T Nation

TRT Newbie Help

Hello and thanks for any help you can offer. My apologies for the long post but wanted to be thorough since I am asking for your help rather than you having to pull teeth to get info!!
I know there are a lot of experts here and an abundance experience so I really could use some practical advice. Perhaps others can benefit because I am probably not unique but I am new to this board.

New to TRT and 12 weeks in on 100mg/wk cypionate by IM, usually thigh. I’m 53 years old, 5’9" and 185 lbs and about 16% body fat (down from around 18% at start of TRT already with a few other changes in diet). Been in the gym and religiously there 3x/week with few exceptions for 3 years now lifting pretty heavy. Doc not taking blood work often enough for my liking so I’ve ordered from PrivateMD labs with great service from them and I use LabCorp. Take all the usual supplements including whey, casein, zinc, curcumin, garlic extract, B, omega 3, CoQ10, creatine.

I drink wine, usually red, almost every night anywhere from 2-4 glasses.

Feeling mostly pretty good overall, sleeping better, more energy, more positive, but erections are weaker than before starting TRT which may be the E2. I am looking to increase my dosage to 200mg/week occasionally as a cycle to gain some extra muscle but not maintain that dose long-term. My blood work suggests I may actually need to decrease the dose which has me a little bit bummed because I am concerned I won’t feel as well.

Questions:

  1. HCT has crept up to 54.9% in recent trough test (day 6 actually, not 7 before weekly injection) with Total T at 785 and Free T at 28. I gave blood 12/11/18 and that seemed to keep it down around 46 to 48%. I recently restarted taking ashwaghanda which has a lot of iron and I eat a lot of spinach and other high iron stuff. I stopped creatine and ashwaghanda and have increased water intake which I have been sloppy on lately. Could the higher iron intake and dehydration have caused the high HCT? Ideas on how to best manage HCT?

  2. Same bloods as above showed everything else ok except:

MCHC 30.8 LOW (range 31.5-35.7 g/dL)

Monocytes(Absolute) 1.1 HIGH (range 0.1-0.9 x10E3/uL 01)

Both slightly out of norm. Thoughts on those? Do they matter much?

  1. Mid-week blood on day 3 after injection (was trying to estimate peak) on Jan 11; about week 7 into TRT:

Total T: 975

Free T: 36

HCT 46.2% (about 4 weeks after blood donation)

E2 Sensitive 49.5 HIGH (range 8.0-35.0 pg/mL) - remember this is day 3 after weekly injection; this is up from E2 of 26 at start of treatment but doc didn’t order sensitive apparently so these are not apples to apples?)

Haven’t tested E2 again recently but at nearly 50 mid week could this be too high back then over a month ago and would it likely be even higher now a month later? Best way to manage E2? Should I be testing E2 or E2 sensitive?

  1. For one other data point on progression, blood at week 6 trough, day 7 before injection:

Total T: 527 (this is up from 190 at start of treatment)

Free T: 21 (up from 10 at start of treatment)

PSA: 0.2 (same as start of treatment)

Thanks for any advice and insight you can offer.

Just 100mg T each week and some supplements? That’s ALL you take?

Thanks for the response… that all I take

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Your SHBG has got to be on the lower end, meaning you can expect very high Free T at high normal ranges do to having lower SHBG which binds sex hormones, Free T->E2. Free E2 may be very high if estrogen is high in the same way Total T is high in relation to Free T being high as well.

You may even find E2 higher in the months to come.

You can do a few things to lower E2, inject smaller doses more frequently decreasing weekly dosage by 10-15% do to keeping steadier levels which require less testosterone to achieve similar levels as before, you can also take an E-blocker which isn’t recommended if you can help it.

If you want a doctor to optimize all your levels, you would then need to go private to escape the range chasing robots/doctors who are controlled by the insurance companies. This is why your doctor will not do extra testing or optimization ~ money.

You will notice no difference in muscle mass between 700-1500, you need a much larger ratio to significantly increase muscle mass, more like 5000-10,000.

Thanks, S, and you are spot on. My SBHG was on the lower end in December before starting at 23 and a month or so later was at 25 nmol/L (range 19.3 - 76.4).

So is my E2 sensitive a problem at a level of 50 pg/mL?

Thoughts on how to get hematocrit (HCT) down?

Given your point about needing much higher T levels to see a difference in mass it almost suggests I should actually not bother increasing T dose since I won’t be going as high as you think necessary and actually maybe I should lower the dose to better control HCT and E2. What do you think?

By the way, you are all great. It is good to know people who have more experience are willing to help out the new guy, and old man no less, instead of just making fun of him.

Thanks to all for the help.

Possibly. Make sure you are well hydrated next time.

Also possible.

