probably being prescribed sustanon-250 every 3 weeks; options?

[Aki]

Hi all,

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I'm cross-posting this (with some alteration) from the All Thing Male forums, where I used to be somewhat more active in the past. I hope that's all right. In the extremely unlikely chance someone has the time or interest to read my history, it's all there on ATM forums. Please excuse the use of colors, text effects and footnotes; just trying make the post read easier.
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I'm 39 and I've had secondary hypogonadism for a long time, although MRI indicates pituitary is normal. (The last MRI was done just a couple of weeks ago.)

I used clomid for a long time and while it works on paper, raising my total T to mid-range normal levels, but subjectively (like a lot of other guys) I don't feel that much benefit from it[1], due to the estrogenic side effects or whatever.

Anyway, after spending years trying to make clomid work - as evidenced by my old posts on the ATM forums - I've decided to bite the bullet and give conventional HRT another[2] chance.

I've been off clomid for several months now and my last total T measured around 180 ng/dL.

My goals/hopes are to feel reasonably good and healthy, have reasonable amounts of energy and motivation for work and play, and not perceive life as being burdensome and tiring most of the time. (Also, fertility is not a concern for the time being.)

I've spoken to multiple endocrinologists at my present location (I'm currently in a small middle eastern country) and I've found without exception they all want to prescribe the "Sustanon-250 mg every three weeks protocol" with possible increase of frequency based on the response.
I am already aware of the deficiencies of this protocol. And "find another doctor" isn't a feasible suggestion.

The endo I've decided to settle on (and have met once with) seems good in the sense he took me seriously when I demonstrated I wasn't totally ignorant of the science behind my issues. I will meet him on Sunday the second time with the results of MRI. But I'm pretty sure (based on our discussion) that he's going to go for the sustanon-250 every three weeks protocol to start with.

Anyway, my questions:

- What useful alternatives/modification to this protocol is a reasonably open-minded endo likely to consider (apart from an eventual increase in frequency of injections)? I do not know whether any other options are actually available in my present country at all, besides HCG (which they normally use if fertility is the issue), but I don't think he was interested in concurrently prescribing it.

- Is sustanon-250 suitable to be divided into small doses and self-administered subcutaneously? (Assuming that's the form of injectable testosterone they have and that I could obtain the vial rather than be administered the shot at his clinic.)

- Are there people who do all right with this kind of protocol, maybe if it's a somewhat higher frequency? I'm trying to conceive of an explanation why this protocol has survived so long. (I believe its decades old.)

- What reason could there be for someone not feeling any better from these shots altogether, even for a few days after shot day? [2]

Thank you!

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[1] The only time I felt remarkably good with clomid was when I added a bit of danazol on top... felt great for about a month and a half but then experienced a sudden and total crash. (I think I now know why that may happen, but I'll skip presenting my theory here.) I did talk about it here

[2] The very first endo who took my low-T complaint seriously several years ago put me on the one Sustanon-250 shot per 3 week protocol. (I got a total of three shots.) Thing is, I did not experience any subjective benefit from it at all, not even for a few days after taking the shot. This was in India, and the only explanation I can think of is the quality of the product was really subpar. But it couldn't have been altogether fake, because at the end of this protocol my total T had fallen to even less than 80 ng/dL, so some kind of suppression had happened.

 

[BenM]

I don't know about injecting it subQ but there's no reason it can't be split up into smaller doses. I tried 125mg every 7 days when enanthate first became unavailable here, but found (based on both bloodwork and the feels) that I needed higher than that to keep my levels where they were. But I found another source for enanthate and went back to that so didn't need to experiment further.

A decent endo should be willing to let you split doses, but not sure what the rules are where you are in terms of quantity... here in Australia you'd be struggling to convince anyone to prescribe more than 125mg/5days.

 

[Aki]

Thanks for the reply. The endo did indicate that based on the response he might increase the shot frequency. I don't know how far he'll be willing to go, but then I also don't know what would feel ideal for me.

In a sense this discussion is a bit hypothetical because the first time I was put on this very same protocol several years ago by a different doctor, in India (this is before I even knew about the difference between primary and secondary hypo), I felt absolutely no benefit at all, not even for a few days post-shot. Even my current endo was surprised when I mentioned to him, and the only non-medical explanation I could conceive of was that the sustain I had bought was subpar product.. however (after 3 shots spaced three weeks apart) it did succeed in lowering my T-levels even further (below 80 ng/dL), and I recall the six or so months after that period were among the worst I can remember in terms of lack of energy and drive.

But hopefully - if this non-responsiveness happens again - this endo is going to take the effort to look into why that might be.. and if anyone has a feasible explanation for it on here, I'd love to hear.

 

[Cataceous]

You'd mentioned the possibility of having somewhat low SHBG—18 nmol/L—at one time. Do any of the endos understand the interplay of SHBG and ideal dosing frequency? In your conditions I'd want to inject quite frequently, and I wouldn't hesitate to go subQ. Being this mix of esters, Sustanon is in some ways taking the worst of each: you don't quite get the hormonal stability of a single long-lived ester, nor do you get the nimbleness in modifying protocols that you have with short-lived esters; five half lives of T decanoate is a long time to wait for stabilization.

