22 years old w/ very low T (Secondary Hypogonadism) and now on TRT. Do I need Hcg or an AI?

[Ryan Bui]

I've always considered myself to be pretty healthy. I've played sports my entire life, eat healthy (rarely go out to eat, avoid processed foods, eat lots of lean meats, vegetables, fruits, and whole grains), lift weights 4x/week, and cardiovascular exercise 2-3x/week, and maintain a decent amount of muscle/leanness.
I've never had any health problems besides having to get surgery to get my appendix removed 3 years ago.

Cliffs:
16-19 years old: I was a sexual bunny (like any other teen should be), looked at every girl and was horny all the time, great energy levels, always smiling and positive.

20 years old: began to notice a slight decline in the above (libido, energy), but nothing that serious. I chalked it up to the stress of life, college, etc.

21 years old: more decline, still not too concerned but it is obvious that I am much more mellow in terms of libido and energy. Still maintaining a positive outlook on life and smiling all the time.

22 years old (now): no morning/spontaneous erections for the past 8 months, EXTREME fatigue/malaise, deteriorating physical performance in the gym (but no loss of muscle mass, yet), very little ejaculate, no libido whatsoever, don't even look at girls.

3 weeks ago, I then got a hot flash while I was at work, which prompted me to go the doctors. He ordered a # of blood tests.
My lipid panel came back great, but my testosterone came back very low, so he tested again along with other sex hormones to make sure the 1st test wasn't a false positive.

Here were my results:
1st test:
Testosterone (Total): 45 —> Reference Range (>= 240 ng/dL)
Testosterone (Free): 12 —> Reference Range (59 - 166 pg/mL)

2nd Test:
Testosterone (Total): 41 —> Reference Range (>= 240 ng/dL)
Testosterone (Free): 13.9 —> Reference Range (59 - 166 pg/mL)
FSH: 1.4—> Reference Range (1.4-18.1 mIU/mL)
LH: <0.1 —> Reference Range (1.0- 12.0 mIU/mL)
SHBG: 29.5 —> Reference Range (10 - 60 nmol/L)
Prolactin : 15 —> Reference Range (2 - 18 ng/mL)
TSH: 3.53 —> Reference Range (0.10 - 5.50 uIU/mL)
Free T4: 1.0 —> Reference Range (0.8- 1 .7 ng/dL)

I also had an MRI done, which found nothing abnormal in my pituitary. I was referred to an endocrinologist, where, after about 2 hours of her being convinced I have used (intentionally/accidentally exposed) some sort of exogenous hormones, gave me the options of go with TRT or an attempt at a restart with Clomid. She suggested heavily going with Clomid but admitted that there was a very low chance that it would work given my situation and if it were to work, would take at least several months to see any difference, and even longer for me to normalize.

Not being able to see myself living this way for another week, let alone months, I opted for TRT, and went with the injections route using Test Cyp.

The current plan is as follows:
50mg E2W for 1 month (had my 1st shot last Friday)
100mg E2W for 1 month
200mg E2W for 1 month
Blood Work (Endo ordered Cortisol, IGF1, Andrenocorticotropic Hormone, Total Test LC/MS/MS, Hgb/Hct, PSA, ALT)
In-person check-up
200mg E2W

I voiced my concerns about high estrogen and concurrent use of Hcg to which she replied that if we stay within normal levels, high E2 won't be a problem but during the follow-up, she would check for any signs of high estrogen (development of breast tissue, etc.) and adjust my dosing frequency if E2W makes me crash, which based off of research, will probably happen at my 100-200 dose.
We're aiming for 700-800 total test, according to my endo.

My questions/concerns are:

1. Going from such a low T level to normal, which is presumably 700-800, what can I expect?

2. How concerned do I need to be with aromatizing if I stay within physiological limits?

3. How much should I push for the concurrent use of Hcg with TRT, if I am not planning on having kids for a long time and testicular atrophy isn't that big of a concern to me? Are there any other benefits?

4. Any other general advice?


It just seems so surreal that one day, I am a seemingly normal 22 year old Asian just trying to make it through college and the next, am on TRT for the rest of my life.


Thanks everyone!

