About to Start a New Protocol

[Astro]

I am new to this forum.

I’m an active 69 y/o male in generally good health. I’m not overweight, I exercise regularly, my resting pulse is 55, I eat fairly healthy, don’t smoke and only drink one or two beers per week. I have been diagnosed with secondary-hypogonadism. My LH and FSH were “inappropriately normal” according to my endo (both should have been higher). An MRI showed a very small tumor (adenoma) on the pituitary gland, which may be responsible—but this is an unknown and will be monitored each year going forward, to see if the tumor changes shape or size. I qualified for TRT because of low Free Testosterone and typical low-T symptoms. I have been on TRT for 6 months and currently taking 75mg Test-enanthate weekly.

I’m seeking some advice on a proposed new protocol—suggested by a new doctor.

Baseline Before TRT:
Total-T: 333 (129-767)
Free-T (dialysis/MS): 42.4 (44-244)
SHBG: 67 (10-57)
Estradiol (not sensitive): 17.7 (11.3-43.2)
DHT: 300 (106 - 719)
DHEA-S: 24 (42-290)
TSH: 3.14
T3: 3.0

My goals for TRT are (in order of priority)

Productivity: restore my energy, motivation, quick decision-making, sociability, mood.

Sexual Function: rescue my libido (now at zero), improve erections, restore penile sensitivity and orgasm intensity.

Physical: At my age, I fight muscle-loss and even just maintaining muscle is difficult. Gaining a little would be nice—but not essential.

I’ve been with an endo for 6 months. We tried daily gel (50mg then 75mg). Then switched to T-enanthate injections sub-q at 50mg weekly and then 75mg, injected weekly—which is where I am today.

Her sole focus throughout this process was on getting my Free-T to a “normal” level. She recently declared victory when my FT reached 137 pg/ml (47-244 ARUP labs). She achieved this by switching to blood labs taken at mid-point (day 3.5), instead of at trough-level (day 7, pre-injection). Through six months of treatment she has been thoroughly uninterested in whether any of my symptoms had diminished. So I've recently changed doctors.

Here are some current lab numbers:

Total-T: 1129 (250-1100) tested at mid-point
Total-T: 1102 (250 - 1100) tested at trough
Free-T (dialysis/MS): 170.4 (30-135) Quest/tested at mid-point
Free-T (dialysis/MS): 80.6 (6-73) Quest/tested at trough
SHBG: 74 (22-77)
Estradiol (sensitive): 40 (< 30) Quest/tested at mid-point
Estradiol (sensitive): 29 (< 30) Quest/tested at trough
DHEA-S: 12 (20-217)

My symptoms have improved somewhat.
My mood is a bit better and I no longer feel depressed.
I have some improvement in energy/productivity for about 3 days per week as I move through the weekly roller-coaster.
These improvements are short-lived and not as strong as I was hoping for. My endo is not interested in any of this.

My new doctor is recommending the following:

160mg Test-cyp per week, split into 80mg every 3.5 days.
500 mg HCG twice weekly
20mg DHEA daily

I have not started this yet. I can sort of understand the reasoning for this. I'm getting some benefit from 75mg but it doesn't last the whole week. The new protocol takes care of this by (1) switching to Cyprionate, and (2) adding another dose of approximately the same size each week. However, this more than doubles the amount of testosterone and adds 2 new factors (HCG and DHEA).

I’m somewhat worried that this amount of Test could push my estradiol too high and require AI to control it—I’m really not eager to go there. My current Test:E-2 ratios suggest that I could actually use more E-2 so perhaps I'm worrying over nothing.

I'm also curious about the dose of HCG. I may not need that much. Is it easier to titrate upward or downward? Would it be better to start low and move up? After 6 months of TRT my testes are already atrophied. I'm not concerned about that. I''ve no intention of having children and I'm not upset with the cosmetic effect of a smaller scrotum. I've gathered from reading other posts that HCG has other benefits (like making you generally feel better), but I wouldn't want to take more than necessary.

Sorry if this post is a bit scattered. I'm just a bit nervous about making such a big change all at once.
Any comments, suggestions or advice would be welcome. Thanks to all of you. This is a great site.

 

[madman]

I am new to this forum.

