What would you do with these symptoms/lab results/goals? Need input please

[killfort]

Hi,

I hope you can help me decide the best plan of attack given my bloodwork, symptoms and goals:

-Male
-37 years old
-5'9"
-175 lbs
-Want to maintain fertility (for possibility of one more child)
-Have a rare retina disease and cannot afford to risk side effects from something like Clomid because any drop in vision acuity would result in losing driving privileges, etc.
-Neck pain due to disc issues; take Cymbalta at 60mg and Tramadol at 50mg, each once per day in the morning both for pain management (I'm afraid this is causing low serum levels but I've been on it for several years and felt fine until I reached 36 years old)
- Not on any TRT, starting clean

Symptoms:
-Near zero libido but used to have very high libido up to a year and a half ago. Basically, it was like someone flipped a switch right before I turned 36 and it just stopped
-No morning wood, no random wood
-If I do get an erection, it leaves quickly and is of poor quality
-Tired/low energy, daytime drowsiness, fall asleep on couch many nights by 8pm
-Not as motivated/competitive/more easily distracted/less focused than I used to be
-Not as happy/excited as I used to be in general, moodier I would say
-Ever increasing levels of belly fat with decreased muscle mass/strength; basically a beer belly although I don't drink alcohol. I've noticed it in the past year and half, about the same time as the libido drop but maybe even six months earlier. The rest of me is fairly skinny.

All my tests were down in the AM before 10AM.

My initial bloodwork by my family doctor:
Date: Nov 2018
TSH = 1.80 uIU/ml
Total Testosterone = 284 ng/dL
Free Testosterone = 10.5 ng/dL
No E2 test performed

Doctor ordered a follow-up but just for the testosterone:
Date: Early Feb 2019
Total Testosterone = 368 ng/dL
Free Testosterone = 11.0 ng/dL

I did a LabCorp test on my own to get E2 and some other values:
Date: Mid-Feb 2019
TSH = not tested
LH = 4.5 mIU/mL
FSH = 4.4 mIU/mL
Total Testosterone = 363.3 ng/dL
Free Testosterone = 8.14 ng/dL
Estradiol, Sensitive = 16.8 pg/mL
Progesterone = 0.1 ng/mL
SHBG = 22.6 nmol/L

Everything shows in the "normal" range per the reference values but of course that covers the whole damn human male possible specturm from childhood to death. I see that I have both low Testosterone and correspondingly low E2. The testosterone is definitely sub-optimal for my age.

Since I can't risk something like Clomid to do a restart and it doesn't make sense for me to take something like an AI since my E2 is already low (I assume because there's not that much test in the first place to convert to estrogen), what would you do? I just feel old most days at 37. It seems my only option is TRT with HCG perhaps? And see if I can ditch the Tramadol and get away with just the Cymbalta? What would you do? Agree/Disagree?

I really wish I had known to get a true baseline a few years when I actually felt good but didn't start exploring this world until I had a reason to. That way I would know my dial-in stats based on my younger self.

Any help is much appreciated.

 

[Systemlord]

Your low testosterone may be caused by Cymbalta and Tramadol, these type of nerve pain medicines are known to cause low testosterone. You present with hormone levels of an older man and you are at risk for cardiovascular disease at these levels.

SHBG levels are only the lower end and any protocol should focus on frequent injections, two (50-60mg) or more injection per week. The standard of care for TRT in mainstream medicine is poor at best, standard starting protocols call for 200mg every 2 weeks, clinical studies published in 2005 show poor results on these protocols.

The only way to increase estrogen is more testosterone.

Low Testosterone Levels Associated With Venlafaxine Use: A Case Report

Effects of opioid (tramadol) treatment on testicular functions in adult male rats: The role of nitric oxide and oxidative stress.

 

[killfort]

Thank you. I appreciate the response.

What are your thoughts on Test with HCG?

 

[Systemlord]

Thank you. I appreciate the response.

What are your thoughts on Test with HCG?

While HCG can work and also increase testicle size back to normal, with it comes increased estrogen which can ruin the good feelings TRT brings to the table.

I have estrogen problems and don't want to pile on more estrogen on top of more estrogen. Controlling estrogen can be the single most difficult aspect of TRT.

 

[killfort]

Sounds like it's a case of less is more here. I'm not opposed to taking an AI like Aromasin if I had to but then I'm starting to complicate and stack things. I like the idea of just trying test at replacement levels first.

I don't have a problem with learning to pin properly. Any other suggestions? Really appreciate your help.

 

[Systemlord]

Sounds like it's a case of less is more here. I'm not opposed to taking an AI like Aromasin if I had to but then I'm starting to complicate and stack things. I like the idea of just trying test at replacement levels first.

I don't have a problem with learning to pin properly. Any other suggestions? Really appreciate your help.

I use 29 gauge insulin syringes which are painless and is considered shallow IM, I pin in the shoulders and quads rotating sites often to minimize muscle tissue damage. I over-respond to all AI's, aromasin isn't as harsh as anastrozole, the latter acts too quickly and just feel terrible on it.

 

[killfort]

What are your thoughts on subQ injections? Seems some are doing that right into the fat. I saw Dr. Crisler, apparently a well respected doctor in TRT and men's health, do a video on it before he passed. He said it helps avoid poking holes in your muscles and the body responds to it just as well.

 

[Systemlord]

What are your thoughts on subQ injections? Seems some are doing that right into the fat. I saw Dr. Crisler, apparently a well respected doctor in TRT and men's health, do a video on it before he passed. He said it helps avoid poking holes in your muscles and the body responds to it just as well.

SQ increase estrogen in myself, I prefer IM.

 

[Sean Mosher]

Like Systemlord has said, there's lots of room here to try various things.
You might do just fine with Test + hCG........or you might not.
Is maintaining fertility an absolute must for you?
That will factor in.

Same with SubQ.
I happen to love it and it works very well for me.
For Systemlord and many others, IM is their preference and works best for them.

At this point I'd just be open to working with your doc and don't confine yourself too much in the beginning.
Just be aware of your options, possible side effects (this depends very much so on the individual), etc...

THE biggest thing you can do to help yourself is continue to self-educate and find a doctor who understands all the nuances of this stuff.

 

[Cataceous]

SQ increase estrogen in myself, I prefer IM.

Per the Anatares study, average estradiol is the same between IM and SQ injections. However, my thinking is that with SQ peak levels are lower, while trough levels are higher. As we mostly test at troughs, this latter phenomenon may give the impression of higher levels.

 

[Nashtide]

You are dealing with a bunch of low T symptoms. You need to give TRT serious thought. If fertility is a concern I would do two things. First, I would donate some sperm before starting TRT and second, I would use hcg right from the beginning.