T Nation

TRT in Russia, Advice Needed

Hello! I think I need an advice about using TRT for treating hypogonadism.

I’m a 37 yo man, live in Russia, recently diagnosed with “Primary hypogonadism” - it’s from blood tests, which show testosterone level at 8.7-10,3.

There are well-being issues also. I’m a long-time user of antidepressants due to OCD, ICD, anxiety - I have been using them from 2007. Unfortunately, after years of use, withdrawals, switches, trying different options and combinations, I developed both tolerance and dependency. I’m currently on Cymbalta, and while feeling shitty on it I completely unable to switch from it or combine with some other AD - because of absurd withdrawal syndrome, and because I already tried almost every AD available.

Well, at the moment my issues are:
1.) Near-zero libido.
2.) Absence of morning woods. Bad erection in overall. It doesn’t get up with girls, unless on Viagra. And even Viagra has uncomplete effect.
3.) Overall lack of arousing in anything.
4.) Heavily delayed ejaculation.
5.) Little muscle mass, low strength indices.
6.) Extreme chronic fatigue, tiredness, sleepiness, unrefreshing sleep.
7.) Low motivation, activity, very apathetic.
8.) Brain fog, poor concentration, bad working memory, lowered cognition, tinnitus.

Moreover, the condition is constantly worsening, year after year.

And why I want to try TRT:
1.) Blood tests shows lack of testosterone.
2.) I run out of options with antidepressants anyway.
3.) Every AD gives incomplete effect at best. And nothing but adverse effects at worst.
4.) Fatigue and tiredness manifested right after 30 y.o. - which can be associated with testosterone drop.

In general I feel like dead forever-sleeping potato, barely able to function, work and move.

Here are my blood tests:
Testosterone: 297
LH: 1.52 mIU/ml
FSH: 4.15 mIU/ml
SHBG: 29,7 nmol/l
TSH: 3.49 uIU/ml
Prolactine: 152 mLU/L [sic!]

There are other data in the test, but nothing interesting, I believe.

Well, I visited a few local doctors - one of them prescribed Androgel, another prescribed nothing, and the third - testosterone undecanoate (Nebido) alone. I even bought that Androgel stuff, but then quickly googled and discovered that testosterone solo leads to testicular atrophy. And then I visited two other docs. “Nothing” as prescription doesn’t satisfy me also, because I’m already at my wits end, and doing something is better then doing nothing. And about Nebido - I’m not gonna solo it, and AFAIK it takes up to 10 month to start to feel the effects, not to say it costs a lot.

Here, in Russian pharmacy we have the following testosterone drugs:
1.) Androgel
2.) Sustanon
3.) Omnadren
4.) Nebido

And no cypionate/enanthate things.

There are problems with these.
1.) First, these drugs can be bought by one-time Rx. And the Rx costs as much as the drug itself. Going to a doctor each 1-2 months to pay a ton of money for a simple Rx is a huge waste.
2.) Local doctors don’t combine testosterone drugs with hCG, clomid, AI, etc - they don’t know how to do it and have no idea about right dosages for these combos.
3.) All these drugs seems shady to me. Gel is both quite ineffective and expensive. Nebido costs a lot, has very delayed onset, and as I heard, painful to inject and unpopular among TRT users. About Sustanon and Omnadren - I have no idea what is it, how good they are, and what to do with them.

And there are other source of receiving t drugs - online stores. I completely unfamiliar with them, not sure which ones are fraud, sell fake drugs or something. But I found one that looks like real - and it sells good old cypionate/enanthate at affordable prices at various dosages, as well as clomiphene, tamoxifen, anastrozole.

Uh… I lean towards buying from the online store. I know it is retarded to buy unreliable drugs from unreliable sources. But I presume it is also retarded to buy shady things like Sustanon/Omnadren/Nebido and pay a ton of money for Rxes forever. While the online store can actually sell quality drugs with known effectiveness.

Can you guide me with drugs, dosages, blood tests, target levels, symptoms?

AFAIK:
1.) For t drugs cypionate/enanthate are most common. I prefer enanthate just because there are wider choice in the store. I should use it twice per week or every three days.
2.) For testicular atrophy prevention I can use hCG, or clomiphene, or tamoxifen. I would like to use tamoxifen: it is present in the store while hCG is not; no need for more injections; it’s cheaper than hCG; more tolerable than clomiphene.
3.) I have to not use anastrozole right from the start, but only if blood tests shows high estrogen levels. And if indicated, I should use it in dosage 0.25-0.5 per week.

Am I right, can you correct me? What dosage and timing can you recommend me for t enanthate and tamoxifen?

What are my target levels of testosterone? I read that some Vermeulen dude says, that lower t level for my age is 11,4, mean is ~19, and higher is ~30. Which level or range should I target?

What blood tests and how soon should I undergo to check my progress? How often?

Thanks all for reading this and possible advices.

You have secondary hypogonadism, not primary hypogonadism. A primary hypogonadism blood test would see LH very high and testosterone low, secondary hypogonadism is low LH and low testosterone. All these drugs likely contributed to your low testosterone, klonopin is why I need TRT in the first place.

Androgel is a poor option, men tend to absorb it poorly, women is another story. Nebido isn’t your best choice, Sustanon would be, Omnadren is no longer marketed. Everyone will need different injection frequencies do to individual metabolization and excretion of testosterone.

A good protocol would be 60mg twice weekly, large infrequent injections can drive estrogen high negating some of the good effects of TRT like mood, libido and erections. If estrogen becomes a problem on this protocol, try injecting smaller doses every 2 days.

TSH is terrible, beware the ranges are invalid as the mean TSH group that made up the ranges were later found to be contaminated with individuals that had various degrees of hypothyroidism and autoimmune diseases, yet doctors are unaware.

