1. #1

    Looking for input: Considering protocol changes to discuss with Dr Saya, to resolve side effects

    Protocol:
    -T cyp 42mg E3D for a total 97mg/week.
    -HCG I have been reducing prescribed dose of 500, now at 440mg E3D feeling no ill effects on the boys
    -DHEA 25mg/day
    -Pregnenelone 25mg/day
    -No AI

    Latest labs at trough for total T and free T look good to me:

    -Testosterone 879 Range: 264-916 ng/dL
    -Free Testosterone(Direct) 20.9 Range: 7.2-24.0 pg/mL

    Symptomatically, feels like relative to T levels I am doing OK.

    However, I am having symptoms of high E2 and high HCT/HGB

    High systolic BP
    shortness of breath with exercise, feeling of fullness in chest
    feeling warmer than usual, often flushed face
    some bloating coming and going, hands feel puffy when I wake up in the morning

    E2 at 45
    HCT 52.5
    HGB 18.2

    And last check of ferritin was low at 27


    I don't have really up to date SHBG, will have it done next round in a few weeks, but previous tests were 43 Last June, and 46.7 last november when T levels were very high from starting T cyp at too high a dosage.


    So my primary intended objective right now is bring E2 down and reduce exogenous T stimulation of higher HCT/HGB

    More and more frequently guys are posting that lowering total dose and injecting more frequently is accomplishing these objectives. I am considering asking for a daily dosage protocol of both T cyp and HCG at reduced weekly totals. However with my SHBG at 46.7 and realtive half lives of the two, what are my trade offs?



    Also wondering if I should go ahead and request phlebotomy anyway and deal with being low ferritin. I am feeling the HCT more strongly as time goes on.

    My high PSA is a somewhat confounding factor as well, but is dropping. My belief is this is based in part on lowered T dose, but also other measures I am taking. Hopefully will continue that trend especially if total weekly T dosage is reduced further.

    Really could use input thoughts here...
    Last edited by Blackhawk; 04-14-2018 at 11:54 AM.

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  3. #2
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    Quote Originally Posted by Blackhawk View Post
    Protocol:
    -T cyp 42mg E3D for a total 97mg/week.
    -HCG I have been reducing prescribed dose of 500, now at 440mg E3D feeling no ill effects on the boys
    -DHEA 25mg/day
    -Pregnenelone 25mg/day
    -No AI

    Latest labs at trough for total T and free T look good to me:

    -Testosterone 879 Range: 264-916 ng/dL
    -Free Testosterone(Direct) 20.9 Range: 7.2-24.0 pg/mL

    Symptomatically, feels like relative to T levels I am doing OK.

    However, I am having symptoms of high E2 and high HCT/HGB

    High systolic BP
    shortness of breath with exercise, feeling of fullness in chest
    feeling warmer than usual, often flushed face
    some bloating coming and going, hands feel puffy when I wake up in the morning

    E2 at 45
    HCT 52.5
    HGB 18.2


    And last check of ferritin was low at 27


    I don't have really up to date SHBG, will have it done next round in a few weeks, but previous tests were 43 Last June, and 46.7 last november when T levels were very high from starting T cyp at too high a dosage.


    So my primary intended objective right now is bring E2 down and reduce exogenous T stimulation of higher HCT/HGB

    More and more frequently guys are posting that lowering total dose and injecting more frequently is accomplishing these objectives. I am considering asking for a daily dosage protocol of both T cyp and HCG at reduced weekly totals. However with my SHBG at 46.7 and realtive half lives of the two, what are my trade offs?

    Also wondering if I should go ahead and request phlebotomy anyway and deal with being low ferritin. I am feeling the HCT more strongly as time goes on.

    My high PSA is a somewhat confounding factor as well, but is dropping. My belief is this is based in part on lowered T dose, but also other measures I am taking. Hopefully will continue that trend especially if total weekly T dosage is reduced further.

    Really could use input thoughts here...
    Hi blackhawk, I'm probably not the expert you are looking for but here's my 2 cents.

