TRT After Chemo

I have had low T since completing chemo nearly three years ago after non-Hodgkins Lymphoma. I was put on 5g Androgel in mid-06, and numbers went from total 317 to 920, free .88 to 2.84 ng/dL free T. So I initially responded well.

I didn’t have T tested again until recently. My numbers were lower than the initial low levels (171, 3.2L pg/mL(note: different measurement unit)). I was retested and came in at the “much improved” 288/7.9, both numbers which are still below normal on this scale.

My doctor thinks this is alright after talking to her partners and the Androgel rep. I obviously don’t. I do not have the symptoms I had coming out of chemo and have better energy than then, but looking back I think some of the energy levels I had marked up to work travel might be related to this. My libido is lower than it has been with no ED symptoms, but libido is definitely not dead. So I’m in a middle ground that I think she sees no need to treat. I on the other hand would prefer to see if things could be better. My gains in the gym have been very slow this past year, and I’ve had more trouble breaking down below 12% bf lately even with a lot of hard work.

I told her I wanted to look into injections since I do not feel this is a good level. She I wanted me to go to 7.5 g of androgel, but didn’t see that dosage on her info so we agreed to stay at 5 g until I talked with the oncologist. Doing some reading it sounds like to get that dose I should do a 5g pack and a 2.5 g pack or go to the pump (which wouldn’t work very well with travel I suspect).

I am getting PET/CT scanned in a week or so and plan to talk to my oncologist about her experience with post-chemo patients. I think I would rather get a referral to an endo from her than from my PCP as I suspect she has more experience with this or at least knows endos more familiar with cancer/chemo issues.

Has anyone here that is on TRT had to do so due to chemo complications? Anything different I should be on the lookout for? Questions I should ask, etc?

Why would an oncologist have any knowledge about these issues?

PM me and tell me more about your situation.

Lets play a game where a young man goes through this and his testosterone are normal youthful values. Would there be a conversation about the dangers of being a normal male and the need for castration to reduce T levels?

You need to fight to get T, hCG and AI to control estrogen. The biggest challenge is finding a doctor who is not an idiot.

Testosterone supports your immune system and your immune system is your first defense against cancers.

[quote]KSman wrote:
Why would an oncologist have any knowledge about these issues?[/quote]

I didn’t mean to imply she did, but she has dealt with endos specifically on hormonal situation resulting from cancer and chemo. I suspect from talking to my regular doctor she hasn’t. So I trust my oncologists ability to refer me to an endocrinologist who has seen men who’s testosterone production didn’t return to normal after chemo.

However, 3 years on HRT and I’m not sure that this applies vs anybody else who doesn’t produce much T after HRT of a similar time frame. But I still go back to she seemed to have dealt with this before and might give me a better referral.

[quote]PM me and tell me more about your situation.

Lets play a game where a young man goes through this and his testosterone are normal youthful values. Would there be a conversation about the dangers of being a normal male and the need for castration to reduce T levels?[/quote]

I’m sure the fear is the typical prostate / cancer fears on a patient not too far from round 1. I can kind of understand wanting to be conservative a bit, but I’m the one that needs to make the final decision as to what risk I accept IMO. The PCP isn’t opposed to a referral, she just thought 280 was OK and should be sufficient without any more critical symptoms.

As to my situation, I’m not sure what I didn’t put in the original post. I am still waiting on the latest test in paper form. She said estradiol and cortisol were “normal”, but as I’ve said her normal doesn’t necessarily equate to what I think should be normal.

[quote]You need to fight to get T, hCG and AI to control estrogen. The biggest challenge is finding a doctor who is not an idiot.

Testosterone supports your immune system and your immune system is your first defense against cancers.[/quote]

I don’t think my PCP is an idiot. She caught my cancer very early on when I only had minor symptoms. However, I do feel she is not very knowledgeable in this area. She isn’t flat refusing treatment or I’d be looking for another doctor already. She agreed to refer me to an endo, I just want to wait a couple of weeks to see what the oncologist has to say.

I guess what I’m after here is what to start asking for specifically via blood work and what to expect. I also was curious if anybody had all of this start due to chemo complications and what differences that might make in the situation. I have been doing some more reading from links I’ve found in this forum (like allthingsmale.com, etc.). So I feel I’m a bit better prepared as this goes on to know what to ask/request. But I still have a lot to learn.

I dread figuring out all the insurance stuff, too. Mine covers the Androgel semi-reasonably (I pay about $50/mo). Is cypionate more/less expensive? I assume if the other drugs are more critical with injection vs topical that will be something else to see if they will cover.

Thanks.

At 100mg/wk of testosterone cypionate, a 200mg/ml 10ml vial will last 20 weeks. That will cost around $100 at typical pharmacies and 42 at Sam’s Club with a business membership - or similar at Costco.

Syringes are cheap when purchased in a box of 100.

