40 and lean, been on TRT for a while but only feel dialed in when making changes

[Flimpy]

Hi everyone, I’m having a difficult time getting dialed in and I’m hoping I can get some insight from all of you.

I’m 40, lean (15% BF) and exercise 3-4 times a week. My main challenge has been ED, erection quality, ability to maintain an erection and nipple pain. I try to be as objective as possible about this so I log my libido, nocturnal erections, and how long I can maintain an erection every day. My main signal has been nocturnal erections in the hope that it rules out most other aspects of life’s distractions. Consistently I’ll have issues with ED and no nocturnal erections, so I make a change, and within a few weeks I go through a great period of good nocturnal erections and strong daytime erections for sex (with PDE5i). However, inevitably without fail, things suddenly drop off and all the benefits go away. I also often have nipple pain, with a lump under both nipples. It’s important to note that I had bad nipple pain during puberty, and unfortunately with no sex ed I didn’t know what was happening and I did squeeze my nipples enough to have fluid discharge. I suspect my nipples are sensitive to hormones now.

Over the past few years I've tried many different protocols under advisement with my doctor. As high as 140mg per week (70 e3.5d) to where I’m at now 70mg per week (20mg eod). Right now I’m feeling very calm, mentally much sharper, BP is in a great place, I’m exercising a few times a week, sleep is great, and energy is great. Other than erections and some occasional nipple pain, I’m feeling great right now (including libido, gym performance, etc). My current protocol:

Testosterone Cyp: 20mg eod (total of 70mg per week)
Pregnenolone: 10mg ED - this drastically improved my memory
Multivitamin: ED
Vitamin D & K: ED
Magnesium: ED
Metamucil: 1-2 times per day
Creatine: ED
Daily Cialis: 5mg (recently added, worked great for a while but stopped working, did not cause a change in E2)

I’ve tried higher doses, but that caused nipple pain. I tried adding in t-scrot and had CRAZY nocturnal erections for a while, but they eventually faded. It also spiked my cholesterol to an unhealthy level (LDL ~125 and I have genetically high lipoprotein-little-a so I need to be careful). My latest labs (quest), without any aromatase inhibiter are:

E2 Sensitive: 28pg/Ml <— despite this I had nipple pain and ED
Total T: 643 ng/dL
Progesterone: <0.5 ng/mL
AM Cortisol: 21.5 mcg/dL
SHBG: 42 nmol/L


In the past I’ve also tested:
DHEAS: Typically 205-230
IGF-1: 142 ng/mL
Prolactin: 5.2 ng/ML
Free T3: 4.0 pg/mL (but on occasion is lower around 3.4-3.8, not sure if it’s due to time of day or meds)
Free T4: 1.2 ng/dL
TSH: 1.07 (although this is sometimes over 2)
Reverse T3: 17 ng/dL


I’m not a fan of taking aromatase inhibitors which is why I’m taking my testosterone EOD. Despite that, I still get deep nipple pain. Not just burning or itching, but deep pain with a lump behind my nipples. It gets almost intolerable if I let it sit for too long. My SHBG seems to be fluctuating a lot, and I think it’s SHBG adjusting that eventually leads to my erection and nipple problems. When I added daily testosterone scrotal cream (1 click) to my current protocol, my E2 jumped to ~34-38 and SHBG went to 34. DHT also went way above range to 185 ng/dL (ref: 12-65) and caused my LDL to spike. I also tried EOD testosterone scrotal cream and on the off day my E2 was down to 19 without any AI and my SHBG was at 28. I felt best during this time, but was worried about lipids.


My current thought is to add back in EOD testosterone scrotal cream, maybe a smaller dosage, and keep an eye on lipids. I recently discovered the ultimate adrenergic control of erections, and can try some of the meds mentioned there (doxazosin, yohimbe, etc). This is particularly intriguing because sometimes when I have nocturnal erections, they fade extremely fast upon waking (other times my erection sticks around).


My main questions are:

• Has anyone else noticed that they feel best during a change of protocol that then fades?
• Should I be trying anything else?
• Is progesterone too low?
• Should I try nolvadex or have gyno surgery?

I’ve not tolerated HCG well and not currently taking it, but one remaining option would be to take that for a while to kick start my testicles and then stop TRT to see if that works out better. For each of these changes I’ve tried to make one change at a time, and give it 6-8 weeks, but inevitably things end up worse again.


I appreciate any help and comments.

 

[Cataceous]

The honeymoon effect is very common. I also get a temporary boost from pretty much any significant protocol change.

If you're below the male reference range for progesterone then it is low and you might consider supplementing. This can help with opposing estradiol. If you're in the U.S. then experimenting can be as simple as ordering a transdermal product on Amazon and applying a little at bedtime each day. You need to monitor serum levels so you don't overdo it. I'd target the middle of the reference range for starters. Maybe see if this helps before resorting to tamoxifen or surgery.

