T Nation

TRT for Hypogo 3rd Class Medical for Pilots

I thought I would chronicle my TRT here since there are so many with knowledge on this site. I’ll take any advice I can get since talking about it is the only way I can learn more about it.

I am a Mechanical Engineer by profession. I also hold a private pilots license. I have learned a lot here as I have been lurking for a couple of years now. This is my first post.

One of the things I am careful about is not losing my private pilots license. The FAA can cancel your medical license (which allows you to fly) if you are taking any prescription drugs that are not approved by them, TRT included. This means that first a pilot has to go to an FAA doctor. That doctor gives them the run down about rules and regulations.

The FAA is mostly concerned that you are not doing anything that will mess with your mind. Nothing that will make you tired or interfere with your reasoning. Certainly nothing that will make you feel low or depressed. So I use caution before a doctor writes any prescription. My FAA doctor referred me to an endocrinologist for TRT.

Having a special written note about your TRT with special wording is needed to keep the medical license required to fly airplanes. Finding an endocrinologist for TRT done right is difficult enough without the FAA looking over their shoulder. My hope is that whatever I experience in my quest for better health under so many watchful eyes will be helpful to others.

After reading the stickies and advice of KSman and others here is my case information.

Age: 47
Height: 5 feet 11 inches
Weight: 190lb
Body hair is minimal

I am carrying weight around my waist and some in my chest. No Moobs but its not muscle either. yuck! I used to be thin and no body fat. Like 2% to 5% when I was in my early 20s. After attaining my first engineering position (behind a desk) Fat accumulated to 10% to 12% with my weight around 165. Since hitting 42 it has been a steady climb to 190. I will exercise and work on my diet and get down to 180 but then I become discouraged and the weight comes back within a few weeks. When I am not working out and working on being healthy my eating habits are poor. So I am sure a permanent change to my diet would do wonders. I will be picking up better eating habits with my new TRT regimen. I will try to post progress (wins and fails) here in general terms. Not every meal.

In general for the last several years I have been feeling less and less energetic. I usually keep very busy but just want to sit and do nothing any more. People used to remark how much I used to get done. Now I get frustrated at what I haven’t achieved. It comes and goes in waves but the waves of energy to get things done are shorter now. I have become frustrated enough that concern of complicating my pilot license medical has be overtaken by concern of just being productive. Sex drive to me is a relative thing. I still have sex drive but it is not like it used to be. I would say it is about 25% of what it used to be. Instead of an enthusiastic Hell Yea! twice a day its more of a yea, okay once a week. The function is still there but its not everything it used to be. Nocturnal wood at times but becoming more rare. Morning wood at times but becoming more rare. Used to be every day in 30s now it is once every two weeks or so.

I am not taking any nor have I ever taken any hair loss or prostrate drugs. I do use Nyoxin hair shampoo and conditioner with a scalp gel. If that is important.

Training is weak. I would like to go more but just don’t. Diet is good (calculated and monitored) when training. When I’m not training then it is whatever satisfies the moment. Usually not healthy. So there is work I can do here.

Last but not lease here are the lab results. I’ll try to hit the important numbers. Let me know if there are others you want to see.

Labs done by LabCorp

Total Cholesterol: 184 mg/cL Range 100 - 199
Triglycerides: 64 mg/cL Range 0 - 149
Iron, Serum: 60 ug/cL Range 4- - 155
TSH: 1.290 uIU/mL Range .450 - 4.50
LH 3.4 mIU/mL Range 1.7 - 8.6
FSH 4.4 mIU/mL Range 1.5 - 12.4
Prolactin: 5.9 ng/mL Range 4.0 - 15.2
Free Testosterone (Direct) 4.4 pg/mL Range 6.8 - 21.5
Estradiol: 26 pg/mL Range 0 - 53
Vitamin B12: 323 pg/mL Range 211 - 946
Folate (Folic Acid), Serum 13.9 ng/mL Range >3.0
Cortisol: 7.9 ug/dL Range 2.3 - 19.4
Prostate Specific Ag, Serum 1.0 ng/mL Range 0.0 - 4.0
Vitamin D, 25-Hydroxy 13.9 mg/mL Range 30.0 - 100.0

Things of note. Low free T and Low Vitamin D.