10,000iu of hCG [now] costs around $42 at Sam’s with a biz membership. They no longer sell that at cost. At 250iu [SC] EOD, that lasts 80 days. 100 #29 .5" .5ml “50 unit” insulin syringes cost 12.60 at Sam’s or Walmart.

The above costs are trivial. Arimidex is expensive, if for no other reason that it is a drugs used to treat [female] cancers. Expect to pay $9 for each 1mg tablet.

Injections are more effective, what you inject, you get. The issue of individual variations of transdermal absorption are gone. More cost effective. You inject 100mg test cyp per week which becomes 70mg bioidentical test in the body. With transdermals, you will be applying 350 to 700 mg of test per week and on average, one absorbs 10% of that. Some absorb well. Some who absorb well have changes to the skin from the TRT and they then loose the ability to absorb. This is a well known problem. And those who are hypothyroidic are known to not absorb much at all. Failure to respond to transermal T is not unusual at all. And some who do respond well can have skin reactions or just do not like the application routine.

Transdermals are not viable for those who work hard and sweat, or train and sweat or need to shower or swim before the transdermal is absorbed. Transdermals also increase E and DHT more than injections through the actions of the skin/follicles on the local high levels of T. DHT and E are considered to be a threat to the prostate in terms of BPH. And T was thought to be be the same for decades, however that was a groundless assumption that became “truth” after been repeated over and over again … as an act of faith. It turns out the estrogen is large factor in BPH. Case in point. My TT, FT, DHT were all low before I started TRT. My E was lowish, because of low amounts of T, but the E:T ratio was higher. T and E oppose each other. In some ways, I was becoming estrogen dominant. Now 2 years later with high TT, FT, DHT, my urine flow is way better than it was 10 years ago. I keep my E2 levels in the 20-24 pg/ml range. by “conventional thinking” my increased T and DHT levels should have made things worse, but the opposite happened. My PSA level is very low.

The prostate has E receptors and E stimulates the prostate. Men who have syndrome-X aka metabolic disorder have low T and high E. They are estrogen dominant, have female fat patterns and apple shaped guts. They are primo for CHF and heart attacks/strokes. They also as a group have high[er] levels of BHP and prostate cancer. They have higher levels of blood sugar and are often prediabetic and many progress to insulin dependant diabetes. The loss of T with age and or obesity can lead to this end state.

TRT without estrogen control might have the opposite effects. As TRT increases E, the principles of HRT, restoring hormones to youthful levels and maintaining a proper balance of hormones; TRT without an AI [arimidex] can be seen as doing harm.

TRT also increases life expectancy by improving endothelial function. TRT also lowers cholesterol as well. MY total cholesterol went to 202-206 from 270’s. I also respond well to folic acid, vitamin B-6, naicin and my HDL is now 73, was 48 before TRT.

Thanks for the informative post. I had been looking at Sam’s prices as well as mail order insurance company’s site.

Looking at the allthingsmale.com article on TRT, it looks like Arimidex he starts with at .25mg every third day, so that’s one pill every 12 days (1/4 1 mg pill every 3 days so a pill ever 12 days or so) total or maybe 2.5 pills a month. Using 3 pills a month would end up being pretty cheap with my insurance at less than $30 for 90 days.

It will probably end up not being much different in costs to my current treatment, with hopefully better results.

I suspect I’ll end up with quite a few Dr visits to get this sorted and dosages set. Hopefully I can find somebody who will be open to giving me new options.

The typical dose of adex when on an effective RTR dose is 1mg/week. That can be adjusted after labs. This starting dose would be for a TRT that delivers TT near or a bit over the upper lab range and often FT that is over the range. And that 1mg/wk dose can be scaled by body mass, pre-TRT E2 numbers and amount of body fat. Relative to a weight of 160 pounds, someone weighing 240 pounds could start on 1.5mg/wk.

.25mg EOD would be .875mg/wk which is still probably not enough for most to get into the lower 20’s.

With injected T, your T levels are quite predictable. Adex can be used from day one without waiting for a lab result after T alone to see that E2 has increased. If you start on adex from day one, your first post-TRT lab will be an dose adjustment and you will not be suffering from estrogen poisoning until after the lab results and a visit to the Doctor’s office.

Ditto for hCG. You do not need to wait for your testes to shrink and your scrotum to pull up tight. Effective TRT shuts down your testes and only injections of hCG will do the job.

[quote]MannishBoy wrote:
KSman wrote:
Why would an oncologist have any knowledge about these issues?

[/quote]

The answer to KSman is “They should know everything about these issues.”
To the OP:

Part of treatment planning has to do with issues of fertility and hormone preservation in HD, a curable disease. Presuming that you got ABVD, and not BEACOPP, fertility may be preserved and hormonal independence should have been preserved.

Some points:
The initially low T level is not unanticipated, and typically rises on its own 2 to 4 months after completion of chemo.
Now, after 3 years of topical use, your pituitary axis may be blunted. (This is not irreversible, but your oncologist may not be up to that question.)
Even if you have not had radiotherapy to the neck, get your thyroid (T4 and TSH level) checked, and consider getting blood level for prolactin.

