Ask The Urologist Anything (Dr Michael Rotman)

sh1973

Active Member
Dr Rotman, been on TRT going on nine years and most of that time has been a struggle. The majority of the time has been on injectable at about 100mg per week. I have shbg values in the 60-70 range and have tried various injection frequencies and doses. What I’ve found the last several months is by dropping my total weekly dose to 60mg I now feel pretty well. My trough levels is coming back in the mid 500ng range and calculated free t in the 9-10ng range. These are fairly conservative numbers but I feel better than I have in years. I’ve tried coming off trt a few times to no avail. My question for you is if you had to put a range where you see the most patient satisfaction, where would that be? My urologist is sort of stumped by my case as well as other doctors I’ve had over the years. My urologist states 95% of his patients are on at least 100mg per week and I’m the lowest he has at 60mg per week. Any thoughts appreciated.
 
Dr. Rotman,
Thank you so much for taking your time to answer these questions. I was blown away by the level of detail of your responses. I was wondering if you have ever encountered pelvic pain as a side effect of low T or estrogen related. I’ve struggled with pelvic pain, painful ejaculation, constant pelvic spasms and premature ejaculation (which I had never had before) at the same time my low testosterone symptoms began. All symptoms began at the same time so im convinced they are related. I have seen a urologists and was diagnosed with non bacterial prostatitis or chronic pelvic pain. Since starting TrT it seems to come and go based on my levels. My assumption is it’s estrogen or testosterone related as both my E and T were very low prior to treatment. Any hypothesis on the physiology behind this?
 

Nelson Vergel

Founder, ExcelMale.com
Thread starter #283
There are 15 pages of posts here with over 36,000 viewers!

Can I ask you guys for a favor before I close this thread? I am planning to interview Dr Rotman again. Can you guys go through all posts here and find out what questions have not been asked yet?

We were thinking about focusing on fertility and prostate cancer. Any thoughts? Thanks
 
All I can say is Dr. Rotman is a great doctor and has been monitoring me now for just about 2 years with my struggles. He is very knowledgeable, and if you see him in his office make sure to follow his protocols. He uses Empower pharmacy and Hallandale, and his staff is great and supportive.
 
Humbled by your response. I will be very willing to answer any questions that I am able to, going forward on this forum. Nelson is a great resource to me personally as I frequently will ask of him advice on things I encounter. Never be ashamed to ask for help in this field. Cowboys in this field create more problems than they solve unfortunately. There are no geniuses in this field, only doctors and professionals willing to learn and adapt to problems that have not been addressed in the past and apply their education to current problems.
 
I agree with the other poster. I found dr rotman from this site. And appreciate that dr is not afraid to ask for help esp in this field. And your office is great esp Emily. Dr very accessible.

Btw my name is not charlie.

I have a question that i will state here i think it can help others.
I am pretty stable. Feel good. Though a couple months ago i switched to im injection and feel my e2 is lower than b4. But still feel good. I take no ai.

Heres my question. My tsh has been anywhere from 2.3-3.5. Free t3 keeps up - mid range. I am consistently on the very low end on total t4 and total t3. And free t4 usually on low end too. I am seeing an endo next week and expect to be put on t4 medication. I think my thyroid is struggling to keep up. And low total t3 and t4 can Indicate subclinical hypothyroidism. I do have some symptoms of hypothyroidism like cold hands during the day. One minute I could have cold hands 30 minutes later my hands feel fine. Sounds erratic to me and tells me thyroid struggling.

My shbg is in low mid 20s. I gather t4 meds can increase shbg. I also hope having a more efficient thyroid will help decrease my triglycerides.
I also read that ppl with hypo have slighly elevated prolactin and igf which i do.

Do you think i will need a protocol change with thyroid treatment?

Thank you.
 
I agree with the other poster. I found dr rotman from this site. And appreciate that dr is not afraid to ask for help esp in this field. And your office is great esp Emily. Dr very accessible.

Btw my name is not charlie.

I have a question that i will state here i think it can help others.
I am pretty stable. Feel good. Though a couple months ago i switched to im injection and feel my e2 is lower than b4. But still feel good. I take no ai.

Heres my question. My tsh has been anywhere from 2.3-3.5. Free t3 keeps up - mid range. I am consistently on the very low end on total t4 and total t3. And free t4 usually on low end too. I am seeing an endo next week and expect to be put on t4 medication. I think my thyroid is struggling to keep up. And low total t3 and t4 can Indicate subclinical hypothyroidism. I do have some symptoms of hypothyroidism like cold hands during the day. One minute I could have cold hands 30 minutes later my hands feel fine. Sounds erratic to me and tells me thyroid struggling.

