Some Advice for a New Guy, Please

[KeyserSöze]

Some Advice for a New Guy (in San Diego), Please

I recently purchased Nelson's book Testosterone: A Man's Guide - Second Edition; it is a treasure trove of useful information and I sincerely appreciate it. I recently (4 weeks ago) started TRT and the book (and online information) have been greatly helpful.

Some background on me:
- 36 y/o male
- No known disease(s)
- Very active in fitness and martial arts
- Lack of energy, poor sexual performance, irritable, always tired, consistently bad mood, and trouble focusing

Because of the above, a friend of mine recommended that I investigate TRT. After a consult at Total T Clinic, I was informed that my T level was at 223. They ran additional blood work (included as an attachment) and recommended that I begin TRT.

The clinic has me on:
- 150mg of Testosterone Cypinate weekly (taken on Fridays)
- 50 units of HCG weekly (Taken on Tuesdays). I think they compounded B12 in the HCG to try and help with the MCV and MCH levels.
- Their take on Arimidexfor me: "You do not need Estrogen blocker at this time, your estrogen levels were 10.2"

My insurance covers the treatment as long as I pay the co-pay of $20/visit. The clinic will not allow me to self administer (testosterone) if I pay with insurance; self administration is only available if I pay cash/card directly to the clinic. While my current situation (going to the clinic every Friday for testosterone shots (I am able to self administer the HCG) is cheaper, it is also very difficult to adhere to with a busy schedule.

Additionally, I haven't heard anything about additional blood work after the one-month mark (this coming Friday) until I mentioned it to them.

Can you please provide some advice for me based on this information? I am located in San Diego, California and would like to find a doctor that could possibly:
- Take my PPO insurance (co-pay is fine)
- Allow me to self administer
- Be more proactive with the monitoring, vice me having to ask; it would be nice if the doctor is more knowledgeable than me on the subject.

Thanks!

 

[Pacman]

According to what you wrote, TRT will definitely be very beneficial for you. Smart move!! By the way, did you only post part of your blood work? Because I cannot seem to see your T levels in the attached image... Have they tested LH and FSH as well?

And yes, you really have nothing to gain at the moment from an AI. If your levels start increasing way too high on TRT, then it would be wise to incorporate it. Estrogen is a very important hormone. If your levels drop too low, you will have a bunch of other issues you do not want (it's very important for bone health!). You are very unlikely to deal with any physical changes from too high estrogen before you start dealing with all the emotional ones first. So you are very likely to feel the rise anyway. You have a long way to go before you need to start worrying about your E levels though.

Regarding a doctor in your area that allows you to self administer, you will probably find one if you just look around (and it probably won't take that long either). Being that you have a PPO plan, you can set for yourself appointments, and you don't need to stay with this current doctor. So this doctor doesn't allow you to self-administer, go to a different one that does. You can just call and ask about it, so you don't waste too much time. Just have all your recent labs and medical records sent over, so you don't have to go through the process again. An alternative to a conventional doctor is to go through private clinics, such as Defy Medical. Most doctors allow you to self-administer, so it is kind of your luck that you just fell upon a doctor who happens to not.

Another major point: TRT is not a very common subject that you'll find a lot of doctors know about. Most doctors are very cautious about it anyways because there is a very thin line separating TRT from steroid use, at least to the uneducated minds (which is like most people I think lol). I suggest you do a lot of research and find a good doctor who knows what he's doing, and one who is just as proactive as you are. Just because they are not the majority, doesn't mean that they are not around. They are around, you will find them. I been through two endocrinologists before I found a doctor that seems to be right for me (at least as of right now).

Also, this website is filled with people who are (or who have been) in your exact position, so you came upon the right community! I myself have been on TRT for 14 months. Welcome!

 

[Nelson Vergel]

I am glad my book was of help to you. Welcome to our community!

