T Nation

TRT - 51 YO Male - Re Discovering your Sweet Spot? *UPDATE*


#1

Having trouble with my TRT regimen. Main symptoms are still tired, muscle softness lack of pump, not able to lose any fat especially on my chest. Now puffy inverted nipples excess fat on chest getting belly. Low energy etc. Basically soft. Eating clean dropping some weight but have boob issues. I'm gyno prone and have had it in the past (lump wise) got rid of it with Letro.

Im a 51 year old male 6' 225 muscular but never been cut. 10 months out from my 4th surgery on shoulders both replaced. rehabbing and progressed to lifting again. Could use suggestions. DR Endo is young but willing to work with me, HRT TNT not his specialty. Could use some help.

Current Meds
Atrovastin 20mg ED

TRT HISTORY
Started TRT in between my 1st replacement surgery and 2nd to aid in recovery in 2014, had all the typical low T symptoms TT was at 250. GP put me on 100mg a week which got me to 1100, which caused GYNO lump after 6 Weeks , stopped and referred to idiot Endo. Had to beg for Letro which got ride of it. Then when I was tapering off I felt great for 3 weeks then crap again , Obviously blew thru my E2 sweet spot. Endo said go back on Letro, which I did and crushed E2, felt like crap again.

New Endo, Back on 100mg a week, same thing High E2 , so he put me on Tamoxifen , didn't work , Then he wanted to try Androgel , lowered TT still high E2.
Back on injectable this time with AI Arimidex , too much crushed E2 , backed off and now E2 at 24 , but still same symptoms. Boobs fat low energy flat muscle tone etc.

Here are my labs from this year ------------

5g Androgel ED
Labs 02/02/16
TT 557 ( 240 - 950 ng/dL)
FT 10.11 ( 4.25 - 30.37 pg/ml)
E2 55.1 ( <39.8 pg/ml)
Prolactin 19.93 ( 2.5 - 17.0 ng/ml)
LH <0.1 (1.4 - 18.1 mIU/mL)
FSH <0.5 (1.5 - 9.3 mIU/mL)
PSA 0.95 ( <4.00 ng/mL)

T Cyp .50mg E3D - ARIMIDEX .50mg - ED
Labs 03/23/16
TT 988 ( 240 - 950 ng/dL)
FT 10.27 ( 4.25 - 30.37 pg/ml)
E2 20.0 ( <39.8 pg/ml)
Prolactin 14.65 ( 2.5 - 17.0 ng/ml)

fasting cholesterol 131 mg/dl 135-200
LDL 85 <100
HDL 37 >40

T Cyp 50mg x E3D Arimidex .50mg ED
Labs 05/26/16
TT 1097 ( 240 - 950 ng/dL)
FT 11.38 ( 4.25 - 30.37 pg/ml)
T Bioavailable 668 ( 50 - 190 ng/dL) 50-59 years old
SHBG 29.3 ( 10-57 nmol/L )
E2 11.80 ( <39.8 pg/ml)
Estradiol Sensitive: 4.8 ( 8.0 - 35.0 pg/mL)
Prolactin 13.48 ( 2.5 - 17.0 ng/ml)
Progesterone 0.21 ( 0.28 - 1.22 ng/ml)
LH <0.1 (1.4 - 18.1 mIU/mL)
FSH <0.3 (1.5 - 9.3 mIU/mL)
PSA 1.21 ( <4.00 ng/mL)
TSH 1.828 (0.340 - 5.6uIU/mL)(0.340 - 2.500uIU/mL)
fT3 n/a
fT4 1.0 ( 0.8 - 1.9 ng/dL)

HEMATOLOGY (CBC)-------------------------
WBC 5.5 103/ul 4.0-11.0
RBC 5.16 106/ul 4.4-5.9
HGB 16.5 g/dl 13.0-17.0
HCT 50.01 % 40-52
MCV 97.0 fl 82.0-97.0
MCH 32.0 pg 27.0-34.0
MCHC 33.0 g/dl 31.0-35.0
RDW 13.9 % 11.8-15.2
Platelets 196 103/ul 150-400
MPV 8.4 fl 5.2-11.1
NEUTROPHILS % 59 % 45-75
LYMPHOCYTES% 33 % 15-50
MONOCYTES% 6 % 0-10
EOSINOPHILS% 1 % 0-5
BASOPHILS% 1 % 0-5

