Clomid (and maybe more) with Defy

[Esq]

As I've noted in the past, and it's easy for me to make a statement like this, patience is a virtue in this game. Should you reach the point that Clomid's clearly not working for you - subjectively - you have the option to turn to traditional TRT.

Absolutely, regarding patience. I'd rather figure all of this out the right way than rush into a treatment with more long-term effects that may not even remedy the underlying problem. I do wonder, however, whether traditional TRT is even an option for me, at least at this juncture. My natural total testosterone is around 700 (free around 17 and SHGB at 52). If all other options fail to remedy the symptoms, I'd be willing to give it a go just to see what happens, but I don't know if that would be an option with my natural numbers. I realize that chasing numbers is not the goal of all of this, but there seems to be a consensus on this forum (and elsewhere) that regardless of symptoms, if natural numbers are 600ish and above, TRT is out of the question.
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Frankly, that's why I've been so hopeful that everything else we're trying will alleviate the symptoms, because plan B isn't all too clear to me at the moment.

 

[Dr Justin Saya MD]

Absolutely, regarding patience. I'd rather figure all of this out the right way than rush into a treatment with more long-term effects that may not even remedy the underlying problem. I do wonder, however, whether traditional TRT is even an option for me, at least at this juncture. My natural total testosterone is around 700 (free around 17 and SHGB at 52). If all other options fail to remedy the symptoms, I'd be willing to give it a go just to see what happens, but I don't know if that would be an option with my natural numbers. I realize that chasing numbers is not the goal of all of this, but there seems to be a consensus on this forum (and elsewhere) that regardless of symptoms, if natural numbers are 600ish and above, TRT is out of the question.
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Frankly, that's why I've been so hopeful that everything else we're trying will alleviate the symptoms, because plan B isn't all too clear to me at the moment.

You are spot on Esq. Not necessarily that you're disqualified or a poor candidate for TRT if other measures fail, but that the "smoke" seems to be pointing a bit more towards your adrenals at this juncture. I'll be very curious to see if the adaptogens offer some benefit. If not, we have other things to talk about.

 

[Esq]

You are spot on Esq. Not necessarily that you're disqualified or a poor candidate for TRT if other measures fail, but that the "smoke" seems to be pointing a bit more towards your adrenals at this juncture. I'll be very curious to see if the adaptogens offer some benefit. If not, we have other things to talk about.

Thanks, Dr. Saya. Good to know. By the way, would you recommend the Ortho Molecular Adapten-All as a good adaptogen? I believe Defy patients get a discount on Ortho Molecular products, so I assume that means they are quality? So far, it's the only adaptogen I've been able to find that has rhodiola, ashwagangha, and licorice all in one (plus eleuthero root, schisandra berry, and a micronutrient blend).
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I've been emailing with your staff about ordering that along with more anastrozole, but there seems to be some confusion about whether I can order Ortho products through Defy.

 

[Dr Justin Saya MD]

Thanks, Dr. Saya. Good to know. By the way, would you recommend the Ortho Molecular Adapten-All as a good adaptogen? I believe Defy patients get a discount on Ortho Molecular products, so I assume that means they are quality? So far, it's the only adaptogen I've been able to find that has rhodiola, ashwagangha, and licorice all in one (plus eleuthero root, schisandra berry, and a micronutrient blend).
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I've been emailing with your staff about ordering that along with more anastrozole, but there seems to be some confusion about whether I can order Ortho products through Defy.

Yes that's a good product/manufacturer, though I don't believe we stock that particular one in office. Even so, staff should have no problem ordering it for you (calling can sometimes be more efficient than email due to turnaround time as well).

 

[Esq]

Yes that's a good product/manufacturer, though I don't believe we stock that particular one in office. Even so, staff should have no problem ordering it for you (calling can sometimes be more efficient than email due to turnaround time as well).

Thanks, Dr. Saya. I spoke with Sam (who I had been emailing with) and Christina, and they got it all straightened out and placed the order for Adapten-All. Defy's prices for that particular product beat the prices I saw from various online retailers by a long shot, even accounting for not-inexpensive shipping, so that's nice. Christina also suggested I order 1mg anastrozole tabs and break them into quarters rather then having the 0.25mg compounded. It makes the anastrozole about 50% less expensive and she said it usually ships faster that way.

 

[Dr Justin Saya MD]

Christina also suggested I order 1mg anastrozole tabs and break them into quarters rather then having the 0.25mg compounded. It makes the anastrozole about 50% less expensive and she said it usually ships faster that way.

