Why am I Tired on Injection Day?

I need some help/advice. I am currently 34 and have been suffering with low testosterone for years now but I only recently figured out that it was my main problem. I am 5 ft 9 in and weigh 207 as of 3 weeks ago. My testosterone went in the tank back in December of 2011 all of the sudden. It was as though someone just turned off a switch. I thought it was a thyroid problem and as it turns out, I am mildly hypothyroid. I am being treated for hypothyroidism by taking Armour. My doctor is good enough to recognize that the reference ranges are screwed up so he knows where I should be. Anyway, he put me on compounded testosterone cream too and I was on that for 6 months. My Testosterone lab work is below from this visit:

Testosterone, Serum: 352 ng/dL (348 - 1197)
Testosterone, Free: 9.0 pg/mL (8.7 - 25.1)
Estradiol: 22.1 pg/mL (7.6 - 42.6)

At my request, I quit the compounded cream because it didn’t really seem to work. I restarted with the help of HCGenerate and once I came off of it, about a month or so, I recovered to about 75% or so of what I was before it went in the tank. I never got it retested either. My libido was good, had good wood, brain fog lifted, etc after coming off the cream. Then in June of this year, it went in the tank again, exactly like it did before. I saw the urologist my doctor recommended (and there are no anti-aging doctors where I live here in North Alabama). The lab work is below for this first test. I tried to convince the urologist to run Total Testosterone, Free Testosterone, SHBG, FSH, LH, Prolactin, DHT but he said that even if it’s a hypo-pituitary problem or my testes, the treatment is the same. Of course I was pissed about this but I didn’t know what else to do. Honestly though, I didn’t care enough because I wanted some relief.

Testosterone, Serum: 304 ng/dL (348 - 1197)
Prostate Specific Ag, Serum: 0.5 ng/mL (0 - 4)

I was definitely below the reference range here. I noticed that being on TRT injections that I started feeling tired about 5 days into a 7 day cycle. After some research I decided to split my 100 mg/week injections down to 50 mg every 3.5 days. My doctor lets me do the injections at home thankfully. As an aside, my insurance won’t pay for Testopel because if my records show anything that says anything to do with erectile dysfunction or sexual dysfunction, it’s an automatic disqualifier even if it says hypgonadism. Anyway, I do fine most of the time as far as energy and libido except generally on injection day (trough). I start to feel run down and usually the day after the injection, I feel a lot better again. I talked to my doctor about this and he won’t change my dosage because my trough is about where he’d like to see it and he won’t prescribe HCG. I’ve started the Paleo diet (after a failed attempt 2 years ago) and started exercising every day by jogging/walking about 3 miles a day. I’m losing weight and feel better but still suffer lethargy on days that I need to inject. Below is lab work during a trough (on a day I need to inject but waited until after the blood draw):

Testosterone/Estradiol during trough
Testosterone, Total: 773.21 ng/dL (240.00 - 871.00)
Estradiol: 26 pg/mL (11 - 44)

So, my questions are: Besides finding another doctor, which I may do anyway, what is really going on? Do I need to be bumped up slightly to overcome the trough? Are there some supplements I can take? He is willing to test SHBG and Free Testosterone but says that he normally won’t unless the patient is generally over 50. So he seems to be a bit old fashioned. Something else I heard from my doctor who treats me for hypothyroidism is that the Alabama Board of Medicine monitors testosterone prescriptions very closely and limits what the doctors here can do as a result. Since my trough is fine he won’t change it. Any help I can get is appreciated. Last, I’m fine with being on TRT for life and injecting. Thanks!

I have been experiencing heavy sleep on injection days -

Based on the two sets of #'s you posted and below, and the fact you didn’t mention the use of an AI
I would bet that you have higher SHBG.

In the first set of #'s your free T and E2 are at the bottom of the range.
In the second set, your T is more than doubled, yet your e2 has only come up 4pg/ml.
In terms of total T to E2 you went from 16:1 to 29:1 yet your e2 barely moved.
This suggests that SHBG is high, and is binding your E2 and Free T.

It’s actually an easy fix in that all you require is more T to up your free T, although with more T
you may require an AI to keep your E2 from rising too high and robbing you of the benefits
you are looking for.