    High systolic BP
    shortness of breath with exercise, feeling of fullness in chest
    feeling warmer than usual, often flushed face
    some bloating coming and going, hands feel puffy when I wake up in the morning

    E2 at 45
    HCT 52.5
    HGB 18.2
    These are pretty big flags IMO.
    Some will suggest only changing one thing at a time, so you know which one worked, however with your numbers and symptoms I'd change a bunch.
    We all know high altitude and elevated TT lvl increases HCT. So see what a TT of 600-650 gets you. This might even help your PSA numbers.
    Drop the HCG until you see/feel issues with your balls. That along with the Tcyp dose drop should lower the E2 without and AI.

    Trying to run a high TT just might not work for you do to all the other issues you are fighting. You may have to just deal with less than optimum TT/FT.
    I would not donate blood with your low ferritin.
    Last edited by FeelingLost; 04-14-2018 at 11:19 PM.

  4. #3
    Thanks FL.

    Yeah I feel pretty much the same way. I just scheduled consult yesterday, sorry I waited until now, but kind of getting a bit of run around.... have to get labs before scheduling... WTF? didn't have any such pre-condition before. Anyway, talked her into scheduling me with payment which is Defy's norm anyway. Dr Saya not available until May 22... getting antsy to make changes. Looking at next blood draw April 26

    I am definitely not after high TT per se, just a good range FT, so concerned about reduced daily dosage affecting TT/FT ratio in this regard.

  5. #4
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    On a side note from my last consult I got permission to experiment with reduced doses. I am currently on .16 M/W/F Tcyp.
    For HCG I am using .10 M/W/F same syringe.
    I only take my Ai (.125) if I feel extra sensitive. Most weeks I need one pill around Thursday sometimes two and never 3.

    hth

  6. #5
    Awesome.

    I took the liberty to start reducing HCG without specific permission.

    A side aspect is currently I am doing a 3 day cycle.

    Day 1: T cyp
    Day 2: no injection
    Day 3: HCG

    So I am already injecting 2 out of three days for a E3D schedule. I have more trouble with injection site with larger injection volumes, so combining T and HCG and doing every day would in some ways be preferable.

  7. #6
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    Quote Originally Posted by Blackhawk View Post
    Thanks FL.

    Yeah I feel pretty much the same way. I just scheduled consult yesterday, sorry I waited until now, but kind of getting a bit of run around.... have to get labs before scheduling... WTF? didn't have any such pre-condition before. Anyway, talked her into scheduling me with payment which is Defy's norm anyway. Dr Saya not available until May 22... getting antsy to make changes. Looking at next blood draw April 26

    I am definitely not after high TT per se, just a good range FT, so concerned about reduced daily dosage affecting TT/FT ratio in this regard.
    They have always required me to have fresh/current bloods before shceduling a consult.
    If I was you I would go get the blood draw as soon as possible so you have your current condition captured. An then change your protocal that very afternoon.
    I don't believe they will yell at you for reducing anything, esp with your numbers. Blindly following a protocal when you know it is giving you health issues in not a good strategery. sorry for the crap spelling I was typing kind of fast. I'll shut up now so other can join in. Best of luck to you.

  8. #7
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    I agree with FL. We are in this for the long term and need to be safe and healthy. You know the answer is to lower your T dose and perhaps your HCG. I only take 250iu twice weekly and my boys are full and happy. Also might want to drop the DHEA as it can increase E2. Now for the unpopular part of my post. Taking a very small amount of anastrazole if necessary is NOT THE END OF THE WORLD!

  9. #8
    I would drop the two things that just aren't necessary here...the DHEA and the Preg. Keep everything else stable. Your FT is fine I wouldn't up or down the Cyp dose as you're only using 98mg a week/14mg/D, and get your phlebotomy/donation done.

    Re-eval in 4 weeks.