Free T3 should not have been skipped, Free T3 (not TSH) increases body temperature, metabolism speeding every cell in your body, if low regardless of TSH, you would have symptoms. Sometimes Reverse T3 can be the cause for elevated TSH and then hypothyroidism.

The evidence for a narrower thyrotropin reference range

Reference ranges for TSH and thyroid hormones

Wow I thought steroids were born in Russia and perfected in Germany. I would think that your docs would be the most knowledgeable around! Lol

Seriously though, I agree with SL that you are secondary not primary. I also agree that you should probably get a full thyroid panel done before you start TRT and try to get that straight.

Imo, you would be better off with Sustanon solo to start, adding HCG only after you get the testosterone dialed in. Sustanon has multiple esters that make it somewhat tricky to dial in protocol wise. I have no experience with it personally, but most of my reading indicates that most do better with once weekly injections on Sustanon regarding the combination of slow and fast release esters. @unreal24278 could probably give you better advice regarding this drug as I believe he has experience with it. Even if he doesn’t, the kid is a hormone and drug wizard and he would still give better advice than most. Lol.

A typical starting dosage would be around 100mg Test per week. Whatever dose and frequency you choose, stick with it for at least 6-8 weeks (some experts say 3 months is better) and then get bloodwork ran again to see where you’re at.

2 Likes

alright, sustanon is a combination of test prop, phenyl prop, isocaporate and decanoate from what I recall. The total amt of each is like a 30/60/60/100 ratio (feel free to correct me here)

Fluctuations in hormonal status given the shorter estered test will occur, however I don’t see that as too much of an issue if you’re pinning like 50mg 2x/wk (or you could just pin 1/4ml 2x/wk for 125mg/wk, it’s simpler and less of a pain with accurately measuring out doses, just go “well that’s about a quarter, yeet”)

HCG isn’t nessecary, testicular size is vanity, seriously, who cares. I doubt girls notice that much (unless they watch a ton of porn and thus have the expectation that during… actually I’m not going into that it’s strange to describe, you get what I mean tho)

If you want to try conceive a child, sure go for HCG. If you truly have primary hypogonadism though chances are you’re infertile and thus won’t respond to a LH mimick as the hormonal problem stems from the testis, thus no amount of LH/FSH stimulation will make a difference thus it likely won’t do jack shit for you. Long term use of HCG (in rodent models and potentially humans) will down regulate LH receptors, thus impeding you’re bodies ability to respond to LH over time… Besides that HCG comes with some sides that can be irritating to deal with, it’s just adding another drug that isn’t particularly needed.

Go by how you feel, not bloods (although I do recommend regular, comprehensive bloods. Are private bloods a thing in Russia?)

Привет!

  1. Судя по анализам у тебя не первичный гипогонадизм, а вторичный. При первичном гипогонадизме ЛГ и ФСГ стремятся в “небеса”. Либо ты попал к очень-очень плохому доктору, либо ошибся с диагнозом.
  2. Большинство урологов-андрологов/эндокринологов в России не обучены правильному подбору препаратов, дозировки и пр. В лучшем случае они ознакомлены со стандартными протоколами в духе: Омнадрен 250 раз в 2-4 недели. Даже в МСК будет очень тяжело найти толкового доктора.
  3. В твоём случае использование геля не только не оправдано (в случае вторичного гипогонадизма более эффективным считается использование кломифена/тамоксифена или ХГЧ, чем геля), но и более рискованно, в свете побочных эффектов (угнетение ГГЯ и, соответственно, собственной выработки тестостерона).
    Сустанон и Омнадрен это смеси эфиров тестостерона. Тестостерон Ципионат, например, это один эфир. Сустанон/Омнадрен — 4. Из-за этого возникают некоторые сложности в администрировании данных препаратов.
  4. Антидепрессанты принимались по предписанию врача или сам решил прибегнуть к их использованию? Побочные эффекты могут включать в себя почти всё, что ты описал в виде симптомов гипогонадизма. И да, это неспецифические симптомы.
  5. Есть ли анализы Т3 свободный, Т4 свободный, Т3 общий, Т4 общий, АТТПО, АТТГ, витамина д? Если нет, то советую сдать. Плохое самочувствие и низкий уровень тестостерона может быть связан и с ними.
  6. Ты, конечно, можешь покупать тестостерон с рук, но это чревато. Во-первых, наказуемо по-букве закона. Во-вторых, большое количество подделок даже андерграундных препаратов. В-третьих, обычные барыги-кидалы
  7. Не существует “одного размера, что подходит всем”. Да, большинство людей на этом форуме используют в ГЗТ ципионат/энантат, но что касается дозировок и уровней — тут всё индивидуально и подбирается под конкретного пациента.
  8. Кломифен и тамоксифен не помогут тебя избежать атрофии тестикул на ГЗТ. Для этого используется только ХГЧ, но из-за него появляются дополнительные проблемы в администрировании протокола (в основном, с уровнем эстрадиола, приливами, жаром, акне, и т.д.) на ГЗТ.
  9. Что касается анастрозола и его приёма, опять же, всё довольно индивидуально. Сейчас считается, что важен не сам высокий уровень эстрадиола для его контроля, но его соотношение с уровнем тестостерона и самочувствие пациента, вкупе с выраженностью симптомов.
  10. Мой совет, либо сдай все анализы и поищи хорошего доктора, либо попробуй начать с кломифена соло, в случае вторичного гипогонадизма он рекомендован. Сесть на пожизненную ГЗТ препаратами тестостерона всегда успеешь, и поверь мне, это ещё то удовольствие.

