New Defy Medical Patient - Please Critique Protocol

[DrSilkWater]

Hello ExcelMale Community,

I am new the to community, but have been lurking for a while. I finally took the plunge to address my low T, got my labs done, contacted Defy, had my consultation with Dr. Calkins (super nice & informative guy.


CBC With Differential/Platelet
WBC 5.2 x10E3/uL 3.4 - 10.8 01
RBC 4.60 x10E6/uL 4.14 - 5.80 01
Hemoglobin 14.2 g/dL 12.6 - 17.7 01
Hematocrit 41.6 % 37.5 - 51.0 01
MCV 90 fL 79 - 97 01
MCH 30.9 pg 26.6 - 33.0 01
MCHC 34.1 g/dL 31.5 - 35.7 01
RDW 13.8 % 12.3 - 15.4 01
Platelets 214 x10E3/uL 150 - 379 01
Neutrophils 55 % 01
Lymphs 31 % 01
Monocytes 10 % 01
Eos 3 % 01
Basos 1 % 01
Neutrophils (Absolute) 2.9 x10E3/uL 1.4 - 7.0 01
Lymphs (Absolute) 1.6 x10E3/uL 0.7 - 3.1 01
Monocytes(Absolute) 0.5 x10E3/uL 0.1 - 0.9 01
Eos (Absolute) 0.2 x10E3/uL 0.0 - 0.4 01
Baso (Absolute) 0.0 x10E3/uL 0.0 - 0.2 01
Immature Granulocytes 0 % 01
Immature Grans (Abs) 0.0 x10E3/uL 0.0 - 0.1 01
Comp. Metabolic Panel (14)
Glucose, Serum 88 mg/dL 65 - 99 01
BUN 14 mg/dL 6 - 20 01
Creatinine, Serum 0.84 mg/dL 0.76 - 1.27 01
eGFR If NonAfricn Am 115 mL/min/1.73 >59
eGFR If Africn Am 133 mL/min/1.73 >59
BUN/Creatinine Ratio 17 9 - 20
Sodium, Serum 139 mmol/L 134 - 144 01
Potassium, Serum 4.1 mmol/L 3.5 - 5.2 01
Chloride, Serum 100 mmol/L 96 - 106 01
Carbon Dioxide, Total 22 mmol/L 18 - 29 01
Calcium, Serum 9.5 mg/dL 8.7 - 10.2 01
Protein, Total, Serum 7.2 g/dL 6.0 - 8.5 01
Albumin, Serum 4.5 g/dL 3.5 - 5.5 01
Globulin, Total 2.7 g/dL 1.5 - 4.5
A/G Ratio 1.7 1.2 - 2.2
Bilirubin, Total 0.7 mg/dL 0.0 - 1.2 01
Alkaline Phosphatase, S 78 IU/L 39 - 117 01
AST (SGOT) 16 IU/L 0 - 40 01
ALT (SGPT) 18 IU/L 0 - 44 01

Lipid Panel
Cholesterol, Total 248 High mg/dL 100 - 199 01
Triglycerides 46 mg/dL 0 - 149 01
HDL Cholesterol 55 mg/dL >39 01
VLDL Cholesterol Cal 9 mg/dL 5 - 40
LDL Cholesterol Calc 184 High mg/dL 0 - 99



25-Hydroxyvitamin D LCMS D2+D3
25-Hydroxy, Vitamin D 30 ng/mL 02
Reference Range:
All Ages: Target levels 30 - 100
25-Hydroxy, Vitamin D-2 <1.0 ng/mL 02
25-Hydroxy, Vitamin D-3 30 ng/mL 02


IGF-1
IGF-1(BL) 112 ng/mL 02

Hemoglobin A1c
Hemoglobin A1c 5.4 % 4.8 - 5.6 01
Please Note: 01
Pre-diabetes: 5.7 - 6.4
Diabetes: >6.4
Glycemic control for adults with diabetes: <7.0


Thyroid Peroxidase (TPO) Ab 9 IU/mL 0 - 34 01
Triiodothyronine,Free,Serum 2.7 pg/mL 2.0 - 4.4 01

