about 260 lbs. Up until my late 20’s, I weighed between 210 - 220, but then abruptly put on 40+ lbs that I have lost and gained back several times, never able to keep it off long. I workout daily. Weights 3 - 4 days/wk and light cardio on off days. Right around when I gained the weight, I lost my libido and my sense of self confidence.

I struggled for the last few years and about 7 weeks ago, my PCP drew labs to look at my thyroid. I asked that he also check my total testosterone while he was at it. My tT came out to be 231 (ref range 250 - 827). My PCP was not able to give any recommendation on what to do but gave me a referral to a local endocrinologist. I had to wait 6+ weeks to see the endo, so I found an anti-aging doc and told him about my recent blood test. He recommended that I get further blood work (see below) and suggested I start clomid @ 25 mg / day, which he promptly prescribed. I started the clomiphene the next day (June 22) @ the recommended 25 mg dose. After a bit of research I decided to reduce my clomid dose to 12.5 mg EOD (so 1/4 the prescription amt). After about 4 - 5 days or so I began to have an intense headache, which progressed to get worse each day. I had not changed anything else and the headaches were not going away so I was pretty sure that clomid was the cause. I halted the clomiphene and the headaches went away within 24 hours or so. In all I believe I took about 75 - 100 mg of clomid, in total.

These were the labs, pre-clomid:

June 2:

  • Total T: 231 (250 - 827)
  • Free Thyroxine (t4): 1.0 (0.8 - 1.8)
  • Free t3: 3.0 (2.3 - 4.2)
  • b12: 355 (200 - 1100)
  • Folate: 16.3 (normal >5.0)
  • TSH w/REFLEX to FT4: 1.15 (0.4 - 4.5)

June 21 (day before starting clomid):

  • FSH: 6.3 (1.6 - 8.0)
    * LH: 4.1 (1.5 - 9.3)
  • Total T: 387 (250 - 1100)
  • Free Testosterone: 49.4 (46.0 - 224.0)
  • Bioavailable T: 108 (110.0 - 575.0)
  • SHBG: 33 (10 - 55)
  • Albumin: 4.8 (3.6 - 5.1)
  • SHBG (again, same day, not sure why they did this): 35 (10 - 50)

I was not able to have a follow up appointment with the anti-aging doc to discuss the clomid headaches or to discuss the new labs from 6/21 and moved from CA to Oregon about two weeks ago. I found a local trt clinic in the Portland area and had my first appointment on 7/14 and had more blood work done there:

7/14 (2 weeks post clomid) - LabCorp:

  • TSH: .884 (.45 - 4.50)
  • Free t4: 1.2 ng/dl (.82 - 1.77)
  • LH: 9.4 mIU/mL (1.7 - 8.6)
  • Prolactin: 4.2 ng/mL (4.0 - 15.2)
  • hematocrit: 46.1% (37.5 - 51.0)
  • PSA: .2 ng/mL (0.0 - 4.0)
  • Testosterone, serum: 346 ng/dL (348 - 1197)
  • SHBG: 39.3 (16.5 - 55.9)
  • Estradiol: 27.7 pg/mL (7.6 - 42.6)
  • Free T*: 5.86 ng/dL (9 - 29)
  • glucose, serum: 84 mg.dL (65 - 99)
  • AST: 20 (0 - 40)
  • ALT: 26 (0 - 44)

*this was not in the lab report, but Dr. wrote it in

When I reviewed the most recent labs (7/14) with my new doctor, based on my low testosterone level coupled with high LH (9.4), he determined that I had Primary Hypogonadism, which I now understand to mean that the problem is with my testes and not my HPTA axis. He also suggested that I was smart to have stopped the clomid when I did and that the headaches may have been related to the clomiphene pushing already high LH levels even higher. I asked whether the high LH from the 7/14 labs could have been effected by the clomid, which I had stopped taking two weeks beforehand, and he said that it was highly unlikely that it could have boosted LH that high considering the short time I took it (about one week total) and the low total dosage (75 mg all together). From what I can tell, seems like he is right that clomid would not have such a drastic effect over such a short period of time, especially considering labs were taken 2 weeks after stopping. However, it looks like my labs from 6/21, 3 weeks prior, showed LH was at 4.1.