T CYP 40mg = E3D - Arimidex .25 EOD
Labs 08/15/16
TT 858 ( 348 - 1197 ng/dL)different lab
FT 154.38 ( 52 - 280 pg/ml) different lab
T Bioavailable n/a ( 50 - 190 ng/dL) 50-59 years old
SHBG n/a ( 10-57 nmol/L )
E2 24.1 ( <39.8 pg/ml)
Estradiol Sensitive: n/a ( 8.0 - 35.0 pg/mL)
Prolactin n/a ( 2.5 - 17.0 ng/ml)
Progesterone n/a ( 0.28 - 1.22 ng/ml)
LH n/a (1.4 - 18.1 mIU/mL)
FSH <0.3 (1.5 - 9.3 mIU/mL)
PSA 1.21 ( <4.00 ng/mL)
TSH 3.110 (0.340 - 5.6uIU/mL)(0.340 - 2.500uIU/mL)
fT3 n/a
fT4 1.0 ( 0.8 - 1.9 ng/dL) 2/2/16

CHEMISTRY
TOTAL PROTEIN 7.3 g/dl 6.0-8.3
ALBUMIN 4.4 g/dl 3.5-5.5
GLOBULIN (calc.) 2.9 g/dl 2.0-4.0
A/G RATIO (calc.) 1.5 ratio 1.1-2.5
SGOT (AST) 27 IU/L 1-40
SGPT (ALT) 22 IU/L 5-45
ALKALINE PHOS. 53 IU/L 30-125
BILIRUBIN, TOTAL 0.7 mg/dl 0.1-1.4
GLUCOSE 84 mg/dl 65-99
CALCIUM 9.4 mg/dl 8.3-10.5
CHLORIDE 104 mEq/L 96-110
CO2 27 mEq/L 15-35
SODIUM 140 mEq/L 135-155
POTASSIUM 4.0 mEq/L 3.5-5.5
ANION GAP (calc.) 9 0-25
BUN 16 mg/dl 6-25
CREATININE 1.1 mg/dl 0.5-1.3
BUN/CREATININE (calc.) 15 ratio 7-30
E.GFR 75 >60
HEMATOLOGY (CBC)-------------------------
WBC 6.9 103/ul 4.0-11.0
RBC 5.28 106/ul 4.4-5.9
HGB 17.1 g/dl 13.0-17.0
HCT 49.8 % 40-52
MCV 94.0 fl 82.0-97.0
MCH 32.4 pg 27.0-34.0
MCHC 34.3 g/dl 31.0-35.0
RDW 13.5 % 11.8-15.2
Platelets 190 103/ul 150-400
MPV 8.8 fl 5.2-11.1
NEUTROPHILS % 57 % 45-75
LYMPHOCYTES% 35 % 15-50
MONOCYTES% 6 % 0-10
EOSINOPHILS% 2 % 0-5
BASOPHILS% 0 % 0-5

fasting cholesterol 151 mg/dl 135-200
LDL 93 <100
HDL 45 >40


#2

Your T related numbers look pretty good. So I'm a little baffled by all the symptoms. You may have thyroid issues. Your cholesterol is too low. Shooting for 180.


#3

Lipitor and other statins work by reducing activity of enzyme pathways that make cholesterol in the liver. So far so good. But for some people, this affects the enzyme pathways that also make CoQ10 and a CoQ10 deficiency can result. That lowers energy levels by slowing down mitochondrial production of ATP, the universal currency of cellular energy.

What was cholesterol before Lipitor?
TRT can improve cholesterol numbers.

Thyroid hormone fT3 also regulates mitochondrial metabolic rates as part of body temperature regulation.

You could have low energy from low CoQ10 and low thyroid function.

Do not take total cholesterol so low. <160 is associated with increased all-cause mortality. 180 would be ideal.