T4,Free(Direct) 1.23 ng/dL 0.82 - 1.77 01
TSH 0.795 uIU/mL 0.450 - 4.500 01


Testosterone,Free and Total
Testosterone, Serum 341 Low ng/dL 348 - 1197 01
Free Testosterone(Direct) 6.8 Low pg/mL 8.7 - 25.1 01

DHEA-Sulfate 306.8 ug/dL 138.5 - 475.2 01
Luteinizing Hormone(LH), S
LH 2.0 mIU/mL 1.7 - 8.6 01
Prolactin 8.2 ng/mL 4.0 - 15.2 01
Estradiol, Sensitive 19.9 pg/mL 8.0 - 35.0 03
Sex Horm Binding Glob, Serum 31.5 nmol/L 16.5 - 55.9 01



Prostate-Specific Ag, Serum
Prostate Specific Ag, Serum 0.4 ng/mL 0.0 - 4.0 01

IGF-1
Insulin-Like Growth Factor I 132 ng/mL 88 - 246 03


C-Reactive Protein, Cardiac 0.59 mg/L 0.00 - 3.00 01



IGF-BP3 2789 ug/L 2610 - 5977 03




Insulin 4.8 uIU/mL 2.6 - 24.9 01
Ferritin, Serum 130 ng/mL 30 - 400 01

PROTOCOL:

Testosterone Cypionate 200 mg/ml – 0.35 ml intramuscular/subcutaneous, twice a week. (25G, 5/8” needle/ (1cc syringe Luer Lock only)

HCG 400iu subcutaneous, twice a week. (to reverse/prevent testicular atrophy)

Anastrozole 0.25mg twice a week. (h/o elevated E2, titrate on follow-up)

Vitamin D3 5000iu daily

Fish oil 3-4g every day for HDL support

Nature Thyroid 1/2 grain every morning, 30 min before food.

QUESTIONS:

1) I've read conflicting info on HCG dosing. Should I be taking it 1 day before my twice weekly test injections as Dr. Crisler recommends or same day?

2) Dr. Calkins suspects I have hypothyroidism, however, is it smarter to separate the thyroid hormones from the TRT treatment so I can isolate any sides vs taking concurrently and not knowing what is causing what?

3) dosing schedule mentions AI immediately, but from what I've gathered, is it smarter to take 2-4 weeks down the road? It seems that flatlining E2 tends to be a major cause of disruption for dialing in and feeling great on TRT

4) Any real studies on Sub Q vs IM Test absorption rates as well as results via each delivery method?

5) Why only a luer lock? (says on dosing instructions above)

6) needle recommendation anyone, e.g. optimal gauge, length, CC size.

7) I carry alot of fat on my gut and chest, no gyno, no lumps, just my fat storage pattern, should this be taken into consideration if i go the Sub Q route?

8) Also, should I be concerned about gyno and E2 since I already hold fat there and am predisposed.

9) I want to continue losing fat as I have been before I hit a wall, anyone recommend any dietary protocols or "best practices" for achieving fat loss and greek god ripped (lol) when on TRT?

Disclaimer: This is no way a reflection of Dr. Calkins service or knowledge, he was excellent and I felt truly in good hands vs PCP whom for over a decade told me my 300ish test was ok and there was no issue with my thyroid. Howver to be honest, I am scared because I've never injected myself with anything so want to find out as much info as I can. I think it's only smart to do as much diligence as possible on a lifetime protocol. So tired of being average and restricted due to my hormones. I am 34 years old and ready to live my life to the max.

Thanks!

PS - I apologize if I deviate from any thread posting protocols, I've never posted before. Thanks

 

[DrSilkWater]

DISCLAIMER: since I just signed up, realized I f'd up on my username. I am NOT a doctor. it's an old gamer handle my buddy gave me. lol smooth like Silk + Water lol thus DrSilkWater was born.

 

[Vince Carter]

You should take all your meds exactly as dosed and prescribed. Sub Q and IM really doesn't matter, most of us use a 29g 1/2" syringe, luer lock doesn't mean anything that I know of, just a type of syringe, and 25g is larger than is necessary. Most of these you should have asked Dr Calkins, not to many people are going to advise you differently on a protocol you haven't even begun yet. Get on it, stay on it faithfully, then in 90 days when you have your follow up you can start to discuss some or any changes. Most of those questions have the cart before the horse, as it were.