АПД: Также не вижу у тебя:
В анализах: эстрадиола, глюкозы натощак.
Рост, вес, процент жира.
Есть ли проблемы с сердечно-сосудистой? (Например, эректильная дисфункция расценивается как ранний маркер системной эндотелиальной дисфункции).

Yup Don’t just take trt with that tsh level. You 100.% need to look into your thyroid. Without thyroid optimized you’ll continue to feel fatigued.

Get them to prescribe higher levels and take less. How much is it for you when you say expensive, is that a car payment for you or less? Totally curious. Russia has issues with supply since the UN places restrictions on trade. I would try to pick a medicine that’s produced locally in Russia and stick with that,

Hi there, thanks for yor replies.

1.) Regarding primary vs secondary. Should I point this out to the docs, like “Doc, you are wrong, people in the internet said it’s secondary hypogonadism” - or I can silently ignore the difference? Does it matter much?

Doc arguments that it’s primary because “Your LH/FSH is OK but testosterone isn’t - which means your brain is OK and the problem in the testes” - seems logical. You say “Your testes doesn’t produce enough testosterone but brain doesn’t try to compensate it by raising LH/FSH levels - so it’s the brain” - which is logical too. I don’t understand. Are mixed states possible? Where brain is weak enough and unable to boost LH/FSH levels, and balls also cannot produce enough testosterone for adequate LH/FSH provided?

2.) About thyroid. I visited an endocrinologist right about an year ago. At that time I still was on 25 ug L-thyroxine daily, which I had been taking for ~5 years. She told me that she is a pro with over 20 years of experience etc, that I’m completely OK with thyroid, that 25 ug is nothing, and strongly insisted me to cancel L-thyroxine. I have blood tests of those times, here they are.

2018-04-06
TSH: 1.71 uIU/ml
FT4: 12.6 pmol/l
SHBG: 50.1 nmol/l
Testosterone: 251

2018-06-14
TSH: 1.44 uIU/ml
FT3: 1.82 pg/ml
FT4: 15.6 pmol/l
Cortisol: 298 nmol/l
Prolactine: 134 mLU/L
SHBG: 30.4 nmol/l
Free testosterone: 9.8 pg/ml
Testosterone: 282

After the test above I canceled L-thyroxine as endo recommended. Then took another small test.

TSH: 1.96
FT4: 14.5

And now TSH is 3.49. It seems that small 25 ug doses of L-thyroxine are able to keep TSH at good levels. But in regard to mood - I doubt I felt much difference. Definitely no improvements in fatigue, activity, motivation, cognition, memory etc. Libido might be lowered without L-thyroxine - but I’m not sure here.

3.) I’m not going to say buy to my balls, DHEA, and pregnenolone - I prefer to keep myself intact, and DHEA and pregnenolone are important for cognitive and mood effects. If I really have secondary hypogonadism, activating the balls would boost these effects.

4.) I agree that antidepressants and other psychoactive drugs can cause wide range of effects. But I can’t withdraw from them anyway, I assume we can can simply ignore their presence.

Yes, one can perform blood tests as much as he wish, as long as he has enough money. They are expensive, though.

badtimes92, PRIVIET TOVARISCH COMRADE.

Первые шесть лет - по назначению того или иного врача. Потом самостоятельно. Я сам до сих пор думаю, что в значительной степени именно антидепрессанты виноваты в моём теперешнем состоянии. Но на текущий момент сильно их теребить не имеет смысла - каждая смена дозы, смена препарата - это новый всплеск побочных эффектов и толерантности. Сейчас я застрял на Симбалте и не могу откорректировать дозу ни в одну сторону, чтобы не офигеть от синдром отмены или побочных эффектов. В целом, перепробованы большинство мыслимых и немыслимых комбинаций. Антидепрессанты, нейролептики, ламиктал, физическая активность, светотерапия, БАДы, стимуляторы - от всего или нулевой эффект, или без кардинальных улучшений. Жалобы всегда те же: усталость, слабость, сонливость, тупость, плохая память, концентрация, отвратительное либидо, почти пропавшая эрекция. И вот наконец, спустя многие годы, только недавно я наконец натыкаюсь на объективный физиологический показатель - низкий уровень тестостерона, ниже нижней границы. Я сложил 2+2: всё остальное перепробовано и безрезультатно; усталость и слабость внезапно накатили после 30 лет; вместе с этим стал расти живот; плохие либидо и эрекция - всё указывает на то, что проблема может быть в тестостероне. В любом случае, если дефицит тестостерона есть, то ни одно альтернативное лечение не компенсирует его недостаток. Надо в любом случае его исправить. Сейчас, пока я окончательно не слёг из-за бессилия, очень быстро начал копать именно в эту сторону.

Часть анализов я привёл выше. D3 анализ делал: 36,3 мкг/л при норме 30-100. Не очень много, поэтому с момента получения анализа, с лета 2018-го, принимаю витамин D3 в дозе 5000 МЕ через день. С нулевым эффектом.

До модерации первого поста я там вписывал ссылки на интернет-магазин. Судя по массе отзывов - сайт может быть настоящим. В отзывах пишут, что ампулы “бьются” - вероятно, на них есть какие-то серийные номера, которые можно сравнивать с каким-то справочником на сайте производителя. Что может говорить, что препараты тоже настоящие. Производители - Балкан, ЕПФ и другие. Тестостерон не входит в список запрещённых препаратов, только рецептурных - по идее, любой гражданин может купить таковые без рецепта в любом месте кроме аптек, которые обязаны требовать рецепт. Кстати, такая покупка “рецептурных препаратов через интернет” разрешена и в других странах, типа США.

