Optimal TRT Strategy for low SHBG guys; SSRI effects; HCG vs. T injections effect on polycythemia

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Simon7

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Hi everyone,

I've been reading here for a little over a year and I've found this site most educational. Thank you to Nelson for all the informative material on this website (I also enjoyed your book which I bought on Amazon) and for everyone else here who contributes information and shares their experience.

Background on me and my TRT journey:

I'm 55 yo male, all my life I've enjoyed a high sex drive and high sexual function. My wife and I had problems conceiving children some 20+ years ago and my sperm was tested and turned out to have low quantity and very low motility so we were given the express path to IVF/ICSI. My Testosterone was tested then too and was on the low side of normal. My sexual dysfunction problems began three years ago after several months of taking an SSRI to alleviate stress of dealing with a life crisis. The SSRI crashed my libido and caused ED, but I wasn't too worried as I knew this to be temporary as I experienced similar symptoms before when I took an SSRI for several months and also when I took a Propecia for a month - but I rebounded very well both these times after I stopped taking the medication. However this time the symptoms of low libido and ED persisted after I got off the SSRI. I finally got tested and had Total Testosterone that was below the low normal range, as well as low LH & FSH, thus deducing secondary hypogonadism.

I tried both Nebido (Aveed) shots as well transdermal Testosterone but they were not able to provide me a stable level of Testosterone in the normal range. About a year ago I had a most helpful consultation with Dr. Crisler who pointed out that my low SHBG (around 17, which is the low side of normal) is causing the Testosterone to be flushed quickly out of my system. Dr. Crisler recommended me to go on bi weekly SUBQ injections of Testosterone, explaining that the slower release from the subq tissue would enable me to sustain a normal level of Testosterone. And indeed Dr. Crisler was right and when I switched to bi weekly Testosterone Enathate shots I was finally able to sustain a normal and stable level of Testosterone. Dr. Crisler also recommended taking DHEA and that indeed had a noticeable very positive effect on my libido, along with the HCG. For some reason I am still dependant on PDE5 inhibitors to overcome ED issues despite having for a year now normal Total Testosterone , managed E2 and high libido.

A couple of months ago I tried Clomid for two weeks (50mg three times a week) after a week of discontinuing the injections of T&HCG. However I had no response to the Clomid (LH remained low and my T and libido crashed) so I got off the Clomid and resumed the T&HCG therapy.

My current protocol:

45mg SUBQ Testostone Enathate twice a week
500IU SUBQ HCG three times a week
0.25mg Anastrazole twice a week
50mg DHEA twice a day

With the above protocol I am able to sustain a level of Total Testosterone of 600-650 ng/dL. When I increased the above dosage I was able to increase my Total Testosterone levels. My E2 levels are around 50-55 pg/ml, and I prefer to keep them a little higher than the normal range since the sensitive LC/MS test is not available here and the CLlA test used here to measure E2 may erroneously elevate the results.

My Questions:

1. What is the optimal level of Total Testosterone that low SHBG guys on TRT should be aiming for? It seems that most guys here on TRT aim for Total Testosterone in the upper fourth quadrant of the normal range. But If guys with low SHBG have a higher Free T, then it seems logical that we should aim for a lower range of Total Testosterone or perhaps aim for a certain range of Free Testosterone? Does anyone have any data on that? (I should note the labs of my health provider in my country only test for Free T when the total T is on the low end. Hence I need to rely on online calculators that compute Free T based on Total T, SHBG and Albumin).

2. Since I switched a year ago from transdermal T to injections I've seen an increase in my Hematocrit and Hemoglobin up to the high range of normal (Hematocrit as high as 52.5, Hemoglobin as high as 17.7). Thus I began donating blood every three months and I am reconsidering what level of Total Testosterone to aim for as mentioned in (1) above. I also wonder if there is any data on whether Exogenous Testosterone or HCG cause more polycythemia? As I am using a mix of Testosterone Enathate and HCG to generate my level of Testosterone, I can increase one at the expense of the other if one is more prone to inducing polycythemia.

3. Is there any data on how the use of SSRI may cause permanent alterations of Serotonin/Dopamine levels in the brain even after their use is discontinued? If indeed my Serotonin levels were altered and pose a problem for ED for example, is there any known and safe method to affect them with minimal side effects?

4. I am trying now daily Tadalafil at dosage of ~7mg/day and I'm experiencing some back and muscle pain. When I first began using Sildenafil l I experienced headaches but they eventually disappeared and all I feel now when I use Sildenafil is flushing in my face. Do the symptoms of back and muscle pain of Tadalafil typically disappear after persistent period of use of Tadalfil too?
 
Defy Medical TRT clinic doctor
I believe your on the right track there in para 1, we probably need to toss out the Total Test and work towards the Free T and keep it at the upper lab limits, as you know low SHBG = very high Free T and perhaps keeping that to the lab range would work better for us low SHBG guys. I'm working towards that myself right as now as I convert to E at a very high rate.
 
You ask some really great questions. I refused to take SSRIs when I was severely depressed because I researched them extensively, and discovered that there was great concern for long-term sexual dysfunction. I realized there was no point in being happy if my **** didn't work (not like they'd magically make me happy anyway), and that I'd probably be even more depressed if my sex drive worsened. I am far from an expert on the subject, but I have read that SSRIs can dysregulate dopaminergic neurotransmission, and that cabergoline has occasionally been concomitantly prescribed to combat these effects. If your worsened sex drive has anything to do with dopamine, there is a very good chance, hypothetically, that a low dose of cabergoline might result in improvement. Of course, do so at your own discretion and under the supervision of your doctor. If your doc refuses, you can always purchase it on alldaychemist.

Assuming you are using the sensitive E2 test (I'd hope), your e2 levels are probably too high for someone with low SHBG. Remember that like testosterone, estradiol is a sex hormone, and therefore bound by SHBG. The issue with estradiol and low SHBG (as Dr Crisler has explained) is that because androgens (especially DHT, the most important hormone for male sex drive) bind with higher affinity to SHBG than estrogens, they are quickly flushed from the system while the latter group tends to accumulate with disproportionately high levels of free hormone. Assuming you are using the sensitive E2 test, you'd probably be better off with total levels between 20-35 pg/mL.
 
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Thanks Vince and AbsolueZ3RO. I don't have the sensitive Estradiol essay available where I live. I considered taking Cabergoline a while back but I was concerned about the side effects and risk of developing DAWS if I needed to stop taking it (DAWS - Dopamine Agonist Withdrawal Syndrome).

With my protocol I no longer have any problem with my sex drive and the recent introduction of daily Tadalfil has worked great to overcome the ED issues and to enable spontaneous sex. The back pain and muscle aches due to Tadalafil disappeared after a week or so of using it daily.
 
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