TRT: 31 YO Male, 184 Pounds, 6'2

Zinc will help if you are deficient. Otherwise maybe not. High amounts can block absorption of copper and might induce a deficiency over time.
If you also have zinc in multi-vits, note the total.

Many do well getting near E2=22pg/ml. A good balance of energy and libido.

The only major unknown is how fast/slow SHBG response is to a drop in estrogen levels.

Zinc and other trace elements form the reaction sites in many enzymes and are thus mission critical for things to work properly. A good high potency B-complex multi-it with trace elements, including zinc, selenium and iodine would be beneficial and perhaps better than focusing on a single mineral. Men should avoid supplements and iron fortified foods unless iron levels are low. [Low (iron, hemoglobin, hematocrit, ferritin) can be indications of a GI bleed from a food allergy/sensitivity or other condition.]

Ksman,

Thanks so much for your latest reply. Per your advice, I started taking a B-Complex/zinc vitamin about 1.5 months ago. (It’s called Nature’s Bounty Stress B-complex with Zinc, see attached image for ingredients.) To see it’s affected my T levels, I just got a new blood test done 2 days ago for Total and Free Testosterone (see attached image). My TT levels are about the same as last time (a bit lower) at 432ng/dL but my FT levels seem to be at a great level (23.2 pg/mL). My earlier blood tests didn’t measure FT so unfortunately I have no baseline to compare this to.

Any thoughts on what I should do going forward?

It seems good. But with natural guys FT levels are pulsatile. So you do not know average levels. But it seems to be a great result.

The TT/FT ratio implies lower SHBG. E2 labs would have clarified things a bit.

How are you feeling now? Any changes to mental clarity, energy, libido, socialization or mood?

I haven’t really noticed a difference in mental clarity, energy, libido, socialization, or mood since 1.5 months ago before the B-complex and now.

I have noticed that some of my lifts are going up again though (like my bench press and number of pullups I can do).

Maybe I should test for TT/FT and E2 in another 1.5 months and report back? At this point, can you say definitively that I do not need TRT?

Did you do anything about E2?

Are you asking if I got bloodtested for E2 recently or if I am taking anything to manage it lower?

If the former, I didn’t get E2 tested, just FT and TT this time. If the latter, then I am just taking the B-complex with zinc as I thought I would try an over the counter method to get E2 lower and increase TT/FT before trying anastrozole.

Thoughts?

If zinc worked well we would not be needing anastrozole. Zinc does help if one is zinc deficient.

OTC is basically ineffective

Ksman,

So I decided to get a full panel of blood tests done again before I started taking anastrazole. Above are the results from this week. Now I am confused on what to do as my estradiol now seems to be at a good level at 21.5 vs last time it was tested it was 34.7. The only difference between then and now is that I’m taking the B-Complex vitamins with zinc daily.

Also, my TT is low at 403, but my FT is toward the high end of the range at 19.3.

What do you think I should do next?

You total cholesterol is too low. 180 is ideal. 160 and below are associated with increased all-cause mortality.
Please change diet to increase cholesterol. Cholesterol is the foundation for all of the steroid hormones, including cortisol and Vit-D.

TSH=2.24 is too high. Better near TSH=1.0
The thyroid ranges are misleading.
Your TSH could be elevated from not using iodized salt.
Please see the thyroid basics sticky and check oral body temperatures as suggested [I asked in August].
Why did TSH increase?

Hi Ksman,

I saw a testosterone doctor (Justin Saya from Defy Medical). Based on the above test results I already posted, he said the following:

-Needs to test but would bet his house my DHT is probably low due to finasteride use
-My free T is high but TT is low; wants to raise SHBG; your body is keeping your T in FT form but it’s getting excreted quickly; body is probably doing this to compensate for the low DHT
-LH is normal, but could get it higher
-Doesn’t want to throw me straight on testosterone replacement off the bat
-Wants to try a stimulation regimen first; if that fails then we have other backup plans including TRT
-Suggests clomid: half tablet every day for 35 days; wants to look at T, E2, and LH, DHT, and prolactcin (if elevated, can cause low libido and lack of erections) again at 30 day point

After the above, he had me get my DHT and prolactin tested. The results were:

Dihydrotestosterone 9.3 ng/dL / Reference Range: Adult Male: 30 - 85
Prolactin 8.0 ng/mL (4.0 - 15.2)

KSman, do you think the 25mg a day of clomid is a good idea like the Doctor is suggesting? Thanks again!