Как раз на этом же сайте я читал, что это один из допустимых протоколов - Т + кломифен/тамоксифен, дающий результат, сравнимый с Т + ХГЧ. Попробую поискать ссылки.

Я читал посты на этом сайте и на реддите. Подавляющее большинство говорит о том, что кломифен соло, хотя и объективно повышает уровень тестостерона, улучшения самочувствия не даёт. Описывают это так: 1-2 недели хорошо, потом опять плохо. Вот из недавнего поста: Clomiphene Success vs TRT?

Анализ эстрадиола ни один врач не додумался назначить, а я на тот момент не знал о его важности. Глюкоза в порядке - 4,9. Рост и вес около 183 и 73. Проблем с ССС нет.

I barely had any improvements on L-tyroxine, but if you guys say that TSH level is abnormal, I’ll start poking endos again.

That maybe a good idea. You know, I doubt dr Rxes for several reasons. First, cypionate/enanthate seems understanable to me, and weird mix of Sustanon looks weird. Second, I don’t like the idea to be dependent on some dude, whose only privilege is that someone call him “doctor”, and pay to him to get mercy. Third, concoctions from online stores are way cheaper and can be bought in large quantites. And last, t drugs are sold in very few local pharmacies, so they are somewhat difficult to reach. Below I’ll try to clarify local prices for y’all.

One of my friends is a scientist. His salary is ~12 000 r/month.
Another friend is engineer with salary of 30 000 r/month.
Doctors have 20 000 - 30 000 r/month.
I as a web-dev have 0 - 50 000 r/month depending on how much work I have. Starting from 2018 I have less workinghours than usual due to countries starting fighting each other, crysises here and there, financial markets crashes etc - entire world seems like went crazy.

Local:
Cymbalta costs 3100 per month for me.
Private blood test costs 2000-5000.
Rx for testosterone from the private doctor costs 3000.
Androgel is 3000 per month.
Nebido is 5000 per ampule.
Sustanon AFAIK is 700 per ampule. Can’t find a single price online - too rare drug for us.
New cars are like 700 000, 900 000, 1 200 000 and so on. Personally I’m totally uninterested in cars.

Online shop:
Testosterone enanthate 1 ml 250 mg is 184.
Testosterone enanthate 10 ml 2500 mg is 1560.
Delivery costs 400-1200.

I don’t know about dosages, but my calculation for local is: 3000 for Rx + 4x700 for Sustanon + 400 for taxi would be 6200 per month.
And for online: ~800 + 400 or 1200 for the same dosage. It gives 1200-2000 in total. Or cheaper if buying a bunch of bottles at once. It may be cheaper six times in comparison to local pharmas.

I can ask another docs about cost of their Rxes, ask them to prescribe more, or ask pharmacies to not take my Rx away. But for this I must first convince them, like “Hey, doc, I already know I need Sustanon, tamoxifen, anastrozole, so just gimme the Rx for huge doses, I know what to do with them”. I presume the doc will be like o__O.

On other side, the online store I found looks like reputable - judging by large amount of reviews, discussions, and some of them say that bottles can be verified by something like serial number, so it’s not fake. It looks like reputable, but of course I cannot be sure.

SUMMARY
1.) I refuse to atrophy my testicles, testosterone alone is not an option.
2.) Taking clomiphene alone is not an option due to very poor reviews.
3.) Please advice me if I should use testosterone + hCG - or can I use testosterone + tamoxifen for same purpose. I prefer testosterone + tamoxifen. a.) It is way easier to administer. b.) It’s cheaper. c.) It’s available online, while hCG is available only in local pharmacies. d.) Here, on t-nation I read that tamoxifen gives better sperm quality than hCG.
4.) Do you think that Sustanone is comparable in effect with testosterone enanthate, so I can use it safely and effectively?
5.) I agree I should continue with my thyroid examinations.

  1. Да, это важно, это, например, как СД первого типа и второго. Также это показывает несостоятельность доктора (без обид). Что касается аргументации доктора, то это просто ужасно. В этом нет никакой логики. Есть диагностические критерии и доктор должен их придерживаться. НЕЛЬЗЯ поставить диагноз первичный гипогонадизм, когда у тебя нормальные уровни ЛГ/ФСГ и сказать, что это твои гонады не справляются с продукцией тестостерона. Это врачебная ошибка.
    Смотри:
    https://imgur.com/a/02YN1On
    Однозначно рекомендую сменить доктора, с ним всё очень плохо.
  2. Даже в старых анализах видно, что у вас низкий уровень FT3. Это не хорошо, есть проблема с конвертацией.
  3. Тут запрещено обсуждение покупки тестостерона из “андера” и его использование, но т.к. мы русскоговорящие, мы можем этим пренебречь. Коды, конечно бьются, особенно на Балкане, его уже годами подделывают в подвалах России и Украины. Схема: закупается партия настоящего Балкана из молдовы, перебиваются коды на левак из подвалов России/Украины, ВУАЛЯ, и даже левак теперь бьётся через сайт. Если хочешь минимизировать вероятность покупки левака, то советую обратить внимание на продукцию Фармакома(у них если код бьётся на сайте, то сразу видно сколько раз его уже пробивали, в норме = 0 пробитий до тебя) и Женгжу Фармасютикалс(у них коды, своё литьё ампул и виал с обозначением производителя и сложные для подделки коробки).
    Что касается легальности, то с 16 Августа 2014 года это чревато, т.к. теперь тестостерон находится в перечне сильнодействующих веществ. Чем больше покупаешь за раз, тем “чреватей”. Случаев “посадки” уже было довольно много. Это точно не разрешено. Информации по этому поводу в интернете куча, можешь глянуть в ру-сегменте.
  4. Не нужно искать ссылки, антиэстрогены(тамоксифен, кломифен, етц) работают совсем не так, как ХГЧ, в данном случае — они не стимулируют гонады и не предотвращают угнетение оси ГГЯ.
  5. Насчёт кломифена. Не стоит ориентироваться на частные случаи, если обратите внимание, то довольно многим на этом форуме и ГЗТ не помогает, лучше обратите внимание на мед. исследования и рекомендации андрологов из клиник США. Например:
    https://www.ncbi.nlm.nih.gov/pubmed/19694928
    https://www.ncbi.nlm.nih.gov/pubmed/24657837
    Насчёт того, что 1-2 недели хорошо, а потом опять плохо, во-первых, частные случаи, которые не стоит вот так вот просто экстраполировать на всех и вся, во-вторых, с экзогенным тестостероном тоже всё не так просто и быстро, в-третьих, он также не начинает работать с первых дней, недель и даже с первых двух-трёх месяцев.
    Вообще, всё, что касается тестостерона и терапии состояний его дефицита, тут речь будет идти скорее о долгосрочной перспективе улучшения самочувствия.
  6. Тоже плохо. Высокий эстрадиол может быть причиной уровня низкого свободного тестостерона и, соответственно, всего того, что вы связываете со своих плохим самочувствием.
    Это, конечно, ваша жизнь, ваше здоровье и ваше решение, но я всё таки повременил бы с переходом на ГЗТ, тем более, если есть альтернатива (а в случае вторичного гипогонадизма, она действительно есть), которая имеет доказанную эффективность (исследования, а не единичные случаи с этого форума и реддита).