I've had similar problems with TRT, and playing with the basic tools, including progesterone, was not enough to resolve the issues. I resorted to a pretty drastic protocol to fix things in the end, but a simpler approach is to try switching to a testosterone nasal gel product such as Natesto. Over time your HPTA should regain function while you continue to get the benefits of higher peak testosterone.

 

[Systemlord]

I go through a great period of good nocturnal erections and strong daytime erections for sex (with PDE5i). However, inevitably without fail, things suddenly drop off and all the benefits go away.

If you think about it, naturally our hormones are always changing, never the same day to day. Some of us need the constantly changing hormones to get our sexual parameters working and these static hormones on TRT doesn't work.

My advice is change your dosage every 1-3 days, plus or minus 3-5 mg and keep your body guessing.

 

[Flimpy]

If you think about it, naturally our hormones are always changing, never the same day to day. Some of us need the constantly changing hormones to get our sexual parameters working and these static hormones on TRT doesn't work.

My advice is change your dosage every 1-3 days, plus or minus 3-5 mg and keep your body guessing.

This is what I'm thinking too, which is why I think using test cream on my scrotum every 2-3 days might be enough variance.

 

[Vince]

Hi everyone, I’m having a difficult time getting dialed in and I’m hoping I can get some insight from all of you.

I’m 40, lean (15% BF) and exercise 3-4 times a week. My main challenge has been ED, erection quality, ability to maintain an erection and nipple pain. I try to be as objective as possible about this so I log my libido, nocturnal erections, and how long I can maintain an erection every day. My main signal has been nocturnal erections in the hope that it rules out most other aspects of life’s distractions. Consistently I’ll have issues with ED and no nocturnal erections, so I make a change, and within a few weeks I go through a great period of good nocturnal erections and strong daytime erections for sex (with PDE5i). However, inevitably without fail, things suddenly drop off and all the benefits go away. I also often have nipple pain, with a lump under both nipples. It’s important to note that I had bad nipple pain during puberty, and unfortunately with no sex ed I didn’t know what was happening and I did squeeze my nipples enough to have fluid discharge. I suspect my nipples are sensitive to hormones now.

Over the past few years I've tried many different protocols under advisement with my doctor. As high as 140mg per week (70 e3.5d) to where I’m at now 70mg per week (20mg eod). Right now I’m feeling very calm, mentally much sharper, BP is in a great place, I’m exercising a few times a week, sleep is great, and energy is great. Other than erections and some occasional nipple pain, I’m feeling great right now (including libido, gym performance, etc). My current protocol:

Testosterone Cyp: 20mg eod (total of 70mg per week)
Pregnenolone: 10mg ED - this drastically improved my memory
Multivitamin: ED
Vitamin D & K: ED
Magnesium: ED
Metamucil: 1-2 times per day
Creatine: ED
Daily Cialis: 5mg (recently added, worked great for a while but stopped working, did not cause a change in E2)

I’ve tried higher doses, but that caused nipple pain. I tried adding in t-scrot and had CRAZY nocturnal erections for a while, but they eventually faded. It also spiked my cholesterol to an unhealthy level (LDL ~125 and I have genetically high lipoprotein-little-a so I need to be careful). My latest labs (quest), without any aromatase inhibiter are:

E2 Sensitive: 28pg/Ml <— despite this I had nipple pain and ED
Total T: 643 ng/dL
Progesterone: <0.5 ng/mL
AM Cortisol: 21.5 mcg/dL
SHBG: 42 nmol/L


In the past I’ve also tested:
DHEAS: Typically 205-230
IGF-1: 142 ng/mL
Prolactin: 5.2 ng/ML
Free T3: 4.0 pg/mL (but on occasion is lower around 3.4-3.8, not sure if it’s due to time of day or meds)
Free T4: 1.2 ng/dL
TSH: 1.07 (although this is sometimes over 2)
Reverse T3: 17 ng/dL


I’m not a fan of taking aromatase inhibitors which is why I’m taking my testosterone EOD. Despite that, I still get deep nipple pain. Not just burning or itching, but deep pain with a lump behind my nipples. It gets almost intolerable if I let it sit for too long. My SHBG seems to be fluctuating a lot, and I think it’s SHBG adjusting that eventually leads to my erection and nipple problems. When I added daily testosterone scrotal cream (1 click) to my current protocol, my E2 jumped to ~34-38 and SHBG went to 34. DHT also went way above range to 185 ng/dL (ref: 12-65) and caused my LDL to spike. I also tried EOD testosterone scrotal cream and on the off day my E2 was down to 19 without any AI and my SHBG was at 28. I felt best during this time, but was worried about lipids.


My current thought is to add back in EOD testosterone scrotal cream, maybe a smaller dosage, and keep an eye on lipids. I recently discovered the ultimate adrenergic control of erections, and can try some of the meds mentioned there (doxazosin, yohimbe, etc). This is particularly intriguing because sometimes when I have nocturnal erections, they fade extremely fast upon waking (other times my erection sticks around).


