Help with blood test results and erectile dysfunction

[TestBoosted]

Hello friends,

Hope you are well!

I am a 33 year old male, height 183cm, weight 95kg with body fat around 20%.

Around 10 years ago, I was diagnosed with secondary hypogonadism. My natural T levels were 8 nMol/L and my FHS and LH were low. The main symptom that led me to do the blood test for testosterone was erectile dysfunction.

At the national hospital, they put me on tesosterone enanthate at 250mg every 3 weeks (1 shot every 3 weeks). Unfortunately, this didn't work for me. During the first week, I felt really anxious and panicky with headaches. During the second week, I used to feel so and so while on the 3rd week, I used to feel extremely tired and letarghic, with no energy. This continued for around a year and during that year my erections never improved.

After some time, I decided to try HCG monotherapy. Unfortunately, this used to spike my estrogen a lot and again I had to stop it. No improvements in erections.

Next, I tried Nebido. The first and second shot of 1000mg is given in 6 week intervals, with future shots being given in 10 week intervals. Along with CIalis 5mg, this gave me the best erections of my life. I used to wake up with very strong erections almost every day. Whenever I even had the slightest sexual thought of women or a woman touched me, I would get a strong erection instantly and sex was finally possible and enjoyable again. Past issues with premature ejactulation resolved as well and I was positive that I was finally cured.

Unfortunately, this only lasted around 2 years and my erectile dysfunction returned, even on the same protocol and trying to experiment with shortening or lengthening the injection intervals. Right now, I am only able to get soft erections only in specific positions, like when I am sitting on the toilet or manually stimulating. The head does not engorge and I lose the erections very quickly. PDE5 inhibitors like Viagra and Cialis no longer work, even if I try taking the maximum doses (100mg Viagra or 20 mg Cialis). The erections are not suitable for sexual intercourse as the head is very soft and the erection is lost quickly.

After a lot of reading on these forums, I decided to convince my doctor to go back to basics. No more Nebido, just get on testosterone enanthate and try frequent injections.

For the past 5 weeks, I have been taking testosterone enanthate, 2 injections per week on Monday evening and Friday morning (every 3.5 days). Each injection is 50 mg, for a total of 100 mg per week. I inject IM in the outer thigh.

I took bloods and you can find the results attached in this thread. These bloods were taken 5 weeks since starting the new protocol, on Friday morning just before next injection.

Some key takeaways:

i) Total testosterone is 19 nmol/L, which I believe is a good value for trough.
ii) Free thyroxine is very slightly elevated (20.64 pmol/L against a maximum of 20.3 pmol/L).
iii) Oestradiol seems to be very elevated and this is at trough level (204 pmol/L against a maximum of 146.1 pmol/L).
iv) Haemocrit is slightly elevated (51%)

Unfortunately, I tried getting SHBG tested but for some reason or another, they couldn't book it for me. I had tested for SHBG when I was originally on testosterone enanthate 250 mg every 3 weeks, and the value was around 18 to 21 around 6 years ago. In the future, I will try to test it privately along with total t and albumin so that I can then calculate free t.

I would like to get assistance on how to improve my TRT protocol for better erections. How can I improve it further please? Thank you so much for your dedication and assistance and apologies for the very long post.

EDIT

One last important piece of info.

I am currently taking these medications:

i) Anafranil (Antidepressant) - Lowest dose at 10mg
ii) Diagnosed with High cholesterol (Low HDL and high LDL) - Being controlled using Atorvastatin 20 mg
iii) Cialis 5 mg daily

 

[USMC]

Could your high estrogen be causing that? Has it always been high since your ED issues? I'm sure others will chime in soon...

 

[TestBoosted]

Could your high estrogen be causing that? Has it always been high since your ED issues? I'm sure others will chime in soon...

Hi USMC,

Thank you for your reply.

I remember that when I used to take test enanthate 250mg every 3 weeks and then when I switched to HCG, my estrogen was always high.