Guys, you’ll get much more info from more people if you post in English. This one-on-one conversation that nobody else can contribute to can only get you so far.

The reason one is not benefiting is because thyroxine is shit. You need t3. Thyroxine simply gives the body t4 and hopes it will convert. But if the t4 is not converting to t3, then zero benefit comes. Tsh sucks as a gauge it’s not 100% reliable. A doc who relies solely on tsh and thyroxine is a doc who doesn’t understand how to properly look at the thyroid.

My doc gave me t4/t3 and many guys here are also on that. If this works you know your body is craving more.

You can tell if a doctor is a quack in his field of medicine if he believe in range automatically means you are normal, obviously is testosterone is low, LH cannot be normal. Doctors are mostly like robots chasing these labs values like these ranges are the word of god, this is how they are taught in medical school.

Doctors are mostly idiots who lack analytical thought and critical thinking.

I think at least some of us need to understand that doctors are not idiots. They know what they know, they do not know everything. Would you go to a mechanic with a question about your heart valves?

Doctors know what they were taught. Plus, it is very difficult to let go of what you learned first. Doctors are taught that there are normal lab ranges and if you are within those ranges, you are fine. By definition, you do not have hypogonadism if your total testosterone is 330. You do not have hypothyroidism if your TSH is 4.15.

Most doctors participate in managed care networks or are in network for various insurance plans. Insurance companies are in business to collect premiums, not pay claims. Their entire purpose is profit and part of that is reducing claim exposure.

If your total test is 330 and your doctor submits a claim to your insurance plan that claim must have a diagnosis and treatment consistent with the diagnosis. If the submitted diagnosis is hypogonadism and the treatment is regular testosterone injections, the doctor is committing fraud. Most insurance systems will flag the claim and deny treatment. Do it enough times and they’ll report the doctor to the state medical board.

Even if you qualify for treatment, doctors were taught to treat low testosterone with no more than 200mg injections and no more frequently than every other week. Some will go every three weeks (maybe 300mg then) or every month.

So, you consult with your PCP. Let’s say he or she sees an average of 120 to 150 patients a week. How many of them do you suppose are low test guys? As my retired PCP, and good friend, told me, “we aren’t trained in this.” Of course, some will try to help you, they know something about it. They know what they were taught. Was it accurate or enough? No. But they don’t know that.

Take an endocrinologist or urologist. They likely have more experience with low test than the primary. What were they taught? Are they even interested in this? What really is their specialty? Testosterone? I know an endo who is a pediatric endocrinologist specializing in diabetes. Would you like her to handle your low T?

Point is, why would you not consult with someone who specializes in treatment of low testosterone, or hormone optimization? Yes, your PCP could be consulted, but do you really think you’ll get top shelf, state of the art, care? You may get it cheaper, especially if the insurance route is attempted. Sometimes you get what you pay for. I don’t know who is worse, us for going to a primary expecting specialist treatment for low testosterone, or the GPs for treating something when they know, or should know, the patient might be better off elsewhere. I wouldn’t call an endocrinologist or urologist an idiot, but keep in mind what they have been taught about testosterone.

I think the best option is a doctor who only does hormone restoration/replacement/optimization or whatever you would like to call it. If possible, referral is usually the best route in which to choose a doctor so if you know anyone on TRT ask them who they see. If you do not, look around. Do you train at a gym? If so, approach guys who look like they might be on testosterone. They are plentiful. Most will be open with you and willing to answer your questions and help you. We’ve all been there.

A primary will try to help you, but they are also focusing on all the other conditions they see. A hormone doc does only hormones, that’s their interest, their passion.

Another thing, I’d look for someone who is also on TRT, walking the walk. A cardiothoracic surgeon does not need to have their chest cracked because it’s the best thing going, but a TRT doc that is not taking his own medicine is suspect in my opinion. If I’m consulting a doctor for TRT, I want to be looking at someone who looks jacked, fit, in shape, whatever, maybe even looks young for their age. Someone looking overweight or obese, unhealthy, frail or just out of shape, is not for me.