Labs:
TSH
fT3
fT4
IGF-1 to eval GH status
AM cortisol - at 8AM please
A1C
DHEA-S [not DHEA]

Check overall thyroid function by checking oral body temperatures as per the thyroid basics sticky. Note that in this case, low temperatures could be a mix including effects of low CoQ10.

Do you sometimes feel cold easily?
Outer eyebrows sparse?
Poor absorption of transdermal T is a symptom of low thyroid function.

You can try 50mg Ubiquinol [ note spelling carefully] form of CoQ10. It is not cheap. If you feel better ...

Low CoQ10 can also lead to muscle soreness/weakness, persistent cough from weakened heart muscles leading to the same mechanism of the cough of congestive heart failure - I have seen Ubiquinol stop that.

Note that either of these things that slow down your metabolism can increase blood sugars, cholesterol and triglycerides.

TSH should be closer to 1.0
T4, T4, fT3, fT4 should be mid-range or a bit higher
Problems expected if not using iodized salt and/or multi-vits that list iodine+selenium
Might need a thyroid auto-immune panel. Auto-immune problems can be from selenium deficiency and/or long term iodine deficiency that increases TSH.

SERM's do not decrease E2, they increase E2

Labs 03/28:
TT looked OK, but FT to low. SHBG assumed high inflating TT. Suggest that you aim for higher FT and ignore that TT is high. However, HTC may be your limiting factor.
E2 was good, Please clarify Armidex dose - does not make sense VS 5/26

Do not test LH/FSH on TRT, stupid to continue.

Prolactin seems elevated all of the time which may tie into gyno.
Dostinex/Cabergoline 0.5mg/wk Rx would tackle that.

Please read these stickies found here: https://forums.t-nation.com/t/about-the-t-replacement-category/38/2?u=ksman

  • advice for new guys
  • things that damage your hormones
  • protocol for injections
  • finding a TRT doc

#4

Thanks for the reply, I hope I can answer all the questions

fasting cholesterol 201 mg/dl 135-200
LDL 148 <100
HDL 40 >40

I have a moderate calcification on my left anterior descending artery, Statin more to prevent it from breaking off then lowering overall Cholesterol thou it is helping to lower LDL
I discussed low number with my Cardiologist, she doesn't think its a issue, but she is not dealing with TRT issue on her end, I could reduce Statin to bring it up a bit.
Calcification was caught as a fluke when doing Cat Scan looking for clots in lungs (which there where none) since D Dimmer test came back 1 click above normal and my GP flagged it before my first shoulder surgery ( family history dad died at 47 blood clot)

I am currently on
Atorvastatin 20mg x 1
Aspirin 81mg x 1
Slo-Niacin 500mg x 1
Multi Vitamin x 1
B-Complex x 1
C 1000mg x 1
D3 4000iu x 1
E 400iu x 1
C0Q10 300mg x 1 (kirkland costco brand)
Fish Oil 1400mg x 1
(epa 647mg)
(dha 253mg)
Vitamin K complex x 1
(K1 1000mcg)
(K2 -mq4 1000mcg)
(K2 -mq7 200mcg)

I can switch to Ubiquinol type if you think its better absorbed ?

No

I guess always had thin hair, no hair on legs anymore hair on head thin
Letrozole mad it thinner when going through that.

No symptoms , just feel flat when working out

Saw Endo today mentioned this , he said was "in range" but will do follow up tests

my mistake
T Cyp .50mg x E3D - ARIMIDEX .50mg - ED Labs 03/23/16 =E2 20
T Cyp .50mg x E3D - ARIMIDEX .50mg - ED Labs 05/26/16 =E2 11.38
T CYP .40mg x E3D - ARIMIDEX .25mg - EOD Labs 08/15/16 =E2 24

I must have been still coming down from 55 at 3/23 test, thinking I was ok , so kept dose the same , sailed through it to 11.38 on 5/26 . so I backed off and am at a steady 24with .25 EOD -

Question - do I keep experimenting with amount of test and AI to try to get to a higher free test number and perfect E2 number "22" or be lucky at where I am and work on trying to figure out what else I can do to fell better and loose this fat?