My shbg is in low mid 20s. I gather t4 meds can increase shbg. I also hope having a more efficient thyroid will help decrease my triglycerides.
I also read that ppl with hypo have slighly elevated prolactin and igf which i do.

Do you think i will need a protocol change with thyroid treatment?

Thank you.
Hi sir, thank you for the kind comments . I apologize for the delayed response. I personally do not treat thyroid issues as it is not something I have experience in treating. I defer to endo and other medical doctors who are in tune with current thyroid supplementation. I will certainly evaluate the protocol if thyroid supplementation is initiated and adjust accordingly. I always screen for thyroid issues though. Only follow up will tell us on how to proceed.
 
Dr. Rotman,

From this posting I am pretty sure you will have an idea of who I am. You have been the only support doctor in my case and I just wanted to give an update on the status of my condition with OAB. Even though my blood work seems to be stabilizing the recent discovery of my increasing TPO, and slightly elevated ALT over the course of just about 2 years has me concerned. My thyroid levels seems to be normal, just my antibodies are elevated. My endocrinologist does not seem to think the TPO antibodies are alarming. He explained some people have them, and some don’t, and to retest in a year. Also my TSH levels are quite normal, so there was no need to further test the thyroid, he explained. He also elaborated that he does not feel that their is a hypogonadal cause to my OAB. He said once diabetes and diabetes inspidus are ruled out he cannot do much more to help from an endocrinological perspective. Surprisingly my LH & FSH are rebounding which is great news and my Testosterone levels are showing great improvements.

On the other hand, my episodic OAB is still causing me to have some very bad days which leave me just about paralyzed, and glued to a bathroom. Some days are very tough to get out of the house. Luckily my job allows me to work at home which probably doesn’t help. Exercise is very limited, so my weight doesn’t really change. Even when I limit my diet (eliminating caffeine and alcohol) and avoiding bladder irritants, I do not see improvements. On a positive note I do want to add that from looking back in April 2017, to present day I feel I could be improving. I just am hesitant to say “I am improving” because I have episodes which break down my confidence and build anxiety when I urinate almost 15-20 times a day, without drinking much water.

At the beginning of 2018, I was seeing a health psychologist for about 3-4 months in regards to all of this and he concluded that I had mild anxiety and actually discontinued to see me because he felt there was nothing he could do to help me.

I am worried that my symptoms will be written off as, “it is all in my head” ordeal. I am concerned about losing my job and the strain on my family. The one thing I want to avoid best as possible is taking SSRI’s or Benzodiazepines, those have showed to help in the past. But becoming reliant on those medications for a long period of time is scary. Would it be best to try a low dose of Desmopressin? I have heard success stories with individuals using this medication to help with Polyuria/OAB. I would love to get my hands on legit Androxal and missed out on a Clinical trial in my area. I am not sure where this medication stands with FDA approval, not much information on it.

Episodic symptoms:
-OAB (Polyuria, 2-3 nighttime bathroom trips)
-Light headed (as if I am on a boat, not vertigo)
-Dry eyes (when I wake up I can barely open my eyes)
-Zero appetite (no hunger triggers)
-Difficult to lose weight (morning weight 213, bedtime weight 220)
 
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Hi Dr. Rotman,

Is this thread still open? I hope.

Do you ever see ED come and go while on TRT?

When I started TRT almost 1 year ago Viagra and Cialis had stopped working very well for me and I could barely have erections. About 10 days into TRT, my ED went away completely and I was back to functioning about like I was when I was 20. Full long lasting erections just thinking about sex. I was beyond thrilled. But this only lasted about 4 days, then in a few more days I was right back to baseline ED same as before I started. That continued until late November, when once again over the course of a few weeks my ED got better and better to the point where I could easily have sex without any medication, but then it has gone away again.

One positive change is that once I started TRT nocturnal erections completely returned and have never gone away.

I have been using Trimix for my ED and my Doc says the dose is very low which means I have good vascularity.

Here are all my stats:

49 years old, I eat healthy and workout a lot, not overweight, not under any stress.

Labs:
LH <0.07 mIU/ml
Pregnenolone 5.9 ng/dL
E2 27.4 pg/mL
DHEA 229.2 ug/dl
Total T 885 ng/dl
SHBG 36 nmol/L
Free T 19.75 ng/dL
Bioavail T 462.8 ng/dL
Cortisol 21.6 ug/dl
T3, free 3.6 pg/ml
T4, free 0.97 ng/dl
TSH 1.782 uIU/ml

I take:
76 mg cyp 2/week sub Q
HCG 500 IU 3/week sub Q
Pregnenolone 30mg/day
DHEA 50/mg twice a day
Cialis 5 mg/day
Neo40 nitric oxide 1/day

I have been taking anastrazole 1mg twice a week, but this I started about 3 months after I started TRT only because I still had ED and it was a guess at a solution. My E2 went to about 49 before the anastrazole. I have seen no affect whatsoever after taking it and I plan to stop and let my E2 go back up.

