T increasing, E2 decreasing on TRT, no AI. Why?

[neel]

Male 42, young teenage voice, no visible adams apple, patchy facial hair, no male hair on arms. T varied between 155-190 from 2013-2016. E2 was 20 in 2013. Prolactin 15, increased to 25 after starting thyroxine, decreased to 4-14 after increasing salt intake. I struggled with thyroxine for 4 years to get a grip on TSH (TSH 15, T4 8.5 in 2013, no goitre ever, clean USG, AMA,ATG >600, ATG decreased on thyroxine) but to no avail. Went to the doctor and he's suspecting Kallmann, but that is impossible as I have a very strong sense of smell (like an addisons patient, and cortisol is also repeatedly near 12 at 8am). Doc prescribed sustanon recently after I had already started it. I will be doing the MRI though, just to be sure, but at a government hospital as it's cheaper, so will have to wait in queue (I'm in India). Anyway, in 2017 I decided to do something about the testosterone. Ran some experiments:


Baseline: T 189, LH 5.72, FSH 2.51 in June 2016; T 196, LH 3.33, FSH 2.08, PRL 14.36, cortisol 15.08 in Dec 2016 (yeah, I'm an idiot for not having a E2 baseline here. It was 20 in 2013)
HCG 625 IU/day for 3 weeks: T 424, E2 71, PRL 11.6, Cort 13.42
HCG 312 IU/day for 2 weeks: T 216, E2 33
clomiphene 12.5mg/day for 2 weeks: T 388, E2 24.5, LH 6.53, FSH 4.73, PRL 12.09
Letrozole 1.25mg/day for 2 weeks: T 408, E2 <11.8, LH 10.96, FSH 7.03, PRL 12.36
Sustanon 50mg/week for 2 weeks: calcium 8.64, sodium 143
Sustanon 50mg/week for 2 more weeks: T 452, E2 16.21, LH 3.53, FSH 2.64, PRL 17.2, Cort 12.7, Calcium 8.75, albumin 4.4, sodium 143, magnesium 2.05. 24Hr urine: calcium 116mg, Phos 499mg
[potassium came normal at 4.5, 2 weeks after last sustanon dose, even though mild cramps remain]

So now 2 questions (first one really important):
If I assume the E2 baseline for me is 20, how did it drop to 16 on sustanon, even though T doubled? Did this ever happen to anybody? Seems like all my E2 is intratesticular in origin from the HCG results, so will probably have to add HCG. Did this happen to anybody? I did feel splendid on HCG despite the high E2, just that all my lymph nodes started swelling up. (they also swelled up on hydrocortisone and clomiphene, no fever, so I'm not sure what the problem is... and yes I did go to a doctor who gave me a tablet for gas).


Secondly, I started having severe muscle cramps, twitching, tingling etc on sustanon. Apparently, internet says this happens to many people. My doc (MRCP endocrinologist) has never seen this, nor the hypocalcemia, and doubts it is hypocalcemia. I disagree, the prolactin shot up, probably to correct the calcium. Me and my paternal family has a history of muscle cramps (usually leg). On sustanon it was 10x bad. Can this happen if E2 decreases? Has anybody seen this happen? It maybe theoretically possible as E2 does regulate calcium intake, bone and PTH, but actual evidence anyone? The cramps did not happen much on letrozole though. I didn't feel good on sustanon though (actually felt horrible due to the aches), but it did cure my headaches (probably due to sodium retention? resting BP increased to 120/80). Interestingly, nicotine gum relieves the cramps (had some gum lying around, I don't smoke).


Also, any questions and answers I have missed, please ask or answer

 

[madman]

Your protocol is nutty especially 50mg/sustanon week............too low. Most would do 100mg-125mg/week as 50mg would not bring your total t up enough and 2 weeks trying different medications is not going to give any consistent blood work let alone confusing your hpta with what you are taking. Regarding trt it takes 6 weeks to reach stable levels. You should have chosen one therapy and gave it time to really see how it is affecting your total t/free t and e2 levels among many other things. Your erratic short term trial/error approach is going to cause you nothing but grief. You need to start from scratch and speak with a knowledgeable doctor who specializes in treating males with hormones.