Those statements are true and certainly important considerations for the budget conscious, however one caveat is that the 1mg anastrozole tablets are not scored and so tiny that it is impossible to precisely cut into 1/4s (i.e. dosage will never be exactly 0.25mg)...it's a trade-off.

 

[Esq]

Those statements are true and certainly important considerations for the budget conscious, however one caveat is that the 1mg anastrozole tablets are not scored and so tiny that it is impossible to precisely cut into 1/4s (i.e. dosage will never be exactly 0.25mg)...it's a trade-off.

Oh. She didn't mention that part. It's definitely not worth the small difference in price to risk inaccurate doses. I emailed her to ask if she can switch the order, but it may be too late.

 

[Esq]

Oh. She didn't mention that part. It's definitely not worth the small difference in price to risk inaccurate doses. I emailed her to ask if she can switch the order, but it may be too late.

Christina got the order fixed, so I'll be getting the 0.25mg capsules again.

 

[Esq]

The Adapten-All arrived yesterday (lightning fast). This morning, I compared it to my multivitamin (Legion Triumph) just to be sure the vitamin complex in Adapten-All wouldn't give me astronomical doses of any vitamins when taking with the multi, and I learned that my multi has both rhodiola and ashwagangha in it at pretty high doses. So, I've actually been taking those two compounds at clinically effective doses for roughly six months without knowing it.
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Unfortunately, that means neither compound has done anything for my symptoms, and both were in my system when my last bloods were done and cortisol levels were tested.
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The suggested dosing for Adapten-All is 2 to 4 pills per day, so I'll start out taking 2 a day for a boost of rhodiola and ashwagangha, plus the licorice root. Once I work through this bottle, I'll probably scrap that product, keep taking the multi, and add in some licorice root.
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Either way, it doesn't look like adrenal adaptogens are going to be the fix for me, but I don't think it can hurt to keep taking them.

 

[Dr Justin Saya MD]

The Adapten-All arrived yesterday (lightning fast). This morning, I compared it to my multivitamin (Legion Triumph) just to be sure the vitamin complex in Adapten-All wouldn't give me astronomical doses of any vitamins when taking with the multi, and I learned that my multi has both rhodiola and ashwagangha in it at pretty high doses. So, I've actually been taking those two compounds at clinically effective doses for roughly six months without knowing it.
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Unfortunately, that means neither compound has done anything for my symptoms, and both were in my system when my last bloods were done and cortisol levels were tested.
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The suggested dosing for Adapten-All is 2 to 4 pills per day, so I'll start out taking 2 a day for a boost of rhodiola and ashwagangha, plus the licorice root. Once I work through this bottle, I'll probably scrap that product, keep taking the multi, and add in some licorice root.
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Either way, it doesn't look like adrenal adaptogens are going to be the fix for me, but I don't think it can hurt to keep taking them.

Ah so the plot thickens, Esq. That's certainly an unexpected curveball! I know you listed taking a multivitamin on your initial HQ, but I've never seen a basic multi with rhodiola and ashwaganda...that's very unusual. Interestingly, I believe we have now found the culprit for your persistently high DHEA-S levels even prior to our initial chat. I've seen a few cases of a robust DHEA-S response to the adaptogens (particularly rhodiola) concurrent with suppression/lowering of cortisol. How long have you been on that multi?

This actually changes everything at this point. You mentioned picking up some separate licorice root - that's exactly what I would do at this point and discontinue the ashwaganda and rhodiola (I know this is a complete change of plans, but there is new information now that we weren't previously privy to). I would want your next salivary cortisol and DHEA-S test OFF of the ashwaganda and rhodiola now that we know you were actually TAKING them at the time of your previous sample.

 

[Esq]

Ah so the plot thickens, Esq. That's certainly an unexpected curveball! I know you listed taking a multivitamin on your initial HQ, but I've never seen a basic multi with rhodiola and ashwaganda...that's very unusual. Interestingly, I believe we have now found the culprit for your persistently high DHEA-S levels even prior to our initial chat. I've seen a few cases of a robust DHEA-S response to the adaptogens (particularly rhodiola) concurrent with suppression/lowering of cortisol. How long have you been on that multi?

This actually changes everything at this point. You mentioned picking up some separate licorice root - that's exactly what I would do at this point and discontinue the ashwaganda and rhodiola (I know this is a complete change of plans, but there is new information now that we weren't previously privy to). I would want your next salivary cortisol and DHEA-S test OFF of the ashwaganda and rhodiola now that we know you were actually TAKING them at the time of your previous sample.