On first visit I explained that we were in this together and that I would have questions about what he was requesting or prescribing. He said that was fair and we proceeded with the exam. He did not request E2 lab so I talked about E follows T and that I wanted a baseline on E2. He agreed that was a good idea but normally only requested that with men with gynecomastia. With this I though I was getting a doctor that was willing to listen.

Tests came back a week later and the doctor suggests Androgel 1.62% and Vitamin D 5000 units per day. I have requested T-cyp injection twice a week (he countered with once a week) I figure what he doesn’t know won’t hurt him, and I’m okay with the Vitamin D. I have asked for AI for the reasons stated in the stickies. He said no because my E2 was low and I didn’t need it. This tells me he doesn’t quite get it yet.

I also asked about testes shrinking and not producing pregnenolone. He agreed this was important, but countered that my LH was within normal range and so my brain was sending the right signals. Just my testes were not responding. I countered that yes but when the T is inserted into the system then the brain would stop sending the signal and LH would drop off the radar and the testes would retract. I then asked about HCG and its use. He pushed it off and said it was not FDA approved. Implying he could not prescribe it. Any thoughts or help on this would be appreciated. I have bounced this all off of my FAA doctor and will call my endocrinologist to have him write the prescription for t-cyp in the morning.

I will also hit him up again with the AI and a dosage. He treats a lot of women so he may be thinking I want those high dosages. I will suggest the 1 mg KSman suggested in his sticky.

Thoughts or observations on the test results or conversations are welcome. I’ll check in tomorrow with what is prescribed.

You are quite estrogen dominant.

What other Rx or OTC drugs/supplements?
What other health issues?

Any CBC, glucose, total testosterone, AST, ALT, HTC, DHEA-S, AM cortisol, ferritin, serum iron?

Have you read the advice for new guys sticky and thyroid basics?

  • have you been using iodized salt continuously for years?
  • any selenium in your supplements?
  • body temperatures?

FT is very low and FSH./LH do not explain that. So testes may be an issue. They feel OK, had them examined, lost size?

hCG, not indicated for hypogonadism does not involve “approved”, can be prescribed of label.

Find 5,000iu tiny vit-D3 caps. Take 25,000 for five days then 5,000 thereafter.

I’m in a similar situation with my doc, as I’ve written about. You know what you want/need. Tell him you’ve gotten an AI and you’re going to take it. Tell him you’ve gotten hCG and you’re going to take it. Tell him what your logic is and what amounts you’re going to take.

At the end of the day, if you’re honest with him and keeping him in the loop, then you’re really putting ball back in his court. If he wants to drop you as a patient, then he will (and you never wanted him in the first place). If he doesn’t drop you, then you’ve gotten exactly what you wanted.

Cortisol: 7.9 ug/dL Range 2.3 - 19.4

This is enough to make many feel crappy. Was this done first thing in the morning. Best at 8AM and below 10 is not a good thing.

KSman, yes it appears I am estrogen dominant which my idiot does not realize. To him that value of 26 looks like a good value. Not high nor low. But put next to my free t number of 4.4 it says I am estrogen dominant. I asked him for a prescription of Arimidex at 1mg per week with my prescrip for 100 mg test cyp. He denied me the prescrip saying it was not approved by the FDA.

Two things here. One is that he is old school. I’m learning that as I work with him. Second is his potential impact on my aviation license. I do have to be careful here. I have put a lot of money into the freedom to fly and love it dearly so I protect it as best I can. Not at the expense of my health but I will manage all messages about my health.

If you think doctors can be idiots then you will have a new appreciation for the word idiot when dealing with FAA policy makers. My FAA doctor is very active helping people continue to fly. He works hard for his money to keep pilots flying, and he put me on this endocrinologist for a reason. I will ask him about that reason soon but now the endocrinologist says no drugs that are not FDA approved which is painful to hear but might be important to me keeping my medical (and ability to fly).

So it is a dance of words with the doctors for the benefit of the FAA. Anything that is written as a prescription is visible to the FAA and will be interpreted with harsh criticism under strict rules. I learned this the hard way after spending over $20k for privileges that were denied due to a general practitioner who prescribed mood altering meds that the FAA questioned.

Because of that lack of knowledge by me and the dr. I have a letter of special issuance that I must submit every 2 years with follow up. Hence my caution and willingness to work the issue with appropriate words. If you or others would like more information on what the FAA is trying to drive through their policies or the rules as written I can give links.

