Seeking advice for next Doctor visit

[HarryCat]

I'm seeing my TRT doc in a couple of weeks and need advice on what to do.


Background:
52 yrs old
Height 6'4"
Weight: 190lb.


Comorbidities:
Hypo-thyroid
Complex sleep apnea
Restless legs
These conditions are more or less under control at this point.


I've been on one form or another of TRT for almost 2 years. Original test results
that got me started in TRT are:
Total T 260 range 241-827
Free T 2.2 range 3.8-34.2


Latest test results are:
Total T 815 range 358-1197
Free T 27.8 range 7.2-24.0
Estradiol, Sensitive 29 range 3-70


For past 6 months have been using 20% compounded test. cream.


I have not noticed much benefit on TRT, other than maybe a little improvement in stamina and strength.
Libido and ED are a little worse than when I started. I was really angry about this for a long time but am slowly coming to acceptance that
there might not be much I can do about this.


I have done a trial of anastrozole for a few weeks and did not notice any difference.


My doc has offered to let me try injections if I want. In the past, before I edjucated myself, I had tried IM injections
200mg every 2 weeks, and also didn't notice any improvement.


I guess what I'm wondering is, if it is worth a try to do injections again the right way, 1 or 2 injections per week.


Any comments appreciated.

 

[Nelson Vergel]

Your T value is good but obviously you are not feeling as sexual as you wish. Libido and ED are not only linked to testosterone and thyroid but also to dopamine and endorphins.

Having said that, you may want to stay on the cream and bring in HCG injections of 500 UI twice a week (your TT will be higher, so you may want to lower the cream dose by probably 20 percent). If this experiment does not show benefits in 3 weeks, then I would switch from the cream to T injections (100-200 mg per week in one injection or two 50-100 mg injections per week) while keeping the HCG.

Also, when I am on daily 5-10 mg Cialis (plus TRT + HCG) my sex drive and erectile quality dramatically improve. That could be experiment number 3.

 

[HarryCat]

Do you think there is any value in getting my SHBG and DHT levels tested at this point? I've never had them tested and I read a lot about SHBG, not so much about DHT, just wondering if they could provide any insight to my situation.

 

[Gene Devine]

DHT is sometimes important to check. Some men don't convert Testosterone to DHT well.

DHT is all things male and a big driver of libido.

Ask your Doc about applying some of your Testosterone "cream" to your scrotum as this can increase libido via 5ar conversion of Testosterone to DHT.

Also, as Nelson mentioned, you should be using HCG as well with your protocol.

Many men, myself included, get a better sense of well being and an increase in libido.

 

[HarryCat]

Saw my Dr. a couple of weeks ago and decided to try injections. Did my first injection of 100mg IM then after experiencing a lot of post injection pain I switched to SubQ. I plan on doing 50mg twice a week, I've done 3 injections this way so far. I don't have any negative reaction to injecting this way.
Prior to the switch to injections I had cut my transdermal T does back to 50mg/day from 200mg/day for a couple of weeks so my T levels were down from the peak results I mentioned in my first post.
About a week after starting injections I had a huge boost in libido and my ED disappeared, it was great, but this only lasted about 2.5 days. Now I'm back to baseline, not feeling any benefit at all. I had the same response when I first started TRT with Angrogel about 1.5 years ago. I'm wondering if anything can be inferred from this response in terms of guiding my TRT protocol, or is this just something to file away as a interesting curiosity.

 

[Vettester Chris]

Harry, regarding SHBG, it can be calculated easily enough with your Total & Free Test labs, plus your albumin value. Going on your last labs, presuming your Albumin is in the 4.3 to 4.4g/dl area, your SHBG is sitting right at 12nmol/L. Again, that will deviate a little bit up/down with different Albumin levels, but it's probably not too significantly higher or lower than what's noted above. My SHBG is also on the low end, suspected to be tied in with my liver and genetic issues effecting ferritin and iron. With that said, I tend to keep my total serum level in the 600ng/dl to 700ng/dl range, as low SHBG will obviously promote higher Free & Bio Testosterone levels; yours is currently sitting at 3.41%.