The ECLIA test (aka immunoassay or IA) for E2 management is commonly used for those on TRT. It is not an incorrect test or a test for women, but simply one way to check estradiol levels. The other commonly utilized test is the LC/MS/MS method (aka liquid chromatography dual mass spectrometry, sensitive or ultrasensitive). It is the more expensive of the two. There are inherent advantages and disadvantages to each of these two methods. I have been fortunate to be able to speak with professionals who work with both methods. One is a PhD researcher for Pfizer and the other is a medical doctor at Quest. I’ll summarize their comments.

The ECLIA method is the more reliable of the two in terms of consistent results. The equipment is easier to operate thus accuracy is less reliant on the skill of the operator. If the same sample were to be tested twenty times, there would be very little, if any, difference in the results.

The ECLIA method is not as “sensitive” in that it will not pick up E2 levels below 15pg/mL. If your E2 level with this test is 1-14pg/mL, the reported result will be “<15”. Because of this, it is not recommended for menopausal women, men in whom very low levels of E2 are suspected, or children. In other words, if your levels are below 15pg/mL, and it is important to know if the level is 1 or 14pg/mL, you do not want this test. For us, this is likely moot, since if you are experiencing low E2 symptoms and your test comes back at <15, you have your answer. For a woman being treated with anti-estrogen therapy for breast cancer, it may be necessary to know if the E2 level is zero or fourteen because therapeutically, they want zero estrogen.

A disadvantage to IA testing is that it may pick up other steroid metabolites, which in men would be very low levels, but still could alter the result. Another potential disadvantage is that elevated levels of C-reactive protein (CRP) may elevate the result. CRP is elevated in serious infections, cancer, auto-immune diseases, like rheumatoid arthritis and other rheumatoid diseases, cardiovascular disease and morbid obesity. Even birth control pills could increase CRP. A normal CRP level is 0-5 to 10mg/L. In the referenced illnesses, CRP can go over 100, or even over 200mg/L. Unless battling one of these serious conditions, CRP interference is unlikely.

The LC/MS/MS method will pick up lower E2 levels and would be indicated in menopausal women and some men if very low E2 levels are suspected and it is desired to know exactly how low, children and the previously mentioned women on anti-estrogen therapy. It will not be influenced by elevated CRP levels or other steroid metabolites.

While some may believe the ECLIA test is for women, on the contrary, as it pertains to women on anti-estrogen therapy, such as breast cancer patients, the LC/MS/MS is the test for women as CRP levels are a consideration and it is necessary to know if the treatment has achieved an estrogen level of zero.

On the other side of the coin, LC/MS/MS equipment is “temperamental” (as stated by the PhD who operates both) and results are more likely to be inconsistent. Because of this, researchers will often run the same sample multiple times.

It is not clear if FDA approval is significant, but this appears on Quest’s lab reports: This test was developed, and its analytical performance characteristics have been determined by Quest Diagnostics Nichols Institute San Juan Capistrano. It has not been cleared or approved by FDA. This assay has been validated pursuant to the CLIA regulations and is used for clinical purposes. This statement is on LabCorp’s results: This test was developed and its performance characteristics determined by LabCorp. It has not been cleared by the Food and Drug Administration.

It is unlikely that any difference in the same sample run through both methods will be clinically significant. Estradiol must be evaluated, and it should be checked initially and ongoing after starting TRT. It obviously makes sense to use the same method throughout. Most important are previous history and symptoms related to low or high E2. Those are correlated with before and after lab results. Any estradiol management should not be utilized without symptoms confirmed by lab results.

Below are some results with both tests run concurrently:

IA%20vs%20LCMS%20result
IA%20LC%2021%2018
IA%20LC%2023-23
IA%20LC%2026-21
IA%20LC%2028-27%20clear
IA%20LC%2028-27

Nothing for now. Only slightly out of range.

527 at trough, you could be higher. You do not need to decrease your dose because you were at 975 at peak. Most that are 800-1000 at trough are close to 2000 at peak. Go with how you are feeling. Running your test up to higher levels at trough will definitely help you increase muscle and increase your strength.

Regarding labs, speak to your doctor. The only reason he might hesitate is if you are expecting your health insurance to pay for them. If you are willing to pay, he’ll probably order them, though you could might get them cheaper on your own. But, maybe not.

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That levels of E2 would give the majority of men symptoms, lower libido, softer erections, low depressed mood, bloating and even mental fatigue.

Highpull:
This is all really great stuff and can’t thank you enough for the really detailed and factual responses. Great videos and good points that they don’t treat people at altitude for high HCT. And yes, like the video you sent, I have seen several reports that higher E2 in men is not something to be concerned about and can in fact be beneficial, I guess depending on symptoms like breasts and fat is when we do something about it.