Adding to what Pacman said so well, I would try calling each one of these doctors and talk to the head nurse or physician's assistant. Tell them you are looking for a primary care physician that can treat hypogonadism and also testicular atrophy.

http://www.medibolics.com/physic2.htm

If you have no luck, try these directories:

https://www.excelmale.com/?s=154-Ho...t-Prescribes-Testosterone-HCG-and-Anastrozole

Estradiol: You probably don't need anastrozole but that decision can not be made until your week 6 or 8 blood work. Make sure they use the ultrasensitive test.

How many UI of HCG's are you taking? Did they give you a powder to reconstitute or HCG already mixed in with water?

 

[KeyserSöze]

By the way, did you only post part of your blood work? Because I cannot seem to see your T levels in the attached image... Have they tested LH and FSH as well?

The labs I attached were from Blood Work drawn and sent out to a separate lab. That is the printout I received back (with my personal information edited out). They took a separate vial to test my Testosterone Levels in house as that is all they are capable of in their office. They only gave me the Total T Count (223). I get more blood drawn from them this week and asked that they include Total T, Free T, FSH, and LH in the results.

Thanks for the warm welcome and insightful reply.

 

[KeyserSöze]

I am glad my book was of help to you. Welcome to our community!

Adding to what Pacman said so well, I would try calling each one of these doctors and talk to the head nurse or physician's assistant. Tell them you are looking for a primary care physician that can treat hypogonadism and also testicular atrophy.

http://www.medibolics.com/physic2.htm

If you have no luck, try these directories:

https://www.excelmale.com/?s=154-Ho...t-Prescribes-Testosterone-HCG-and-Anastrozole

Estradiol: You probably don't need anastrozole but that decision can not be made until your week 6 or 8 blood work. Make sure they use the ultrasensitive test.

How many UI of HCG's are you taking? Did they give you a powder to reconstitute or HCG already mixed in with water?

Thanks for the resources...I tried calling the 3 doctors on http://www.medibolics.com/physic2.htm with the below results:
- Houghton: meets some criteria (insurance, self administer, labs), but does not prescribe HCG
- Vrhel: number was disconnected
- Strebel: number was disconnected

I'll look into the other link you sent me on the Forum tomorrow and report back with any findings.

Testosterone shots are 150mg on Friday (mid morning - administered by clinic IM in glute) and HCG are 50 IU on Tuesday (early am - self administered SQ in abdomen). As this was my first attempt at any of this, they prepped the HCG for me. It was a powder in a vial that they reconstituted. I think she mentioned that it has B-12 in there as well...it is a pinkish/purpleish tint.

 

[KeyserSöze]

Clinic agreed to include Total T, Free T, FSH, and LH in latest labs that were drawn today (after 1 month of therapy). I am looking forward to the results and should have them back on Tuesday or Wed.

I felt like crap so I inquired about and started TRT. I began the therapy and started to feel (I think...could have been mental) a little better for a week or two. I then began to resume training at about week 3, but then felt the same symptoms (fatigued, unfocused, irritable, etc). I got a vasectomy a couple days ago, so I am out of training again for a bit.

- I wonder if the therapy will only help me if I am less active.
- I look forward to the labs that'll come back and the #s I"ll see.
- I hope to be back training in about 3 more weeks so I'll be interested to get more labs a couple weeks after that for comparison.


I am super interested in how it'll play out...

 

[Vettester Chris]

Keyser, from one So Cal guy to the other, welcome to EM! Glad you joined!

Great talking points noted above from Nelson and Pac!

Couple things ... On the labs for LH & FSH, the problem is that you have already been on exogenous therapy for a month now, so gonadotropin production will naturally be suppressed. The point of getting them at baseline is to determine if your testosterone deficiency (aka hypogondism) is diagnosed as primary or secondary.

My suspicion is that you were more than likely "secondary", meaning your HPTA was probably not producing sufficient amounts of LH and FSH, thus a lack of signal to the testes to produce testosterone. However, it's only speculation without the baseline labs. Not that you should put a stop on the current labs, but the anticipated results should no doubt be noted low and well under the reference range ...