    Telling you not to donate and let your HCT keep rising vice Ferritin, is very poor advice. Of the two if Defy were to intervene in your treatment, which they could, it will be because of the HCT. Again, that's irresponsible advice.

  10. #9
    Thanks guys. I have mixed feelings making such changes myself without consulting Dr Saya, and possibly creating a new situation where before I get to speak to him again I'll need two different rounds of labs, in terms of cost, inconvenience and timing i.e. creating a need for another 6-8 week interval before testing for changes that I might make based on my own decisions.

    Also, regarding HCG 250iu 2x/week, We increased my dose to 500iu E3d because the original dose of 350, then adjusted doses of 400 and 450 didn't do the trick. A case where your needs and mine are pretty obviously different. I am looking forward to seeing how I do as I continue reducing HCG. For me adequate dosage has been quite necessary as I have had pretty serious testicular discomfort and retraction without.
    Last edited by Blackhawk; 04-14-2018 at 01:30 PM.

  11. #10
    Quote Originally Posted by Blackhawk View Post
    Thanks guys. I have mixed feelings making such changes myself without consulting Dr Saya, and possibly creating a new situation where before I get to speak to him again I'll need two different rounds of labs, in terms of cost, inconvenience and timing i.e. creating a need for another 6-8 week interval before testing for changes that I might make based on my own decisions.

    Also, regarding HCG 250iu 2x/week, We increased my dose to 500iu E3d because the original dose of 350, then adjusted doses of 400 and 450 didn't do the trick. A case where your needs and mine are pretty obviously different. I am looking forward to seeing how I do as I continue reducing HCG. For me it has been quite necessary as I have had pretty serious testicular discomfort and retraction without and with inadequate dosage.
    Keep in mind that what you say youre feeling and experiencing aren't necessarily reflected in the numbers you posted and there's a fair chance that the problem is just a little anxiety, mental, etc etc

  12. #11
    Quote Originally Posted by Vince Carter View Post
    I would drop the two things that just aren't necessary here...the DHEA and the Preg. Keep everything else stable. Your FT is fine I wouldn't up or down the Cyp dose as you're only using 98mg a week/14mg/D, and get your phlebotomy/donation done.

    Re-eval in 4 weeks.

    Telling you not to donate and let your HCT keep rising vice Ferritin, is very poor advice. Of the two if Defy were to intervene in your treatment, which they could, it will be because of the HCT. Again, that's irresponsible advice.
    Thanks Vince,


    I know your bias against DHEA especially, but for me it was the first thing that actually gave me significant improvement in symptoms before starting with Defy.

    The HCT has not been on a continuous increase, but has stabilized at 52.5 based on labs Jan 23 and Mar 22. HGb went up 0.5 to 18.2. Based on the life cycle of RBCs at 120 days, it could be that I have peaked, but we don;t really know yet. Dr Saya only said I'm between a rock and a hard place with low ferritin and this HCT and wanted to wait out the T cyp reduction to see if HCT decreases. Full iron panel is in next scheduled bloodwork.

  13. #12
    Quote Originally Posted by Vince Carter View Post
    Keep in mind that what you say youre feeling and experiencing aren't necessarily reflected in the numbers you posted and there's a fair chance that the problem is just a little anxiety, mental, etc etc
    Cheers, I am fully aware of my mental tendencies and have indeed had anxiety issues. Also have had cardiac issues and know what cardiac angina is, also other forms of anxiety induced chest pain from PTSD. While using TRT, an incredible amount of these anxieties have decreased, and with regular meditation I have both become more relaxed about these ongoing health issues and see things more objectively and cognitively, less based on emotional response. However, I have never had consistently high systolic before and this comes during a generally more emotionally relaxed circumstance.

    Not denying that it can indeed be hard to sort out actual physical symptoms relative to emotion, but I feel I have a pretty good grasp of these issues.
    Last edited by Blackhawk; 04-14-2018 at 01:41 PM.

  14. #13
    So a concern over this stuff is I don't fully understand the concept that for higher SHBG you need higher individual doses to increase free T. Somehow this is in my head, but I don't know where it came from. Is this right or wrong and if this is true, why? and where can I find studies showing this?