I’m an active 69 y/o male in generally good health. I’m not overweight, I exercise regularly, my resting pulse is 55, I eat fairly healthy, don’t smoke and only drink one or two beers per week. I have been diagnosed with secondary-hypogonadism. My LH and FSH were “inappropriately normal” according to my endo (both should have been higher). An MRI showed a very small tumor (adenoma) on the pituitary gland, which may be responsible—but this is an unknown and will be monitored each year going forward, to see if the tumor changes shape or size. I qualified for TRT because of low Free Testosterone and typical low-T symptoms. I have been on TRT for 6 months and currently taking 75mg Test-enanthate weekly.

I’m seeking some advice on a proposed new protocol—suggested by a new doctor.

Baseline Before TRT:
Total-T: 333 (129-767)
Free-T (dialysis/MS): 42.4 (44-244)
SHBG: 67 (10-57)
Estradiol (not sensitive): 17.7 (11.3-43.2)
DHT: 300 (106 - 719)
DHEA-S: 24 (42-290)
TSH: 3.14
T3: 3.0

My goals for TRT are (in order of priority)

Productivity: restore my energy, motivation, quick decision-making, sociability, mood.

Sexual Function: rescue my libido (now at zero), improve erections, restore penile sensitivity and orgasm intensity.

Physical: At my age, I fight muscle-loss and even just maintaining muscle is difficult. Gaining a little would be nice—but not essential.

I’ve been with an endo for 6 months. We tried daily gel (50mg then 75mg). Then switched to T-enanthate injections sub-q at 50mg weekly and then 75mg, injected weekly—which is where I am today.

Her sole focus throughout this process was on getting my Free-T to a “normal” level. She recently declared victory when my FT reached 137 pg/ml (47-244 ARUP labs). She achieved this by switching to blood labs taken at mid-point (day 3.5), instead of at trough-level (day 7, pre-injection). Through six months of treatment she has been thoroughly uninterested in whether any of my symptoms had diminished. So I've recently changed doctors.

Here are some current lab numbers:

Total-T: 1129 (250-1100) tested at mid-point
Total-T: 1102 (250 - 1100) tested at trough
Free-T (dialysis/MS): 170.4 (30-135) Quest/tested at mid-point
Free-T (dialysis/MS): 80.6 (6-73) Quest/tested at trough
SHBG: 74 (22-77)
Estradiol (sensitive): 40 (< 30) Quest/tested at mid-point
Estradiol (sensitive): 29 (< 30) Quest/tested at trough
DHEA-S: 12 (20-217)

My symptoms have improved somewhat.
My mood is a bit better and I no longer feel depressed.
I have some improvement in energy/productivity for about 3 days per week as I move through the weekly roller-coaster.
These improvements are short-lived and not as strong as I was hoping for. My endo is not interested in any of this.

My new doctor is recommending the following:

160mg Test-cyp per week, split into 80mg every 3.5 days.
500 mg HCG twice weekly
20mg DHEA daily

I have not started this yet. I can sort of understand the reasoning for this. I'm getting some benefit from 75mg but it doesn't last the whole week. The new protocol takes care of this by (1) switching to Cyprionate, and (2) adding another dose of approximately the same size each week. However, this more than doubles the amount of testosterone and adds 2 new factors (HCG and DHEA).

I’m somewhat worried that this amount of Test could push my estradiol too high and require AI to control it—I’m really not eager to go there. My current Test:E-2 ratios suggest that I could actually use more E-2 so perhaps I'm worrying over nothing.

I'm also curious about the dose of HCG. I may not need that much. Is it easier to titrate upward or downward? Would it be better to start low and move up? After 6 months of TRT my testes are already atrophied. I'm not concerned about that. I''ve no intention of having children and I'm not upset with the cosmetic effect of a smaller scrotum. I've gathered from reading other posts that HCG has other benefits (like making you generally feel better), but I wouldn't want to take more than necessary.

Sorry if this post is a bit scattered. I'm just a bit nervous about making such a big change all at once.
Any comments, suggestions or advice would be welcome. Thanks to all of you. This is a great site.