That is a good approach.

Test LH and FSH!

Test bio-T. I do not agree that FT is simply pissed away. T+SHBG is not bio-available. So there is FT and weakly bound albumin+T that really matter.

FT is released in pulses and any single lab number has limited value as things are changing so much and average or effect levels are unknown.

Hi Ksman,

I got LH and FSH tested like you said. I didn’t get bio-T tested cause it was $250 alone for that test. If needed I can afford it, so let me know if you still think I should get that tested in my next lab test. I put all my lab results including the latest into the table below so it’s easier to read. I also put my medication timeline in there too.

Here are my notes from my last visit with Dr Saya on 7/20/16:

“Your body has had a good response . Pituitary gland reved up LH and it actually went above range. Testes responded by increasing testosterone by just about double. That indicates that your testes are fairly capable. Downside is that DHT (erection, energy, libido) only went up to 18. At this point he thinks finasteride is going to be the real inhibitor for me. Might be preventing you from feeling your best. DHT is a double edged sword. Hair loss is usually at high levels. Usually you can attain a good balance at 30s to 40s of DHT and you typically won’t accelerate hair loss. Would recommend cutting in half finasteride or even better switching to topical. You will get a minimal fraction of systemic absorption from topical as what you get with oral. Topical is 1mg per mL (0.1%). For transdermal you typically absorb 10%. So you’ll get 0.1mg in theory per application. If you want to be conservative, you can try cutting down your oral by half and then recheck DHT in 5 weeks. Would continue clomid as that’s working well but also put me on 0.3mg twice a week anastrozole (arimidex) to control estrogen. Testosterone levels are pretty good, but what’s missing is DHT going up and you feeling better. Ideally, we taper off the finasteride, continue on clomid and arimidex, get your TT, DHT, and E2 where they need to be, and then taper off the clomid/arimidex eventually.”

So per the table above, on 7/20/16 I stopped taking 1.25mg/day of oral finasteride and started 0.1% topical finasteride in the form of 1mL/day of minoxidil with 1mg of crushed finasteride tablets dissolved in it. Also on 7/20/16, I began 0.25mg of arimidex, 2x per week (0.50mg total per week). I am continuing the 25mg/day of clomid.

I began clomid on 6/7/16. The next two mornings I noticed morning erections but after the first two days they went away again (I assume from my E2 spiking). Since I started on the arimidex 4 days ago, the morning erections haven’t come back yet. Maybe it’ll take some more time?

So was just hoping for you feedback on the above and any additional thoughts you may have. Thanks so much as usual!

As soon as I saw high LH I thought high SERM dose without knowing anything else. The high LH/FSH is driving high T–>E2 inside the testes and Arimidex/anastrozole is cannot control T–>E2 inside the testes as T levels there are too high for a competitive AI to work there.

Doctors do not know this, it took an engineer [me] to figure that out!

One needs to only understand the essence of what “competitive drug” implies and know that intratesticular testosterone levels can be up to 80-100 time higher than serum levels.

So your dose of Clomid is too high for [you]. Also possible risk of desensitization of LH receptors.

So Anastrozole cannot fix this. You must use less Clomid. If resultant T levels are too low, then you need to start T+hCG or T+[low[er] dose Clomid]. Higher dose hCG has same problems.

FT levels could be higher for a TRT context.

DHT is not a concern unless you have genetics for hair loss.

Should not test LH, should test LH/FSH together! LH levels change too much. FSH is a better indicator of LH status than LH itself because of half-life differences.