With everything you have described, there's a "good" chance that some level of hypothyroidism could be evident. This could stem or contribute to other sub-related areas like the adrenals, electrolytes, and as you noted B12, which could also tie-in with iron serum, binding capacity, ferritin, and D3. Without getting too deep into a litany of all the different labs, I would suggest just getting a thorough and complete thyroid panel. The results will tell us a lot about what is or isn't going on, and used as a marker for other areas to address. If you're going to do it, get the following ...
* TSH
* T3 - Free Serum
* T4 - Free Serum
* Reverse T3
* Antibodies .. TPO, TgAb. (If they add TSI, that's OK, but the first two are musts)

The only other comment for the moment is your RBC's .. Would IMO be good to see them lower. Not sure if you know what is contributing to this? Maybe some form of inherent secondary polycythemia? I know San Diego isn't in the Alps, so I hope your medical team is addressing this? TRT will further promote RBC's to increase, so I strongly encourage to get a plan in place promptly!

 

[KeyserSöze]

Keyser, from one So Cal guy to the other, welcome to EM! Glad you joined! Great talking points noted above from Nelson and Pac! Couple things ... On the labs for LH & FSH, the problem is that you have already been on exogenous therapy for a month now, so gonadotropin production will naturally be suppressed. The point of getting them at baseline is to determine if your testosterone deficiency (aka hypogondism) is diagnosed as primary or secondary. My suspicion is that you were more than likely "secondary", meaning your HPTA was probably not producing sufficient amounts of LH and FSH, thus a lack of signal to the testes to produce testosterone. However, it's only speculation without the baseline labs. Not that you should put a stop on the current labs, but the anticipated results should no doubt be noted low and well under the reference range ... With everything you have described, there's a "good" chance that some level of hypothyroidism could be evident. This could stem or contribute to other sub-related areas like the adrenals, electrolytes, and as you noted B12, which could also tie-in with iron serum, binding capacity, ferritin, and D3. Without getting too deep into a litany of all the different labs, I would suggest just getting a thorough and complete thyroid panel. The results will tell us a lot about what is or isn't going on, and used as a marker for other areas to address. If you're going to do it, get the following ... * TSH * T3 - Free Serum * T4 - Free Serum * Reverse T3 * Antibodies .. TPO, TgAb. (If they add TSI, that's OK, but the first two are musts) The only other comment for the moment is your RBC's .. Would IMO be good to see them lower. Not sure if you know what is contributing to this? Maybe some form of inherent secondary polycythemia? I know San Diego isn't in the Alps, so I hope your medical team is addressing this? TRT will further promote RBC's to increase, so I strongly encourage to get a plan in place promptly!

Thanks for the reply...I wish I would have known about the forum and book prior to investigating TRT, but I am glad that I know now nonetheless. I do know that the doc expressed some concern with my RBCs when she went over the initial labs. She had some ?s about lifestyle (diet, sleep, exercise) which I admitted were all less than stellar at the moment. She advised that I attempt to get them in order and that they would continue to monitor RBCs through upcoming labs.

I do have another question though...It seems that most posts on the forum reference HCG protocols at much higher doses than mine (50 IUs / week)...is this something that I should question with them?

 

[Pacman]

I wouldn't worry too much about the actual starting dosage of HCG, as you can always increase it (and smart doctors work their way up, instead of down), but they seriously should have tested your LH + FSH. The HCG is essentially LH, so if you have primary hypogonadism, it is a useless treatment to be on, at least in the beginning (because your LH levels will naturally be very high).

While the best indicator for diagnosing whether you have primary or secondary is your baseline LH levels, you should definitely still test them even though you've been on TRT for a month already. You could stop TRT for a few weeks just to see what they are at baseline, but if you test them now, you can still see how high/low they are.. If after a month of TRT your LH is high, then you likely have primary, and you should definitely investigate that (get ultrasound, make sure that there isn't some underlying more serious problem etc). Although if your LH is very low, then it is likely you have secondary (although still possible that you have primary, and your LH just dropped really fast).