 

[Aki]

Thanks for the replies, gents.

So I had my appointment yesterday and here's the situation so far:

• the doc is starting me off straightaway on 250 mg every two weeks (instead of every three weeks). He wants me to do a total of three shots, and get labs done the day before the third shot, so if I take my first shot today/tomorrow I should be seeing him again in around 4 weeks time to review.
• he hinted that he might go higher if needed (or dial it down).
• He wrote me a prescription for three ampules all at once. So I should be able to divide it up and take lower doses at higher frequency, by self-administration (but I won't do that just yet)[*].
• for labs, he has only requested I get total testosterone done on the day before shot #3, but I plan to get SHBG and estradiol done too. (LH and FSH seems pointless, but probably I'll do all of them because I can get them for free.)

The good thing about this doctor is that he listens to what you have to say, doesn't talk down to you, and is humble enough to admit non-awareness or lack of experience of specific things. His protocols do seem to be rather conventional though, and it appears sustanon-250 is his "go-to treatment". I still do not know what other options are available here; but if things do not look good after the first set of shots, I'll ask him to consider other options if available (gel or subcutaneously injectable testosterone etc.) And finally - if nothing other than sustanon-250 is available - it seems quite feasible to be able to increase the frequency of the shots at lower dosage.

@Cataceous I'm sort of aware of the conventional wisdom about SHBG levels and shot dose/frequency, although it didn't occur to me to talk about it when I was having my consultation (and I only read your reply later). From various labs I've done over the years, my SHBG tends to be around 14-16 nmol/L if I've been off the clomid for sufficiently long, but if I've been on a low daily dose of clomid for long enough it creeps up to around 30[**].

Since I've been off the clomid for 4-5 months now, I expect (from past experience) by now it'll have settled down at the ≈15 nmol/L. (My last set of labs, done over 2 1/2 months ago, already had my SHBG at 24 nmol/L down from 30 nmol/L.)

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So if my understanding/recollection is correct, with very low SHBG and a low-frequency/high dose shot, I should be worried about steep T-level fluctuations between successive shots, and also about a possibly large rise in estradiol? [***]

If sticking to HRT for sufficiently long raises my SHBG somewhat, that should be good, I think? My mental model of SHBG is that it's like a buffer in the sense a higher value will smooth out the T-level fluctuations.

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[*] My plan is to go along with his treatment for the first three shots and if I experience issues consistent with low SHBG, rise in estradiol, etc. or a subjective lack of benefit, I will bring it up with him. @user_joe, hopefully it won't come to prison.

[**] SHBG seems to be at the heart of it all and notoriously difficult to control.

[***] I recollect when the first I did the sustanon-250 (albeit once every three weeks) at the end of it my estradiol had risen considerably. Unfortunately I had not done SHBG though, either prior or after (didn't even know what it was back then) but my assumption is it might've been low.

 

[Systemlord]

I see a lot of low SHBG men feeling virtually nothing on protocol that focus on infrequent large injections, you'll often hear they feel absolutely nothing from TRT. I respond very poorly to once weekly and twice weekly injections regardless of the dosages or levels.

I didn't start to see massives changes until I started injecting 20-25mg every 2 days, my SHBG hovers around high teens to low 20's. When I inject 20mg or more is when my muscles start to get firm quickly, within as little as 2 weeks.

You can inject me with twice as much Test twice weekly with much higher levels and I feel nothing. High dose, low injection frequency is better for a high SHBG men, increased injection frequency and smaller doses for lower SHBG men.

 

[Aki]

I see a lot of low SHBG men feeling virtually nothing on protocol that focus on infrequent large injections, you'll often hear they feel absolutely nothing from TRT. I respond very poorly to once weekly and twice weekly injections regardless of the dosages or levels.

I didn't start to see massives changes until I started injecting 20-25mg every 2 days, my SHBG hovers around high teens to low 20's. When I inject 20mg or more is when my muscles start to get firm quickly, within as little as 2 weeks.

You can inject me with twice as much Test twice weekly with much higher levels and I feel nothing. High dose, low injection frequency is better for a high SHBG men, increased injection frequency and smaller doses for lower SHBG men.

Thank you, this "felt absolutely nothing" is consistent with my own first experience with sustanon-250 several years: I felt absolutely nothing. And even though I (later) came to know that low-SHBG men do better with higher frequency shots at lower dose (like you and Cataceous reminded me) I did not associate this fact with my own case because back then I did not have my SHBG checked (didn't even know what SHBG was).

First time I had my SHBG checked was after I spoke to Dr. Crisler, and it was quite low. And I have no reason to believe it hadn't always been low, including when I was first administered the sustanon-250 protocol.