When I was on Nebido, estrogen was around 80-100 pmol/L, which is in range. However, this was after 9.5 weeks at trough level. Most probably it was higher in the beginning of the shot cycle.

Judging from my results now that I am on testosterone enanthate 50mg twice weekly, it seems that estrogen is the hormone out of whack. Do you know how I can reduce this please? Unfortunately I don't have access to AI.

 

[Systemlord]

It’s normal for estrogen to be higher on injections. Why is high estrogen a problem?

 

[TestBoosted]

It’s normal for estrogen to be higher on injections. Why is high estrogen a problem?

Thank you for your reply.

From what I read, estrogen should ideally be between 35 and 45 pg/ml.

Using the units for estrogen in my blood results, this optimal range translates between 125 and 165 pmol/L. Mine is 206 pmol/L at trough level, so it must be even higher at the beginning of the injection.

High estrogen can lead to fatigue, gynecomastia and erectile dysfunction. I need to find a way to lower it, otherwise I may not reap the full benefits of TRT.

 

[Systemlord]

Thank you for your reply.

From what I read, estrogen should ideally be between 35 and 45 pg/ml.

Using the units for estrogen in my blood results, this optimal range translates between 125 and 165 pmol/L. Mine is 206 pmol/L at trough level, so it must be even higher at the beginning of the injection.

High estrogen can lead to fatigue, gynecomastia and erectile dysfunction. I need to find a way to lower it, otherwise I may not reap the full benefits of TRT.

Nope, high estrogen doesn’t lead to gyno, an imbalance of testosterone, estrogen, DHT and prolactin triggers gyno. Gyno is more common in men with low testosterone, not high testosterone.

Study show that some men on TRT with estrogen below 42.5 have lower libido and ED because their testosterone to estrogen ratios are off.

It’s common when guys stopped their gear, when their hormone levels are crashing is when they tend to develop Gyno.

Manipulate your TRT dose and/or injection frequency to get the right testosterone estrogen ratios.

 

[TestBoosted]

Nope, high estrogen doesn’t lead to gyno, an imbalance of testosterone, estrogen, DHT and prolactin triggers gyno. Gyno is more common in men with low testosterone, not high testosterone.

Study show that some men on TRT with estrogen below 42.5 have lower libido and ED because their testosterone to estrogen ratios are off.

It’s common when guys stopped their gear, when their hormone levels are crashing is when they tend to develop Gyno.

Manipulate your TRT dose and/or injection frequency to get the right testosterone estrogen ratios.

Thanks for that. What would you say is the optimal testosterone to estrogen ratio please?

I was thinking of doing 30mg injections, 3 times weekly fpr a total of 90mg per week.

 

[WhiteMale]

T:E ratio is a very flawed concept, as much as telling him his E in a normal lab range is fine and not a problem.

If his SHBG is in some area of about 20 as he said, the result is more likely to be Estrogens are too high, FOR HIM.

 

[Aron]

Your testosterone trough level looks good at 19 nmol/L, but the elevated estradiol (204 pmol/L) may be a key reason for poor erection quality. You could try slightly lowering your weekly dose (e.g., to 90mg) or injecting more frequently (e.g., every 2–3 days) to manage E2 better.


Your old SHBG value (18–21) suggests you might benefit from higher free T and more stable levels, so getting updated SHBG and Free T tests would help.
Also, Anafranil can significantly impact sexual function. It may be worth discussing alternatives with your doctor. PDE5 inhibitors may not work well if E2 is high or if vascular function is affected — consider checking cardiovascular health or doing a penile Doppler. You're on the right path — now it's about fine-tuning. Keep at it and stay consistent.

 

[TestBoosted]

T:E ratio is a very flawed concept, as much as telling him his E in a normal lab range is fine and not a problem.

If his SHBG is in some area of about 20 as he said, the result is more likely to be Estrogens are too high, FOR HIM.

Hi friend, thank you for your reply.

I just got hold of my SHBG level for the same day, I phoned the laboratory to do it for me.

My SHBG is 16.3 nmol/L.

