When to start clomid after Pellets to target consistent 600-800 range; 54 yrs old

[Holden]

Hello,

Had pellets inserted 3.5 months ago, T level started at 390 (range 250-1100) and Free at 52 (range 35-155) then went up to total 1300 1 month after insertion. 2 weeks ago total was at 1100 with free at 240 (estradiol 25 (range 23.8 - 52.2); 1 week ago total at 880, free 146.

Switched doctors and new doctor suggesting Clomid 25mg EOD + cabergoline .5mg twice weekly (prolactin is 4 ng/mL). New doctor says okay to start Clomid now even though Pellets are probably still in process of wearing off. Said will take awhile for Clomid to start its effects and there's no worry for a potential additive effect of the pellets (what's left) and the Clomid.

My goal is to stay at a consistent mid-range 600-800.

Thoughts on this approach? Looking for some opinions based on others who may have been prescribed either or both clomid and/or cabergoline during or after TRT.

Thanks!

-H

 

[CoastWatcher]

Welcome to EM. We hope you'll be an active member. When would you be due for the next pellet insertion?

For future reference, based on the reference range, your doctor probably measured your estradiol with the standard estradiol test - of little or no value for men. Keep that in mind as you move to Clomid.

 

[Holden]

Welcome to EM. We hope you'll be an active member. When would you be due for the next pellet insertion?

For future reference, based on the reference range, your doctor probably measured your estradiol with the standard estradiol test - of little or no value for men. Keep that in mind as you move to Clomid.

Thanks CoastWatcher. Pellet Dr only says 3 - 6 months, it's been 3.5 now. He says I'll feel it when they wear off, which is a different duration for everyone, and at that point I should come in again. Because of this and because he overshot our target, I changed doctors to the current one recommending Clomid.

Thanks for the heads up on the estradiol. What's the correct reference range, do I need to ensure they do the sensitive test or is there a different name for it? On a related note, what's the reference range for men for LH and FSH, do you happen to know?

-H

 

[Vince]

You could also consider injections of testosterone and HCG every 3 1/2 days, if you are not happy with clomid. It would keep your levels in a nice steady range.

 

[johndoesmith]

Hello,

Had pellets inserted 3.5 months ago, T level started at 390 (range 250-1100) and Free at 52 (range 35-155) then went up to total 1300 1 month after insertion. 2 weeks ago total was at 1100 with free at 240 (estradiol 25 (range 23.8 - 52.2); 1 week ago total at 880, free 146.

Switched doctors and new doctor suggesting Clomid 25mg EOD + cabergoline .5mg twice weekly (prolactin is 4 ng/mL). New doctor says okay to start Clomid now even though Pellets are probably still in process of wearing off. Said will take awhile for Clomid to start its effects and there's no worry for a potential additive effect of the pellets (what's left) and the Clomid.

My goal is to stay at a consistent mid-range 600-800.

Thoughts on this approach? Looking for some opinions based on others who may have been prescribed either or both clomid and/or cabergoline during or after TRT.

Thanks!

-H

Your E2 was below range with 1100 total testosterone? Are you taking AI? That's an insanely low aromatization rate.

Another question is why are you taking caber with a low normal prolactin level?

Did you have LH and fsh measured prior to starting TRT? Clomid is really only for men with secondary.

I am concerned about the quality of care you are receiving.

 

[Vince Carter]

Ive seen our Drs state on video treating Prolactin @ 4/5/6 (&7?) with Caber but it's still a curious thing why your Dr thinks that that's a course of action.

 

[Holden]

Your E2 was below range with 1100 total testosterone? Are you taking AI? That's an insanely low aromatization rate.

Another question is why are you taking caber with a low normal prolactin level?

Did you have LH and fsh measured prior to starting TRT? Clomid is really only for men with secondary.

I am concerned about the quality of care you are receiving.

Thanks johndoesmith, yes the pellet doctor said there is an AI in the pellets which is why the E2 may be low. I'm moving away from the pellet doctor. Yes, he did measure my LH prior to the pellets, it was 3.6 (1.2-8.6 range). Would you consider that low or normal?

The Caber and Clomid has been prescribed by a different doctor than the pellet doctor. So this second doctor says the Caber will help with libido while taking Clomid and may help prevent prolactin based gynecomastia. This second doctor did not measure my current LH, so I did it myself and will have results by tomorrow or Saturday. Waiting for these prior to starting Clomid.

Are you mostly concerned about the quality of care from the first (pellet) doctor or the second (clomid) doctor? The pellet doctor is from a "clinic", the clomid doctor is a Urologist.

 

[johndoesmith]

Thanks johndoesmith, yes the pellet doctor said there is an AI in the pellets which is why the E2 may be low. I'm moving away from the pellet doctor. Yes, he did measure my LH prior to the pellets, it was 3.6 (1.2-8.6 range). Would you consider that low or normal?