Because I have had these periods where I can get great erections, I get the feeling there is some little piece of the puzzle that is missing and if I find it my ED will go away.
 
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Have you tried dropping the dhea and preg?



Hi Dr. Rotman,

Is this thread still open? I hope.

Do you ever see ED come and go while on TRT?

When I started TRT almost 1 year ago Viagra and Cialis had stopped working very well for me and I could barely have erections. About 10 days into TRT, my ED went away completely and I was back to functioning about like I was when I was 20. Full long lasting erections just thinking about sex. I was beyond thrilled. But this only lasted about 4 days, then in a few more days I was right back to baseline ED same as before I started. That continued until late November, when once again over the course of a few weeks my ED got better and better to the point where I could easily have sex without any medication, but then it has gone away again.

One positive change is that once I started TRT nocturnal erections completely returned and have never gone away.

I have been using Trimix for my ED and my Doc says the dose is very low which means I have good vascularity.

Here are all my stats:

49 years old, I eat healthy and workout a lot, not overweight, not under any stress.

Labs:
LH <0.07 mIU/ml
Pregnenolone 5.9 ng/dL
E2 27.4 pg/mL
DHEA 229.2 ug/dl
Total T 885 ng/dl
SHBG 36 nmol/L
Free T 19.75 ng/dL
Bioavail T 462.8 ng/dL
Cortisol 21.6 ug/dl
T3, free 3.6 pg/ml
T4, free 0.97 ng/dl
TSH 1.782 uIU/ml

I take:
76 mg cyp 2/week sub Q
HCG 500 IU 3/week sub Q
Pregnenolone 30mg/day
DHEA 50/mg twice a day
Cialis 5 mg/day
Neo40 nitric oxide 1/day

I have been taking anastrazole 1mg twice a week, but this I started about 3 months after I started TRT only because I still had ED and it was a guess at a solution. My E2 went to about 49 before the anastrazole. I have seen no affect whatsoever after taking it and I plan to stop and let my E2 go back up.

Because I have had these periods where I can get great erections, I get the feeling there is some little piece of the puzzle that is missing and if I find it my ED will go away.
 
So if you always took the dhea, try without it.
I am open to anything, but can you give me a good reason why that might work? The way I see it, my DHEA levels are low to mid range and I haven't seen anyone saying lower DHEA to improve ED, rather that many men's DHEA levels should be higher. Please correct me if I'm wrong.
 
I am open to anything, but can you give me a good reason why that might work? The way I see it, my DHEA levels are low to mid range and I haven't seen anyone saying lower DHEA to improve ED, rather that many men's DHEA levels should be higher. Please correct me if I'm wrong.
No one knows this stuff for sure.
You need to start eliminating things you are taking other than the t injections . Except for cialis. I have no Ed.

I take no ai. No hcg. No dhea even though am low normal. Just t injections and daily cialis like you.
 
Hi Dr. Rotman,

I have been taking anastrazole 1mg twice a week, but this I started about 3 months after I started TRT only because I still had ED and it was a guess at a solution..
2 mg Anastrazole a week seems like WAY TOOOOOOOO much.
You might want to do a search on anastrazole and dose.
That high a dose might tank your E2 and then you will have other significant negative issues to deal with.
Have you been tracking your E2 with the PROPER E2 blood test?
 
Hello Doctor, please read this and tell me what you think. Should I be concerned ?:

This is my first post. I found your site after panicking about the details of possible priapism. I had my first shot today at the uro. I obvioiusly do not know alot about this so I trusted my doctor. He injected me with 20 units. I went home and after 2 hours there was no sign of a let up. I had feeling that this was just not going to go down for possibly another couple hours so I took sudafed. I started panicking more when it was 3 1/2 hours and I was still rigid. I had already had ice packs on my shaft for about an hour at that point. After 4 hours the erection began to subside a bit and it was , from a scale of 1-10, at about a 6. I called my doctor and asked if I should go to the ER and he said that as long as it has atleast begun to subside, I should be ok and that if the pain was not that bad then I should be fine. Well, the pain was there but it was not unbearable, but the erection had not gone down 100 percent , until about 5 or 5 1/2 hours. I have not had 5 hours of hell like that , worrying , in years. I am worried that I might have damage to my penis, is worrying about that warranted?................there is no black and blue and my penis looks normal now. I think what people say sometimes about doing your own research and being your own doctor (up to a point of course) is definitely good advice for everyone to follow. When I do the injection myself I intend on using only 5 or 6 units. This stuff is ridiculously potent.
 
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