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!


#6

An update on my first post above, and wondering where to go next: Following my above post, I began:

120MG Test CYP (split 60MG Monday AM and 60MG Thursday PM)
1 MG Anastrazole 2x per week (Monday AM Thursday PM)
250 MG HCG (EOD)

It was definitely a tough transition off the HCG monotherapy and the lab ranges referenced above. Energy dipped, strength dipped, libido and function dipped substantially. Six weeks labs (done on morning of trough) were as follows:

F SHBG 60.8 H 20.0-60.0 (nmol/L)
F ESTRADIOL 43.8 20.0-75.0 (pg/ml)
F TESTOSTERONE 768 375-1000 (ng/dl)
F TESTOSTERONE, FREE 1.29 0.87-5.47 (ng/dL) SLI
F HEMATOCRIT 41.3 38.5-50.0 (%) NL2

Things were definitely not dialed in so we made the following changes:
160 MG Test Cyp (split 80MG Monday AM and 80 MG Thursday PM)
1 MG Anastrazole 3X per week (M/Th/Sat)
300 MG HCG (EOD)

Despite the changes, I feel largely the same as I did six weeks ago. Things definitely are not dialed in. Perhaps a bit better, but libido and function still way way down as is general wellness. I’ve got very little get up and go. Six weeks labs following the changes (done again on morning of trough) were as follows:

F SHBG 58.0 20.0-60.0 (nmol/L)
F ESTRADIOL 51.9 20.0-75.0 (pg/ml
F TESTOSTERONE 1048 375-1000 (ng/dl)
F TESTOSTERONE, FREE 1.55 0.87-5.47 (ng/dL) SL
F HEMATOCRIT 43.7 38.5-50.0 (%) NL2

I am at a bit of a loss for where to go from here. More T is clearly not the next step given my trough level on the second phase of this transition, but I’m still enjoying very little upside on the Free T front and Estradiol is running away from me at 51.9. I’m thinking maybe it makes sense to back Test Cyp down to 150 MG per week while adding another 1MG dose of arimidex to see if that corrects course. That may correct the E2 issue. No idea how to address the Free T problem at this point I would really appreciate any feedback on these labs and on next steps. Thank you!


#7

After a recent visit with my doc, I wanted to add information to my question on next steps above:

Providers suggestion for next 6 weeks is:

140 MG Test Cyp (split into two doses - M/TH)
4 MG Anastrazole (1 MG on M/T, TH/F)
250 HCG EOD

Any thoughts on getting things dialed in would be appreciated. Thanks!


#8

Thanks to anyone who has followed this thread and who offered assistance including @ksman, and words of wisdom back when I was transitioning off HCG mono to TRT.

Things have gone reasonably well and are finally settling in.

Estrogen management seems to be the final piece of the puzzle and, following my most recent labs, I am wondering if best next step in an attempt to manage E2 is to decrease weekly T Cyp dose or to add additional anastrozole or, perhaps, some combination of both.

Here are my most recent labs done on morning of trough:

TESTOSTERONE 1426 H 375-1000 (ng/dl)
ESTRADIOL 40.0 20.0-75.0 (pg/ml)
SHBG 56.1 20.0-60.0 (nmol/L)
TESTOSTERONE, FREE 3.38 0.87-5.47 (ng/dL)

I am feeling good, but E2 is too high and I am feeling it. With high SHBG we are pushing total T north of high normal and finally, after all this time, I am finally getting Free T in normal and healthy ranges.

The problem with E2 where it’s at is libido and sexual function. Both way low – lower than when I had free T levels below 1.

Here is my current protocol:
140 MG Test Cyp (split into two doses - M/TH)
4 MG Anastrazole (1 MG on Mon, Tue, Thur, & Fri)
250 HCG EOD

In an attempt to bring E2 into a normal range I am considering either lowering T to 120 MG per week for six weeks to see if that brings it down while also keeping T about high normal. If E follows T then perhaps slightly less will get me in range. The alternative would be to add 1MG anastrazole on Wednesday morning for a total of 5mg a week while leaving Test Cyp at 140 MG per week.

I would really appreciate any thoughts, feedback, or advice on that next step decision. Thanks!


#9

I’m relatively new to this myself but it still seems as if your Anastrazole is really high along with your HCG. I would think something more like 1MG Anastrazole per week and maybe .5CC HCG twice per week would be more in line with the levels of T you’re taking. Just my $0.02, definitely not a doctor.


#10

I realized last week that my doctor has been ordering a standard E2 measure and not the Ultrasensitive E2 LC/MS/MS. Given that I’m trying to dial E2 in I went and had that done immediately through direct labs/quest and the result really surprised me.

ESTRADIOL, ULTRASENSITIVE LC/MS/MS 13 < OR = 29 pg/mL

My most recent E2 labs (measured with the normal E2 test) had E2 at 40 and, given libido and function, I was thinking it was too high. Now I’m thinking that, with E2 at 13, these are symptoms of E2 that’s run too low.

With that new E2 number, here are my most recent labs:

TESTOSTERONE 1426 H 375-1000 (ng/dl)
ESTRADIOL 40.0 20.0-75.0 (pg/ml)
SHBG 56.1 20.0-60.0 (nmol/L)
TESTOSTERONE, FREE 3.38 0.87-5.47 (ng/dL)
ESTRADIOL, ULTRASENSITIVE LC/MS/MS 13 < OR = 29 pg/mL

Current protocol:

Here is my current protocol:
140 MG Test Cyp (split into two doses - M/TH)
4 MG Anastrazole (1 MG on Mon, Tue, Thur, & Fri)
250 HCG EOD

Any thoughts on how to best adjust that Anastrazole dose to target E2 mid-20’s?

FWIW, this also seems to be yet another cautionary tale about E2 labs and the importance of using the ultrasensitive test. Based on the standard measure, I was contemplating adding more AI when it looks like I actually need less.

Thanks for any help dialing this in and targeting E2 back to mid 20’s.


#11

This is what is causing libido and sexual issues - period!

If you chase this number you will be miserable.

Low e2 will destroy your joints and cause ED. With a moderately high SHBG and high total t i suspect your e2 sensitive can be over 30 and you will feel good. SHBG binds testosterone and estrogen so you may have less free e2 - free e2 is what causes high e2 symptoms usually.

You need to look at ratio to. if a total t of 600 and e2 at 40 yes maybe to high but your total t is 1400.


#12

Thanks for your thoughts, @Charlie12. I am inclined to agree with you given that my recent ultrasensitive E2 lab came back at a 13.

Looking back at this thread, you can see that when HCG monotherapy concluded (February of this year), my E2 (using the standard measure) was 109.6. After beginning TRT, six weeks labs had E2 at 43.8 using the standard/non-ultrasensitive measure. It would appear at that point, that my E2 had crashed out. All we’ve done since is increase the AI thinking that symptoms were reflective of high E2.

Assuming that we are looking for sensitive E2 to at least double from it’s present 13, is it as simple as reducing 4MG weekly Anastrazole down to 2MG?

If so, what is the generally accepted best practice for reducing AI doses? Should the reduction be gradual and titrated over time to allow the body time to adjust to the lowered dose or simply cut from 4MG to 2MG?

Thanks as always for any thoughts on this case thread. I appreciate them and they have been very helpful.