T Nation

Transition from HCG Monotherapy w/ Daily Arimidex to KSMAN’s Suggested Ideal TRT Protocol?


#1

Greetings
Thanks to all of you, and KSMAN specifically, for the unbelievable work and information you share on the Forum. It is an amazing and very helpful resource.
After a long period of struggling to square away my hormonal profile with low Free T, high SHBG, and often wavering and falling Total T, I began HCG monotherapy approximately 6 months ago. I did so due to the importance of persevering fertility for an additional stretch before moving to TRT.

My beginning labs:
Total testosterone - 682 Testost 280-800 ng dl
SHGB - 86 (SHBG 14-48 nmol L)
Free T - 71 (calcFT 60-185 pg mL)
Estradiol 15 (Estradl 8-45 pg mL)

That was the final test from a three year tracking period that at times had Total T as low as half of what is above Free T below low normal and consistently high SHBG. Although my body was producing enough total T with exercise and diet, I felt truly horrible because it appeared that SHBG was binding it all up and making it unavailable in my body. There was very little Free T left and I felt truly horrible with Free T frequently falling below low normal ranges.
After beginning HCG my total T increased, as did my Free T, and I felt a lot better. Over the last several months, however, my estradiol levels completely ran away from me. Doc initially prescribed Arimidex at 1MG 3X per week with HCG injections. This has now climbed to a 1MG dose of Arimidex daily. Throughout treatment Estradiol has continued to climb, as has total testosterone, but we are getting very little benefit on the Free T front and, whereas fertility is no longer a concern, we are going to transition to something very similar to KSMAN’s ideal protocol. What I am concerned about is how to manage the transition. My estradiol levels have climbed very high and I am concerned that KSMAN’s protocol is for someone starting “fresh” and not for someone coming off monotherapy with such high estradiol and such a high dose of Arimidex.

My current dosing:
1200 IU HCG 3X week
1MG Arimidex daily

My most recent labs:
Total TESTOSTERONE 1321 H 375-1000 (ng/dl)
ESTRADIOL 109.6 H 20.0-75.0 (pg/ml)
TESTOSTERONE, FREE 1.70 0.87-5.47 (ng/dL)
SHBG 82.1 H 20.0-60.0 (nmol/L)

It appears that my body is aromatizing HCG far too rapidly, the daily Arimidex isn’t doing a thing to offset it (as now understand it is not likely to do) and, with things having changed on the fertility front, it seems to be a no brainer now to transition to TRT and KSMAN’s protocol.
I should add, however, that the HCG has doubled my Free T and, despite the fact that it clearly is not ideal and isn’t really working given the sky high estradiol, I have felt a lot better during these 6 months.

My concern is the transition. My doctor will prescribe KSMAN’s protocol, but what do I do about the starting point with estradiol so high and my current Arimidex dose so high?
Should I start with T 100 MG divided 2x week, with HCG 400 IU 2X week w/ T shot, and then taper down Arimidex to ideal dose? Or should I just stop the daily Arimidex and begin splitting a 1MG tablet to dose with the T and HCG on injection days?

I would love to see my Estradiol start to fall over the first six weeks on T such that I could taper this Arimidex dose down and dial it in. I am concerned that If I drop the Arimidex down too rapidly I won’t give my body a chance to actually respond to the T because my estradiol is now so high.

Again, in line with KSMAN’s protocol, I will begin:
100 MG Test Cyp (divided into 2 50 MG doses per week)
500 IU HCG (2X per week taken with T shot)

Any thoughts on where I should go with this Arimidex dose to start? I am presently at 1MG a day while on HCG and Estradiol is off the charts.

Thank you so much for any thoughts on managing the transition. KSMAN, if you are available and able to chime I would really appreciate it as well. Thank you!


#2

HCG dose too high creating too much T->E2 inside the testes where arimidex can’t work.

I would start by cutting the HCG dose to 250 IU EOD, Arimidex 0.5 mg/week divided in EOD and see how it goes.

Hopefully SHBG will decrease once E2 will go down.


#3

Thanks and I agree.

With splitting the 100MG T into two weekly 50MG doses at 3.5 days I am trying to line up HCG for 2X week as well instead of EOD so I can inject all at once.

Agreed HGH way too high now and driving estrogen way too high at current dose which is why we are transitioning.

Biggest concern really is the transition from 1MG daily Arimadex to something more in line with KSMAN’s protocol while estrogen is so high from the HGH monotherapy. Any thoughts on that would be much appreciated.

Thanks!


#4

T aromatizes, hCG does not.

Thanks for this “war story”!

hCG dose is way to high and from what we expect this is leading to high T–>E2 inside the testes from very high T inside the testes and because anastrozole is a T competitive drugs we do not expect anastrozole to be able to control T–>E2 inside the testes. So everything is as I would have expected including a doctor understanding none of this and increasing anastrozole dose and not understanding the lack of response.

Your FT=1.7 is inadequate and we know that TT is misleading.

SHBG is supported high by high E2 and FT/Bio-T is not high enough to point it down slope.

Suggest 150mg T per week hoping for some FT downward pressure on SHBG. Stop hCG for a week and resume at 300mg EOD. We only need enough hCG to support testes from shrinking and are not trying to make testicular T, as injections do that. Stop Anastrozole for 1 week as well. You can start T then add AI and hCG one week later. These delays are working on current high levels and half-life considerations.

I hope that your doc finds this a learning experience. Intratesticular T levels ITT can be up to 80 times higher than serum levels. With high hCG doses or high LH from high SERM doses, your ITT could be 150 times higher than serum.

I think that you will feel better. Suggest subq T, #29 1/2" 0.5ml insulin syringes and doc can learn by that too.

SHBG is made in the liver in increasing amounts driven by estrogens and estrogen dominance [low FT] to scavenge sex hormones. SHBG+T is not bio-available. SHBG+t -/-> E2, only FT–>E2. As FT is low, FT–>E2 must be low. When E2 is high we suspect impaired liver E2 clearance rates. And we also should be looking at a possible liver condition prompting high SHBG levels, although not seen very often here.

Please note that meds might be a factor.


#5

KSman:

Thanks for the really insightful thoughts and response. Truly invaluable insight and feedback. I appreciate it and thanks also for the link on SHBG - certainly a riddle to keep on trying to solve as I treat its symptoms.

Doc wants to start at 100MG T per week split into two 50MG doses to see where it goes. My sense is in line with yours that it will not be enough to navigate around the high SHBG, but it’s where I’m starting until the first 6 week panel comes back and then work up from there if necessary.

So, after giving my body a week off of the AI and HCG, and beginning the T, the normal protocol will look like:

Monday AM/Thursday PM

50 MG T
1 MG Anastrozole

M/W/F

300 IU HCG

Thoughts on the beginning dose of AI being 1MG 2X week w/T given that current E2 levels are so high after this period of monotherapy and I’m coming off a month of 1MG Anastrozole ED? Wondering if I need to start higher and taper it down. The reality is that won’t get a clear read on which way it’s going until I get the first panel back but just wondering what you think about that.

Thanks again. I appreciate it!