2 Likes

I agree that’s why I chose the docs and previous clinic. They were taking it themselves and it made me comfortable they trusted in there ability. TRT is a totally different field for docs. It’s not within the sick care realm. When you spend your entire career covering symptoms, it’s hard to think otherwise. Keep in mind most folks with diabetes and BP issues want a quick fix. They don’t want to change there diet

Then you have docs who are stupid and it’s amazing how blind they are or how stubborn they are. If you are going to prescribe hormones you should research it. You have a responsibility to do right by your patient. Improper HRT Can make one worse. This is what amazes me.
You prescribe cypionate but don’t understand the basics of free t and conversion to e2? How it benefits and etc… or they think it’s bad for men. These docs are just stuck in a rut and do not realize how unprofessional this is. I call this stupid.

Docs are also incentivized to work within these parameters. They make money by working within insurance guidelines. When they meet a self pay client they rarely realize it and often continue treating as though your an insurance patient. There honestly doing there best to help you within those parameters.

That’s why you find a doc who is not working within the confines of insurance and is a private care physican. This is usually why they go private. They could not help there patients properly. For us these docs are perfect for us.

It is insanity to start trt with a sick care doc and expect proper care. At least to us it’s clear how insane it is. I guess some folks cannot wrap there mind around it.

Two of my friends who are physicians told me this. People want the quick fix. They don’t want to work at it. They won’t change diets and get fit. Overall lazy.

This is the mindset we’re dealing with.

1 Like

Those people who are looking to optimize their health shouldn’t be going to a sick care doctor, they treat disease and illness. My second endo was happy with a trough of 440 even without speaking with me on how I felt, how I felt was irrelevant to her because I was within the normal ranges.

The problem is a lot of these ranges are not normal for everyone, you can’t apply a particular range to any one person without knowing where they were naturally. Sick care cannot do TRT effectively because they are brainwashed into fixating on labs.

The moment you are within the normal ranges on TRT, “go home, get out of my office as I have many, many patient’s to see today”. If sick care doctors did anything different, they would never be able to see 20-30 patients in a day.

Hello again. I returned with a big report.

First of all, I did a thyroid test:

TSH:      1.67
Total T3: 92.6
Total T4: 6.5
Free T3:  3.4
Free T4:  12.5
Anti-TPO: 10.0
Anti-Tg:  5.4

Looks good.

Then, I found a doc who at least can hear me, discuss things, agrees to try different strategies, tune them in an effort to achieve some results. For the start we agreed to try the most easy way - using Androgel, with ability to switch to injections, add hCG, use clomiphene, tamoxifen, anastrozole, if needed.

Here is the chronology of the glorious crusade.

From 2019-03-27, lasting about 2 weeks - same duration almost every antidepressant has, kind of “adaptation period”.

  1. I can hold water, at last. Before I was a peeing machine peeing every 2 hours, including sleep - so, after 2 hours after falling asleep I had to wake up, and then could not fall asleep again, suffering from insomnia. And now I actually can drink water as much as I want anytime. Before I drank very little. After some googling I found that that’s because testosterone converts to estradiol, which allows a body to retain water.

  2. Sleep quality improved. Falling asleep way more quickly and sleeping without interruptions.

  3. Mood immensely brightened (in a wrong way). Really crooked for first two weeks, then some sanity started to appear. Right after first dose I completely abolished learning new things for web dev. Instead started gaming with much more interest than before. Stopped giving a fuck to anything. Lack of work? - IDGAF. Little money income? - IDGAF. Talking with friends? - nope, IDGAF. Cleaning, dusting, bathing, eating - meh, IDGAF. That’s like: mood significantly brightened, but motivation, interests, cognition - crashed. On that side TRT reminds me of SSRI on steroids. Like people very often complain that antidepressants improve their mood, but makes them apathetic.

  4. Mood started to swing wild swings. Happiness, deep dread, irritability, apathy, complete apathy, tiredness, feeling miserable, no libido, explosive libido etc.

  5. My morning and evening activity levels flipped. Previously I was more apathetic/sleepy/calm, stable at mornings, and more active, angry, feeling unhealthy at evenings. Now I easily awake at ~05:00, drop asleep at 13:00 - and then can’t open my eyes until 19:30, and even then I remain very sleepy.

  6. Hair became more oily, I need to wash them more often.

  7. Eye strain greatly reduced. I can look into PC monitor without feeling pain and fatigue.

From 2019-04-12 (16 days in)
“Broken happiness” disappeared, started again to think about work, life problems and such. But heavy sleepiness creeped in. I started to sleep nearly 3/4 of a day - day, evening, night. Only mornings remained active.

Also, that day I did a blood test. Here are compilation of previous results and current one:

TSH:        1.67          -> 3.24
Cortisol:   298, 433, 640 -> 83.7
Prolactine: 152           -> 114
LH:         1.52          -> 2.0
FSH:        4.15          -> 3.25
TT:         296.64        -> 380.16
E2:         20.0          -> 38.1

Cortisol tests are from previous year.

Things I noticed:

  1. TT is increased by ~30%, but E2 by ~100%
  2. Huge drop of cortisol, below acceptable minimum of 101. Like 4-8 times.

The doc agreed to try to add anastrozole - to lower E2 to <25 levels, prevent testosterone aromatising, thus rising it’s level.

Then I felt like I see some new tendency in my condition, some improvement of the mood, I thought I might had stabilized and decided to not to start anastrozole immediately, but to wait for a while to be completely sure.