And these are the rest of the values which are already in the original post:

Total testosterone = 19.1 nmol/L.

Albumin = 46.6 g/L

Estrogen = 204 pmol/L (55.57 pg/ml)


Seems like estrogen will be giving me a hard time. It is very high at trough, must be much higher on injection day.

How would you change my original protocol of 50 mg twice a week?

I was thinking of doing 30mg , 3 times a week (MWF). This will be more frequent pinning and a reduction of 10mg of the dose per week.

Thanks a lot!

 

[FunkOdyssey]

I think you are focused too narrowly on the particulars of your protocol and need to investigate the root cause of your excessive aromatization. Your HDL and triglycerides are abysmal and suggest serious metabolic dysfunction. Insulin strongly promotes the expression of aromatase enzyme. Excess body fat also produces more aromatase.

I am less interested in your TRT protocol and more interested in everything else. What are you eating, how are you sleeping, what do you do for exercise, and what does your percent body fat look like? Alcohol or cannabis consumption? Something is broken here.

 

[TestBoosted]

Your testosterone trough level looks good at 19 nmol/L, but the elevated estradiol (204 pmol/L) may be a key reason for poor erection quality. You could try slightly lowering your weekly dose (e.g., to 90mg) or injecting more frequently (e.g., every 2–3 days) to manage E2 better.


Your old SHBG value (18–21) suggests you might benefit from higher free T and more stable levels, so getting updated SHBG and Free T tests would help.
Also, Anafranil can significantly impact sexual function. It may be worth discussing alternatives with your doctor. PDE5 inhibitors may not work well if E2 is high or if vascular function is affected — consider checking cardiovascular health or doing a penile Doppler. You're on the right path — now it's about fine-tuning. Keep at it and stay consistent.

Hi Anon,

Thank you so much for your detailed reply, really appreciate it.

Regarding my SHBG level, I asked the lab to work it out for me. It came back as 16.3 nmol/L.

So,

Total testosterone = 19.1 nmol/L

SHBG = 16.3 nmol/L

Estrogen = 204 pmol/L (55.57 pg/ml)

Albumin = 46.6 g/L

According to this calculator (Free Testosterone Calculator - Balance My Hormones),

Free testosterone = 0.533 nmol/L = 2.79 %

Bioavailable testosterone = 13.5 nmol/L = 70.6 %

Regarding my injections, I was thinking of doing 30mg, 3 times a week (MWF) for a total of 90mg a week.

Regarding Anafranil, I will discuss with my psychiatrist. Are you aware of other medications that I should avoid or else should try?

Regarding Doppler test, I did it twice and unfortunately the results were very bad. Arterial inflow was very good but end diastolic velocity was very high, indicating venous leak. Below are the results:

Doppler 1 – Right corpus cavernosum
Peak systolic velocity - 127 cm/sec
End diastolic velocity - 11 cm/sec

Doppler 1 – Left corpus cavernosum
Peak systolic velocity - 152 cm/sec
End Diastolic velocity -13 cm/sec

Doppler 2 – Right corpus cavernosum
Peak systolic velocity - 140 cm/sec
End diastolic velocity - 18 cm/sec

Doppler 2 – Left corpus cavernosum
Peak systolic velocity - 152 cm/sec
End diastolic velocity - 7 cm/sec

End diastolic velocity should be maximum 5 and ideally below 0.

I read that sometimes unoptimized testosterone levels or high E2 can lead to venous leak. I saw several papers where hypogonodal men with venous leak recovered after TRT.

Dramatic improvement of penile venous leakage upon testosterone administration. A case report and review of literature - PubMed

The main effect of testosterone was long-time assumed to be on sexual interest and, indirectly, on erectile function. Newer insights demonstrate that testosterone deficiency impairs the anatomical, ultrastructural, biological and physiological/functional substrate of penile erection, which can...

pubmed.ncbi.nlm.nih.gov

https://onlinelibrary.wiley.com/doi/full/10.2164/jandrol.108.005264

Thing is, when I did the doppler tests, I had already been on Nebido for 5 years, which worked wonders for the first 2 years and gave me very good erections for those 2 years.