Thats my goal whats the secret?

This is something Endo is looking into, seems He mentioned Auto Immune but actually said he dosent know'
I asked about "back filling" my hormones thru HCG or Progesterone since my levels were so low Progesterone 0.21 ( 0.28 - 1.22 ng/ml)
He wasn't ready to go there yet

Said to keep same TRT regimen and gave me a script for below ( I didn't get KSwan responce till after appointment but I can just hand right whats missing)
TSH
FREE T4
TOTAL T3
TEST TOTAL
TEST FREE
E2
PROGESTERONE
DHEA S
CRP HS **
VIT D
IODINE SERUM
ZINC
B12

** looking for inflammation, heard this is worthless if you have arthritis (thus 2 shoulder replacements) or on statins

will look into this , thought I was "in range" but I've learned that doesn't mean much around here.

Thanks for your suggestion and help.


#5

Get FT3 AND DROP T3 if possible.

CRP is a generalized inflammatory marker, not cardio specific.
Homocycteine is cardio specific and indicates arterial inflammatory processes.

You need natural source Vit-E, synthetic misses a lot of related compounds.

Vit D lab should be Vit-D25

Multi-Vit has 150mcg iodine + selenium?

Glad to see that you are on Vit-K to control calcium in your arteries.

Increase FT by lowering SHBG. Lower SHBG with lower E2 levels and higher T dose as more FT lowers SHBG - yes that is a circular argument.

IT WOULD BE HELPFUL IF YOU POSTED REQUESTED ORAL BODY TEMPERATURES.


#6

Will add FT3 Vit-D25

Yes 150mcg Iodine + 55mcg Selenium is that sufficient ?

Ordered Basil Thermometer

Will Draw blood next week since I will not change protocol , even thou Endo appointment is't until December , I'll gather results and post when completed.

Thanks Again


#7

Latest Lab work 9/13/16
TRT Protocol and med adjustments
100mg TCyp IM - .50mg E3D - upped from 40mg
Arimidex .25mg (1/4 pill) EOD same as before

Switched Blood Pressure medication from Verapamil HCl ER 180 MG Oral Capsule ER , exhaustion, muscle weakness, to
Lisinopril 10 MG Oral Tablet, Now cant Pee but less tired , will be switching again
concerned muscle weakness is Stain related will be discussing with Cardiologist

TSH ___________3.773_____uiU/mL 0.340 - 2.500 or 5.600
FREE T4_________1.1______ng/dL 0.8 - 1.9
FREE T3________2.90______pg/mL 2.3 - 4.2
TOTAL T3________91_______ng/dL 72 - 170

TEST TOTAL______1095_______ng/dL 240 - 850
TEST FREE_______9.03_______pg/mL 4.25 - 30.37
E2_______________30.7______ pg/mL <39.8
PROLACTIN______17.04_______ng/mL 2.5 - 17.0

PROGESTERONE_____0.44_____ng/mL 0.23 - 1.22
DHEA S_______________92_____ug/dL 80 - 560
CRP HS______________0.30____ mg/L <1.0
VIT D 25_______________51_____ng/mL >30 - 100
IODINE SERUM _____ requested but failed to provide ?
ZINC_________________103_____mcg/dL 56 - 134
B12__________________719_____pg/mL 193 - 982
IGF-1________________329.0____ng/mL 87 - 238
AM CORTISOL_________14.6____ug/dL 8.7 - 22.4
A1C__________________4.7 % ___<5.7 %

Oral Body Temps

97.3__97.5__97.3
97.0__97.1__97.3
97.1__98.1__97.7
97.4__98.1__98.4
97.1__97.6__98.1
Temperature levels seem low and sporadic, Im not to confident in the thermometer I bought with multiple readings different seconds apart, getting another to verify and will post new readings

Observations
By increasing T Cyp from 40mg to 50mg a dose (to try and increase my Free T levels) my E2 and Prolactin elevated without effecting my Free T (actually lowering)
Should I return to 40mg which gave me mid 800's or should I increase Arimidex