 

[CoastWatcher]

The current plan is as follows:
50mg E2W for 1 month (had my 1st shot last Friday)
100mg E2W for 1 month
200mg E2W for 1 month
Blood Work (Endo ordered Cortisol, IGF1, Andrenocorticotropic Hormone, Total Test LC/MS/MS, Hgb/Hct, PSA, ALT)
In-person check-up
200mg E2W

I voiced my concerns about high estrogen and concurrent use of Hcg to which she replied that if we stay within normal levels, high E2 won't be a problem but during the follow-up, she would check for any signs of high estrogen (development of breast tissue, etc.) and adjust my dosing frequency if E2W makes me crash, which based off of research, will probably happen at my 100-200 dose.
We're aiming for 700-800 total test, according to my endo.

My questions/concerns are:

1. Going from such a low T level to normal, which is presumably 700-800, what can I expect?

2. How concerned do I need to be with aromatizing if I stay within physiological limits?

3. How much should I push for the concurrent use of Hcg with TRT, if I am not planning on having kids for a long time and testicular atrophy isn't that big of a concern to me? Are there any other benefits?

4. Any other general advice?


It just seems so surreal that one day, I am a seemingly normal 22 year old Asian just trying to make it through college and the next, am on TRT for the rest of my life.


Thanks everyone!

You're on a protocol, Ryan, that's likely to fail. Your doctor is following an outdated schedule, administering testosterone every two weeks. Given the half-life of the drug, you'll feel terrible again by the time you're do for your next injection. It's been demonstrated that that sort of protocol simply isn't going to work. The standard procedure now, as outlined in the most recent version of the MERCK MANUAL, the go-to reference for physicians in the English speaking world, is to administer smaller amounts of testosterone on a more frequent basis. Typically here on the Forum those who have achieved success are injecting two-three times a week, anywhere from 30 - 80mgs per injection. I'm sorry to say that you'll wind up feeling no better, and possibly worse, than you do now. Did you have a discussion about your fertility and how TRT is a life-long commitment? Was a psa run in order to capture a baseline?

 

[Ryan Bui]

You're on a protocol, Ryan, that's likely to fail. Your doctor is following an outdated schedule, administering testosterone every two weeks. Given the half-life of the drug, you'll feel terrible again by the time you're do for your next injection. It's been demonstrated that that sort of protocol simply isn't going to work. The standard procedure now, as outlined in the most recent version of the MERCK MANUAL, the go-to reference for physicians in the English speaking world, is to administer smaller amounts of testosterone on a more frequent basis. Typically here on the Forum those who have achieved success are injecting two-three times a week, anywhere from 30 - 80mgs per injection. I'm sorry to say that you'll wind up feeling no better, and possibly worse, than you do now. Did you have a discussion about your fertility and how TRT is a life-long commitment? Was a psa run in order to capture a baseline?

Hi Coast,

Thanks for your reply.

Based on my conversation with my endo, she's aware that people will crash dosing E2W, but said we would adjust dosing frequency after my 1st follow-up, so my plan was to do the 1st two injections of 200mg as planned, get my bloods done mid-way before the next 200mg shot and then switch to 100mg/wk injections from there on out, even if she does not approve when I voice concerns at the follow-up.

We did speak at length about fertility and it being a life-long commitment. At the moment, as I am only 22 and don't plan on having children for about a decade, maintaining my fertility isn't a huge concern but based on my research on the forums, a lot of people run Hcg concurrently with their TRT. However, given that I am probably much younger than most on TRT, I made this post to inquire about any other benefits Hcg may have outside of maintaining fertility/testicular size.

With the above in mind, should I still push for Hcg? Truthfully, I'm more concerned that my endo isn't going to test E2 for my follow-up labs and only said she would check for physical signs of elevated estrogen.

Unfortunately, I did not get a baseline PSA level.

 

[CoastWatcher]

Hi Coast,

Thanks for your reply.

Based on my conversation with my endo, she's aware that people will crash dosing E2W, but said we would adjust dosing frequency after my 1st follow-up, so my plan was to do the 1st two injections of 200mg as planned, get my bloods done mid-way before the next 200mg shot and then switch to 100mg/wk injections from there on out, even if she does not approve when I voice concerns at the follow-up.

We did speak at length about fertility and it being a life-long commitment. At the moment, as I am only 22 and don't plan on having children for about a decade, maintaining my fertility isn't a huge concern but based on my research on the forums, a lot of people run Hcg concurrently with their TRT. However, given that I am probably much younger than most on TRT, I made this post to inquire about any other benefits Hcg may have outside of maintaining fertility/testicular size.