 

[neel]

I agree, time was short between therapies (gap was 1 week between them). However the differences were clearly perceptible. Side effects changed from one to the other. Besides, doses are low, co changeover time could be reduced. And then, as for the low dosage... well, I do not want to repeat my mistake of taking thyroxine for 4 years and praying for a miracle. If things are to improve, I will likely notice in the first couple of days itself. Only side effects take longer to show up. I need to see results before debating if I want to live with the side effects. Also, I have to be taking thyroxine through all this anyway, so I can't really remove all cross reactions. Besides, some effects also change seasonally (yes, I have a diary for last 4 years), or with diet etc, so I just wanted to get it over with quickly. Running the experiment over 6 months would have come with it's own problems, and maybe would be even more difficult to interpret.

As for the nutty 50mg sustanon, it did raise T from 175 or so to 450. Surely I should at least see my fatigue improve? That did not happen. And I cannot see why E2 should still be low after more than a month of stopping letrozole during which time T almost tripled on sustanon. Makes no sense.

I have to admit the 50mg sustanon looks low, that is what the doc had also prescribed, and after 6 weeks may have reached a healthy 500 (I'm not a bodybuilder, just trying to survive). But here I am a month after my last dose, and balls still shrinking (am on clomiphene now). So 50mg is scary enough for me. And anybody wanting me to raise it to 100-125mg, needs to be here to take care of my muscle cramps, or worse (yeah, I was scared my heart would cramp).

Here's what the medications cure for me (and they all show evil sides as well):
thyroxine : depression
hydrocortisone : fatigue
HCG : mood
clomiphene : fatigue
letrozole : no benefit really
sustanon : headache

[no knowledgeable TRT docs here, and no doc here has more than a few minutes... so that chapter is closed. Thankfully tests and medicines are mostly readily available]

 

[AbsoluteZ3R0]

The majority of aromatization occurs in the testicles, so once you switched from drugs that create testosterone in your testicles (HCG, clomid) to a drug that puts testosterone in your body exogenously (sustanon), you eliminated the majority of aromatase activity in your body. Furthermore, 100mg of testosterone weekly is not a whole lot, so your estrogen levels seem reasonable considering that dose. If you were to raise your total T to 400 on HCG, you'd probably see higher E2 than if you were to raise your total T to 800 on pure testosterone. If you included a small dose of HCG as an adjunct to your test injections, you'd definitely see that E2 number go up. As for your muscle cramps, I can't imagine why nicotine gum would assist the cramping. It suggests to me that it may be an issue involving acetylcholine, but that's pure conjecture. Any history of Alzheimer's in your family?

 

[neel]

No, no history of Alzheimers. Both parents still have excellent memory. In fact, only one hypothyroid aunt has bad memory. I had a brilliant memory till about age 7, never seen anyone that good again. And then it went downhill fast... eyesight, memory, energy level, handwriting, maths, languages... and although I think I'm retarded, everyone still thinks I'm a genious, so maybe I managed to retain some of my intellect. The lethargy has probably been since birth. My earliest memories (age 4 or so) are of always being tired and depressed. Dad says I had overly soft bones at age 1 and used to always sleep like a log. I have knock knees and bad teeth (yellow and molar cavities). The molar cavities stopped at puberty.

[Also, there is a history of nicotine use on my father's side. Granpa quit smoking and used snuff. Uncle was a smoker. Uncle's son smokes a lot. My sister smokes. I smoked lightly in 2004, 2006, 2008-2009. Never got addicted and quit. Unlike nicotine gum, smoking increases my headaches.]

Here's additional data.. I tried tamoxifen yesterday and it increased my muscle pain (in about 30 minutes). Clomiphene had reduced it day before. My muscles are not cramping anymore, since it's now been a while since the sustanon, but intermittent pains still remain. I had to reduce the thyroxine dosage as that is increasing the muscle pain too.

Thanks for the explanation about E2. It does make sense. But I'm 65kg, height 62". So not lean, I have plenty of fat. So how come no aromatase there? I see others posting their blood work on T, and it always seems they have problems with E2 reaching the upper limits and beyond. I admit, no one is on 50mg, but will adding another 50mg push E2 to the upper limit? And testes still shrinking, so I'm scared anyway.