Until the doctor told me about my high LH levels, based on everything I had read, I thought I was likely to be secondary. I had a few head injuries from motorcycle and car accidents. I also used painkillers daily for the past few years. So I was not surprised to learn I was hypogonadal, but I was not expecting the Primary diagnosis (any thoughts on this would be appreciated). Is it normal for LH to fluctuate to such a degree (more than doubled in 3 weeks from 4.1 to 9.4)? Could clomid from 2 weeks prior still be effecting LH values? The new doctor here in Oregon suggested that I start TRT immediately, which I began on 7/18.

The doctor prescribed:

  • Testosterone Cypionate @180 mg/week (90 mg e3.5) [+ 300 mg injection 7/18, then begin @180/wk yesterday 7/25- is this normal??)
  • Anastrazole @ 1.25 mg 24 hours after each T injection, so 2.5 mg / week (this seems like a lot??)
  • HCG @ 500 mg 24 hours prior to each T injection, so 1000 mg / week

At this point, my main questions/concerns are:

  • Am I actually primary hypogonadal or is the clomid responsible for LH of 9.4?
  • Is 180 mg of Test C/week broken up into two doses e 3.5 days a good dose for me to start at?
  • Is 2.5 mg Anastrazole too much for this protocol? How about the timing of 24 hours post T injection? should I be taking Anastrazole yet or should I wait until I see how the Test alone effects my e2 before?
  • HCG at 1000 mg/week a reasonable dose? Should I even be taking HCG if I do not plan on having any more kids for at least a year or two from now? (Doctors assistant I met with yesterday said taking HCG would protect me from crashing T if I ever decided to stop TRT - is she right about this? Sounds too good to be true.)
  • Does this doctor seem like he knows his shit or should I look elsewhere? My next appointment is for labs in 8 weeks. (I am looking into switching to Defy Medical. Any recommendation for docs in the Portland, OR area would be appreciated, too)
  • When might I expect to begin noticing effects of TRT? Any effects that come on first usually?

I posted to a few other forums and was advised to decrease the AI and was told that 180 mg Test C was a hefty starting dose.

Thanks in advance, any input is appreciated. Lots to learn!


#2

Anastrozole should be introduced at 1mg for every 100mg T ester. Dose is too high.

T dose may have been scaled to body weight. We often see guys not getting balanced on high doses. Large doses seem to become fashionable in last two years.

250iu hCG SC EOD is all that you need. Higher drives up costs. 1000mg/week is not bad, but better in EOD dosing from a half-life perspective.

Thyroid function has a big influence on fat gain. Please discuss your history of using iodized salt and post oral body temperatures AM and mid-afternoon. Your kids need iodine as well.

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.

KSman is simply a regular member on this site. Nothing more other than highly active.

I can be a bit abrupt in my replies and recommendations. I have a lot of ground to cover as this forum has become much more active in the last two years. I can’t follow threads that go deep over time. You need to respond to all of my points and requests as soon as possible before you fall off of my radar. The worse problems are guys who ignore issues re thyroid, body temperatures, history of iodized salt. Please do not piss people off saying that lab results are normal, we need lab number and ranges.

The value that you get out of this process and forum depends on your effort and performance. The bulk of your learning is reading/studying the suggested stickies.


#3

Thank you for your reply. How you have time to reply to all these posts is beyond me. How many guys would be leading miserable lives following some half baked protocol from their inept doctors if not for you?

I will adjust Anastrozole to 1.0 mg/100 mg Test and will stick to EOD for HCG @ 250 iu.

T dose may have been scaled to body weight. We often see guys not getting balanced on high doses. Large doses seem to become fashionable in last two years.

to clarify, are you saying that this is too much or that it’s ok for someone at my weight (260)? If too much, what would be a better dosage?

Thyroid function has a big influence on fat gain. Please discuss your history of using iodized salt and post oral body temperatures AM and mid-afternoon. Your kids need iodine as well.

I do not use iodized salt and never did as a child as far as I can remember. Just kosher or sea salt mostly. The doctor currently administering my TRT palpated my thyroid during my initial consult and said something about my thyroid feeling slightly enlarged (not quite sure what that means or what he said exactly). He recommended that I take a daily iodine supplement @ 6.25 mg (2.5 as molecular iodine, 2.5 as sodium iodide, and 1.25 as potassium iodide - not sure if this makes any difference). Though my labs seem to indicate thyroid is healthy (though I do not have rT3 values, and I realize that ‘normal’ or in range does not mean healthy), my temperature is often low. I do not check it regularly. I will start taking it each morning and update here as I do.