I don't know if optimizing my testosterone levels will lead to an improvement in my erections. I want to make sure that I did everything in my power before going to the last resort, which is the penile implant.

Thanks a lot

 

[Guided_by_Voices]

I agree with the direction Funk is suggesting which is to look for root cause issues. If viagra is not working that suggests a lack of Nitric Oxide production, so things like Beet Root powder, Nitric Oxide tablets, sunshine and HIIT would be good to try. Bi-mix or Tri-mix would be another option but would not address root cause. I would get the book Perfect Health Diet and make that your dietary home base. There are a lot of other things you can try like PT-141, but the bottom line is to look at the totality of your health. As far as TRT goes. it seems reasonable to stay on whatever was working at one point, and then address other issues which may have caused it to stop working.

 

[TestBoosted]

I think you are focused too narrowly on the particulars of your protocol and need to investigate the root cause of your excessive aromatization. Your HDL and triglycerides are abysmal and suggest serious metabolic dysfunction. Insulin strongly promotes the expression of aromatase enzyme. Excess body fat also produces more aromatase.

I am less interested in your TRT protocol and more interested in everything else. What are you eating, how are you sleeping, what do you do for exercise, and what does your percent body fat look like? Alcohol or cannabis consumption? Something is broken here.

Hi FunkOdyssey,

Thank you so much for your detailed reply, I appreciate it immensely.

You are right, there are several things wrong with my health but I never made the link with ED.

I am 33 years old, weight 95 kgs and have a body fat percentage of around 20%. I don't drink or do any drugs, however I do like to eat. My diet is not that bad per se. Usually in the morning I eat some cereal, at 10am I eat some fruit and then at noon I eat a big meal (sometimes meat and rice, but sometimes can be pasta). In the evening, I usually like to have plain chicken with rice. I think my problem mostly is more portion control in this regards. I mostly drink water and diet (zero sugar soft drinks).

With regards to exercise, I can do much more in this regard. I try to go to the gym 3 times a week (20 mins cardio, 40 mins weights). But lately, I have been slacking and mostly going twice a week.

With regards to my health, I was diagnosed with high cholesterol at around 25. I tried for a year to get it under control with diet and exercise. I had lost some weight as well but my cholesterol still remained high. I was then put on Atorvastatin 20mg every day. My LDL and cholesterol ratio is in check however triglycerides have always been high and my HDL low.

I also sometimes get a high reading when it comes to TSH (sometimes 3.6, 3.7, 3.2). Usually it hovers around 2.5 to 2.7. I'm not under any medication for thyroid.

Regarding diabetes, I don't have it (for now) but my father was diagnosed with type 2 diabetes at around 30 years old. My mother also has diabetes but was diagnosed much later around 50 years old.

I will attach some more screenshots for you with my values over the years. Keep in mind that between March 2019 and around August 2021 my erections were very good, problems restarted afterwards. I will mark the period where my erections were good with green.

Regarding your comment about insulin resistance, I have just contacted a private labrotary and will do the test in the very near future.

Thank you so much for this observation. What you are saying definitely makes sense. No doctor before warned me about the tryglicerides, they usually just look at the cholesterol ratio and say it's ok.

But the thing you mentioned about metabolic syndrome makes sense. I have already cholesterol problems, I do get high TSH from time to time and I am afraid diabetes is in store for me in the future.

 

[TestBoosted]

I agree with the direction Funk is suggesting which is to look for root cause issues. If viagra is not working that suggests a lack of Nitric Oxide production, so things like Beet Root powder, Nitric Oxide tablets, sunshine and HIIT would be good to try. Bi-mix or Tri-mix would be another option but would not address root cause. I would get the book Perfect Health Diet and make that your dietary home base. There are a lot of other things you can try like PT-141, but the bottom line is to look at the totality of your health. As far as TRT goes. it seems reasonable to stay on whatever was working at one point, and then address other issues which may have caused it to stop working.