    Do you need less frequent larger doses to accomplish this or do frequent doses, even daily, result in adequate Free T for those of us with higher SHBG?


    My own reasoning regarding High HCT and E2 leads me to believe cumulative total T dosage would matter, and reducing total weekly amount would help reduce these side effects. So shooting for a given Free T level at trough on more widely spaced doses would require higher weekly totals since you have to overcome the trough effect. So by reducing doses and increasing dosing frequency you maintain more consistent levels of both total and free T with a smaller weekly total. It seems to me that going to daily injection and reducing weekly dose could help drop HCT and E2 while keeping free T around 20.

    Is this sound reasoning or what am I missing?

  15. #14
    Quote Originally Posted by Blackhawk View Post
    So a concern over this stuff is I don't fully understand the concept that for higher SHBG you need higher individual doses to increase free T. Somehow this is in my head, but I don't know where it came from. Is this right or wrong and if this is true, why? and where can I find studies showing this?

    Do you need less frequent larger doses to accomplish this or do frequent doses, even daily, result in adequate Free T for those of us with higher SHBG?


    My own reasoning regarding High HCT and E2 leads me to believe cumulative total T dosage would matter, and reducing total weekly amount would help reduce these side effects. So shooting for a given Free T level at trough on more widely spaced doses would require higher weekly totals since you have to overcome the trough effect. So by reducing doses and increasing dosing frequency you maintain more consistent levels of both total and free T with a smaller weekly total. It seems to me that going to daily injection and reducing weekly dose could help drop HCT and E2 while keeping free T around 20.

    Is this sound reasoning or what am I missing?
    The higher the SHBG the more testosterone bound to SHBG you will have thus lower free testosterone. So yes. High SHBG guys need higher testosterone dosage compared to low SHGB guys to achieve similar free testosterone levels. But keep in mind that low SHBG eliminates testosterone faster so depending on frequenct injection you might end up with a lower free testosterone level compared to a high SHBG guy depending on when you get bloodwork relative to injection day.

    HCT has a lot to do with testosterone levels. In theory someone can eliminate HCT issues solely by reducing testosterone dosage. However for some people that are more sensitive this dosage reduction might end up meaning too low testosterone levels and no improvement in low T symptoms.

    The daily testosterone theory to control HCT didnít work for me (it actually rose my HCT). My theory on HCT is different. It has do to on how long your body has to deal with above range (or somewhat elevated testosterone level relatively speaking - having each individual physiology in mind) testosterone levels. I have heard of many cases of men switching from weekly injections to bi-weekly injections starting to have issues with HCT. More frequent injections means more stable levels and depending on the dosage more time with elevated testosterone levels causing more constant supression of hepcidin etc then causing HCT issues. Example:

    Lets think about someone injecting 120mg once a week and hypothetical FT levels (upper normal range being 25)

    Day 1 FT - 40
    Day 2 FT - 35
    Day 3 FT - 30
    Day 4 FT - 25
    Day 5 FT - 20
    Day 6 FT - 15
    Day 7 FT - 10

    And now 60mg twice a week

    Day 1 FT - 35
    Day 2 FT - 30
    Day 3 FT - 25
    Day 4 FT - 40
    Day 5 FT - 35
    Day 6 FT - 30
    Day 7 FT - 25

    So using these hypothetical numbers just to ilustrate my theory. On once a week injection protocol you are only 3 days above the upper range compared to 5 days on bi-weekly injections protocol, and just one peak vs two. Also on once a week protocol on 3 days your FT is below 20 so much less estimulation on HCT.