 

[Aki]

Revised plan:

I will get the labs done (testosterone, SHBG, estradiol at least) first before getting the first shot. If my guess is correct, by now my SHBG will have settled down at the mid-teens.

I think if this time round I have the same "felt absolutely nothing" experience, I'll suggest to the doctor that it's probably because of my low SHBG and that he needs to look into a different protocol with high frequency low dose injections, or daily gels or what not.

 

[Systemlord]

Low thyroid hormones would be another reason for TRT not working, Free T3 increases metabolism and body temperature, so if this is low TRT will not work.

Free T3 needs to be midrange or better, also Reverse T3 needs to be under 15 ng/dL as it can block Free T3 at the receptors negating some of that Free T3.

 

[Aki]

Low thyroid hormones would be another reason for TRT not working, Free T3 increases metabolism and body temperature, so if this is low TRT will not work.

Free T3 needs to be midrange or better, also Reverse T3 needs to be under 15 ng/dL as it can block Free T3 at the receptors negating some of that Free T3.

My FT4 tends be borderline low. The last one was 12.4 (reference range: 11.6-21.9), but I have not tested for FT3 or reverse T3.

Also, at one point long time ago I was checking my body temperature immediately on waking up, Wilson's test or something (controversial, if I recall correctly). From the data I've kept, the average over several days was less than 96.5 F.

What thyroid tests do you recommend?

 

[DannyManUK]

No Offence, but that is a disgusting protocol, any real T.R.T doctor knows that, if they have this knowledge, it's offence to any man to have injection every 3 weeks on any Testosterone injections, i am on SUST too, and i inject it twice a week every 5 days, so that be 2 injections and i will never look back it's Best for Stability & Slow rising (E2).

 

[Aki]

No Offence, but that is a disgusting protocol, any real T.R.T doctor knows that, if they have this knowledge, it's offence to any man to have injection every 3 weeks on any Testosterone injections, i am on SUST too, and i inject it twice a week every 5 days, so that be 2 injections and i will never look back it's Best for Stability & Slow rising (E2).

As I mentioned above, he decided to start me off on one shot every two weeks. And he said he was open to increasing it, by reviewing labs taken before the third shot. And I am getting my hands on the ampules themselves, so if needed I'll just learn how to self-administer if needed.

I don't know what the reason is, but it seems many endos use this (250mg/three weeks, with possible dosage adjustment after three shots) as a standard protocol. Maybe it's what their textbooks teach them, and maybe they don't want to rock the boat or get into trouble or whatever. My doctor doesn't claim to be a TRT expert, and I'm pretty sure there aren't any exclusively TRT experts where I live (it's a very small country). I'm just happy he doesn't roll his eyes when I use my Internet-gained knowledge and does actually listen to what I have to say.

So I am going along with his protocol for now (one shot every two weeks) because doing otherwise would straightaway send the signal that I have a bad opinion of him. I had my labs done today, and am planning to take my first shot today or tomorrow. So if right before the third shot when I do labs again if things turn out how I (pessimistically) expect them to (low subjective benefit, low T and high estradiol) I will suggest it might be because of low SHBG and maybe he should try high-frequency+low-dose. And that my thyroid numbers aren't too peaky either.

 

[DannyManUK]

Okay all the best mate, like i said above @Aki it is No Offence, but you can inject the entire 1ml ampoule, 1ml CC and see how your estrogen is in 3 weeks, i don't know bad it might be but it might be a very High estrogen unless you got Anastrozole (Arimidex) on hand in your cupboards. All best Bro.

 

[Aki]

Okay all the best mate, like i said above @Aki it is No Offence, but you can inject the entire 1ml ampoule, 1ml CC and see how your estrogen is in 3 weeks, i don't know bad it might be but it might be a very High estrogen unless you got Anastrozole (Arimidex) on hand in your cupboards. All best Bro.

@DannyManWalesUK thanks, mate.
Actually, I had my injection today morning and I have been progressively feeling worse.
Even the last time I had used sustanon-250 (many years ago) I do not remember feeling this bad.
I don't think I will ever inject the whole sustanon-250 ever again.

 

[DannyManUK]

My Erections & MENTAL mood is better improved @Aki on 75MG Sustanon which is 150mg total per week that much i can Vouch for., 2 shots broken into each 75mg. I was on 100mg twice for 200mg but Libido went down with mood, Sorry to hear about your experience Man, did you feel really Edgey? on the big shot? just wondering because when i once injected 100mg Enanthate i felt really edgey and Too Hyper Anxious. too Much Sustanon just makes my Sexual Desire plummet, i finally figured out a sustanon dose that might work for everyone. It's every 5 days to inject 75mg man if it don't work for then 100mg every 5 days might work better for you bro.

 

[DannyManUK]

Never let an DOC inject you for future shots Brother, just take your TEST gear meds home and do it from comfort of your home all the time twice weekly, run blood work frequent for TT, FT,Shbg,estrogen & Full blood count. I hope all this info/knowledge helps out bro.