I dragged my mountain bike out - and all of a sudden discovered that my endurance improved like 5-10 times. I rode much longer, much faster, quite enjoyed the ride, and returned home feeling completely OK, not dead tired like previous years. I jumped into TRT train primarily for chronic fatigue, mental exhaustion, and completely forgot that people often use it for performance. And that huge boost of physical abilities is a pleasant surprise. Now I can say that will alone is not enough to do any kind of physical activity: if you have puny amount of testosterone, no matter how hard you try, all you’ll get is exhaustion, headache, and suffering.

I assume that testosterone boost might be boosting dopamine. On the “bicycle day” I was feeling signs of dopamine enhance: I was in good mood; concentration was also nice; I had will to excercise - it’s well-known that dopamine increases locomotor activity; I was enjoying the ride - dopamine also enhances ability to feel things around, to feel emotions, to have insight, to feel connected to reality.

Unfortunately, after a few days most signs of improvements vanished.

2019-04-22 (26 days in)
Next week was increased sleepiness, tiredness, and irritability. I was feeling like I was withdrawing from something, like antidepressants, - that’s shitty feeling of fever, chills, malaise, anxiety, irritability. At the friday (26th) my boobs started to hurt. Saturday (27th) was a second “bicycle day” - which I forced to have - because actually I was very tired and in poor mood. The results was also poor: like previous years, I barely managed to ride ~2 kms, returned home feeling exhausted, dead tired, covered in sweat, with headache and nausea, and that’s it.

At sunday I got another blood test results - from 2019-04-26 (30 days in).

Cortisol:   760
Prolactine: 169
LH:  1.29
FSH: 3.13
TT:  250
E2:  52.9

Welp… cortisol is completely opposite to previous 83.7, and it seems that it’s irrelevant to my condition: I don’t feel any differences having it tiny or huge amount. Prolactine is roughly the same over years. Absolutely every drop of testosterone was hunted down by aromatase and converted to flood of estrogen. No wonders I had bad results with bicycle.

2019-04-29 (32 days in)
Started taking small amount of anastrozole - 0.125 EOD.
For several days I had darkened mood, quite depressive dreams, was feeling grumpy and moody.

2019-05-01 (34 days in)
Morning was a clone of the first “bicycle day”: nice mood, will to move, riding, enjoying, not feeling tired.

Also that week I had a few days of pretty good working capacity and odd eloquence, constructing fierce sentences from weird combinations of words.

2019-05-06 (39 days in)
Started to have increasing insomnia, that led to sleep being possible only daytime. Note: daytime is the time I have the least anxiety, while night is having the most. So that condition could indicate boosting of noradrenaline. Also mood was cold and depressive, interests was lowered, concentration was poor, as well as locomotor activity, social activity. Started to watch much of TV shows. Overall speculation: high noradrenaline, low dopamine.

2019-05-13 (46 days in)
This week’s second name is “Shitty week”. Had another blood test at 2019-05-15. Results are:

LH:  1.33
FSH: 3.04
TT:  284
E2:  64.4

0.125 of anastrozole EOD ultimately failed to give any benefit. My aromatase is completely mad, E2 rose even more. Increased anastrozole 4x - to 0.25 mg every day (1.75 per week).

Results came in a matter of days. Very bad mood, feeling of fear, dread, anxiety, somewhat increased peeing, eye strain, feeling like losing my mind at evenings, extreme sleepiness and tiredness at evenings, feeling stupid. Only time I have acceptable condition is mornings. Every other time of day is sleeping, a disaster and sheer madness.

After some googling I found that depression and feeling like shit is not uncommon adverse effect of anastrozole, letrozole, etc.

Not going to continue this anymore, this is madness. Going to take another blood test to see what adequate dose of anastrozole is capable in terms of numbers, then going to the doc to discuss other options. Unfortunately he is unavailable until monday.

Final results of using Androgel and anastrozole.

  1. My aromatase - specifically that that works outside of testes and hunts the testosterone from the gel - is absolutely crazy, able to eat everything you throw at it.

  2. Androgel is comfortable to use. No need to poke with needles. Short half-life makes it easy to jump on, quickly get stable concentration, quickly jump off if needed - not like Nebido, which is 2 months obligation, whether you like it or not. Somewhat pricey, judging by reviews aromatizes more than testosterone from injections. According to FDA, T levels are pretty stable with Androgel: https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/21015s012lbl.pdf And I think, that users can even split daily dose into 2 applications. In overall I see Androgel as a nice option for OTHER people, they can give it a try. But In my case it was completely useless.

  3. Anastrozole makes me ill, crazy, stupid and depressed.

  4. Effects that was relatively stable and persisted through entire period of treatment: ability to retain water; to sleep through nights without eternal peeing; reduced eyes strain; improved sleep; aggravated sleepiness, tiredness, fatigue; improved endurance; mood, libido, erections, POMS - not sure what to say, it’s kind of same shit but of another flavor; face and neck acne; fluffy belly - thin light hairs all over the stomach, where I apply Androgel.

  5. Few days ago I had ultrasound scan of the balls to see if there an atrophy. And no - they was the same size as before Androgel. This is interesting, because I read that any TRT quickly leads to shrinkage, and personally I noticed for sure that the ball sack became smaller.

  6. Periodically I had mild pain in testes.

Things to consider:

  1. Looks like I never was a testosterone guy. Skinny, not much body hair, mediocre endurance. But that’s what was making me myself. Thus targeting high levels of testosterone is kind of wrong. I more likely want just enough of testosterone. What is “enough” is another question.
  2. I definitely should keep estradiol above 20. Otherwise I have eye strain, no water retention, pee like damned, and thus I’m dehydrated.

Options I see:

  1. Decrease Androgel dosage to only keep estradiol levels above 20. But while it will help with eye strain and water retention, I doubt it’ll help with mood, energy, and endurance.