IMO, the injection route is the way to go. Not sure what happened with the going back to "baseline" experience. The only time that has really happened with me is a change with E2, which in the past was just getting the AI protocol figured out. The other time was finding out my compound testosterone went bunk. The easiest way to put a finger on it is just getting more labs. Your conversion to E2 might be more significant with the injections, whereas you possibly had a higher rate of downstream conversion to DHT with the Gels. That's a common situation between the different application methods, which again requires attention with incorporating and/or adjusting AI protocols.

Hope some of this helped ...

 

[HarryCat]

Here are my labs after 4 weeks injecting 50mg test. cyp. twice a week (100mg/wk total dose):
Total T 685, range 348 -1197
Free T 16.2, range 7.2 - 24.0

I have improvement in libido and ED on some days, but then it disappears only yo randomly return, it is very inconsistent. Other than that I guess I am feeling OK enough, not great, but better than where I was 6 months ago.

Should I give it a few more weeks at this dose or make an adjustment now?

 

[Nelson Vergel]

Erectile function and sex drive are highly variable even in the presence of "good" lab values. Fatigue, stress, low dopamine/serotonin, etc can get in the way of the best hormone replacement program.

Your numbers are not bad at all. You may want to just increase the T dose to 75 mg twice a week or bring in HCG at 500 IU twice per week if you wanted to try a bit of a boost.

 

[HarryCat]

Thanks Nelson, kind of what I thought.

 

[HarryCat]

I finally have a new TRT doctor and some new labs. These are the results I received from Labcorp. I will be seeing the Doc in a few weeks and want to be prepared for the visit. Here goes:

Lipid Panel

Test Low Normal High Reference Range Units Ldl Cholesterol Calc     104 0-99 mg/dL Vldl Cholesterol Cal   18   5-40 mg/dL Hdl Cholesterol   52   >39 mg/dL Triglycerides   91   0-149 mg/dL Cholesterol, Total   174   100-199 mg/dL

Cortisol

Test Low Normal High Reference Range Units Cortisol   17.9   2.3-19.4 ug/dL

Triiodothyronine,Free,Serum

Test Low Normal High Reference Range Units Triiodothyronine,Free,Serum   3.4   2.0-4.4 pg/mL

Thyroxine (T4) Free, Direct, S

Test Low Normal High Reference Range Units T4,Free(Direct)   1.13   0.82-1.77 ng/dL

Cbc With Differential/Platelet

Test Low Normal High Reference Range Units Wbc   6.1   3.4-10.8 x10E3/uL Rbc   5.61   4.14-5.80 x10E6/uL Hemoglobin   17.7   12.6-17.7 g/dL Hematocrit     52.4 37.5-51.0 % Mcv   93   79-97 fL Mch   31.6   26.6-33.0 pg Mchc   33.8   31.5-35.7 g/dL Rdw   13.3   12.3-15.4 % Platelets   191   150-379 x10E3/uL Neutrophils   63     % Lymphs   26     % Monocytes   8     % Eos   2     % Basos   1     % Neutrophils (Absolute)   3.9   1.4-7.0 x10E3/uL Lymphs (Absolute)   1.6   0.7-3.1 x10E3/uL Monocytes(Absolute)   0.5   0.1-0.9 x10E3/uL Eos (Absolute)   0.1   0.0-0.4 x10E3/uL Immature Granulocytes   0     % Immature Grans (Abs)   0.0   0.0-0.1 x10E3/uL Baso (Absolute)   0.0   0.0-0.2 x10E3/uL

Testosterone, Total, Lc/Ms

Test Low Normal High Reference Range Units Testosterone, Total, Lc/Ms   889.7   348.0-1197.0 ng/dL Comment:   Adult male reference interval is based on a population of lean males up to 40 years old.