 

[torrential]

With apologies for the early morning hyperbole, 50 IU HCG is a speck. 50 IU HCG per week is a speck swirling down a toilet bowl. You have described continual negotiation with this clinic, always behind and never ahead. Ask yourself if given the ongoing experience it's reasonable to expect this to change for the better.

Finances. Often the weakest link once you do start to find your own path to optimal health. I would suggest you consider the true cost in a broader context. First, use a provider such as Defy for reference. That group seems to be well regarded. (I'm not affiliated; I'm a patient of a well known doc with significant expertise in this area.) Write down the expected first year and second year cost - initial consult, expected meds, follow up consults, labs. Now write down your expected first and second year costs for the current clinic under insurance. Deductibles, copays, out of pocket, meds, labs, etc. (Labs likely covered by insurance for both.)

The copays you mentioned for weekly in-office T shots alone amounts to over $1,000 per year. That's about my first year cost of initial and follow up consults, meds, and labs with a gen-u-ine expert, and subsequent years involve fewer consultations and labs.

Now add in the inconvenience of weekly visits to the clinic and these basic questions you've shared about this clinics approach to men's health and hormone modulation therapy.

See where this is going? You may already be spending more money than is necessary and getting what may be less than optimal treatment. The nondollar factors are certainly relevant too.

 

[KeyserSöze]

See where this is going? You may already be spending more money than is necessary and getting what may be less than optimal treatment. The nondollar factors are certainly relevant too.

Thanks for your input...I definitely see what you are alluding to. I've been searching for clinics in the area (San Diego to LA), but can't seem to find anything that is as exhaustive when it comes to testing as what most individuals on this forum suggest is appropriate. I definitely don't want to half-ass my health, so I am open to changing to a more thorough/experienced doc/clinic.

I've noticed that Defy comes up a lot on the forum...are all of those members within reasonable distance of Tampa or do they just fly out there on a regular basis for check-ups?

 

[Brian963]

Thanks for your input...I definitely see what you are alluding to. I've been searching for clinics in the area (San Diego to LA), but can't seem to find anything that is as exhaustive when it comes to testing as what most individuals on this forum suggest is appropriate. I definitely don't want to half-ass my health, so I am open to changing to a more thorough/experienced doc/clinic.

I've noticed that Defy comes up a lot on the forum...are all of those members within reasonable distance of Tampa or do they just fly out there on a regular basis for check-ups?

I live in New Orleans and use Defy. I searched for over 9 years for a doctor to effectively treat my low T before discovering Dr. Saya. I would contact their office and speak with them about how remote practice works. I'm grateful for this as I had given up on finding any local physician to treat my low T.

 

[KeyserSöze]

I live in New Orleans and use Defy. I searched for over 9 years for a doctor to effectively treat my low T before discovering Dr. Saya. I would contact their office and speak with them about how remote practice works. I'm grateful for this as I had given up on finding any local physician to treat my low T.

Thanks a ton...I will give them a call on Monday

 

[KeyserSöze]

I got my 1-month labs back today and I must say that I am somewhat worried...
- While I am happy that Total T is up from 223 to 580, I am not sure what is ideal for Free Testosterone
- Despite the fact that I have been on HCG (50 IU per week) for a month, my FSH and LH appear to be pretty low. I don't have a baseline to compare against as they weren't originally tested
- PSA increased...am I correct in understanding that this is to be expected?
- E2 tripled

The smaller of the 2 images (the one without FSH and LH) is the initial bloodwork. The larger of the 2 images (the one with FSH and LH) is the bloodwork from 4 days ago after a month of therapy. Any input is appreciated.

*** I did have a vasectomy performed 4 days prior to having the blood drawn for these labs...I imagine that it affected the results in one way or another. ***

 

[KeyserSöze]

sorry about the above post on bloodwork...I realized that there is a place on the forum dedicated for this and took this there.