#4

@KSman any thoughts on test dosage or any of the questions from the original post (i.e. whether a primary hypogonadism diagnosis makes sense or is clomid could have caused LH to double). Thanks again.


#5

If you are primary, LH/FSH would be high and T low. Clomid may have restored that functionality but then the testes did not do anything useful.

This is the first time I have had a report of a doctor recommending iodine replenishment [IR]. But the advice if flawed. You need to be getting 200mcg selenium and would be better to be on that 7-10 days prior to IR. Selenium is key to the enzymes that clean up free radicals produced during T4 production that can damage thyroid cells. Then immune system has to clean up the mess and then the immune system can start to miscode normal thyroid tissue as foreign and you have a thyroid autoimmune disease - Hashimoto’s.

Find a high potency B-complex multi-vit that lists lots of trace elements including 150mcg iodine and 200mcg selenium. Many/most enzymes have particular metal atoms as their catalytic reaction sites.

Based on weight your T dose may be OK. Be watchful of E2 levels and high HTC and RBC.


#6

If you are primary, LH/FSH would be high and T low. Clomid may have restored that functionality but then the testes did not do anything useful.

Ok thank you. I ask because I believe my doctor made the Primary Hypogonadism diagnosis based on post-clomiphene LH value (9.4 on 7/14), and did not seem to be taking the pre clomiphene LH value from June (4.1 on 6/21) into consideration, so I am wondering a) if LH of 4.1 is high enough to be considered Primary Hypogonadism (with T being 3/87) and b) if clomid is even capable of raising LH so drastically (4.1 to 9.4) in such a short period of time and such a low dose (if it was the clomid, and my testes worked well, then I would likely have a corresponding increase in T as well, I would think?).

This doctor seems a bit spacey and I want to be sure that his diagnosis was not made in haste - I know if I am indeed primary, there is no other option besides TRT, whereas if I am not, then I may still have other options.

This is the first time I have had a report of a doctor recommending iodine replenishment [IR]. But the advice if flawed. You need to be getting 200mcg selenium and would be better to be on that 7-10 days prior to IR. Selenium is key to the enzymes that clean up free radicals produced during T4 production that can damage thyroid cells. Then immune system has to clean up the mess and then the immune system can start to miscode normal thyroid tissue as foreign and you have a thyroid autoimmune disease - Hashimoto’s.

Ok I got myself some selenium and have taken 200 mcg last two days. Will continue for 8 more days and then begin IR protocol spelled out in thyroid basics sticky. Also started tracking my temps upon rising and in the afternoon and will post them after a few days.

Find a high potency B-complex multi-vit that lists lots of trace elements including 150mcg iodine and 200mcg selenium. Many/most enzymes have particular metal atoms as their catalytic reaction sites.

Any particular brand or product you recommend? Do I take a b-complex multivite containing both 200 mcg selenium and 150 mcg iodine alongside the selenium I started taking or should I wait until I begin the IR?

Based on weight your T dose may be OK. Be watchful of E2 levels and high HTC and RBC.

For this dose would it make more sense to take 50 mg EOD instead of 90 e3.5 in order to limit estrogen aromatization? (I am taking 1 mg anastrozole for every 100 mg Test, so about 1.8 mg weely). I don’t have labs with my doctor for another five weeks or so - is that sufficient or should I look into getting labs drawn sooner to check e2? RE: HTC and RBC, I am planning to donate blood next week.


#7

I have been meaning to get this done

age: 33

height: 6’

waist: 38

weight: 260

describe body and facial hair: thin to average. Used to be thicker in the beard and thicker chest hair when in early twenties.

describe where you carry fat and how changed: I have always carried a bit of extra weight. From 17 to about 27 years old I averaged about 210 and was relatively athletic, but still carried extra weight in my lower back and stomach mostly. Now I am 260 and most extra fat is now carried on stomach, chest, lower back/hips, and upper legs.