Thank you so much for your detailed reply Guided_by_Voices. In the past I did try Beetroot juice, L Arganine and Nitric Oxide supplements, to no avail.

I also tried Caverject (Alprostadil, penile injection). Unfortunately we don't get Bimix and Trimix in Europe. Caverject at 20mg and 40 mg only produced a very weak erection not suitable for penetration. I used Caverject a total of 4 times, for the 2 Doppler tests, for an ultrasound and alone.

I will take a look at the Perfect Health diet book, thank you so much for this.

Regarding PT-141, I had read about it but it is not available in Europe as well

I will try to improve my diet, lose some weight and speak to a cardiologist about the tryglicerides and low HDL.

Thanks a lot!

 

[FunkOdyssey]

I am 33 years old, weight 95 kgs and have a body fat percentage of around 20%. I don't drink or do any drugs, however I do like to eat. My diet is not that bad per se. Usually in the morning I eat some cereal, at 10am I eat some fruit and then at noon I eat a big meal (sometimes meat and rice, but sometimes can be pasta). In the evening, I usually like to have plain chicken with rice. I think my problem mostly is more portion control in this regards. I mostly drink water and diet (zero sugar soft drinks).

This is the type of lower fat, high refined carb, pseudo-healthy diet that most Americans are eating, resulting in 50% of the population being either prediabetic or diabetic.

Regarding diabetes, I don't have it (for now) but my father was diagnosed with type 2 diabetes at around 30 years old. My mother also has diabetes but was diagnosed much later around 50 years old.

This is the direction you are also heading, unless you make significant course corrections.

The ED you are dealing with is likely vascular in nature, and will not respond well to TRT for that reason. The insulin resistant endothelium loses its capacity to produce nitric oxide, essential for erections and vascular health throughout the body. Erections are called the "canary in the coal mine" when it comes to cardiovascular health. You should ask your doctor to run a coronary calcium scan if you haven't already, to screen for the presence and severity of calcified coronary plaque. You are still young, but I would say there's a good chance it will come up positive based on your labs.

I would recommend the book Why We Get Sick, by Ben Bikman, to better understand how insulin resistance lies at the root of most chronic illness and major causes of death, how to measure it, and how to reverse it: Amazon.com

Besides dietary changes, metformin might be a useful tool for you to simultaneously improve insulin sensitivity and reduce aromatase in a healthful manner, by reducing its genetic expression rather than disabling the aromatase enzyme like an AI. There's a great video on the situation you are dealing with here (the intersection of TRT with poor metabolic health) that you should watch, which explains why metformin can be so valuable:

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[Nelson Vergel]

I am currently taking these medications:

i) Anafranil (Antidepressant) - Lowest dose at 10mg
ii) Diagnosed with High cholesterol (Low HDL and high LDL) - Being controlled using Atorvastatin 20 mg

When did you start these? Did it coincide with your softer erections?

 

[TestBoosted]

This is the type of lower fat, high refined carb, pseudo-healthy diet that most Americans are eating, resulting in 50% of the population being either prediabetic or diabetic.


This is the direction you are also heading, unless you make significant course corrections.

The ED you are dealing with is likely vascular in nature, and will not respond well to TRT for that reason. The insulin resistant endothelium loses its capacity to produce nitric oxide, essential for erections and vascular health throughout the body. Erections are called the "canary in the coal mine" when it comes to cardiovascular health. You should ask your doctor to run a coronary calcium scan if you haven't already, to screen for the presence and severity of calcified coronary plaque. You are still young, but I would say there's a good chance it will come up positive based on your labs.

I would recommend the book Why We Get Sick, by Ben Bikman, to better understand how insulin resistance lies at the root of most chronic illness and major causes of death, how to measure it, and how to reverse it: Amazon.com

Besides dietary changes, metformin might be a useful tool for you to simultaneously improve insulin sensitivity and reduce aromatase in a healthful manner, by reducing its genetic expression rather than disabling the aromatase enzyme like an AI. There's a great video on the situation you are dealing with here (the intersection of TRT with poor metabolic health) that you should watch, which explains why metformin can be so valuable:

To view this content we will need your consent to set third party cookies.
For more detailed information, see our cookies page.

