T Nation

TRT and Addison's


#1

Long time lurker, first time poster.

I'm 43. I have had Addison's Disease (meaning my adrenals don't work) for most of my adult life. I take meds for that every morning -- currently 0.5 mg dexamethasone (to replace the cortisol), 0.1 mg fludrocortisone (to replace the aldosterone), and 50 mg DHEA (to replace the DHEA, although it doesn't actually seem to have much of any effect).

After fighting for years with endocrinologists who didn't know crap about Addison's, I found one who really knows his stuff and is willing to "tinker" (his word) to optimize my health.

I saw him a couple of weeks ago, we discussed the possibility of low T, and sure enough the bloodwork seems to have confirmed it. I don't have the full lab report in hand yet -- they're sending it -- but one of the other docs in the practice read me a few key numbers over the phone:

Total T: 251 [ref 250-1100 ng/dL]
Free T: 58 [ref 46-224 pg/mL]
Bioavailable T: 146 [ref 110-575 ng/dL]

(Lab is Quest Diagnostics, as was probably obvious to some of you.)

There's reason to believe that my T has been low for years -- I've been fighting moderate depression, fatigue, and problems with focus and motivation for a long time, and my post-workout recovery times have always been kind of long (and I never could build much muscle). My libido etc isn't bad, actually, but I'm on Wellbutrin, which is probably propping things up (so to speak).

For various reasons I won't be able to see the doc until (at least) next week. TRT is almost certainly in the cards, and while he will probably be pretty clued-in about the state of the art, long experience as an Addison's patient has taught me to be very well-informed when facing something like this.

So here I am, to get informed. I've read the stickies and skimmed Nelson Vergel's book on TRT, and I'm working on assimilating it into some sort of checklist I can have in hand (or at least mind) when I talk to the doc. What questions should I be ready to ask? What other resources, if any, should I be looking at?


#2

Read the stickies and posts of others. Decide if you want to do T-gels, creams or injections. If paying out-of-pocket, injections are least cost. If you have thyroid issues, there is a good probability that you can't absorb transdermals.

Don't assume that any doc is going to have a good understanding of TRT. Doc may have a lot of knowledge about how to do it wrong.

Write down the protocol that you want to start with. If needing Arimidex/anastrozole and hCG, be ready to articulate reasons.

If you are injecting anything right now, the answer is easy.

You need:
PSA now and 6 months after TRT and annual thereafter
DRE -digital rectal exam -now and 6 months after TRT and annual thereafter
Estradiol before and ongoing

Prostate concerns are not normally called for at your age, but in many ways, you may not be normal.

Post more lab work.


#3

Thanks for the response, KSman.

Prostate already gets monitored. I have PSA and DRE annually... no problems so far, no symptoms, no family history of problems. Thyroid likewise, fine so far.

Protocol... not sure yet. I don't inject anything now, but the idea doesn't bother me. Insurance will cover the usual injectibles, Testim, Androderm, and the pellets, so those are the obvious choices, though I have no idea if this doc will do the pellets or not. I'd rather avoid Testim because of the transfer risk. Realistically the choice is probably between injections and the patches, assuming the doc doesn't have a thing against self-injection.

I'll post the lab results when I have them in hand.


#4

If thyroid is fine because doc says normal, that can be wrong. Please post if possible.

With no prostate problems now, you can do TRT. You will need to compare PSA to pre-TRT baseline.

Patches are costly. Chemicals added to increase T transport, and the adhesive, lead to many trying something else. If you sweat under the patch, a layer of sweat can interfere with absorption.


#5

Thyroid gets checked every 6 mos by an endo who is actively looking for early signs of Hashimoto's. I doubt anything would be missed in my particular case, but I'll post numbers when I get them.

For injections, is there a reason to favor T-cypionate over T-enathanate or vice-versa?


#6

Had a phone call with the doc today... self-injections are fine if I'll let his nurse "teach" me the technique ("so I don't have to worry about you shooting it into your sciatic nerve or something"), which should happen in the next day or two. Still waiting on a copy of the labs, supposedly mailed a week ago. If all else fails I'll have them make a copy when I go see the nurse. I don't know yet what dosage, frequency, etc., he'll want, or which ester he will prescribe. He gave me the basic speech about how I might not notice any effects for several months.

Thyroid is fine. I could bore you with Addison's-related details about kidney function if anyone cares.

I'll post more after the visit.