Please print this off for your doc. I can tell that he is really trying to help and I am always happy to assist.

Clomid/Nolvadex are cheap. T injectables are cheap. hCG can be more of cost concern. There are multiple ways to skin the TRT cat. Your doc seems to be wanting to spare you the burden of self injecting. Injecting T/hCG with insulin needles is really not a problem.

Thanks for the reply!! Ok, I don’t have a follow up appointment with my doctor for 6 weeks, but I just copied your last post and emailed it to him. Hopefully, he’ll reply soon.

While I wait for his reply, a few follow up questions please:

  1. So my clomid dose it too high. Should I cut it down immediately? To what, 12.5mg/day?

  2. Should I stay on 0.25mg 2x per week of arimidex?

  3. Are you saying you don’t support he use of arimidex in general or it’s just not going to work in my case? I thought T+hCG+arimidex was your recommendation for a standard TRT protocol.

  4. You said DHT doesn’t matter unless I have genetics for hairloss. I do have genetics for hair loss (that’s why I’m on finasteride and minoxidil.) So do you agree with the doctor that targeting 30 to 40 ng/dL is a good range of DHT to prevent accelerating hair loss while also not dropping it too low to get low energy, libido, and other sides?

  5. Is the fact that my morning erections haven’t come back after starting arimidex, evidence of your your point about arimidex not working within the testes to reduce E2 for me?

Thanks again!

1- I certainly wood, but we might hurt doc’s feelings. 12.5mg would be a good guess.

2- That would be a good start. We do not know where your T levels will then go and required Arimidex dose depends on T levels.

3- I am stating that Arimidex will not control T–>E2 inside the testes, but it does work in peripheral tissues and you will still need it. It cannot reduce existing E2, only reduce T–>E2 aromatization.

4- I have no idea what DHT levels one can tolerate with a disposition for MPB.

5- Exactly. If E2 starts to drop, you should easily notice improvements.

Thanks for the reply. So I got an email back from the doctor:

" There is some truth to the role of intratesticular T/E, but his root problem is STILL the longtime finasteride use that has his DHT levels in the range 9-18. I’ve discussed discontinuing this several times with him in favor of a transdermal treatment. Also, I have seen on many occasions anastrozole adequately control E2 levels even in the presence of elevated LH/FSH.

Also, the note of HCG + Clomid is inaccurate (as HCG mimics LH but suppresses endogenous LH at the same time) and TRT + Clomid (as the suppressive effect of TRT is too much for Clomid to overcome).

I am certainly okay with reducing the Clomid to 12.5mg daily until next f/u, but again I believe his path to feeling better starts with stopping the finasteride (as we discussed in consult). "

Any thoughts on the above? Since you both agree with 12.5mg/day, I have reduced my clomid to that while continuing 0.25mg 2x/week of arimidex. When do you think I should get my next bloodtest? 4 or 6 weeks? Thanks!

When to do labs is never an easy question. Too many variables as well as in your case, tissue and organ responses.

I do not see where finasteride plays a dominant roll. However, DHT is very important for development and maintenance of male sex organs and is mission critical for libido - brain mediated.

Hi, I just had my new labs come back. Since switching from oral to topical finasteride, my DHT has increased to a level in the 30s that Dr Saya will probably be happy with (I haven’t had my follow up with him yet. Hopefully it will be in the next couple weeks.) Estradiol is still at a high level. I got LH and FSH tested together this time per your recommendation. Any thoughts on what to do next? Thanks!

Dr Saya is top notch. I’ve read many of his posts at Excel forums. You are in good hands.

LH and FSH are very high, indicating that your reduced dose of clomid is still too much.

As expected with this, E2 is way too high and Arimidex/anastrozole ineffective as expected.

You are not going to get very far with Clomid. You need to reduce Clomid to get lower LH/FSH and then I expect that your T levels will not bring much joy. Your prior Clomid dose reduction did not reduce E2 even with addition of 0.5mg Arimidex per week.

Suggest that you seriously consider self-injected T, see protocol for injections.