SHBG is hard to move up or down, be happy yours is on the high vs low side…
Having low SHBG makes TRT WAYYY more difficult.

Best bet is to have your Doc test SHBG and Free T if he is willing to do so, it will confirm
or deny my suspicion.

Testosterone, Serum: 352 ng/dL (348 - 1197)
Testosterone, Free: 9.0 pg/mL (8.7 - 25.1)
Estradiol: 22.1 pg/mL (7.6 - 42.6)

Testosterone/Estradiol during trough
Testosterone, Total: 773.21 ng/dL (240.00 - 871.00)
Estradiol: 26 pg/mL (11 - 44)

PKNY, thanks for your input. What you said makes sense. I wish my knucklehead doctor understood this. I will request those on my follow-up. I read yesterday, and can’t find it, that high SHBG requires more T while low SHBG requires lower amounts of T…and I may have that backwards. Anyway, the moral I got from it is that regulating SHBG is hard to do so you have to alter your regimen to combat it.

EDIT: I don’t know if this will give you more to go on but below is some lab work from when I came off of the compounded testosterone and took two months of HCGenerate (which quantitatively worked). Then, I quit taking it one month before this lab work. Does this mean anything to you?

Testosterone/Estradiol (attempt at HPTA restart)
Testosterone, Total: 323.5 ng/dL (196 - 782)
Testosterone, Free: 5.94 ng/dL (5.2 - 18.0)
Testosterone, Bioavailable: 136 ng/dL (119 - 470)
SHBG: 38 nmol/L: (12 - 59)
Estradiol: 23 pg/mL (11 - 44)

I have very low SHBG and I inject daily 12.5mg with 9mg aromasin EOD.
In the past two weeks I upped to 17.5mg per day, It helped me break a plateau at the gym,
but all the good things from TRT went out the window.
Libido, mood, erection strength all down in the dumps.
*note, if you don’t mind injecting every morning is way better, keeps the peaks and valleys steady,
and mimics what your body does naturally.

I lowered to 8mg for the last two days and I am feeling great again.
So you can see, TRT is a really delicate balance.

To you point, YES. Low SHBG=low dose T IME, High SHBG=higher doses of T.

PKNY, I revised my previous post above to include lab work when I quit TRT previously. My SHBG was 38 nmol/L: (12 - 59). Does this have any meaning to you in reference to your previous comment?

Go to lef.com | products | blood testing and find the basic male panel. Vitamins and Supplements Rooted in Science - Life Extension

Get the membership and get the better price. This will be out of pocket. But first check for a blood draw station near you at: Find Your Nearest Lab Location| Labcorp

Please read these stickies:

  • advice for new guys
    – post full labs with ranges !!!
    – post more info about you <=====================

  • thyroid basics
    – post your oral waking and mid afternoon body temps
    — low temperatures indicate a state of low thyroid function
    ---- can indicate iodine deficiency
    ---- can indicate that a dose of thyroid meds is too low
    – post your history of using iodized salt and any vitamins that list iodine
    ---- if you are iodine deficient, others in your home will be too; check temperatures

You should not be treating a case of iodine deficiency with a life time of thyroid meds. At this point it is hard to sort things out for you.

It is typical for guys with hypothyroidism to not be able to absorb transdermal T products. This is actually a symptom of a thyroid problem.

The fact that you were able to restart your HPTA for a while, suggests to me that you have secondary hypothyroidism. Which then indicates that your testes are able to get the job done. In my mind, not having tested your LH/FSH is mal-practice and laziness.

There are other stickies that you need to read.

There is a lot of reading that you need to do. As you are seeing, you have to take charge of your own health care; so you need to know more than your doctors.

SHBG of 38 is pretty high, it’s definitely the thing that is limiting your free T.

KSman has great advice, and has probably forgot more about TRT then I know in total.
Perhaps you can sort out your thyroid, restart and be fine without the need for TRT.

At 34, do you have a family ? Do you want one in the future ? TRT is for life and it can
effect fertility…something to think about if you don’t have a family yet and desire one in the future.
If you do end up needing TRT, HCG can help maintain fertility.

IME though, SHBG is very hard to effect, up or down.
I do believe there are some drugs used by the steroid side that can lower SHBG, but if it were me,
I’d rather just use more test, and skip the extra compound.