Other than that it would be off topic to the diagnosis of the lab results and general conditions. The funny thing about this is that I am trying to improve my health. If I did not highlight it then the FAA would never know and I could carry on my way without anyone ever knowing. But because I care about my health and have a desire to improve it beyond normal and more towards optimal I am flagged as a risk.

Meanwhile commercial pilots who have careers and families on the line willingly ignore their depression and critical health issues so they can continue flying. They aren’t just flying themselves but they are flying you and me and those we love. It is scary when you shine that different light nod the regs isn’t it? Anyway to your questions.

I take no other prescription drugs, and I don’t take any OTC drugs regularly. Some allergy during season which is not now.

Glucose Serum 97 mg/dL Range 65 - 99
Uric Acid Serum 5.9 mg/dL Range 3.7 - 8.6
BUN 16 mg/dL Range 5 - 24
eGFR 72 mL/min/1.73 Range >79
BUN/creatinine Ratio 13 Range 9 - 20
Sodium, Serum 4.2 mmol/L Range 134 - 144
Potassium, Serum 4.2 mmol/L Range 3.5 - 5.2
Chloride, Serum 106 mmol/L Range 97 - 108
Calcium, Serum 9.1 mug/dL Range 8.7 - 10.2
Phosphorus,Serum 3.1 mg/dL Range2.5 - 4.5
Protein, Total, Serum 6.7 g/dL Range6.0 - 8.5
Albumin, Serum 4.6 g/dL Range 3.5 - 5.5
Globulin, Total 2.1 g/dL Range1.5 - 4.5
A/G Ratio 2.2 Range1.1 - 2.5
Bilirubin, Total .5 mg/dL Range 0.0 - 1.2
Alkaline Phosphatase, S 52 UI/ L Range 39 - 117
LDH 181 UI/L Range 0 - 225
AST (SGOT) 21 iu/L Range 0-40
ALT (SGPT) 27 iu/L Range 0 - 40
GGT 22 iu/L Range 0 - 65
Iron, Serum 60 ug/cL Range 40 - 155
Cholesterol, Total 184 mg/cL Range 100 -199
Triglycerides 64 mg/dL Range 0 - 149
TSH 1.29 uIU/mL Range .450 - 4.500
Thyroxine (T4) 7.7 ug/dL Range 4.5 - 12.0
Triiodothyronine, Free, Serum 3.4 pg/mL Range 2.0 - 4.4
T4 Free (Direct) 1.51 ng/dL Range .82 - 1.77
Thyroid Peroxidase (TPO) Ab 12 IU/mL Range 0 - 34
LH 3.4 mIU/mL Range 1.7 - 8.6
FSH 4.4 mIU/mL Range 1.5 - 12.4
Prolactin 5.9 ng/mL Range 4 - 15.2
Free Testerone (Direct) 4.4 Low pg/mL Range 6.8 - 21.5
Vitamin B12 323 pg/mL Range 211 - 946
Folate ( Folic Acid), Serum 13.9 ng/mL Range >3
Cortisol 7.9 ug/dL Range 2.3 - 19.4 this was taken at about 10:15 AM after waiting at the dr office for an hour and getting up at 7:30 AM
IGF-1 102 ng/mL Range 67 - 205

I have read the sticky on thyroid. I have not considered this an issue.
Temps have been normal but my references are rather random. I will check them and give you an answer soon. I have not been taking any supplements so the answer to Selenium is no. No vitamins nothing.

Testes feel okay but seem smaller. It might be a perception thing but at one time I was impressed at their size. No longer the case. So yes I believe they have lost size over the last 5 years or so, but I was never the type of guy that used a micrometer on his nuts ;’).

As for AI and HCG I might need to find an alternate source. This dr doesn’t seem to be interested in them as alternatives but I will check with my FAA dr to understand first.

Thanks for the heads up un the Vitamin D. I bought 400 capsules of D-3 5000 iu at SAMs club for about $10. I’ll take 5 per day for the next 5 days as suggested. I’m guessing that all at once is okay.

[quote]Fat Boy 33 wrote:
I’m in a similar situation with my doc, as I’ve written about. You know what you want/need. Tell him you’ve gotten an AI and you’re going to take it. Tell him you’ve gotten hCG and you’re going to take it. Tell him what your logic is and what amounts you’re going to take.