 

[CoastWatcher]

We're glad you joined Excelmale. Like my good friend, Vince Carter, I'm a bit puzzled as to why some/many of your questions weren't raised by you in your consultation. At any rate, at the initiation of TRT it is imperative that you adhere to the instructions that you were given, particularly on matters of dosing.

No one with any sense would advise you to start home-rigging your thyroid medications or your AI. Thyroid irregularities must be addressed. Failure to do so can actually impede a patient working toward balanced androgen levels. The AI was prescribed for a reason. What did the doctor say in that regard? If you fail to maintain the protocol designed for you at the outset, making changes in the absence of a single, objective reason to do so, you are liable to fall down the rabbit-hole. Play it straight.

As for the needle, I suspect, that's a standard dispensing instruction. I use a small insulin syringe, as do many here. It's a matter of personal preference.

We wish you all the best and hope you'll be an active member.

 

[DrSilkWater]

thanks for responding. I appreciate it.

 

[DrSilkWater]

Thanks! I plan to adhere 100%, but wanted some other thoughts as there seem to be many knowledgeable members on this board. I also plan to be active in the board.

As for some of the questions (HCG dosing, etc.), I stumbled into some new info after talking to Dr. Calkins so decided to ask here. As for the needles, I am not necessarily scared of the needles, just nervous b/c I've never injected myself with anything so don't want to f it up.

 

[CoastWatcher]

In regard to the SubQ/IM question, absorption rates, you'll find guys who inject one way and who have labs that support their choice. Guys who inject the other way and they have labs that support their choice. In my own case, injecting testosterone every day, it is typically a shallow IM. However, I do rotate and occasionally inject SubQ. No difference in levels. I would think the size needle you use is going to determine your choice.

HCG protocols are varied, too. Having never, not once, realized a single subjective result from HCG (save testicular size), and since I am injecting testosterone every day, I'm not the right guy to advise you. I really don't know that it makes a difference. But others will disagree with me and you should consider their approach.

 

[JMP]

I too am a recent patient at Defy with Dr Calkins. I agree with the other guys that you should do as he says for now as far as HCG dosage/frequency etc. He recommended a small bit of Anastrazole to me, I think .125, 3x/wk, but I asked if I could wait until my first follow up. He was fine with that and just said to call if I have any estradiol concerns and they would dispense it. Now my sensitive test came out around 14, so lower than yours. I also only carry some fat not a lot so that could be a reason for him starting you on it right away. As far as syringes, I use the same 25g 5/8 with luer lock and don't find it bad at all compared to most people on excel that call it a harpoon. However, I use them for shallow IM. I also use the 27g 1/2in insulin as well for different areas. I would think that a 25g needle is large for sub Q, but you can try smaller ones by ordering online. I feel like its a trade off as far as needle size and speed of flow into and out of the syringe. I couldn't see going smaller than 27 for t. cyp, but many others have no problem with 29's, just takes a bit more patience. I was given 31g for HCG and find them a bit delicate as I bent the first one going into the vial. Now I am more careful. With that said, they are virtually painless and I have yet to get any blood when removing the first 4 injections of HCG. I hope this info helps you in some way.

 

[rhino5169]

So I'm curious as well why the AI was prescribed with a reading of 19. I have a reading of 30 on the same scale and was told no need for it.
Is it true that if you already have midsection fat it could help lose it? If that's the case, sign me up.

 

[johndoesmith]

T/E2 ratio is the most likely reason as to why an AI was prescribed initially.

If at 342 your E2 is 19, then what's it likely to be at when your trough is 900? Keep in mind with the increased AUC(area under the curve) from TRT as opposed to being natural, you'll have a lower(MORE aromatization) T/E2 ratio, thus necessitating an AI being added.

So it's very likely that with a 900 trough your E2 is >50pg/ml.

 

[rhino5169]

My last lab showed total t of approx 535 and e of 30

 

[eddydb]

Hi Dr,

We are starting the same protocol minus the thyroid med. I was also recommended the 25g, but I have some 27g that I will use.

Look forward to hear how things go, and I will be sure to post my experience also.

 

[Vince]

I also like the Easy Touch syringe 27g 1/2" I use for both HCG and T.

