Low Ferritin / High Iron & HCT - Suggestions Please

[JYD21]

I am now 13 weeks in to TRT. Started at 120mg weekly pinning MWF. I did 6 week labs on my own from DiscountedLabs (awesome) and had an HCT of 50 then.

So my doc said to donate whole blood, so I did. I also lowered my dose to 100-108 week. MWF.

I just did some 12 week labs and my Ferritin came back fairly low, and my iron is elevated, per below. NOTE: The results below were 48 hours after my pin, on a Wednesday morning, 8:30am.

IRON, TOTAL 208 H 50-180 mcg/dL
IRON BINDING CAPACITY 455 H 250-425 mcg/dL (calc)
% SATURATION 46 20-48 % (calc)
FERRITIN 20 L 38-380 ng/mL

HEMATOCRIT 50.9 H 38.5-50.0 % IG

SEX HORMONE BINDING IG GLOBULIN 31 10-50 nmol/L
TESTOSTERONE, TOTAL, MS 1068 250-1100 ng/dL
TESTOSTERONE, FREE 229.4 H 35.0-155.0 pg/mL

ESTRADIOL,ULTRASENSITIVE, LC/MS 55 H < OR = 29 pg/mL EZ

My Thoughts
1) I likely did not need to donate whole blood because just 6 weeks later, my HCT was EXACTLY the same. I am sure it was partly dehydration and partly the increase in test.
2) My pre-TRT HCT number was 47.
3) I think my dose is too high. I may need to reduce it or increase the frequency.
4) I really don't 'feel' better overall since I started.
5) I was thinking to keep the dose the same, but go to twice a week injections at 50mg to perhaps at least feel it a bit more but then retest at a trough of 3.5 days instead of 2 and see of that makes a difference.

Suggestions?

 

[Guided_by_Voices]

There are a number of threads on this forum related to your question which may help you, but something I haven't seen discussed is the importance of adequate copper levels in the regulation of Iron. You may want to increase your copper intake and read up on it such as found here

Metabolic crossroads of iron and copper

Interactions between the essential dietary metals, iron and copper, have been known for many years. This review highlights recent advances in iron-copper interactions with a focus on tissues and cell types important for regulating whole-body iron and ...

www.ncbi.nlm.nih.gov

Also, the recent writing and videos from Morley Robbins go into great detail on this topic.

 

[Blackhawk]

You are sensibly thinking about further dose reduction. I would indeed get labs at trough, but probably it is not hugely lower. So you may have more T ,Free T, E2 and HCT than necessary. You likely have room to lower dose further.

Beware though, you might feel like Hell for a while each time you lower your dose. To me there are withdrawal symptoms. I've been through this too, and have lowered dose multiple times over about 5 years. I stayed on 84mg/wk for a long time, which still left me supraphysiological then dropped further to 70mg/week, which put me right about top of normal ranges for everything. Right now riding out dropping even further. Dealing with a new HCT problem unrelated to the T, but making every effort to put the brakes on erythrocytosis.

YMMV, everyone is an individual.

 

[PapiChulo]

had an HCT of 50 then.

So my doc said to donate whole blood, so I did. I also lowered my dose to 100-108 week. MWF.



My Thoughts
1) I likely did not need to donate whole blood because just 6 weeks later, my HCT was EXACTLY the same. I am sure it was partly dehydration and partly the increase in test.
2) My pre-TRT HCT number was 47.
3) I think my dose is too high. I may need to reduce it or increase the frequency.
4) I really don't 'feel' better overall since I started.
5) I was thinking to keep the dose the same, but go to twice a week injections at 50mg to perhaps at least feel it a bit more but then retest at a trough of 3.5 days instead of 2 and see of that makes a difference.

Suggestions?

Medicine is continually evolving. What was thought 10 years ago as standard, is now being reassessed (e.g. cardiovascular disease). Be aware that what one physician thinks is "standard of care" may not be embraced universally anymore. You did not state what specialty your physician belongs, and that matters. Keeping up with evidence based data is impossible for physicians today due to their being overwhelmed with EMR. More than 50% of physicians time is spent on administrative tasks. This is a very new development in medicine, and most doctors are suffering burnout.

A few thoughts, given I have been taking IM Test Cyp/Enat for 45 years via prescription / retail pharmacy.