There is another strange thing. I have symptoms of hypocalcemia if I take calcium, drink milk everyday, or take vitamin D, or even if I'm in the sun too long few days in a row. Increasing vitamin D does not increase calcium levels. calcitriol and alfacalcidol decreased my urine volume so I did not experiment with them. My blood test for calcium did come a bit low at 8.8 when I took too much calcium in 2015. But this time it decreased just with sustanon. Since all of these hormones (T, E2, cort, PRL, TSH) are closely linked to calcium metabolism, I'm wondering if there is a problem with that itself. I cannot rely on the PTH results I have as they used clotted blood (came 27 and 20 when calcium was 8.8). Sodium, potassium, magnesium are all fine mostly. Sodium goes down if I reduce intake, but it stayed at 143+ on sustanon, even with reduced intake. I'm wondering if the T is low because of the calcium, and not the other way around.

 

[user_joe]

I didn't read everything, but I can simply tell you that you won't feel better/best until you get e2 in range. 50mg/wk is ridiculous. 100/wk is on the low side but works for some. Even on the right dose it can take a few months for e2 to rise.

 

[madman]

You are missing the point regarding aromatization of testosterone a fair amount of aromatization happens in ADIPOSE tissue especially VISCERAL fat, look into the research as the testes is not the only site for aromatization to happen. 50mg/week is way to low to have an increase in e2...................guaranteed if you start at 100mg especially once weekly you will bring up your e2 and yes as user_joe stated it takes time...............give it a good 6 weeks as rises in e2 does not happen overnight as it takes time to build up!

 

[neel]

Thanks user_joe and madman! Guess I'll just add HCG and see if that helps. The doc has actually prescribed 100mg every 3 weeks, which is clearly ridiculous. I did 50mg/week subcutaneous for 4 weeks (from sustanon 250), but I think this time I'll use the 100mg vial as it has a slightly shorter half life. I may do 50mg/week again and add HCG, and if that goes ok (symptom and blood test), I'll consider increasing the dose. I am still scared though about the testicular shrinkage, although they're slowly growing again. They've always been small. Any idea if some kind of FSH may help?

 

[madman]

Thanks user_joe and madman! Guess I'll just add HCG and see if that helps. The doc has actually prescribed 100mg every 3 weeks, which is clearly ridiculous. I did 50mg/week subcutaneous for 4 weeks (from sustanon 250), but I think this time I'll use the 100mg vial as it has a slightly shorter half life. I may do 50mg/week again and add HCG, and if that goes ok (symptom and blood test), I'll consider increasing the dose. I am still scared though about the testicular shrinkage, although they're slowly growing again. They've always been small. Any idea if some kind of FSH may help?

Testicular shrinkage is an individual thing as some on trt may notice a lot of shrinkage and others minimal shrinkage and if anything it is highly unlikely the testicular shrinkage would be greater than 20% as the leydig cells only make up a small percent of the overall testicular mass and it is not like you are going to be walking around hanging with a couple of raisins!

 

[neel]

Since the testis is an ellipsoid, I measured major and minor axis. Seemed more accurate than an orchidometer with some fixed sizes to compare to. So measurements were (please don't laugh):

Baseline (I guess since early puberty) major and minor axis: 37mm and 17mm
after clomiphene and letrozole : 39mm and 19mm
after 2 weeks on sustanon : 38mm and 18mm
after 3 weeks on sustanon : 36mm and 17mm
2 weeks after last (4th) sustanon inj : 36mm and 16mm
another 10 days later : 33mm and 17mm
another 5 days, some letrozole, clomiphene and tamoxifen later : 36mm and 17mm

I used a vernier calipers and averaged measurements (not more than 1mm change between readings).

As you can see, I'm already walking around with grapes. I'm pretty sure I don't want to walk around at all if they become raisins

PS: just for reference, adult size seems to be 50mm x 25mm. So yeah, I'm feeling hopelessly inadequate..... no wonder women walk away, they can't get a hold on my balls....