Here are some current lab numbers:

Total-T: 1129 (250-1100) tested at mid-point
Total-T: 1102 (250 - 1100) tested at trough
Free-T (dialysis/MS): 170.4 (30-135) Quest/tested at mid-point
Free-T (dialysis/MS): 80.6 (6-73) Quest/tested at trough
SHBG: 74 (22-77)
Estradiol (sensitive): 40 (< 30) Quest/tested at mid-point
Estradiol (sensitive): 29 (< 30) Quest/tested at trough
DHEA-S: 12 (20-217)

My symptoms have improved somewhat.
My mood is a bit better and I no longer feel depressed.
I have some improvement in energy/productivity for about 3 days per week as I move through the weekly roller-coaster.
These improvements are short-lived and not as strong as I was hoping for. My endo is not interested in any of this.


Forget testing mid-point as the goal here is to achieve a healthy trough FT.

We always want to test at the true trough (lowest point) before your next injection.

Seeing as you are injecting once weekly your true trough is 7 days post-injection.

Downfall for many when following a once weekly protocol is that there will be a big swing in the peak--->trough and blood levels will not be as stable throughout the week which can have a negative effect on mood, energy, libido/erectile function and recovery due to the big swing in hormones especially when injecting strictly IM.

Top it off that many are aiming for too high a trough which means that peak TT and more importantly FT will be sky-high!

You would be far better off splitting up the weekly dose and atleast injecting twice-weekly (every 3.5 days) which will clip the peak--->trough and result iin more stable blood levels throughout the week.

As we always preach on here start low and go slow on a T only protocol as we want to see how your body reacts to T and where said protocol will have your trough TT and more importantly FT, estradiol let alone other critical blood markers RBCs, hemoglobin and hematocrit.

There will always be time to increase the dose if need be.

Much easier going up than coming down.

Most men on TTh are injecting 100-200 mg T/week whether once weekly or split into more frequent injections as in twice-weekly (every 3.5 days), M/W/F, EOD or daily.

The majority of men can easily hit a healthy let alone high trough FT injecting 100-150 mg T/week especially when split into more frequent injections.

Yes there will always be those outliers who may need the higher-end dose 200 mg/week but it is far from common as in rare.

Such dose would have the majority overmedicated!

Looking over your lab results as you can see you are hitting a high trough TT 1102 ng/dL but with a high SHBG 74 nmol/L your trough FT is still going to be decent and although your trough FT is on the high-end of the reference range supposedly tested using the most accurate assay (Equilibrium Dialysis) the reference range seems off compared to the reference range given for your mid-point FT.

Even whe looking at your pre-TTh baseline FT you listed dialysis but the reference range would be for the calculated method (modified Vermeulen).

We can easily calculate your FT using the linear law-of-mass action Vermeulen (cFTV) which will give a good approximation.

If we take your high trough TT 1102 ng/dL, high SHBG 74 nmol/L and Albumin 4.3 g/dL (default) then your trough cFTV 15.5 ng/dL would be healthy.

You are hitting a trough TT 1102 ng/dL and trough cFTV 15.5 ng/dL 7 days post-injection which means that your peak TT and more importantly FT will be much higher as in almost double!

Free & Bioavailable Testosterone calculator

FT <5 ng/dL would be considerd low.

FT 5-9 ng/dL would be considered the grey zone where some men may experience symptoms of low-T.

FT 10-15 ng/dL would be healthy.

FT 20-25 ng/dL would be high-end/high.

The majority of men will do well with a trough FT 15-25 ng/dL depending on the injection frequency.

Need to keep in mind that there is a big difference between one running a high-end/high trough FT 20-25 ng/dL injecting daily vs twice-weekly vs once weekly.

Also going to be a big difference in peak--->trough on said protocol!

Many tend to overlook this and gun for a high-end/high trough FT only to end up struggling with sides especilly in the long run.

Just to put this in perspective most healthy young males would be hitting a cFTV 13-15 ng/dL or 10-12 ng/dL tested using the most accurate assay the gold standard Equilibrium Dialysis and this is a short-lived daily peak to boot!

You are hitiing a trough cFTV 15.5 ng/dL 7 days post-injection so there is no way in hell anyone can say your trough FT is too low or subpar!

