Persistent ED after steroid cycle despite normal hormones, normal Dopplers, hormone optimization – could I still be missing a hormonal mechanism?

[Tn198989]

Hi everyone,
I have been trying to solve this for almost 8 years and would really appreciate any ideas, especially from people with experience in endocrinology or post-cycle recovery.

Timeline

First cycle (2017)
Used multiple anabolic steroids (honestly a mess).
Also used 1500 IU hCG every 10 days during the cycle.
After stopping, I developed ED.
Several months later I did a PCT with Clomid + Aromasin, and it completely fixed me.
When I say completely, I mean:
normal libido
normal morning erections
normal erections lying flat
full glans engorgement
normal sex

I stayed like this for about 5 months (March-August 2018).

Second cycle (August-November 2018)

This time the cycle was much simpler:

Testosterone 600 mg/week
Low-dose Proviron
No hCG during the cycle
After my last testosterone injection, before starting PCT, I injected one full Ovitrelle (6500 IU hCG).

The following morning I had probably one of the strongest erections of my life:

full shaft
full glans
extremely high libido

Unfortunately it lasted only one day.

Since the following day I have had persistent ED that has continued until today.

Current symptoms

Erections are significantly worse when lying flat.
Sitting (especially leaning slightly forward) often produces a much stronger erection.

Morning erections are almost absent.

If I abstain from masturbation for 2-3 weeks I begin getting some morning semi-erections again.

I have a persistent problem with glans/spongiosum filling.

I also have long-standing reduced penile sensitivity from years of daily porn/masturbation (this existed before steroids, so I consider it a separate issue).

Testing

Two penile Dopplers.

Both essentially normal according to experienced andrologists.

No significant arterial insufficiency.
No obvious venous leak.

Hormones

Over the last 8 years I have probably had 50+ blood tests.

I have tried virtually every "obvious" hormonal explanation.

Examples:

low testosterone
high testosterone
supraphysiologic testosterone
low estradiol
high estradiol
mid-range estradiol
optimizing free testosterone
SHBG optimization
TRT
hCG
hMG
Clomid (multiple attempts)
Aromasin
Proviron
DHEA
Pregnenolone
DHT cream

Nothing has reproduced the recovery I experienced after the first cycle.

I am currently on TRT.

I know many people will immediately say "low testosterone" or "high E2," but unfortunately I have explored those possibilities extensively over many years.

ED medications

Daily Cialis helps.

Intracavernosal injections help much more.
Interestingly, injections make the corpora cavernosa extremely rigid, but I still do not achieve the same overall fullness that I had before the second cycle, particularly regarding the glans/spongiosum.

The response is much better than baseline, but still not the same as before 2018.

My question

At this point I am no longer asking whether my testosterone or estradiol are "optimal."

My question is:
Is there any hormonal or endocrine mechanism that could still be altered despite repeatedly normal blood work?

For example:
neurosteroids?
altered androgen signaling?
LH/hCG-related mechanisms?
changes in nitric oxide signaling triggered by endocrine changes?
something else that current blood tests simply don't capture?
Or do you think I should stop looking at hormones entirely and assume that whatever happened after the second cycle permanently changed something outside the endocrine system?
I realize this is an unusual case, but any thoughts would be greatly appreciated.

Thank you.

 

[Guided_by_Voices]

Nothing jumps put at me as an obvious omission in what you've tried, but here area few thoughts.

- Have you tried the Nitric Oxide pills such as those from N1o1? If they help, then that is clue that Nitric Oxide is involved
- I assume you've tried a brief short-acting high dose of T to see if that has benefit
- Do you do HIIT? For me I find noticeable benefit for EQ and if blood flow is an issue, HIIT can benefit
- Some people report benefit from injectable DHT which has been discussed elsewhere here. It seems to work when other forms of DHT fail
- Are you getting plenty of Salt? Low salt can be an issue, counter to popular belief.
- If PT-141 or MT-2 give benefit, then that is a clue that the melanoocortin system is in play. Periodic mid-day strong sun exposure can help too assuming you are not too far north or south.
- Do you eat a balanced diet with plenty of animal protein?
- Have you added a low dose (less that 100mg) of nandrolone (preferably short-acting) to your TRT as an experiment? Some people find it benefits EQ
- Do you take supplements that benefit vascular health, specifically at least half a gram of C, nattokinase, D, K2 and Magnesium?

Hopefully others will chime in.

 

[Tn198989]

Nothing jumps put at me as an obvious omission in what you've tried, but here area few thoughts.