**health conditions, symptoms [history]:**no health conditions that I am aware of.

Rx and OTC drugs, any hair loss drugs or prostate drugs ever: no RX currently, sometimes take antacids like omeprazole and cimetidine, advil for headaches every now and then. When I was 19 I began losing my hair and took propecia/finasteride for about a month and then stopped. Do not remember the dose or for exactly how long I took it. Took accutane when I was 16 for about two months, possibly less. Had knee surgery 7 years ago and was on, and addicted to, pain meds for last 5 years.

lab results with ranges:

6/2/17:

  • Total T: 231 (250 - 827)
  • Free Thyroxine (t4): 1.0 (0.8 - 1.8)
  • Free t3: 3.0 (2.3 - 4.2)
  • b12: 355 (200 - 1100)
  • Folate: 16.3 (normal >5.0)
  • TSH w/REFLEX to FT4: 1.15 (0.4 - 4.5)

June 21:

  • FSH: 6.3 (1.6 - 8.0)
  • LH: 4.1 (1.5 - 9.3)
  • Total T: 387 (250 - 1100)
  • Free Testosterone: 49.4 (46.0 - 224.0)
  • Bioavailable T: 108 (110.0 - 575.0)
  • SHBG: 33 (10 - 55)
  • Albumin: 4.8 (3.6 - 5.1)
  • SHBG (again, same day, not sure why they did this): 35 (10 - 50)

7/14/17 - LabCorp:

  • TSH: .884 (.45 - 4.50)
  • Free t4: 1.2 ng/dl (.82 - 1.77)
  • LH: 9.4 mIU/mL (1.7 - 8.6)
  • Prolactin: 4.2 ng/mL (4.0 - 15.2)
  • hematocrit: 46.1% (37.5 - 51.0)
  • PSA: .2 ng/mL (0.0 - 4.0)
  • Testosterone, serum: 346 ng/dL (348 - 1197)
  • SHBG: 39.3 (16.5 - 55.9)
  • Estradiol: 27.7 pg/mL (7.6 - 42.6)
  • Free T*: 5.86 ng/dL (9 - 29)
  • glucose, serum: 84 mg.dL (65 - 99)
  • AST: 20 (0 - 40)
  • ALT: 26 (0 - 44)

describe diet [some create substantial damage with starvation diets]: For the most part, aside from eating out or with friends a few times a week, I eat whole foods like meat, fish/shellfish, vegetables, fruit, cheese, milk, rice/potatoes. Used to be strict low carb paleo and still adhere to much of it, but am not as strict as I once was. I eat the highest quality protein (grassfed, wild caught, etc.) and vegetables (local from farmer’s mkt) I can find. I am a cook so that helps in knowing where to get the good shit. Also tried Dr. Lawrence Wilson’s cooked vegetable diet for a period earlier this year with good results.

describe training [some ruin there hormones by over training]: lift weights 3 times per week, mostly kettlebells and body weight stuff right now. Cardio 3 days per week for 30 min to an hour. I have been working out consistently for 3 or so months now, and inconsistently before then.

testes ache, ever, with a fever?: No.

how have morning wood and nocturnal erections changed I just began having morning wood about a week ago now. Not as strong as when I was younger but definitely there again.


#8

@KSman one thing I forgot to mention in my post earlier. Is it necessary to take additional Anastrozole to counter HCG’s increase in E2? Right now I am taking 250 iu EOD. You have said a good place to start with Anastrozole is 1 mg per 100 mg of Test (so for my 180 mg T dose I take 1.8 mg), not sure if addition of HCG needs to be taken into acct also.


#9

@KSman 4 days into selenium supplementation, will begin taking iodine after 7.

I am considering a slight change to my protocol from test @ 90 mg e3.5 (180 mg weekly), as prescribed, along with 1.8 mg ANASTRAZOLE weekly, and 250 iu hcg eod. To make things a bit simpler and maybe better from aromatization standpoint, I am thinking of going with 50 mg Test eod (175 mg weekly), taken along with the 250 iu hcg and .5 mg ANASTRAZOLE. From what I have read this should be the same or better than e3.5, and it would be much simpler to just do everything at once every other day.

Question about anti estrogen supplements. I have DIM and calcium d glucarate left over from when I was using Clomid breifly. Would these be at all useful for me? If so how much is a good dose or should I wait until my labs coming up in 5 weeks from now? Stuff wasn’t cheap and bottles are full, hoping to use them if appropriate.

I have begun to track my temps to eval thyroid status using a cheap 10 dollar digital Vicks thermometer - is this going to be accurate enough or should I look for another?


