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...

• madman
• hypogonadism; testosterone; hematocrit; cvd
• Replies: 12
• Forum: Testosterone Side Effect Management

• 

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
• Replies: 4
• Forum: Testosterone and Men's Health Articles

 

[Phil Goodman]

Glad you went with another doc. Her being unconcerned with symptom resolution is a big red flag, and switching the testing day to midweek instead of trough and proclaiming victory due to increased levels on test is one of the dumbest things I’ve ever heard.


Off the top of my head with regard to your newly suggested protocol. Doubling your dose and adding HCG at the same time seems like overkill, as madman mentioned.I’d say start with 50 mg twice/week and go with IM over sub q. Since you’ve already noticed significant atrophy I’d say go with 250 ius of HCG 3 times/week. And your DHEA levels have been consistently low so adding that is probably a good idea. 25 mg/day is a good starting point, but you may end up wanting to dial that down to 12.5 mg/day. Actually that would put you on almost the exact same protocol I’m on, only difference being I’m at 120/week for test. I’ve been through a few different protocols over the years but this is one I’ve stuck with for a long time and is the best I’ve found. Obviously everyone is different, but based on numbers, symptoms, and response to your earlier protocol I think that would be a great next step for you. Then just adjust as needed if it leaves anything to be desired. Only other thing I would add is that it would likely be beneficial to coincide your heavy lifting days so that they fall on day of test injection or the day after, as that could help with recovery and muscle growth,

 

[Astro]

Thank you both for your advice and support! I agree that my first Endo's switch to mid-point testing was bogus and essentially cheating. She really didn't seem to know what she was doing and she made mistakes on nearly every Rx she wrote for me--these needed correction before the pharmacy would fill them.

I'm not in a hurry, so taking my time to find the right dose is fine with me. I certainly don't want to overshoot the proper dose and have to titrate downward. I think the doctor mentioned his intent to saturate my high SHBG. Not sure what benefit that would achieve--or even what that means.

Phil, I'm not clear on why you recommend IM injections. I've read as much medical literature as I could find on this topic and I got the impression that sub-Q injections were just as effective in delivering testosterone--plus they are less painful and produce less scar tissue over time. A good article from the JournaI of Clinical Endocrinology and Metabolism that I found in PubMed (PMC9006970) summarizes several other articles and provides context. Testosterone Therapy With Subcutaneous Injections: A Safe, Practical, and Reasonable Option - PMC

Madman correctly spotted an error in my listing of Free-T levels for one of the labs. Sorry about that. My Endo refused to order most of these labs. Once treatment started, she only ordered FT, hemoglobin and hematocrit. I wanted more data so I could track E-2 and other measures, so I paid out of pocket and got my own labs through Quest and LabCorp. Kind of pissed about that.

You've provided several links to articles and posts--I've not reviewed them yet, but I will...I want to educate myself and take more control of my treatment. I think I'm going to start with 50mg Test E3.5D. After 4 to 6 weeks I could make an assessment of my symptoms and get some labs. Then ramp up to 60mg twice weekly and try that. Going up step-wise this way should ensure that I won't skip over the proper dose. I'll wait until I have the proper T-dose figured out before starting HCG. I've already started taking some DHEA (currently 15mg/daily). I also test low on Pregnenolone: 12 ng/dl (22-237). Should I supplement that too? Its available OTC.

Question: Assuming I stick with HCG doses of roughly 700 to 1,000mg/week (split into 2 or 3 doses), how much extra endogenous testosterone would my testes likely produce? For example, if I find that my perfect Test-dose is 120mg/week, would subsequent activation of my testes with HCG cause my internal testosterone (injected + endogenous) to jump to, say, 140mg/week?

Thanks again for your help. It matters.

 

[Vince]

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.

I'm close to your age and I have been on TRT for over 10 years. Here's my protocol.

Thread 'Vince's Labs from October 14, 2024'

Oct 23, 2024

Same protocol, 16 mg of testosterone cypionate daily, 500 iu of hcg every third day and no AI.

Pregnenolone 10 mg and 10 mg of DHEA.

My last injection before labs, about 27 1/2 hrs.

Labs are from LabCorp.

I did "not" get the Equilibrium Ultrafiltration for testing free testosterone. I didn't want to spend the extra money.

Testosterone, Serum 1482 ng/dL range 264-916
Free Testosterone 24.5 ng/dL range 6.6 -18.1
DHT 61 ng/dL (no range on results)
DHEA-Sulfate 260.0 H ug/dL range 30.9-295.6 (age adjusted)
Estradiol, Sensitive 26.7 pg/mL range 8.0-35.0
Sex Horm Binding Glob, Serum 57.5...

• Vince
• Replies: 7
• Forum: Blood Test Discussion