- Have you tried the Nitric Oxide pills such as those from N1o1? If they help, then that is clue that Nitric Oxide is involved
- I assume you've tried a brief short-acting high dose of T to see if that has benefit
- Do you do HIIT? For me I find noticeable benefit for EQ and if blood flow is an issue, HIIT can benefit
- Some people report benefit from injectable DHT which has been discussed elsewhere here. It seems to work when other forms of DHT fail
- Are you getting plenty of Salt? Low salt can be an issue, counter to popular belief.
- If PT-141 or MT-2 give benefit, then that is a clue that the melanoocortin system is in play. Periodic mid-day strong sun exposure can help too assuming you are not too far north or south.
- Do you eat a balanced diet with plenty of animal protein?
- Have you added a low dose (less that 100mg) of nandrolone (preferably short-acting) to your TRT as an experiment? Some people find it benefits EQ
- Do you take supplements that benefit vascular health, specifically at least half a gram of C, nattokinase, D, K2 and Magnesium?

Hopefully others will chime in.

I haven't tried the nitric oxide supplement you suggested.

I have experimented extensively with hormones over the years. I've tried higher and lower TRT doses (100-250 mg/week), different injection frequencies (daily, EOD and twice weekly), hCG monotherapy before TRT, Proviron, DHT cream, testosterone cream applied to the scrotum, lowering estradiol into the mid-20s, and also letting it rise as high as ~80 pg/mL. None of these reproduced the completely normal erections I had before the second cycle.

Some protocols improved libido or made erections easier to initiate, but they always seem to plateau at around 70% unless I'm in a favorable position. Lying on my back is consistently the worst position. If I'm sitting and leaning slightly forward, I can get close to 100%.

A vacuum pump can produce a full erection, but it deflates almost immediately once I remove the pump, even with a constriction ring unless it's uncomfortably tight.

I haven't tried PT-141.

Regarding the Dopplers, I've had two, both performed by experienced andrologists, and neither showed arterial insufficiency or an obvious venous leak. My current doctor has also started me on intracavernosal injections.

They definitely improve rigidity and make erections much more sustainable during sex, but they still don't recreate the completely full erection (especially the glans/spongiosum) that I had before the second cycle.

Morning erections are now rare and, when they do occur, they're usually weak.

At this point, I'm struggling to reconcile normal Dopplers with a position-dependent erection and an incomplete response even to intracavernosal injections, which is why I'm wondering if there's another mechanism I'm missing.

 

[Guided_by_Voices]

I haven't tried the nitric oxide supplement you suggested.

I have experimented extensively with hormones over the years. I've tried higher and lower TRT doses (100-250 mg/week), different injection frequencies (daily, EOD and twice weekly), hCG monotherapy before TRT, Proviron, DHT cream, testosterone cream applied to the scrotum, lowering estradiol into the mid-20s, and also letting it rise as high as ~80 pg/mL. None of these reproduced the completely normal erections I had before the second cycle.

Some protocols improved libido or made erections easier to initiate, but they always seem to plateau at around 70% unless I'm in a favorable position. Lying on my back is consistently the worst position. If I'm sitting and leaning slightly forward, I can get close to 100%.

A vacuum pump can produce a full erection, but it deflates almost immediately once I remove the pump, even with a constriction ring unless it's uncomfortably tight.

I haven't tried PT-141.

Regarding the Dopplers, I've had two, both performed by experienced andrologists, and neither showed arterial insufficiency or an obvious venous leak. My current doctor has also started me on intracavernosal injections.

They definitely improve rigidity and make erections much more sustainable during sex, but they still don't recreate the completely full erection (especially the glans/spongiosum) that I had before the second cycle.

Morning erections are now rare and, when they do occur, they're usually weak.

At this point, I'm struggling to reconcile normal Dopplers with a position-dependent erection and an incomplete response even to intracavernosal injections, which is why I'm wondering if there's another mechanism I'm missing.

Prolactin is another variable but it doesn't sound like that is the issue in your case. I take a cap of Chasteberry every other day just to keep it on the lowish side which may be worth trying. I would strongly consider the Nitric Oxide tablets and/or beet root powder. Pt-141 is certainly worth a try because it works via completely different pathways, but start with what most would consider a low dose of no more than 100-300 micrograms twice per week. Everything you can do to improve vascular health is going to be helpful so certainly do the obvious supps I mentioned and be sure to do high intensity cardio. I seem to vaguely remember a post on here about venous leakage that doesn't show up on doppler scans, but I don't remember the details, however maybe you can find it. As far as other hormones go, make sure your fasting insulin is below 6 or so, since chronically elevated insulin is cardiotoxic. You might also try a fast of at least 24 hours and see if that has any benefit. If it did, that could suggest some sort of food sensitivity is part of the issue. At this point, logic will only get you so far and just trying a lot of different things is likely your best course of action, particularly focusing on vascular health and neurotransmitters. Review @Gman 's posts for his commentary on the benefits of nandrolone in his case for erections.