Can't be easy, right? Okay, so I went back through my Amazon order history and I first ordered the Legion Triumph on February 5. My timing in my post above was a little off.
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Up until that time, I was taking Controlled Labs Orange Triad (which is what was reported on my Defy intake form). Orange Triad does NOT contain ashwagandha or rhodiola (though it does have a "Digestion and Immune Complex" containing echinacea, ginger extract, quercetin, giant knotweed, bilberry powder, and a few other things).

When my initial Defy labs were done on January 16, I had not yet switched multis so the elevated DHEA-S from that test would not have been influenced by ashwagandha or rhodiola, though maybe the toremifene could have elevated that?
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My next round of Defy labs were done on April 10 (salivary cortisol on April 11), so at that point I would have been taking the Triumph multi for approximately 2 months.
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So, based on this, I should discontinue both the Legion Triumph multi and the Adapten-All, and just use a separate, stand-alone licorice root product (and perhaps a different multi)?
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By the way, thanks for responding on a Sunday evening!

 

[Dr Justin Saya MD]

Can't be easy, right? Okay, so I went back through my Amazon order history and I first ordered the Legion Triumph on February 5. My timing in my post above was a little off.
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Up until that time, I was taking Controlled Labs Orange Triad (which is what was reported on my Defy intake form). Orange Triad does NOT contain ashwagandha or rhodiola (though it does have a "Digestion and Immune Complex" containing echinacea, ginger extract, quercetin, giant knotweed, bilberry powder, and a few other things).

When my initial Defy labs were done on January 16, I had not yet switched multis so the elevated DHEA-S from that test would not have been influenced by ashwagandha or rhodiola, though maybe the toremifene could have elevated that?
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My next round of Defy labs were done on April 10 (salivary cortisol on April 11), so at that point I would have been taking the Triumph multi for approximately 2 months.
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So, based on this, I should discontinue both the Legion Triumph multi and the Adapten-All, and just use a separate, stand-alone licorice root product (and perhaps a different multi)?
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By the way, thanks for responding on a Sunday evening!

Sure thing, Esq.

The easy cases are never all that interesting anyways

Correct, since we already have measurements from when you were taking the ashwaganda and rhodiola (unbeknownst to us at the time) and at this point we can't determine for sure if the adrenals paradoxically "adapted" down on the cortisol from same, stick with the licorice root only and a new (simpler lol) multivitamin.

 

[Esq]

The licorice root supplement (Now Foods) arrived today, and I am utterly confused about the correct dosage. Various websites recommend anywhere from 150mg up to 6000 mg per day. I'm also reading that higher doses can both decrease testosterone and increase DHEA (I assume not results I want), in addition to raising cortisol, the desired effect. Higher doses also apparently can raise blood pressure and cause significant edema/bloating and sodium/potassium imbalances?
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The particular product I bought recommends two 450mg capsules one to three times per day (so 900 to 2700mg). That's a huge range based on the potential sides effects in reading about.
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Everything also seems to indicate that long-term usage (more than 4-6 weeks) is a bad idea. This includes the label on the bottle I purchased.
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So, how much of this stuff should I be taking per day? And only for 4-6 weeks, then discontinue (next round of labs will be done during that time frame)?
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Note - this is NOT a DGL product. The glycyrrhizin is present.

 

[Dr Justin Saya MD]

The licorice root supplement (Now Foods) arrived today, and I am utterly confused about the correct dosage. Various websites recommend anywhere from 150mg up to 6000 mg per day. I'm also reading that higher doses can both decrease testosterone and increase DHEA (I assume not results I want), in addition to raising cortisol, the desired effect. Higher doses also apparently can raise blood pressure and cause significant edema/bloating and sodium/potassium imbalances?
.
The particular product I bought recommends two 450mg capsules one to three times per day (so 900 to 2700mg). That's a huge range based on the potential sides effects in reading about.
.
Everything also seems to indicate that long-term usage (more than 4-6 weeks) is a bad idea. This includes the label on the bottle I purchased.
.
So, how much of this stuff should I be taking per day? And only for 4-6 weeks, then discontinue (next round of labs will be done during that time frame)?
.
Note - this is NOT a DGL product. The glycyrrhizin is present.

Raising DHEA is not a bad thing as long as it raises your cortisol as well.

Take 1 cap three times a day of that dosage and labs 4-6 weeks.

 

[Esq]

Raising DHEA is not a bad thing as long as it raises your cortisol as well.