    Most of us measure testosterone levels at trough and have FT/TT close to or above upper range. So at your lowest point your testosterone level is already over theoretical physiological levels. And at peak and on average your levels are way above physiological levels. Hence problems with HCT, estradiol, etc.
    By using lower dosage you can still have great benefits (if not the same benefits) of higher dosages and much lower chances of having side effects. Not saying that everybody can control side effect and still have symptoms improvement. Some people are just very sensitive to exogenous testosterone and will end up with high estradiol, HCT issues etc that will have to be dealt with an AI, blood donation etc.
    We should stop chasing number and a lot of times the less is better when it comes to TRT.
    Last edited by HealthMan; 04-15-2018 at 06:19 AM.

  16. #15
    Um, I think your comparative cases are whacked. You say "someone injecting 120mg twice a week " 120 2x/week would be total of 240 per week and there would be 2 troughs in a 7 day period dosing E3.5D, but your chart shows a 7 day trough interval.

    Then second example is half that dose also E3.5D with just as high peaks but 3.5 cycle of peak and trough?

    The after that you talk about once a week protocol.

    I think I know what you are thinking, but what's written conflicts with itself.
    Last edited by Blackhawk; 04-14-2018 at 09:36 PM.

  17. #16
    Anyway, what I am asking about is going from E3D to every day schedule with reduced total weekly dose to target my through levels or less, trying to keep free T around 20. If my current trough is already 20 and every other day is higher, how could the latter be more causative for higher HCT and E2?

    So for example hypothetically:

    Now I am on 42mg E3D

    Day 1 trough in AM FT@20 Inject T cyp
    Day 2 FT theoretically higher than 20
    Day 3 FT theoretically higher than 20
    Day 4 repeat of day one
    Etc...

    So divide that 3 day dose for 1/3 per day=14mg then reduce that amount to say 12mg or 10 mg/day... No chart needed, every day is peak and trough. Aim for Free T at 20 on a daily basis... lower cumulative dosing, lower overall TT and FT levels compared to totals of 3 day cycle.

    Unless, less frequent dosing changes the ratio of TT to FT for the worse. e.g. compared to my current trough@ TT897/FT20.9 so let's say the result comes out to TT 897/15, then there's a problem.


    Also related, I don't know but how long does it take for a dose of injected T cyp to be absorbed/cleaved and enter metabolism?

  18. #17
    Quote Originally Posted by Blackhawk View Post
    Um, I think your comparative cases are whacked. You say "someone injecting 120mg twice a week " 120 2x/week would be total of 240 per week and there would be 2 troughs in a 7 day period dosing E3.5D, but your chart shows a 7 day trough interval.

    Then second example is half that dose also E3.5D with just as high peaks but 3.5 cycle of peak and trough?

    The after that you talk about once a week protocol.

    I think I know what you are thinking, but what's written conflicts with itself.
    Typo. I meant someone injecting 120mg once a week vs 60mg twice a week

  19. #18
    Quote Originally Posted by HealthMan View Post
    Typo. I meant someone injecting 120mg once a week vs 60mg twice a week
    Right, OK that's what I thought you were getting at.

    So what I am talking about is the case above, post #16, going from E3D to ED and reducing total amount accordingly targeting trough levels from the E3D protocol

  20. #19
    Quote Originally Posted by Blackhawk View Post
    Right, OK that's what I thought you were getting at.

    So what I am talking about is the case above, post #16, going from E3D to ED and reducing total amount accordingly targeting trough levels from the E3D protocol
    Usully when people try daily injections they need a lower dosage to achieve same testosterone levels when they were injecting less frequently (however when i tried daily injections my testosterone levels dropped despite increasing the dosage a bit). A good start point for you is 14mg a day and test after 8 weeks and see where you FT stands. My SHBG dropped i think 7 points when i moved to daily injections therefore altering TT FT ratio.

  21. #20
    Quote Originally Posted by HealthMan View Post
    My SHBG dropped i think 7 points when i moved to daily injections.
    Seems a modest drop in SHBG would be a good thing for me. We'll see where it sits with new labs in a few more weeks.