At the end of the day, if you’re honest with him and keeping him in the loop, then you’re really putting ball back in his court. If he wants to drop you as a patient, then he will (and you never wanted him in the first place). If he doesn’t drop you, then you’ve gotten exactly what you wanted. [/quote]

Fat boy 33. If I wasn’t a pilot and concerned about my freedom to fly I might take that approach, but I am more cautious about who I disregard so quickly. I have been ignoring this issue for some time. I will take the time to ensure I achieve all my goals. Not just getting this dr to agree to my demands. He may have influence on something else that is important to me.

If it was just about the TRT that I think is correct then I might not even bother with a doctor at all. After all there are many who will prescribe anything I want, and there are others that don’t require a prescription at all. I see plenary of huge guys at the gym that aren’t natural.

Per your advice he might just say okay go get your T from that source too. Then where am I? I don’t really have that source so I’m back at square one looking for a dr. I think it is better for me to establish the need through him, and build trust. This is a two way street. He has to learn to trust me too. I have dr friends that are very good but cautious with new patients because they often try to manipulate them. I complain about this dr because he is making me work to get what I want, but the truth is I don’t know him yet and he doesn’t know me. So I am willing to work on that for a bit. After all I have only met him twice now. Total time together is under two hours. If he is a reasonable person then he will come around.

I do like the direct approach, but I’m not sure it is best right now. Maybe in a month or two if a better option doesn’t present itself.

I will have to study up on that. Any advice on where to find more information?

I should also note that my BP is around 107/67 and my pulse is around 57. This is and has been typical for me as long as I can remember. It was typical of my father as well. My dad’s dr used to say he had the hear of a horse. Then my father had a heart attach at 57 and again at 69 or 70. He is now 87 and still going but his experience has taught me not to trust a low BP as a sign that everything is good.

The Feds don’t care about private pilots with a third class medical. Soon your medical for four place private aircraft is going to be your drivers license. It will be similar to the sport pilot license medical requirements but they’re upping the aircraft limits. Rarely do people disclose their excluded or problematic meds when getting a third class medical.

[quote]brentf13 wrote:
The Feds don’t care about private pilots with a third class medical. Soon your medical for four place private aircraft is going to be your drivers license. It will be similar to the sport pilot license medical requirements but they’re upping the aircraft limits. Rarely do people disclose their excluded or problematic meds when getting a third class medical. [/quote]

It is true that there is work being done to get the private pilots license medical reduced to a drivers license but that will not mean that current medical exclusions will be eliminated. And I want to continue flying today. I’m not betting my current license on future legislation. Also it might be a third class today but a commercial or CFI ticket tomorrow. So I want to keep the record clean. Anything that is a prescription drug is visible to the FAA. So maybe I’m not sure about what you mean regarding excluded or problematic meds. The fed checked prescriptions and dates then pulled the medical a day after it was issued. Yes one day. Unbelievable but true. Nothing can fly through any federal system that fast unless it is removing freedoms from a citizen. Restoring that freedom took me 3 days of running around and a restricted 1 year medical after that. I’m careful now.

Well, I can certainly understand your predicament. If you want to play nice with your doc, then you may just have to go through an anti-aging place or something of that nature. Finding places to get gear is not too tough of a trick. You can probably sort that if you need to, but, again, I understand that you don’t really want to do it that way. It makes perfect sense. Unfortunately, that’s the rock/hard place we’re often stuck between.

[quote]Fat Boy 33 wrote:
Well, I can certainly understand your predicament. If you want to play nice with your doc, then you may just have to go through an anti-aging place or something of that nature. Finding places to get gear is not too tough of a trick. You can probably sort that if you need to, but, again, I understand that you don’t really want to do it that way. It makes perfect sense. Unfortunately, that’s the rock/hard place we’re often stuck between.[/quote]

Yes. I may have to go that rout but I’m new to this and have much to learn. If he refuses to listen to reason, I won’t hesitate to find a healthier option. What I have read here makes sense and he has been unable to counter what I have learned here. In fact he seems confounded with the logic of it and then has reverted to his authority. I’m sure it is very hard on his ego if he is honest with it. If he is not honest with it and arrogance blocks conversation then I will end this very quickly. I have some more blood tests coming within a week and I will talk with him again then in a bit more direct tone.

[quote]KSman wrote:

hCG, not indicated for hypogonadism does not involve “approved”, can be prescribed of label.

[/quote]

KSman,
Sorry I don’t understand what you mean by this. Can you explain?

[quote]Tymer5 wrote:

[quote]KSman wrote:

hCG, not indicated for hypogonadism does not involve “approved”, can be prescribed of label.