Sex Horm Binding Glob, Serum

Test Low Normal High Reference Range Units Sex Horm Binding Glob, Serum   27.1   19.3-76.4 nmol/L

Igf-1

Test Low Normal High Reference Range Units Insulin-Like Growth Factor I     232 61-200 ng/mL

Comp. Metabolic Panel (14)

Test Low Normal High Reference Range Units Glucose, Serum     100 65-99 mg/dL Bun   15   6-24 mg/dL Creatinine, Serum     1.36 0.76-1.27 mg/dL Egfr If Nonafricn Am 59     >59 mL/min/1.73 Egfr If Africn Am   69   >59 mL/min/1.73 Bun/Creatinine Ratio   11   9-20 1 Sodium, Serum   142   134-144 mmol/L Potassium, Serum   4.4   3.5-5.2 mmol/L Chloride, Serum   100   97-108 mmol/L Carbon Dioxide, Total   25   18-29 mmol/L Calcium, Serum   9.7   8.7-10.2 mg/dL Protein, Total, Serum   7.1   6.0-8.5 g/dL Albumin, Serum   4.8   3.5-5.5 g/dL Globulin, Total   2.3   1.5-4.5 g/dL A/G Ratio   2.1   1.1-2.5 1 Bilirubin, Total     1.3 0.0-1.2 mg/dL Alkaline Phosphatase, S   55   39-117 IU/L Ast (Sgot)   38   0-40 IU/L Alt (Sgpt)   37   0-44 IU/L

Estradiol, Sensitive

Test Low Normal High Reference Range Units Estradiol, Sensitive   21   3-70 pg/mL

Vitamin D, 25-Hydroxy

Test Low Normal High Reference Range Units Vitamin D, 25-Hydroxy   65.4   30.0-100.0 ng/mL

Tsh

Test Low Normal High Reference Range Units Tsh   3.770   0.450-4.500 uIU/mL

Dhea-Sulfate

Test Low Normal High Reference Range Units Dhea-Sulfate 35.1     71.6-375.4 ug/dL

Here are my comments, I'd appreciate any and all feedback.

Thyroid labs aren't optimal but I continue to work on that. My biggest problem is that whenever I try to increase my T4 dose or add any T3 my insomnia gets much worse.

Hematocrit is high. This is troubling. If it were up to me I would just decrease my T. dose, as opposed to donating blood, since I'm not feeling any real benefit from my current T level.

Total T is at a good level, but hematocrit is high.

SHBG seems reasonable to me.

IGF-1 is high. I have no idea what this means.

Glucose is high, but I'm making progress from where I was a year ago.

Creatinine is high. I have always measured high with this, although this reading is a little higher than I was last year.

E2 looks perfect to me.

DHEA-S is low. This is the real outlier. Any advice/experience with supplementing DHEA? I'm wondering if this is contributing to my libido problem.

 

[Gene Devine]

I agree with most of your comments so no need to get into details as you are spot on.

IGF-1 http://en.wikipedia.org/wiki/Insulin-like_growth_factor_1 is a protein in the blood produced by the liver and is a marker for human growth hormone. Elevated levels, for the most part, is a good sign and one would think that you may be taking Growth Hormone.

DHEA-S is low and is best at the upper end of the reference range. I believe all men on TRT should be supplementing with 50 mg daily of DHEA and Pregnenelone. Read: https://www.excelmale.com/forum/sho...tropin-Pregnenelone-and-DHEA-–-By-Gene-Devine

Give blood to get Hematocrit down, it's good for you and the community.

Overall I think you look great!

 

[HarryCat]

Thanks Gene.

I'll add in some DHEA and see how that goes. I know that the my Doctor is also going to want to add in HCG so I'm looking forward to starting that as well.

 

[Vettester Chris]

Harry, you mentioned that you start seeing some problems with adding T4. Just curious if you had a recent RT3 lab?

 

[HarryCat]

Chris, unfortunately no, I haven't had that one recently. I'll discuss this with the new Doc when I see him.

 

[Vettester Chris]

It could be a factor, being that T4 "should" just be the storage hormone that converts to the more active form of T3. By what you described it sounds like there might be a little more RT3 conversion than desired. You have me curious, so let me know how it turns out. Thanks