1. My Endocrinologist gets really uppity about my elevated HCT (~53) but my Cardiologist yawns. I listen to my Cardiologist on things like cardiovascular and not my Endocrinologist. My PCP does not have a clue - smart man! There is no data on people taking Test with a slightly elevated HCT like me and having cardiac events. None. Even the Endocrine Society agrees.

Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline​

Bhasin S, Brito JP, Cunningham GR, Hayes FJ, Hodis HN, Matsumoto AM, Snyder PJ, Swerdloff RS, Wu FC, Yialamas MA. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018 May 1;103(5):1715-1744. doi: 10.1210/jc.2018-00229. PMID: 29562364.

Cardiovascular. There have been no RCTs that were large enough or long enough to determine the effects of T-replacement therapy on major adverse cardiovascular events (MACE). Additionally, there is no conclusive evidence that T supplementation is associated with increased cardiovascular risk in hypogonadal men. The relationship of endogenous T concentrations and coronary artery disease in cross-sectional and prospective cohort studies has been inconsistent (90). The relationship between T concentrations and cardiovascular events in prospective epidemiologic studies is also inconsistent (91, 92). A small number of epidemiologic studies have reported a negative relationship between T concentrations and measures of subclinical atherosclerosis, such as common carotid artery intima–media thickness (92, 93).

There are no adequately powered RCTs on the effects of T replacement on MACE. The few RCTs that have reported cardiovascular events were limited by their small size, short intervention durations, variable quality of adverse event reporting, and failure to prespecify and adjudicate cardiovascular events (79–82, 84, 95). Retrospective analyses of data using electronic medical records have also been inconclusive and are similarly constrained by the lack of randomized allocation and prospective adjudication of cardiovascular events, confounding by indication, and heterogeneity of patient populations, T doses, and intervention durations (96–101). A number of meta-analyses have examined the association between T-replacement therapy and cardiovascular events, MACE, and death in RCTs (101, 102). Many of these meta-analyses show point estimates . 1. However, most meta-analyses have not shown a statistically significant association between T treatment and cardiovascular events, MACE, or deaths. The trials included in these meta-analyses suffered from various limitations, including heterogeneity of eligibility criteria, dosing, formulations, and intervention durations; variability in the quality of adverse event recording; lack of large trial cohorts; failure to prespecify and adjudicate cardiovascular outcomes; and lack of a sufficient number of MACE. Thus, there are insufficient data to establish a causal link between T therapy and cardiovascular events.

2. I donate 500 ml blood prn, to keep my Endocrinologist off of my back, but also to be cautious. However, I do not lose sleep over this. Medicine is based on the physical sciences practiced as an art. Some physicians are Renaissance artists and some are "paint by number"

3. The goal of taking test is to reach homeostasis. One needs to reach a consistent level in all things physiology throughout life. It is perilous to be continually changing one's dosage/schedule of meds be they hormones or whatever. The body has a marvelous way of responding to stress due to evolutionary pressures, but it can not sustain a constant ying/yang due to our meddling. Stick to one schedule if you are required to take test because it is medically necessary.

4. Feelings are neither here nor there. Alas, instrumentation/diagnostics are imperfect (just like our feelings). Be careful in increasing or decreasing your dosage or frequency based on your feelings. There are likely other parameters at play that may be overshadowing your test regiment.

After taking test for more than 4 decades, I can say with a sense of pride that I have not screwed up my physiology, I have never had a cardiac or cerebral event, my mood is pretty level, and when it is poor it is usually due to other factors like sleep hygiene, nutrition, career/family/home life, or not taking my Test.

TL; DR: Pick a schedule / dose and stick with it.

Eat your vegetables and exercise too!

 

[JYD21]

There are a number of threads on this forum related to your question which may help you, but something I haven't seen discussed is the importance of adequate copper levels in the regulation of Iron. You may want to increase your copper intake and read up on it such as found here

Metabolic crossroads of iron and copper

Interactions between the essential dietary metals, iron and copper, have been known for many years. This review highlights recent advances in iron-copper interactions with a focus on tissues and cell types important for regulating whole-body iron and ...

www.ncbi.nlm.nih.gov

Also, the recent writing and videos from Morley Robbins go into great detail on this topic.

Yeah, I looked a few of those, but I did not really see too many to find some common threads of the issue and resolve. ...I'll check out the link and Morley's stuff.

You are sensibly thinking about further dose reduction. I would indeed get labs at trough, but probably it is not hugely lower. So you may have more T ,Free T, E2 and HCT than necessary. You likely have room to lower dose further.