Don't know anything about Thyroid levels but bold highlighted seem off?
IGF 1 is off the chart?
DHEA S low
PROGESTERONE low
FREE T low after T Cyp increase

Looking for ammo and a list of suggestions and questions for Endo appointment (not until Dec. but will call him after I read comments here. Anything else look fishy ? Same symptoms as before nothing has changed in the way Im feeling

Also if I dont get the answers from the ENDO that match concerns here I'm thinking of going out of pocket to DR Rand McClain. he is local, but I hear costly. Anyone have any experiences with him?

Thanks in advance for suggestions and comments


#8

Obviously the discrepancy between your TT and FT is a concern. Have your SHBG tested. Your E2 is a little elevated. Do you supplement with Vit D?


#9

I am no doc - but I would guess your issues are from the relatively higher levels of prolactin. Prolactin suppresses dopamine in the brain and also suppresses T levels. You have high Free T but lower Free T by comparison - so perhaps this is the cause. There have been cases of prolactin-induced Gyno but more than not, you need some Estrogen to go along with that for it to cause symptoms. Check with Dr Rand (never used him but his vids are top notch and he totally gets it). He may want to do an MRI on your pituitary to make sure you don't have an issue that's causing the Prolactin. (ask him about this - based on your symptoms it seems like a logical next step.). Or, you could try Caber, which will knock down the prolactin, but that sometimes comes with sides as well - low libido, lethargy, etc.


#10

Statin issues and muscle weakness: Ubiquinol should be used, 100mg/day, then if muscles improve, you have the diagnosis and the solution. your doc probably will not take you there, but may see the merit of this. You can do this before you see the doc.

Thyroid numbers and temperatures are a mess.
You can increase iodine+selenium or request thyroid auto-immune labs, which may be refused because you are "normal"

High TT and low FT suggest high SHBG

Injecting once a week?
Inject twice a week and split Arimidex taking at time of injections
Do labs, always, half way between injections.

IGF-1 is high, but not nasty, many would kill for that number

Take 25mg DHEA with lower fiber, higher fat meals.

AM cortisol is good. so not concerned that progesterone might be low

T dose probably not related to change in prolactin.

Increase anastrozole dose by a factor of 30.7/22


#11

Are these all AM?
We also need to see if you warm up to 98.6 mid-afternoon.


#12

These are AM, Afternoon and Evening readings on a ten second digital thermometer
still not confident in thermometer accuracy so I'm ordering another to verify accuracy.


#13

Injecting once a week?
Inject twice a week and split Arimidex taking at time of injections
Do labs, always, half way between injections.

I inject E3D=every three days ex:Monday Thursday, Sunday, Wednesday etc. I Take Arimidex EOD=Every other day in pill form, these are the numbers they produce below

TCyp .50mg x E3D - ARIMIDEX .50mg ED/Labs 03/23=E2 20 TT988 FT
10.27 Prolactin14.65( was coming down from E2 at 55)

TCyp .50mg x E3D - ARIMIDEX .50mg ED/Labs 05/26=E2 11.38 TT1096 FT11.38 Prolactin13.48

TCYP .40mg x E3D - ARIMIDEX .25mg EOD/Labs 08/15=E2 24_TT 858 (FT154 different lab range), Prolactin N/A

TCYP .50mg x E3D - ARIMIDEX .25mg EOD/Labs 09/13 = E2 30.7, TT1095, FT9.03 Prolactin17.04
[/quote]

I've been taking COQ10 for a year 300mg a day ( I read after a certain age its difficult to convert to Ubiguinol) so I switched to Ubiquinol 200mg a day since your recommendation
muscle weakness persists

Increase anastrozole dose by a factor of 30.7/22

I'll look for the sticky on that , popping a pill is easier for me

Question
am I over thinking Injection timing and just go twice a week .50mg and AI at time of injection?