#10

An update for @KSman and anyone who might be following along. Day 20 of TRT.

  • Libido seems to be up. This is the first change I have noticed since starting TRT, aside from good morning wood for last week or so - every morning, and seems to be there any time I wake up during the night/early morning. My girlfriend and I have sex a couple times a month on a good month. We have had great sex last two days in a row. Erection is stronger and no issues maintaining (despite lasting quite a bit longer than I would have expected, both times).
  • No noticeable gains in strength, although working out seems to be a slightly more enjoyable than usual - the pain of lifting hard almost seems to feel kind of good. I do also notice that I seem to be getting a better pump off less reps than I’d usually get.
  • Energy seems to be getting slightly better, though I won’t rule out placebo effec (hard to rule out placebo for any of the above improvement, with the exception of libido. The feeling of strong libido, which I’d all but forgotten over the last few years, is unmistakable and likely no coincidence.).

#11

@KSman Please check out my last few posts if//when you get a chance. Thank you!


#12

It’s pretty easy for threads to get lost in the shuffle.

You can ping KSman to your thread here: KSman is Here


#13

thank you i’ll try that


#14

The hCG may not have any significant affect on E2.

You are primary.

You do not want to take the two sources of selenium. The multi-vits are part of your maintenance dose and a zero cost for selenium.

You had not been using iodized salt and for how long?
Body temps?

Will not be here next week…


#15

@KSman

What is rationale for this? I am not doubting you but I am struggling to understand. I have seen plenty of people with secondary diagnoses who have LH of around 4 (and that’s what mine was prior to clomid, 4.1, from June 21 labs, below). Is it because my FSH was 6.3? Appreciate your patience here - I couldn’t get a straight answer on this from my doc.

Never that I can remember. We may have used it when I was a child but not that I recall.

Will post up body temps.


#16

recent temps (a.m. upon waking; pm between 1 pm and 3 pm):

8/12: (97.8; 98.6)
8/13: (97.9; 98.5)
8/14: (97.8; 98.5)
8/15: (97.8; 98.6)
8/16: (97.7; 98.5)
8/17: (97.8; 98.4)
8/18: (98.0; 98.6)

Unfortunately I do not have temps pre-IR, so I am not sure of effect of below regimen, if any.

8/3 - 200 mcg selenium
8/4 - 200 mcg selenium
8/5 - 200 mcg selenium
8/6 - 200 mcg selenium
8/7 200 mcg selenium
8/8 - 200 mcg selenium
8/9 - 200 mcg selenium
8/10 - 12.5 mg iodine
8/11 - 25 mg iodine; 200 mcg selenium
8/12 - 25 mg iodine; 200 mcg selenium
8/13 - 25 mg iodine
8/14 - 25 mg iodine; 200 mcg selenium
8/15 - 25 mg iodine; 200 mcg selenium
8/16 - 25 mg iodine; 200 mcg selenium
8/17 - forgot
8/18 - 25 mg iodine, 200 mcg selenium


#17

I’m sure @KSman will chime in but those temps look right on the money.


#18

@cdmac24 Thanks for the feedback - wasn’t sure if anyone was seeing my posts anymore. So it would appear that my thyroid is okay considering low tsh, sufficient t3/t4, and temps are good. I sort of assumed that my thyroid was not optimal considering my being prone to gain weight quite easily.


#19

Yes, body temps are good.
Odd that your body temps are this good having avoided iodized salt. But a great outcome.

Primary because FSH is where it is with very low FT and Bio-T. SHBG+T is lifting TT a bit.

Some with primary can have much higher LH/FSH, but that is not the sole criteria. Often we see mixed primary+secondary.

We used to get a few new guys a week here. Now its a flood. I can’t do comprehensive case following any more. I have almost 1000 posting notices in my email since end of April.


#20

Thank you @KSman I appreciate your help getting dialed in with my TRT protocol. I know you get a lot of guys coming through here who need straightening out. From what I’ve learned here from you and others, I will hopefully have improved my chances of seeing success with my treatment. About 1.5 months into treatment and so far it seems, from symptoms at least, that my e2 is in control from 1 mg Anastrozole to every 100 mg Test. I’ll continue to post here so others can hopefully learn from my experience as I’ve learned from the posts of others experiences. If I run into any hiccups or have any questions, I’ll be happy to know I can find solid info or advice here.