Beware though, you might feel like Hell for a while each time you lower your dose. To me there are withdrawal symptoms. I've been through this too, and have lowered dose multiple times over about 5 years. I stayed on 84mg/wk for a long time, which still left me supraphysiological then dropped further to 70mg/week, which put me right about top of normal ranges for everything. Right now riding out dropping even further. Dealing with a new HCT problem unrelated to the T, but making every effort to put the brakes on erythrocytosis.

YMMV, everyone is an individual.

I appreciate this feedback. ...I guess my concern about lowering the dose is that I could feel worse on that lower dose (not just while titrating down). I'm at 108 now. I could go to 90mg weekly? ...Sadly, I don't think my provider has much of a clue on any of this.

Medicine is continually evolving. What was thought 10 years ago as standard, is now being reassessed (e.g. cardiovascular disease). Be aware that what one physician thinks is "standard of care" may not be embraced universally anymore. You did not state what specialty your physician belongs, and that matters. Keeping up with evidence based data is impossible for physicians today due to their being overwhelmed with EMR. More than 50% of physicians time is spent on administrative tasks. This is a very new development in medicine, and most doctors are suffering burnout.

A few thoughts, given I have been taking IM Test Cyp/Enat for 45 years via prescription / retail pharmacy.

1. My Endocrinologist gets really uppity about my elevated HCT (~53) but my Cardiologist yawns. I listen to my Cardiologist on things like cardiovascular and not my Endocrinologist. My PCP does not have a clue - smart man! There is no data on people taking Test with a slightly elevated HCT like me and having cardiac events. None. Even the Endocrine Society agrees.

Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline​

2. I donate 500 ml blood prn, to keep my Endocrinologist off of my back, but also to be cautious. However, I do not lose sleep over this. Medicine is based on the physical sciences practiced as an art. Some physicians are Renaissance artists and some are "paint by number"

3. The goal of taking test is to reach homeostasis. One needs to reach a consistent level in all things physiology throughout life. It is perilous to be continually changing one's dosage/schedule of meds be they hormones or whatever. The body has a marvelous way of responding to stress due to evolutionary pressures, but it can not sustain a constant ying/yang due to our meddling. Stick to one schedule if you are required to take test because it is medically necessary.

4. Feelings are neither here nor there. Alas, instrumentation/diagnostics are imperfect (just like our feelings). Be careful in increasing or decreasing your dosage or frequency based on your feelings. There are likely other parameters at play that may be overshadowing your test regiment.

After taking test for more than 4 decades, I can say with a sense of pride that I have not screwed up my physiology, I have never had a cardiac or cerebral event, my mood is pretty level, and when it is poor it is usually due to other factors like sleep hygiene, nutrition, career/family/home life, or not taking my Test.

TL; DR: Pick a schedule / dose and stick with it.

Eat your vegetables and exercise too!

Lots of great info here, and many thanks for sharing. I'm processing it.

Also, I meant to share these below:

FSH <0.7 L Reference Range: 1.6-8.0 mIU/mL
LH <0.2 L Reference Range: 1.5-9.3 mIU/mL

RED BLOOD CELL COUNT 5.82 H Reference Range: 4.20-5.80 Million/uL
HEMOGLOBIN 17.4 H Reference Range: 13.2-17.1 g/dL

 

[PapiChulo]

Lots of great info here, and many thanks for sharing. I'm processing it.

Also, I meant to share these below:

FSH <0.7 L Reference Range: 1.6-8.0 mIU/mL
LH <0.2 L Reference Range: 1.5-9.3 mIU/mL

RED BLOOD CELL COUNT 5.82 H Reference Range: 4.20-5.80 Million/uL
HEMOGLOBIN 17.4 H Reference Range: 13.2-17.1 g/dL

Consider seeking a Cardiologist, preferably one at a university who deals with bodybuilders / patients who take testosterone, as a consultation. You stated earlier your physician recommended therapeutic phlebotomy, which you did, then regretted. It seems to me you are flying solo, which no man on Test should do. You deserve better.

If you partner with a Cardiologist, you can review your history, prescriptions, labs, and your concerns. Getting input from anonymous folks is not too wise when you have medical concerns

As an aside, I have had a cardiologist since my late-20s, and they all partnered with me to guide me on Testosterone supplementation given my diagnosis in my teen years. Best medical decision I ever made to allow me to sleep in peace.

Best to you!