I'll push for test, can you elaborate on the "mess" or link me to some info on men on TRT and Thyroid issues.
Do some men on TRT experience this or is it a coincidental factor?

could this be cause or contributing factor of muscle weakness?

my test on 5/26 was SHBG 29.3 which I didn't think was high but obviously
something is preventing my Testosterone from becoming available

looking back on my labs my TT seems to have no correlation to Prolactin levels
874/15.32
332/12.98
210/11.9
841/11.95
250/13.54
781/20.95
576/22.49
557/19.93
988/14.65
1096/13.48
1095/17.04

So main questions to be answered
Why low free T when there is plenty of TT
Why thyroid TSH elevated
Why Prolactin levels consitanley high or elevated (but not tumor high)

KSman,
thanks, will follow your other suggestions and update.
"This is getting complicated"


#14

In general low FT and elevated TT means that SHBG is elevated and T production is low. T+SHBG is up inflating TT. That also means that the liver is not clearing T+SHBG very well.

TSH elevates from low body temps and/or the hypothalamus does not see enough thyroid hormones. Some can be from low iodine or a thyroid condition.

Prolactin increased by lower dopamine and lowered by more dopamine. There can still be something going on in the gland that cannot be imaged.


#15

Quick update,

Cardiologist Blood test for Statin related muscle issue causing weakness came back positive. DR. told me to immediately stop Statin and retest in 3 weeks.

I forwarded this info and the results of my last blood work to my Endocrinologist and got this response

Hello
I reviewed the emails and the labs
I am ok with what you are doing
however i do not have any more input or suggestions
maybe a little increase in thyroid medication, but i dont believe it will make a big difference in the symptoms
thank you

First thing Im not on any Thyroid meds. I guess its time to find another Dr. in Los Angeles. Any suggestions? Looking into DR Rand McClain in Santa Monica but it will be out of pocket, tired of spinning my wheels. Anyone use him and what are the fees involved?

I’ll post blood work from CPK test when I get them and see if I can get another TRT panel out of the old Endo. to take to who ever I end up seeing.

Thanks


#16

Got back from Cardiologist

On Atorvastatin 20 mg ED

10/10/16 CPK 816 U/L 38 - 174

OFF Statin
11/09/16 CPK 176 U/L 38 - 174

Obviously severe myositis of muscle tissue was causing my muscle weakness, being off has almost completely alleviated symptoms but fatigue still remains


#17

Latest Lab work 11/29/16 BLOOD DRAWN ON TUES MORNING 2 days after injection

TRT Protocol and med adjustments
100mg TCyp IM - .50mg Sunday Morning & Wednesday Night
Arimidex .75mg at time of injection
25MG DHEA a day
OFF Statins
OFF blood pressure meds

TSH ___4.715_____uiU/mL 0.340 - 2.500 or 5.600
FREE T4_________1.0______ng/dL 0.8 - 1.9
FREE T3
3.07______pg/mL 2.3 - 4.2
TOTAL T3________n/a_______ng/dL 72 - 170

TEST TOTAL______802_______ng/dL 240 - 850
TEST FREE_______12.65_______pg/mL 4.25 - 30.37
E2_______________17.4______ pg/mL <39.8
PROLACTIN______13.07_______ng/mL 2.5 - 17.0
SHBG___________28.9_________nmol/L 10-57

PROGESTERONE_____ 0.3_____ng/mL 0.23 - 1.22
DHEA S_______________230_____ug/dL 80 - 560
CRP HS_____________ n/a____ mg/L <1.0
VIT D 25______________n/a_____ng/mL >30 - 100
IODINE SERUM _____ 56.3____ug/L 40.0-92.0
ZINC_________________n/a_____mcg/dL 56 - 134
B12__________________n/a_____pg/mL 193 - 982
IGF-1________________263____ng/mL 87 - 238

DR added 50mcg of Levothyroxine after seeing blood numbers no adjustments to TRT
Still muscle flatness, hard to hold pump during workout, still fat, could use more energy, not sleeping well. After a month on T4 Med no noticeable difference next labs in late Feb.


#21

Good luck. FWIW, I’d be shelling out the cash to see Dr. Rand McClain asap. Fingers crossed for you… keep us posted.