[quote]DrSkeptix wrote:
MannishBoy wrote:
KSman wrote:
Why would an oncologist have any knowledge about these issues?

The answer to KSman is “They should know everything about these issues.”
To the OP:

Part of treatment planning has to do with issues of fertility and hormone preservation in HD, a curable disease. Presuming that you got ABVD, and not BEACOPP, fertility may be preserved and hormonal independence should have been preserved.

Some points:
The initially low T level is not unanticipated, and typically rises on its own 2 to 4 months after completion of chemo.
Now, after 3 years of topical use, your pituitary axis may be blunted. (This is not irreversible, but your oncologist may not be up to that question.)
Even if you have not had radiotherapy to the neck, get your thyroid (T4 and TSH level) checked, and consider getting blood level for prolactin.
[/quote]

We talked about fertility issues and I did store sperm. So it wasn’t unanticipated that I would have a problem.

HRT started several months after chemo. I think longer than 4 months IIRC, but I would have to go back into my files.

My lymphoma was near my appendix, so I had a bowel resection. Since it was in the bowel and hadn’t spread to any nearby lymph nodes, it did not involve any radiation (as I understand it radiation isn’t typical for bowel issues for a variety of reasons). I did 6 cycles of chemo every three weeks (with a brief pause when my white counts bottomed out completely).

I will definitely make note of your suggestions and ask about those. I’m making some notes to discuss.

So you are saying at this point I might even have a chance to get off of HRT?

1 Like

[quote]DrSkeptix wrote:
MannishBoy wrote:
KSman wrote:
Why would an oncologist have any knowledge about these issues?

The answer to KSman is “They should know everything about these issues.”

[/quote]

If that were true in general… we would not even be here discussing such things. :wink:

[quote]MannishBoy wrote:
DrSkeptix wrote:
MannishBoy wrote:
KSman wrote:
Why would an oncologist have any knowledge about these issues?

The answer to KSman is “They should know everything about these issues.”
To the OP:

Part of treatment planning has to do with issues of fertility and hormone preservation in HD, a curable disease. Presuming that you got ABVD, and not BEACOPP, fertility may be preserved and hormonal independence should have been preserved.

Some points:
The initially low T level is not unanticipated, and typically rises on its own 2 to 4 months after completion of chemo.
Now, after 3 years of topical use, your pituitary axis may be blunted. (This is not irreversible, but your oncologist may not be up to that question.)
Even if you have not had radiotherapy to the neck, get your thyroid (T4 and TSH level) checked, and consider getting blood level for prolactin.

We talked about fertility issues and I did store sperm. So it wasn’t unanticipated that I would have a problem.

HRT started several months after chemo. I think longer than 4 months IIRC, but I would have to go back into my files.

My lymphoma was near my appendix, so I had a bowel resection. Since it was in the bowel and hadn’t spread to any nearby lymph nodes, it did not involve any radiation (as I understand it radiation isn’t typical for bowel issues for a variety of reasons). I did 6 cycles of chemo every three weeks (with a brief pause when my white counts bottomed out completely).

I will definitely make note of your suggestions and ask about those. I’m making some notes to discuss.

So you are saying at this point I might even have a chance to get off of HRT?
[/quote]

Ah, I see. I misread the diagnosis and now I understand.
You had a program incorporating high doses of predisone (possibly R-CHOP, unless you, lucky guy, had Burkitt’s lymphoma).
Prednisone–even when it does not knock off the adrenals–causes squirrelly things to happen to gonads for months.
Talk it over with your oncologist; you may have been only temporarily “nut-stunned.” Fixing it now, however, should be an individualized process.

And, by the way, congratulations!

[quote]DrSkeptix wrote:
Ah, I see. I misread the diagnosis and now I understand.
You had a program incorporating high doses of predisone (possibly R-CHOP, unless you, lucky guy, had Burkitt’s lymphoma).[/quote]

I had a large cell lymphoma. I do not remember hearing Burkitt’s mentioned.

I did have a round of prednisone with treatments. I can’t remember the exact dosage.

The chemo drugs used were adriamycin (red urine was fun), vincristine, cyclophosphamide, and rituxan. Took hours for my treatments every time, but luckily it was once every three weeks.

I definitely will do and have briefly before. She knows I’m on androgel, but did not know of the low T again. I had previously talked to the oncologist about a possible switch to injections and she mentioned referring me out, but I had at the time wanted to get another physical to see what the numbers were doing. Now we know things weren’t going as well as initially.

Thanks. I feel lucky to have caught it early, and it has gotten me back into staying fit and eating right. I even enjoy it now and can’t imagine going back to junk food and no serious exercise. I actually started working out during chemo to keep my energy levels up and build back abdominal muscles from having them cut vertically about 8" for the bowel resection.

Thanks again for the info. I get PET/CT scans in early May, so will start down this path to seeing an endo then I suspect.