With the above in mind, should I still push for Hcg? Truthfully, I'm more concerned that my endo isn't going to test E2 for my follow-up labs and only said she would check for physical signs of elevated estrogen.

Unfortunately, I did not get a baseline PSA level.

There is good, peer-reviewed research that indicates a man's levels will return to baseline, if not lower on a two-week protocol, no matter what the dose. Why she would want to place a patient on a schedule when "she's well aware that people will crash" using it, is a question that begs to be answered. Why place someone in a position they'll not receive the full benefit of? I am very wary, and wonder if she is making this up as she goes along. HCG has plenty of other benefits in addition to fertility and testicular size. https://www.excelmale.com/forum/sho...tropin-Pregnenelone-and-DHEA-–-By-Gene-Devine Here's a paper Gene Devine prepared on that very topic. You should spend some time browsing the Forum sticky posts; there's great stuff there. I can tell you, from personal experience, that it's impossible for a doctor or patient to monitor E2 without tests. It can (and in my case did) creep up insidiously. The emergence of symptoms comes much later. With frequent testing I avoided the feelings of high estradiol. If you live in the United States you can easily test yourself for a reasonable fee at Discountedlabs.com (or other services). It's worth the investment. I wish you all the best, but I worry that you're not being supported in this journey by a doctor on top of her game.

 

[ERO]

You need a doctor that understands TRT as this protocol is all but guaranteed to fail. Many of us had to do some searching for a doctor that truly understands TRT, but it makes all the difference. I would recommend Defy Medical (I have no affiliation with them) they know what they are doing and they have very good pricing, plus they are easy to work with over the phone and email.

 

[Gene Devine]

I can't add on to the excellent response by CoastWatcher but at your age I would still want to investigate why your serum levels are so low...there's a reason.

Did you have any more Thyroid labs run?

Many times the Thyroid looks good even when you run FT4 and FT3 but when you look at RT3 it tells another story.

Your TSH 3.53 suggests your Thyroid is running on low steam and why TSH is high.

I would ask to see a Endo who only specializes in Thyroid conditions and get a thorough diagnosis there...at least that's what I would ask for.

You're not Primary or else LH would be through the roof.

Keep in mind, Hypothyroidism has many of the same symptoms as Hypogonadism and will cause the same in fact.

Ask to find an specialist on Thyroid and see what you find.

TRT is for life and at your age it should have been the last resort after an exhaustive diagnostic search.

 

[Re-Ride]

Asking a 22 y.o. to make a lifelong commitment to anything is unrealistic. Trying to find out why you are hypogonatic is going to be a challenge. Getting the MRI to check on the pituitary demonstrates commitment in that area. Investigate thyroid issues as recommended. No matter how well you eat it's wise for all men to take a closer look at estrogenic foods as well as toxic compounds they may becoming in contact with. Ideally you will exhaust all solutions before turning to TRT. It's asking a lot to be patient but the long term rewards can be worth it.

hCG- I only see benefits with its use IF used in an appropriate manner. I would want to know what natural levels of T were achievable in advance of TRT. A trial will likely require dosing significantly higher than what is used for combo therapy with TRT. How high one is willing to go is a personal decision. Typically hCG monotherapy requires 3500 to 12,000 iu/week but every man is different. Many will argue against this based upon theoretical stress to leydig cells which is highly controversial.

One approach might to be trying 250 - 500 iu hCG EOD and see if this wakes up the leydigs which can take a up to month but is often much faster. The argument against this is the belief that high "shock" dosing is required to push T levels acceptable levels w/o exogenous use. Where a low dose is ineffective a month off cycle has sometimes been recommended for alleged temporary desensitization of leydigs to pass. Unfortunately few studies exist that clearly support any hCG mono regimens for long term hypoG therapy.

If you decide to try short term hCG mono make sure you have complete baseline labs done, that you have standing orders in for multiple estradiol tests and have given some thought to an AI such as Arimidex. It is important to adhere to regimen for two weeks with E2 testing before making changes. If you respond well to hCG mono you will want to have thought out an exit strategy to begin on the day following your last hCG dose one to six months of hCG monotherapy. A "crash" coming off hCG isn't the same as one coming off exogenous T but you'd want to avoid it. Most will transition to T w/hCG with relatively few having success with long term hCG mono alone.

Keep a log of everything you are doing and how you are feeling from day to day. Finally, everything above regarding hCG is nothing more than feedback from my own experience and should not be taken as any sort of recommendation.