So I do have emphysema, apparently pretty severe although I have no real symptoms yet… can push very hard both aerobically and anaerobically without really noticing it (smoked from a young age and quit 4 years ago and turned life around). I don’t live at high altitude. I am also in the middle of diagnostic testing which seems to be pointing toward sarcoidosis - some autoimmune/inflammation of some unknown cause. SED rate was very low and am going to be doing CRP soon.

While all of this is true, my HCT and E2 were both normal before TRT - - HCT at 46% and E2 at 28 pg/mL by ECLIA methodology (normal range 7.6 to 42.6).

Nothing about whatever is going on with the inflammation and emphysema has changed in the relevant timeframe that HCT and E2 went up so much.

Thanks, systemlord. Libido, mood, energy all seem great and improved. No brain fog, actually better. No bloating. I say so far all these are good but definitely noticing the erection issue though. That’s the only reason I thought my E2 might be too high. Now as you said, this could all get much more heightened as I get further don the road and some of those other things could start showing up. Maybe best to make the small adjustments suggested like go to 2x/week and keep dose a little lower first then go from there based on symptoms and bloods.

Don’t be surprised is the more time passes, those good feelings vanish. That would indicate your levels are swinging more than your body would prefer. More frequent injections would fix that problem.

Thanks again, systemlord. I guess it is about each of us getting individually dialed in through trial and error. Just for a newbie it is all a little bit scary and daunting…

Keep this in mind moving forward. Don’t focus excessively on dosing and steady levels, focus on your symptoms. There are a lot of guys taking testosterone that are doing it underground and never testing blood. They take 200mg a week and with no E2 management. As long as test is high enough, higher E2 is usually fine. That is usually, not always.

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captain the only way I have been able to keep my HCT under 52% is to keep my Free T in range and never allow it to go over even on peak days. You can only donate blood so often before you crash your ferritin. If you are donating every two months you should consider adding ferritin to your blood tests. Once your ferritin drops below 30 you are done donating.
I have found cruising on 80mg/wk keeps everything in range. No AI no blood donations required. I also take 800iu/wk of HCG. Twice a year I do a blast of 300mg/wk for 10-12 weeks You will feel the difference. Be ready to spend a lot of money on good food and nothing should get in your way to the gym or you will be wasting your time. when you are read for that start a thread up in pharma.
Good luck. Oh my shgb is 22 for reference. I have been on TRT for >4 years I’m 65.

Thanks, hrdlvn. Do you mind me asking your weight, etc?

Why do you use HCG?

Thanks

5’9" 190# waist 34" BF ~16-19%
My balls ache (low and dull) without HCG no other reason.

You had stated in your original post you drink wine. Did you have a couple or few cups the night before your blood draw? Alcohol makes one super hydrated. A couple cups would get me a nice buzz dehydrate me enough to feel it the next day. I don’t drink anymore but I recall.

I believe I saw a video where the docs said they ask clients if they drink or smoke thc. They ask because it causes issues with e2. Increase or lower can’t recall. Might want to consider this.

Also I would wait 48 hours after my last drink before taking blood again … ensuring your hydrated.

Thanks, hrdlvn. You and I are almost exactly the same build, etc. I realize we are all different but maybe if I drop back to 80mg/week like you I might fall into line. Maybe I will try 40 every 3 to 4 days too if 80/week still not working.

Thanks, enackers and good advice. Wine has both iron (HCT issue, especially red) and is an aromatase (E2 synthase) like any alcohol. I am probably not disciplined enough to stop drinking wine but I can try to adjust my drinking habit. There is even a low alcohol white from Portugal that’s excellent … maybe switch back to that since it is getting hot here in FL again!! My doc knows I drink wine and didn’t give me an AI and when I asked him about E2 and he said no need unless I start putting on fat around the waist. Regardless, I know any alcohol is not going to help E2 OR HCT so I need to pay attention to your advice now that I am on the TRT journey…

This series of blood tests would likely would not have had any variation in the amount I was drinking and the only thing different from those in range on HCT and the recent one is the restarting of creatine (pulls water from blood into muscles causing lower plasma volume), ashwaghanda (recently learned it is apparently high in iron) and I may have eaten extra iron that week too like spinach several nights, beef, etc… Add on a little extra dehydration from not drinking enough water and maybe that’s what happened. So I am adjusting those things now to see if it changes.

For E2, I really don’t want to do an AI so I am hoping it helps to adjust dose down to something like hrdlvn is doing and maybe splitting dose as systemlord suggests.

Has anyone had any experience with DIM? Upping cruciferous vegetables? I understand zinc may help?

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80mg/wk should keep your HCT in check. A trick I found to prep for blood tests is buy several bottles of Pedialyte that stuff kids take for dehydration and start drinking it the whole day and night before your blood draw. No wine no sugery drinks no coffee.

I don’t think you posted your SHGB but here’s what 80mg/wk gives me. As you can see Free T is still over range. I might have to cut back to 75mg/wk