#7

I hope they aren't having you do it in your ass. That's a terrible idea. You should be injecting into your outer thigh.


#8

I plan to. I think they just want to make sure I'm not likely to do anything stupid.


#9

Okay, I have (some of the) lab results:

LH: 2.00 [ref 1.24 - 8.62 mIU/mL]
FSH: 3.40 [ref 1.27 - 19.60 mIU/mL]
Albumin: 4.6 [ref 3.5 - 4.8 g/dL]
SHBG: 21.7 [13 - 71 nmol/L]

Total T: 251 [ref 262 - 1593 ng/dL]
Free T: 58 [ref 47 - 244 pg/mL]
Bioavailable T: 146 [ref 130 - 680 ng/dL]

They apparently didn't do estrogen, and they failed to mail me the thyroid stuff. I'm going in later today to get "trained" on the injections and presumably get my first dose; I'll try to get more then.


#10

Suggest that you not do E2 now, no real benefit. Test E2 later to see what you need to deal with. At that point the prior E2 status is a curiosity. SHBG indicates that E2 levels were not high.

LH and FT are variable and specific numbers are not actionable. TT, LH and SHBG are valuable.

TRT will increase your metabolism. Normally one's adrenals would adapt. In your case you need to watch for signs of changes to cortisol demand. That will be hard to do as TRT will deliver a boat load of changes.

If thyroid levels are low, you need to treat that right away. TRT with weak thyroid levels can be a problem.


#11

Saw the nurse, who watched my gf inject 200 mg of T-cyp into my glute, just as the doctor's notes had directed (because that what Pfizer's package insert says, she said). Doesn't matter, she will tell the doc I'm good to do this on my own at home, and that's what's important. I'll talk to him next week to ask him about thyroid and get the prescription set up with my pharmacy.

Man this has been a slow process -- 4 weeks from "I think we need to do this, pending bloodwork" to first dose.


#12

Quick update... my doc has been on vacation, nurse got one of the residents to write the prescription, and apparently the resident is new to this whole TRT thing. So's my pharmacy, I guess, but finally, today, I got 3 of the little vials of brand-name t-cyp (yes, the insurance company had fits that they chose the absolute most expensive way to order the stuff, $80 out of pocket, arg) and 2 bizarre needle/syringe combo things that the pharmacy had to special order "because that's what the doctor prescribed". Yep, 3 vials and 2 syringes. Tell me how the math on that makes sense. Fortunately, I live in a state where I don't actually need a scrip to buy syringes and needles, so I will go to a different pharmacy and get the proper stuff tomorrow.

Meanwhile, 10 days after the initial 200 mg injection, the effects of the first dose are fading, as anyone on Earth except an endocrinologist and whoever writes Pfizer's package inserts could have predicted. I have a little bit of nipple soreness, just showed up today. Balls ached a little for the first few days, not enough to be bothersome. My weight's up a couple of pounds and I've been really hungry, need to be a little more careful about food choices than I have been. No other sides that I've noticed so far. I've mostly felt great.

I'm supposed to talk to the doc on Wednesday. I'll ask about follow-up bloodwork then (particularly if the nipples continue to be sore). I am a little skeptical that he will be willing to prescribe Arimidex or whatever if my estrogen's up, and I bet hCG is out of the question, but we'll see.


#13

Forgot to post these. Thyroid:

TSH: 1.63 uIU/ml [ref 0.34 - 5.60]
free T4: 0.76 ng/dl [ref 0.58 - 1.64]

They apparently didn't do free T3.


#14

T4 is too low, you need a complete thyroid panel. Has doc palpated your thyroid?

Check and record waking body temps and report here.

If TRT hunger is hard to satisfy, try whey protein shakes. If that satisfies, then your body is screaming for amino acids and probably trying to recover muscle mass.

Are you getting iodine from iodized salt or vitamins?


#15

Eh. It's a little low. I'm not gaining weight (or wasn't until TRT), my face isn't puffy, and my skin's not dry. We checked thyroid antibodies about 6 months back and there weren't any, and the relevant symptoms I do have weren't new then. I'll ask for a panel, though.

Waking body temps won't be useful -- my morning temp has been under 98 for years. Remember that my cortisol rhythm is nonstandard.

Re hunger, eggs worked out pretty well. I'll try shakes.

I am getting iodine from iodized salt, sea salts, and seafood. I doubt I'm deficient.