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Testosterone Replacement, Low T, HCG, & Beyond
Testosterone Side Effect Management
Should We Be Managing Estradiol and Hematocrit in Men on Testosterone Replacement?
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<blockquote data-quote="J. Keith Nichols MD" data-source="post: 71150" data-attributes="member: 15691"><p>Dr Saya, </p><p>Thanks so much for the welcome. It's my pleasure to be able to interact with you gentlemen. Your question opens up a excellent opportunity for me to hopefully give you a good answer but also to discuss related issues. </p><p>Firstly, I would have to ask about your patient a little more with regard to what symptoms he was experiencing when he is "not doing very well subjectively". The reason I would ask is to gain a little further insight into the possibility that some of his symptoms may not be completely T related. I bring this up because in addition to optimizing testosterone I am optimizing DHEA, Vit D3, and especially free T3. We will just assume he is already eating appropriately, exercising, utilizing appropriate supplements etc... I can't stress the importance of optimizing free T3. I do everything I can to decrease their fatigue, improve energy and sexual function, and most importantly for their long term health decrease their visceral body fat. The best way I have found to decrease visceral body fat is T, not blocking E2, DHEA, and optimizing free T3 ( I usually aim for a range of 4-7 or until symptoms improve) and of course exercise. I follow their lipid profiles (small particles as well) and their insulin resistance. Nothing is better than seeing them removed from their statins, anti hypertensives, and metformin etc... I feel that the success I have with TRT is not just the T....but the thyroid as well. So I don't know if all of these other issues were addressed with your new patient by his previous provider</p><p> Secondly, something that doesn't get mentioned very much but is extremely important is the timing of lab testing. I measure all my men patients 5 hours after application and dosages are adjusted accordingly. Measuring labs and making adjustments obtained with varying times after application is a recipe for disaster . This is also a consideration with new patients that are already on HRT by another provider. </p><p> Lastly, your patient and his labs. Let's assume (which is bad I know) that his DHEA and free T3 are exactly where we would want them (doubtful his thyroid is optimal though). I would have increased his T dosage to 150 mg bid ( 200mg/gm concentration in a HRT or lidoderm base) so 3/4 gm applied to clean, dry, shaven area of testicles bid. I would then remeasure and follow up in 4 weeks 5 hours after application. I think what may have been concerning to you is that with a T level of 1500 and a free T level of 41 you assume that with those levels he should be doing great and therefore felt the need to make a change. I run into those numbers weekly and the patient does better by just simply increasing the dosage and optimizing the other hormones. Most MDs get scared by an number but in my practice and my personal experience most just start to begin to feel better at 1500. You just can't measure a persons receptor sensitivity so T in the 1800-2000 range don't bother me nor does a free T at 50. The patients feel great without any issues of E2 excess. I did not feel good when I had the numbers of your patient and I personally am optimal with a T level of almost 2000 and free T of 50. I am treating symptoms in my patients and hit home the concept of optimal. I ask them all the time "Do you want to be normal or optimal?". I do not regularly check DHT levels and I have not had to add Hcg to my patients treatment, but if they needed it I would certainly do it. I just haven't had that patient yet. When you aggressively optimize freeT and freeT3 and don't block E2 they do very well</p></blockquote><p></p>
[QUOTE="J. Keith Nichols MD, post: 71150, member: 15691"] Dr Saya, Thanks so much for the welcome. It's my pleasure to be able to interact with you gentlemen. Your question opens up a excellent opportunity for me to hopefully give you a good answer but also to discuss related issues. Firstly, I would have to ask about your patient a little more with regard to what symptoms he was experiencing when he is "not doing very well subjectively". The reason I would ask is to gain a little further insight into the possibility that some of his symptoms may not be completely T related. I bring this up because in addition to optimizing testosterone I am optimizing DHEA, Vit D3, and especially free T3. We will just assume he is already eating appropriately, exercising, utilizing appropriate supplements etc... I can't stress the importance of optimizing free T3. I do everything I can to decrease their fatigue, improve energy and sexual function, and most importantly for their long term health decrease their visceral body fat. The best way I have found to decrease visceral body fat is T, not blocking E2, DHEA, and optimizing free T3 ( I usually aim for a range of 4-7 or until symptoms improve) and of course exercise. I follow their lipid profiles (small particles as well) and their insulin resistance. Nothing is better than seeing them removed from their statins, anti hypertensives, and metformin etc... I feel that the success I have with TRT is not just the T....but the thyroid as well. So I don't know if all of these other issues were addressed with your new patient by his previous provider Secondly, something that doesn't get mentioned very much but is extremely important is the timing of lab testing. I measure all my men patients 5 hours after application and dosages are adjusted accordingly. Measuring labs and making adjustments obtained with varying times after application is a recipe for disaster . This is also a consideration with new patients that are already on HRT by another provider. Lastly, your patient and his labs. Let's assume (which is bad I know) that his DHEA and free T3 are exactly where we would want them (doubtful his thyroid is optimal though). I would have increased his T dosage to 150 mg bid ( 200mg/gm concentration in a HRT or lidoderm base) so 3/4 gm applied to clean, dry, shaven area of testicles bid. I would then remeasure and follow up in 4 weeks 5 hours after application. I think what may have been concerning to you is that with a T level of 1500 and a free T level of 41 you assume that with those levels he should be doing great and therefore felt the need to make a change. I run into those numbers weekly and the patient does better by just simply increasing the dosage and optimizing the other hormones. Most MDs get scared by an number but in my practice and my personal experience most just start to begin to feel better at 1500. You just can't measure a persons receptor sensitivity so T in the 1800-2000 range don't bother me nor does a free T at 50. The patients feel great without any issues of E2 excess. I did not feel good when I had the numbers of your patient and I personally am optimal with a T level of almost 2000 and free T of 50. I am treating symptoms in my patients and hit home the concept of optimal. I ask them all the time "Do you want to be normal or optimal?". I do not regularly check DHT levels and I have not had to add Hcg to my patients treatment, but if they needed it I would certainly do it. I just haven't had that patient yet. When you aggressively optimize freeT and freeT3 and don't block E2 they do very well [/QUOTE]
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Testosterone Replacement, Low T, HCG, & Beyond
Testosterone Side Effect Management
Should We Be Managing Estradiol and Hematocrit in Men on Testosterone Replacement?
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