 

[johndoesmith]

My last lab showed total t of approx 535 and e of 30

What's your SHBG? Any history of gyno? Was your E2 test a sensitive test? What's the range? There are many variables that play into this, so I'm just guessing here.

 

[DrSilkWater]

In regard to the SubQ/IM question, absorption rates, you'll find guys who inject one way and who have labs that support their choice. Guys who inject the other way and they have labs that support their choice. In my own case, injecting testosterone every day, it is typically a shallow IM. However, I do rotate and occasionally inject SubQ. No difference in levels. I would think the size needle you use is going to determine your choice.

HCG protocols are varied, too. Having never, not once, realized a single subjective result from HCG (save testicular size), and since I am injecting testosterone every day, I'm not the right guy to advise you. I really don't know that it makes a difference. But others will disagree with me and you should consider their approach.

Thanks for the input brother. I tend to overthink things and I am doing just that now.

 

[DrSilkWater]

I too am a recent patient at Defy with Dr Calkins. I agree with the other guys that you should do as he says for now as far as HCG dosage/frequency etc. He recommended a small bit of Anastrazole to me, I think .125, 3x/wk, but I asked if I could wait until my first follow up. He was fine with that and just said to call if I have any estradiol concerns and they would dispense it. Now my sensitive test came out around 14, so lower than yours. I also only carry some fat not a lot so that could be a reason for him starting you on it right away. As far as syringes, I use the same 25g 5/8 with luer lock and don't find it bad at all compared to most people on excel that call it a harpoon. However, I use them for shallow IM. I also use the 27g 1/2in insulin as well for different areas. I would think that a 25g needle is large for sub Q, but you can try smaller ones by ordering online. I feel like its a trade off as far as needle size and speed of flow into and out of the syringe. I couldn't see going smaller than 27 for t. cyp, but many others have no problem with 29's, just takes a bit more patience. I was given 31g for HCG and find them a bit delicate as I bent the first one going into the vial. Now I am more careful. With that said, they are virtually painless and I have yet to get any blood when removing the first 4 injections of HCG. I hope this info helps you in some way.

It does help. I carry almost all my fat around my waist and chest. From what I've researched, metabolically, this could be due to high E2 or just general predisposition so that is why I am running an AI from the start, but wanted differing view points on the matter. My E2 was 19.9 with a free test of 341 so it wasn't too low despite low test so I am prudent and looking out for higher E2 if my test happens to shoot up 2x-3x.

 

[DrSilkWater]

T/E2 ratio is the most likely reason as to why an AI was prescribed initially.

If at 342 your E2 is 19, then what's it likely to be at when your trough is 900? Keep in mind with the increased AUC(area under the curve) from TRT as opposed to being natural, you'll have a lower(MORE aromatization) T/E2 ratio, thus necessitating an AI being added.

So it's very likely that with a 900 trough your E2 is >50pg/ml.

This was my thoughts exactly and I brought this up to Dr. Calkins. My rationale is the same, low T, but almost mid level E2 so higher T----> WAY high E2, not sure if the relationship is linear in that sense (doubt considering all the cascading metabolic relationships), but rather be safe. I do plan to monitor my E2 symptoms closely and run a log of my TRT experience

 

[DrSilkWater]

I know optimal E2 levels are subjective and person dependent, but is there a general rule of thumb with regard to E2 levels in itself or ratio of free test/e2 I should be looking for?

 

[Stevenf]

I know optimal E2 levels are subjective and person dependent, but is there a general rule of thumb with regard to E2 levels in itself or ratio of free test/e2 I should be looking for?

Read all of Nelson's stickied threads on this subject. They have certainly helped me. My understanding is that he recommends a TOTAL T / E2 ratio of 14 - 20. I've followed this advice and allowed my E2 levels to creep up to between 50 - 60 at ~1000 TT, and feel much better than when I shot for 25-35 E2. My protocol is:

Testosterone Cypionate 90mg every 3.5 days
HCG 350iu on injection day
Anastrazole .125mg on injection day.

I'm considering the daily injection protocol that is recommended by many users on this site to see if I could eliminate the AI entirely, but I'm hesitant to fix what really isn't broke.

 

[James]

Stevenf - A lot of guys (myself included) are tempted to tweak things that don't need to be tweaked. At least you know what dose makes you feel good. If daily doesn't work for you, you know what does.