    Also seems to me due to the need to drop HCT/HGB and E2 that lowering daily dose below 14mg would be appropriate. I really don't need a rise in any related hormone level and can probably tolerate some modest decrease in TT/FT. I was doing badly at pre TRT levels of TT 281, FT 3.1, and I was doing considerably better but not there yet on gel at TT 443, FT 14 prior to going to T cyp. I think some of this related hormone elevation is a flywheel effect of starting at much too high a dose of T cyp back in October which put levels at trough of over 1500 and Ft at 39.7, which was seriously overshooting the mark.

  22. #21
    Quote Originally Posted by Blackhawk View Post
    Seems a modest drop in SHBG would be a good thing for me. We'll see where it sits with new labs in a few more weeks.

    Also seems to me due to the need to drop HCT/HGB and E2 that lowering daily dose below 14mg would be appropriate. I really don't need a rise in any related hormone level and can probably tolerate some modest decrease in TT/FT. I was doing badly at pre TRT levels of TT 281, FT 3.1, and I was doing considerably better but not there yet on gel at TT 443, FT 14 prior to going to T cyp. I think some of this related hormone elevation is a flywheel effect of starting at much too high a dose of T cyp back in October which put levels at trough of over 1500 and Ft at 39.7, which was seriously overshooting the mark.
    Maybe try 12mg daily and go from there.

  23. #22
    Quote Originally Posted by HealthMan View Post
    Maybe try 12mg daily and go from there.
    That's what I have been thinking and I will ask Dr Saya.

    So, I still have a hard time verbalizing my unanswered question, I'll try again:

    I have understood since before starting this thread that:

    -Higher SHBG guys need higher amounts of exogenous T to bring up free T compared to lower SHBG guys.
    -Higher SHBG guys generally can tolerate less frequent injections compared to low SHBG guys since they retain more bound (and I assume bound to albumin, so subsequently usable) T
    -Lower SHBG guys convert a lot more T cyp into free T, pee it out, effectively dropping their usable stores of T quickly therefore need more frequent injections to top off the free T tank.

    What I still don't know is the issue of how frequency of injections affect total T to free T ratios for higher SHBG guys.

    Are less frequent larger doses required to bring up free T in relation to total T for higher SHBG guys? Or do more frequent, even daily doses have the same effect?
    Last edited by Blackhawk; 04-15-2018 at 12:31 PM.

  24. #23
    Quote Originally Posted by Blackhawk View Post
    That's what I have been thinking and I will ask Dr Saya.

    So, I still have a hard time verbalizing my unanswered question, I'll try again:

    I have understood since before starting this thread that:

    -Higher SHBG guys need higher amounts of exogenous T to bring up free T compared to lower SHBG guys.
    -Higher SHBG guys generally can tolerate less frequent injections compared to low SHBG guys since they retain more bound (and I assume bound to albumin, so subsequently usable) T
    -Lower SHBG guys convert a lot more T cyp into free T, pee it out, effectively dropping their usable stores of T quickly therefore need more frequent injections to top off the free T tank.

    What I still don't know is the issue of how frequency of injections affect total T to free T ratios for higher SHBG guys.

    Are less frequent larger doses required to bring up free T in relation to total T for higher SHBG guys? Or do more frequent, even daily doses have the same effect?
    High SHBG needs higher TT leves to achieve same FT than lower SHBG guys (just remember low SHBG get rid of testosterone quicker so that might come to play specially having in mind how low SHBG is and when you draw blood). So in theory all it matter is TT levels. Not frequency.
    However injection frequency and amount might impact SHBG. In my case bigger injections raised my SHBG and smaller more frequent injections lowered SHBG. Like my body is trying to adjust my testosterone leves (given exogenous testosterone being supplied to my body). If you flood your body with testosterone it raises SHBG to try to reduce the amount of testosterone available. And the opposite when exogenous testosterone supplied is lower / more frequent (in my case. Not saying this is a proven body mechanism applied to all. I am low SHBG guy so maybe for naturally high SHBG guy the mechanism is the opposite not sure)
    Last edited by HealthMan; 04-15-2018 at 09:51 AM.

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