  2. Use tiny amount of Sustanone instead of Androgel and see what will happen. Considering injections are thrice more effective than gels, it is 10-20 ml twice a week. Probably it won’t aromatize that strong and some testoserone increase is possible. And if entirely converted to estradiol - it will be useful anyway, by preventing overpeeing and eye strain. And it’ll cost 3-5 times less than Androgel. haha.

  3. Use larger amounts of Sustanone if #2 will not show overaromatizing. Then I can expect normal levels of both testosterone and estradiol.

  4. Try to cheat aromatase and switch from Androgel to hCG alone, 2-3 times per week. Might be that testosterone-to-estradiol conversion inside the testes not going to be THAT crazy like outside of them. As a bonus, it will provide not only good levels of testosterone, but pregnenolone and DHEA as well, while making balls big and beautiful, oh yeah.

  5. Jump off from Androgel to clomiphene or tamoxifen. These drugs don’t shut down testes, they actually asks them to work harder and produce more T, pregnenolone, DHEA. Sounds good. Costs less. But data is too controversial. On one side, I didn’t read any positive reviews from users or docs. Clomiphene isn’t approved for hypogonadism by FDA also. On other side bodybuilders often use it for PCT to restart HPTA. And then there is tamoxifen, that sounds like “clomiphene but good”.
    HPTA Restart: Clomid 25 mg EOD - one of the topics about TRT, clomid, tamoxifen, KSman.


Some another article about tamoxifen, popped out from google.
Testosterone +50%, estradiol +341%, increasing SHBG, possible liver damage, blood clots, eyes damage.
With my natural testosterone levels of 230-290, +50% will lead to 346-432, that means it will fluctuate between “not enough” and “just enough”.
Sounds discouraging.

https://www.ncbi.nlm.nih.gov/pubmed/8622006 - tamoxifen and eyes.

Worst expectations: drowning in estradiol, eyes falling out, awful condition.
Best expectations: good levels of T, pregnenolone, DHEA, cortisol, no testicular atrophy, comfortable price, easy administration; everything working more naturally.

Among the listed options I mostly prefer 2, 3, 4.
1 as a temporary solution.
5 as a last resort.

I received the last blood test results. Can someone help me to decipher it?

TSH    3.69
LH     4.43
FSH    4.86
TT     492
E2     56.8
SHBG   32.1

I see that my TSH is jumpy - from OK to high, but mostly tend to be high. I’m going to at last add iodine and selenium supplementation.

My boobies started to burn again. Large dose of anastrozole (0.25 mg/day) barely did anything to control estradiol level, but somehow managed to raise LH, FSH and TT. I don’t understand this.

I thought that AI do these things:

  1. Prevents aromatase from converting testosterone to estradiol, thus keeping the latter from being too high.
  2. By lovering estradiol too much it can signal brain that the level is too low, thus forcing him to tell balls to produce more testosterone. AFAIK, it’s done with both LH and FSH.

And what I see:

  1. Anastrozole failed to limit estradiol level.
  2. There is very much estradiol, but instead of sutting down LH/FSH brain produces even more of it, and testosterone level grew twice.

What’s the science behind it? Heeelp?

Stop messing with estrogen. Let the body adapt. It creates E2 for a reason. Why mess with a natural process.

The body will start utilizing it once it’s receptors are active again. Until then it’s tryingnto get rid of excess.

Adding an ai simply Stop’s you from realizing the full benefits.

1 Like

I take guidance primarily from KSMan’s stickies and posts. They say that:

  1. Gels tend to aromatize more than injections, as they are distributed over a large area
  2. Keep E2 level at 22.4
  3. Using AIs to control E2 is a normal option
  4. If E2 is very high no matter what - check AST/ALT, do CBC

Also simple rules for antidepressants:

  1. Don’t evaluate effects until 10-14 days passed
  2. If there is no positive effects after 30 days - most likely it doesn’t work

I waited 32 days without AI, and body hadn’t adapt - contrarily, I just became dead tired.
And waited another 2 weeks with tiny dose of anastozole, which made no difference.

Checked allowed range of E2 in the results of blood test:

  1. They read as 20-56 pg/ml
  2. My levels are 54-64, which looks very high

I don’t see how 29, then 54, then 64 is adapting.

Also judging by my condition:

  1. I feel dead tired
  2. Nipples are burning
  3. Skin is oversensitive

It doesn’t look very healthy.

I would like to believe that a body is able to regulate itself and does everything for reason, but judging by existence of psychiatrists, endocrinologists, urologists, TRT, and t-nation.com - it can’t.

I agree that not messing with something is better then messing. Less drugs is better than more. For that I’m planning to switch to injections, thus avoiding the by-design bug of gels that forces them to overaromatize into estradiol. I hope this solution will allow me to completely cancel anastrozole.

Furthermore, to take adaptation into account, we can start Sustanon at a low dose, and see how it will go. Slow titration and careful monitoring will allow the body to adapt, and not hit hard as a train.

Thank you for the input, it was valuable.

KSMan hasn’t been active here for a long time, and his methods have proven to be more harmful, rather than helpful for a lot of guys.

Is Test Cyp or Enanthate available where you live? You have been on quite the roller coaster man and you need to find a way to stabilize.

What’s your diet look like? Regular weight training? Current body fat %? Alcohol and/or drugs (prescription or recreational)?

Sorry if you’ve already answered these questions. I didn’t go back and re read the entire thread.

2 Likes

Take advice from doctors at the front of the pack.

Rouzier
Nichols
Dr rob
Nelson Virgil
Eric Serrano
Scott Howell
Steven Devos
Who else… dozens more

You aren’t doing your research. Take charge of your health and properly educate yourself.