Accept third party cookies

Thank you so much for this invaluable information, you really put it into perspective for me.

I have already found a lab that does the fasting insulin test. I will book it today.

I will also book the coronary calcium CT scan.

I will report back with the results of the tests here.

I also intend to go to a dietician to help me change my diet to reduce my triglycerides and hopefully improve my HDL. I will also use the books that were recommended here.

Now that I am reading about metabolic syndrome, I believe I do have most of the markers. My ALT regularly comes above range, out of whack cholesterol values, hypogonadism, and my tsh sometimes comes above range too. The fact that my shbg is low and I am aromatizing so much on a modest dose and injection frequency adds insult to injury.

 

[TestBoosted]

When did you start these? Did it coincide with your softer erections?

Thank you so much for your question Nelson.

I started antidepressants at the age of 21 after the death of my father. However, I believe I always needed them. My father had genetic depression much worst than mine, and I guess I have a predisposition to it. For almost 10 years, I was on Fluvoxamine 100mg every day. I only switched to Anafranil recently by working with a psychiatrist because I thought Fluvoxamine had something to do with my ED. I am working with a psychiatrist to help me find a good antidepressant that doesn't affect ED.

Regarding statins, doctors discovered my cholesterol issues at 25. I had high ldl, low hdl and high triglycerides. They put me on 20 mg atorvastatin (after losing weight, doing exercise everday with only slight improvement) and my cholesterol ratio and ldl are good now. However, my triglycerides and hdl have been out of range for years and doctors never told me there was anything really wrong with them.

Regarding my ED, I realized about it at around 23. At first, doctors were blaming my antidepressants so for a year I worked with a psychiatrist to try other medication (Venlafaxine, Brintwllix, Wellbutrin) but it never improved. Around 24, they discovered I had hypogonadism. At first they put me on tesosterone enanthate 250mg every 3 weeks, but that didn't resolve my issue.

Then, aroind 2019 at the age of 27, my current endocrinologist put me on Nebido 1000mg every 10 weeks and my ED issues were completely resolved in 3 months and this lasted for 2 years. I still remained on the sane protocol for another 3 years, trying to adjust the injection frequency to no avail. After these 2 very good years on Nebido, PDE5 inhibitors and penile injections also stopped working, even though I was still on Nebido.

I only started with the new TRT protocol on test enanthate 50mg twice weekly around a month ago.

I also did a fitness test, 24 hour blood pressure test and echocardiogram and they all gave good results.

I am working with several doctors to try and tackle the ED issue for the past year and a half. Working with a psychiatrist, endocronologist, urologist and cardiologist. To be honest, I am at the end of my rope as all the doctors are basically telling me that all the tests are good, I look to be in good health and that most probably my ED is psychological.

However I know how I felt those 2 amazing years on Nebido and my mental health is not bad right now. The fact that I don't get nocturnal erections and that I don't respond to PDE5 inhibitors and penile injections means there's something else going on apart from psychological issues.

But thanks to the expertise of the gentlemen on this forum, I now have several avenues to investigate.

 

[FunkOdyssey]

I also intend to go to a dietician to help me change my diet to reduce my triglycerides and hopefully improve my HDL. I will also use the books that were recommended here.

If continuous glucose monitors are available over-the-counter where you live, you should wear one for some time. If they aren't available OTC, see if your doctor will prescribe one for you. The minute to minute biofeedback on your glucose levels is invaluable for someone seeking to improve their metabolic health. You will find yourself naturally making impactful dietary modifications, simply because you will not enjoy seeing your blood sugar spike to levels that are damaging to your arteries and organs.

Even as a carnivore, I was able to make improvements to optimize my diet via the use of CGM (I had been eating too much protein and making extra sugar via gluconeogenesis, resolved by decreasing protein/fat ratio). I cannot emphasize enough how useful CGMs are for troubleshooting diet.