My main questions are:

• Has anyone else noticed that they feel best during a change of protocol that then fades?
• Should I be trying anything else?
• Is progesterone too low?
• Should I try nolvadex or have gyno surgery?

I’ve not tolerated HCG well and not currently taking it, but one remaining option would be to take that for a while to kick start my testicles and then stop TRT to see if that works out better. For each of these changes I’ve tried to make one change at a time, and give it 6-8 weeks, but inevitably things end up worse again.


I appreciate any help and comments.

Your levels are relatively low for somebody on TRT. I wonder what your levels were before you started TRT? What caused your your low testosterone levels and made you decide to start TRT?

 

[Flimpy]

Your levels are relatively low for somebody on TRT. I wonder what your levels were before you started TRT? What caused your your low testosterone levels and made you decide to start TRT?

Hi Vince,

When I started TRT my TT through quest was 573 ng/dL. My SHBG was 57 nmol/L. That period of my life was quite stressful (going through a divorce) and may have caused lower numbers. The a few years prior my Testosterone measured through Labcorp was:


2015, using this Labcorp test
TT: 805 ng/dL (348-1147)
FT (equilibrium dialysis): 13.45 ng/dL (5-21)
%FT: 1.67% (1.5-4.2)
SHBG: 56.5 nmol/L

A year later (2016) it was:
TT: 908 ng/dL
FT (direct): 12.1 pg/mL
E2 Sensitive: 27.5 pg/mL
SHBG: 56.5 nmol/L


However, in 2011 my TT was 408 ng/dL and 548 ng/dL measured two months apart with SHBG at 52.6 nmol/L. No idea what caused these to be so much lower at the time.


My urologist suggested I start TRT because I was in my 30s with high SHBG and that my FT was probably too low.

Now that I've done more research I'm not sure my numbers warranted TRT, especially with the new TruT model. Although my FT done with equilibrium dialysis doesn't match what TruT predicts (TruT predicts FT of 25ng/dL).

As for my lower T on TRT, it's been much higher but I've lowered my TRT dose down to 70mg a week (20mg EOD) because of consistent nipple pain and growth on higher doses. When I through in scrotal cream on top of this it peaks around 1000 ng/dL.

 

[Systemlord]

Jatenzo might be another option, my levels are at peak in the 900's 2 hours after dosing, 644 at 12 pm (4 hours after) and 289 at 12 hours or before my next dosing.

I see extremely consistent Total T levels, measured at 12 pm or 4 hours after dosing. The last two labs show 644 ng/dL at exactly 4 hours and the last one done at 12:30 shows 604 ng/dL.

The recommended starting dosage for Jatenzo is 237 mg twice daily.

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[Flimpy]

Jatenzo might be another option, my levels are at peak in the 900's 2 hours after dosing, 644 at 12 pm (4 hours after) and 289 at 12 hours or before my next dosing.

I see extremely consistent Total T levels, measured at 12 pm or 4 hours after dosing. The last two labs show 644 ng/dL at exactly 4 hours and the last one done at 12:30 shows 604 ng/dL.

The recommended starting dosage for Jatenzo is 237 mg twice daily.

SAGE Journals: Your gateway to world-class research journals

Subscription and open access journals from SAGE Publishing, the world's leading independent academic publisher.

journals.sagepub.com

This is very interesting. I just read your experience with it regarding the changing levels. Most of my pre-TRT blood draws were early morning but I had one at noon that was 250 ng/dL lower. That could have been due to the time of the draw or I was just lower that day, but it makes me wonder if my body was used to faster drops in testosterone throughout the day.

Were you able to get insurance to cover it? It looks quite expensive otherwise.

 

[Systemlord]

but I had one at noon that was 250 ng/dL lower.

This was at 158 mg twice daily. Also Jatenzo reaches steady states in 7 days, so in 3 weeks time you could go through three dosage increases and reach steady states three separate times, something that would take at least 3 months on injections.

So dialing in on Jatenzo is a breeze and takes a lot of the guesswork out of one's protocol with regards to finding the best injection frequency.

Once more oral formulations come out and competition reduces costs, I believe oral TRT will become mainstream.

 

[Systemlord]

Were you able to get insurance to cover it?

Yes, I got a medical exception from my endo due to treatment failure for 4 years on injections, gels and creams. I have heard another member the makers of Jatenzo has a good program for reducing the cost substantially.

 

[Flimpy]

Last night I put a small amount of t-cream on my scrotum and has insane nocturnal erections. Every time I woke up to rollover, and this morning while dozing. This has happened before but I can't keep it consistent. I'm hoping scrotum cream EOD will provide enough fluctuation to keep this dialed in, and if not I can try jatenzo or natesto if my doc will go for it.

I've upped my pregnenolone for now as well. I'll report back after some time has passed.

I appreciate everyone's suggestions!