 

[Nelson Vergel]

Ryan

Did you take any "Testosterone Boosters" or supplements before that blood test? Did they measure your prolactin? That is an extremely low T and LH. Can you tell us what you took?

 

[Ryan Bui]

Ryan

Did you take any "Testosterone Boosters" or supplements before that blood test? Did they measure your prolactin? That is an extremely low T and LH. Can you tell us what you took?

Thanks for your reply Nelson,

I have never taken any sort of test booster or exogenous hormone. In terms of supplements, Ive taken and currently take a multivitamin, fish oil, vitamin D3, and an iron supplement, all from name brands. I figure those were all still active in my blood when the tests were done.

As a side note, all my tests were done fasted at 7am.

My original post had my prolactin levels, they were:

Prolactin : 15 —> Reference Range (2 - 18 ng/mL)

Best regards,

Ryan

 

[Nelson Vergel]

Ryan

Is there any reason why you are taking iron?

You should get a free T3, free T4, reverse T3 and thyroid antibodies tested. Your TSH of 3.53 requires deeper investigation.

It is amazing to me how severe your HPTA shut down was without any exposure to androgens. I assume that your doctor checked your LH and testosterone more than once, right?

I am glad your prolactin was OK since it is one of the main factors involved in extremely low T.

50 mg of T plus 500 IU HCG twice per week should be OK to keep fertility and performance in the long term.

 

[Gene Devine]

Ryan

Is there any reason why you are taking iron?

You should get a free T3, free T4, reverse T3 and thyroid antibodies tested. Your TSH of 3.53 requires deeper investigation.

It is amazing to me how severe your HPTA shut down was without any exposure to androgens. I assume that your doctor checked your LH and testosterone more than once, right?

I am glad your prolactin was OK since it is one of the main factors involved in extremely low T.

50 mg of T plus 500 IU HCG twice per week should be OK to keep fertility and performance in the long term.

Nelson is spot on as usual.

Thyroid needs deeper diagnosis.

Also, men do not need to supplement with iron unless there is a clinical need...to much iron in men is not healthy.

 

[Ryan Bui]

Ryan

Is there any reason why you are taking iron?

You should get a free T3, free T4, reverse T3 and thyroid antibodies tested. Your TSH of 3.53 requires deeper investigation.

It is amazing to me how severe your HPTA shut down was without any exposure to androgens. I assume that your doctor checked your LH and testosterone more than once, right?

I am glad your prolactin was OK since it is one of the main factors involved in extremely low T.

50 mg of T plus 500 IU HCG twice per week should be OK to keep fertility and performance in the long term.

Nelson is spot on as usual.

Thyroid needs deeper diagnosis.

Also, men do not need to supplement with iron unless there is a clinical need...to much iron in men is not healthy.

Thank you for both of your replies, Gene and Nelson.

I started taking an iron supplement a couple years ago when I had a physical at my GP, which included a general blood panel and I had slightly low levels of serum iron that would classify me as mildly anemic. I've been taking the iron supplements ever since. During my last round of blood work, we did test ferritin and iron, both came back in the middle of the reference range.

I will talk with both my endo/PCP about getting a more comprehensive thyroid panel done, thanks for the great advice. If I do end up having hypothyroidism, is it possible for my HPTA to be that low as a result? My endo thinks I should be around 700-800 total test, assuming I had severe hypothyroidism, could that really have brought my levels that low?

Nelson,

Unfortunately, only free/total test were tested 2 times. LH, SHBG, Prolactin, FSH were only tested during the 2nd round of tests.

 

[Re-Ride]

Ryan, Be prepared for resistance from these docs to ordering free T3, free T4, reverse T and anti-body. I am not yet fully up to speed on the thyroid theories posted here but several members have posted in great detail.

After ruling out thyroid I'd want an explanation for the hypoG as I'm sure you do. Have you been exposed to any solvents or fumes in the last few years? While its a long shot I might discontinue the fish oil and D supplementation temporarily. Personally I only use "molecularity distilled" or highly purified EPA/DHA (Lovaza).

Have you ruled out trying hCG monotherapy? Even if only used as a diagnostic tool it seems worthwhile to me. There is always the possibility that it will trigger a restart. A significant number get at least 2-3 months relief with great libido before finally going on combo with already functioning testes. If the experts here don't agree with this approach I hope they will explain why.