[/quote]

KSman,
Sorry I don’t understand what you mean by this. Can you explain?
[/quote]

Obviously not KSMan, but here goes. He can correct me if I’m wrong.

Primary Hypogonadism means your testicles aren’t producing testosterone even though the signalling to them (via LH and FSH) is at ‘normal’ levels. hCG takes the place of LH and FSH, but if your testicles aren’t producing testosterone, then hCG isn’t going to make them start.

hCG works well for people with secondary hypogonadism. They have issues with producing the LH and FSH, but their testes will produce the testosterone once the signalling is there.

Does that make sense?

[quote]Tymer5 wrote:

[quote]KSman wrote:

hCG, not indicated for hypogonadism does not involve “approved”, can be prescribed of label.

[/quote]

KSman,
Sorry I don’t understand what you mean by this. Can you explain?
[/quote]

Obviously not KSMan, but here goes. He can correct me if I’m wrong.

Primary Hypogonadism means your testicles aren’t producing testosterone even though the signalling to them (via LH and FSH) is at ‘normal’ levels. hCG takes the place of LH and FSH, but if your testicles aren’t producing testosterone, then hCG isn’t going to make them start.

hCG works well for people with secondary hypogonadism. They have issues with producing the LH and FSH, but their testes will produce the testosterone once the signalling is there.

Does that make sense?

Yep that make perfect sense. That wasn’t what I was confused about. I was wondering what he meant by " does not involve approved, can be prescribed of label.

But while we are on the subject; since I am injecting T won’t that be seen as a signal by my pituitary to stop producing LH? Thus shutting down my testes? Or will they continue to produce LH if my testosterone is within normal? I’m of the opinion that the pituitary will see the T it is calling for and will no longer produce LH, thus making the boys retreat. Thought or evidence to suggest otherwise? My Dr thinks there is no need for HGC since LH is present.

[quote]Fat Boy 33 wrote:

[quote]Tymer5 wrote:

[quote]KSman wrote:

hCG, not indicated for hypogonadism does not involve “approved”, can be prescribed of label.

[/quote]

KSman,
Sorry I don’t understand what you mean by this. Can you explain?
[/quote]

Obviously not KSMan, but here goes. He can correct me if I’m wrong.

Primary Hypogonadism means your testicles aren’t producing testosterone even though the signalling to them (via LH and FSH) is at ‘normal’ levels. hCG takes the place of LH and FSH, but if your testicles aren’t producing testosterone, then hCG isn’t going to make them start.

hCG works well for people with secondary hypogonadism. They have issues with producing the LH and FSH, but their testes will produce the testosterone once the signalling is there.

Does that make sense?[/quote]

hCG is approved for inducing ovulation in women by the FDA, not for testicular stimulation in men. For this purpose the prescription is written “off label”. Many drugs including anastrozole and clomiphene have alternate uses for those they weren’t originally intended.

hCG has a couple of subunits, one of them is identical to LH but no part of it is similar to FSH. For this reason hCG will stimulate the leydig cells and testosterone production but not spermatogenesis. This is reliant on your own FSH production which will likely be eventually zero.

If you can’t take medications because they’re off label you might just want to give up on TRT. Without an AI or hCG life could just suck. Without and AI and hCG, I would have breasts, no palpable testes, acne, no sex drive, and low-normal TT (what I started with).

Hmmm, I thought there was a FSH component of hCG. It’s definitely used to keep people on exogenous testosterone fertile. I don’t claim to have the whole endocrine system figured out, so I’m not trying to be argumentative. The connection with hCG and spermatogenesis is definitely there. It may have nothing to do with FSH, but there are several interactions going on.

[quote]Tymer5 wrote:

[quote]KSman wrote:

hCG, not indicated for hypogonadism does not involve “approved”, can be prescribed of label.

[/quote]

KSman,
Sorry I don’t understand what you mean by this. Can you explain?
[/quote]

Low T can sometimes be fixed with hCG and AI for E management with younger guys who have good testes. For older guys, that approach is not very sucessful; their testes do not perform well enough to get to TRT targets of high T levels.

When T levels are very low and one is estrogen dominant, you can’t get very far by lowering E2 because you don’t want low E2. And as E2 is obviously not driving secondary hypogonadism, lowering E2 will not lead to more T. So anastrozole alone is not going to be very helpful.