Take 1 cap three times a day of that dosage and labs 4-6 weeks.

Got it. Thanks, Dr. Saya.

 

[Esq]

It's been a few weeks since I last posted in this thead, so time for an update.

Current protocol:
12.5mg clomid ED
0.25mg anastrozole EOD
.
Supplements:
1350mg licorice root spread over 3 doses
5000 IU vitamin D3
1000mg stinging nettle root
Multivitamin (changed from previous multi that contained rhodiola and ashwagandha to much simpler Garden of Life Vitamin Code Men)
Probiotic
Fish oil
Creatine HCl
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I have felt mostly baseline/status quo over the last several weeks. Some days are better than others, but generally the symptoms that brought me here persist. I had a rough week when my estradiol spiked last month, but with the addition of anastrozole those sides went away. I seem to be tolerating the anstrozole fine, and have noticed a slight increase in frequency of morning erections (almost never to 3 or 4 times/week now) since beginning it, but no real change in other symptoms, including libido. I haven't yet noticed any changes from the licorice root (or the removal of the rhodiola and ashwagandha).
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My next round of labs will be done in two weeks. I'll post those when available.

 

[CoastWatcher]

It's been a few weeks since I last posted in this thead, so time for an update.

Current protocol:
12.5mg clomid ED
0.25mg anastrozole EOD
.
Supplements:
1350mg licorice root spread over 3 doses
5000 IU vitamin D3
1000mg stinging nettle root
Multivitamin (changed from previous multi that contained rhodiola and ashwagandha to much simpler Garden of Life Vitamin Code Men)
Probiotic
Fish oil
Creatine HCl
.
I have felt mostly baseline/status quo over the last several weeks. Some days are better than others, but generally the symptoms that brought me here persist. I had a rough week when my estradiol spiked last month, but with the addition of anastrozole those sides went away. I seem to be tolerating the anstrozole fine, and have noticed a slight increase in frequency of morning erections (almost never to 3 or 4 times/week now) since beginning it, but no real change in other symptoms, including libido. I haven't yet noticed any changes from the licorice root (or the removal of the rhodiola and ashwagandha).
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My next round of labs will be done in two weeks. I'll post those when available.

When is your next consultation with Defy? In your own mind, do you have a point established when you'll ask that a reset button be pushed and you move on to Plan-B?

 

[Esq]

When is your next consultation with Defy? In your own mind, do you have a point established when you'll ask that a reset button be pushed and you move on to Plan-B?

It's not scheduled yet. The soonest Defy will let you schedule the next consult is when you place the next lab order, which will happen later this week I think. I suspect based on previous wait times it will be late June or early July. Since everything is in flux for me, I have to wait for Dr. Saya (can't use NP or other doctor at this point) until we (hopefully) establish a more long-term protocol requiring only periodic monitoring and adjustments.
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To your second question, no, not really, but each round of labs and consults drives me ever closer to that (those 4-tube cortisol tests are expensive!). Seriously though, after several rounds of labs and consults this has begun to get very expensive with no real improvement to speak of. That's not a knock on Defy - Dr. Saya has been great to work with and I came into this knowing it would be a long (and expensive) process, but I'd be lying if I said I wasn't a little frustrated.
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I suspect that the next step is to look at the cortisol and DHEA numbers again and come to some conclusion as to whether my issues are adrenal or not. If estradiol is in check, then I suspect Dr. Saya will have me titrate off the clomid and see what happens to my numbers. This is all based on what we discussed at my last consult three weeks ago. Assuming a late June consult, more labs after 6 more weeks, then another consult, that's gets us into September before all that plays out. September will be about 8 months since my initial intake and labs. It has been a long journey so far, but at the same time ruling out other potential causes before moving on to Plan B probably is the right approach.

 

[Esq]

Next round of labs were ordered today, and my next consult is scheduled for July 11.

Dr. Saya - if you happen to read this, when I placed the lab order, my chart did not reflect ordering another cortisol test. From your post above (#70), it looks like you wanted another cortisol test run, so I had them add that. Please let me know if this is correct.

 

[Dr Justin Saya MD]

Next round of labs were ordered today, and my next consult is scheduled for July 11.

Dr. Saya - if you happen to read this, when I placed the lab order, my chart did not reflect ordering another cortisol test. From your post above (#70), it looks like you wanted another cortisol test run, so I had them add that. Please let me know if this is correct.

Yes, given all of the developments discussed with your adrenals, repeating the salivary cortisol x 4 is worthwhile.