Even then you could easily split the dose and inject twice-weekly (every 3.5 days) which will clip the peak--->trough as in bring up your trough and soften the peak and your blood levels will be more stable throughout the week.




My new doctor is recommending the following:

160mg Test-cyp per week, split into 80mg every 3.5 days.
500 mg HCG twice weekly
20mg DHEA daily

I have not started this yet. I can sort of understand the reasoning for this. I'm getting some benefit from 75mg but it doesn't last the whole week. The new protocol takes care of this by (1) switching to Cyprionate, and (2) adding another dose of approximately the same size each week. However, this more than doubles the amount of testosterone and adds 2 new factors (HCG and DHEA).


This is overkill off the hop!

Will not make much of a difference whether one is injecting TE or TC when it comes to the PKs as they are basically interchangeable.

160 mg T/week split into twice-weekly injections will most likely have your trough FT too high let alone throwing in the hCG will drive up your TT/FT and estradiol further.

Top it off such dose is a surefire way to drive up your RBCs, hemoglobin and hematocrit.

Standard starting dose across the board is 100 mg T/week or better yet 50 mg T twice-weekly.

Yes some mey choose to start <100 mg T/week.

Again always best to start low and go slow preferably on a T only protocol so you can see how you react to said dose of T and where said protocol (dose of T/injection frequency) has your trough TT and more importantly FT, estradiol let alone critical blood markers RBCs, hemoglobin and hematocrit.

There will always be time to increase the dose if need be or add in hCG.

Starting dose 250iu hCG twice-weekly is sensible no need to jump in at 500iu.

If you start off on T + hCG and end up running into any issues you will be at a loss trying to tease things out.

All that should really matter here is the dose of T one needs to achieve a healthy trough FT which will result in relief/improvement of low-T symptoms and overall well-being.

Yes symptom relief is what truly matters but when it comes to what trough FT level is needed one needs to keep in mind the overall goal would be to use the least amount in order to feel well while at the same time minimizing/preventing sides and keeping blood markers healthy long-term.

Bottom line do what you feel is best for you!





Look over the treads in post #6

Thread 'Erythrocytosis: Diagnosis and investigation'

Dec 24, 2024

FIGURE 2 Management of erythrocytosis (Source: adapted from BSH guidelines 2019).6

Abstract

An absolute erythrocytosis is present when the red cell mass is greater than 125% of the predicted. This is suspected when the hemoglobin or hematocrit is above the normal range. An erythrocytosis can be classified as primary or secondary and congenital or acquired. The commonest primary acquired disorder is polycythemia vera. The diagnostic criteria for PV have evolved over time and this is the main diagnosis managed in hematology clinics. There...

• madman
• testosterone; t-therapy; erythrocytosis; h/h/rbcs
• Replies: 5
• Forum: Testosterone Side Effect Management

post #6

Thread 'Testosterone Therapy and Erythrocytosis - the most common dose-limiting effect of testosterone therapy'

Apr 21, 2024

Testosterone Therapy and Erythrocytosis • The Blood Project

Introduction Androgens play a crucial role in the development and maintenance of: Male reproductive and sexual functions Body composition Erythropoiesis

www.thebloodproject.com

Introduction

• Androgens play a crucial role in the development and maintenance of:
  
  • Male reproductive and sexual functions
  • Body composition
  • Erythropoiesis
  • Muscle and bone health
  • Cognitive function
• Testosterone falls progressively with age and a significant percentage of men over the age of 60 years have serum testosterone levels that are below the lower limits of young...

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• 

Thread 'Age-stratified reference ranges for directly measured (ED LC-MS/MS) serum free testosterone in healthy men'

May 11, 2024

Just to be clear up any confusion this is Fiers camps data for mFT reference ranges not the harmonized reference range being worked on by the CDC.


*Serum samples were analyzed from healthy men participating in the SIBLOS/SIBEX and EMAS studies, both population-based cohort studies

* mFT levels were measured in 867 men using ED LC-MS/MS as previously reported (1). Subsequently, 95% reference ranges were determined using the non-parametric method


Reference: 1. Fiers T, Wu F, Moghetti P, Vanderschueren D, Lapauw B, Kaufman JM. Reassessing Free-Testosterone...

• madman
• free testosterone; ed/refernce range; tth
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