The Caber and Clomid has been prescribed by a different doctor than the pellet doctor. So this second doctor says the Caber will help with libido while taking Clomid and may help prevent prolactin based gynecomastia. This second doctor did not measure my current LH, so I did it myself and will have results by tomorrow or Saturday. Waiting for these prior to starting Clomid.

Are you mostly concerned about the quality of care from the first (pellet) doctor or the second (clomid) doctor? The pellet doctor is from a "clinic", the clomid doctor is a Urologist.

AI compounded in the pellets? Dear God that is absolutely the worst idea I've heard of, how does this doctor plan to titrate it? Not directed at you, just frustrated with what I'm reading.

LH of 3.6 is mid range, but I'd say more secondary than primary.

Wait, you had JUST LH tested? LH needs to be taken with FSH, testosterone, and free test at minimum to have any meaning. Sorry to break it to you.

Can you clarify if the caber is BECAUSE your prolactin is 4, or the caber GOT your prolactin down to 4?

I would absolutely not go back to the pellet doctor, but I'm sure you already know this lol.

If you have other lab results, which it seems you do, upload the full copies. It makes it easier than you adding in an additional lab every so often. It's best to have all pieces of the puzzle before putting it together

 

[1Draw]

Holden if it were me I would go directly to Defy. Any MD who prescribes Cabergoline with a prolactin reading of 4 ng/dl is NOT doing you any good. Check this link out:

http://onlinelibrary.wiley.com/doi/10.1111/jsm.12327/full

Nelson also has a great post here on Prolactin:

https://www.excelmale.com/forum/sho...al-Dysfunction-Psychological-Metabolic-Issues

You are not going to get proper care with this MD IMHO.

 

[Holden]

Holden if it were me I would go directly to Defy. Any MD who prescribes Cabergoline with a prolactin reading of 4 ng/dl is NOT doing you any good. Check this link out:

http://onlinelibrary.wiley.com/doi/10.1111/jsm.12327/full

Nelson also has a great post here on Prolactin:

https://www.excelmale.com/forum/sho...al-Dysfunction-Psychological-Metabolic-Issues

You are not going to get proper care with this MD IMHO.

Thanks for those links and the post by Nelson. Interesting thing is the Clomid / Cabergoline doctor is a Urologist from a Top 10 Urology department as ranked by US New & World Report's latest hospital and specialty rankings. Not defending or promoting the use of either, just mentioning. Again thanks for those articles.

 

[CoastWatcher]

Thanks for those links and the post by Nelson. Interesting thing is the Clomid / Cabergoline doctor is a Urologist from a Top 10 Urology department as ranked by US New & World Report's latest hospital and specialty rankings. Not defending or promoting the use of either, just mentioning. Again thanks for those articles.

The doctor who initially was managing my hypogonadism holds an endowed chair in the endocrinology department at one of the medical schools in the city in which I live. He prescribed an outdated protocol that left me feeling miserable.

I continue to be astonished at the lack of knowledge so many doctors practicing in the field of men's health regularly display. Urology, endocrinology...and we consult them in good faith.

 

[johndoesmith]

Thanks for those links and the post by Nelson. Interesting thing is the Clomid / Cabergoline doctor is a Urologist from a Top 10 Urology department as ranked by US New & World Report's latest hospital and specialty rankings. Not defending or promoting the use of either, just mentioning. Again thanks for those articles.

I believe Dr saya commented saying he receives offers for him to pay to be listed in those rankings. I wouldn't put much faith in them. I've always wondered how you can rate a doctor objectively. A doctor who gives out high doses of painkillers will have a high patient satisfaction rating and measuring patient health disincentivizes the doctor from taking sticker patients. There's really not a good way to do so AFAIK.

The doctor who initially was managing my hypogonadism holds an endowed chair in the endocrinology department at one of the medical schools in the city in which I live. He prescribed an outdated protocol that left me feeling miserable.

I continue to be astonished at the lack of knowledge so many doctors practicing in the field of men's health regularly display. Urology, endocrinology...and we consult them in good faith.

I had a urologist tell me injectable testosterone is bad for the liver and confuse "iatrogenic" with "idiopathic". Truly had no words at that point.

 

[Dr Justin Saya MD]

I had a urologist tell me injectable testosterone is bad for the liver and confuse "iatrogenic" with "idiopathic". Truly had no words at that point.

Sounds like that doctor could quickly turn idiopathic INTO iatrogenic due to lack of knowledge...oh some weekend medical terminology banter!

Holden - as noted above. The Clomid is reasonable, but I would question the cabergoline especially if your baseline prolactin was 4. All the best!

 

[johndoesmith]

Sounds like that doctor could quickly turn idiopathic INTO iatrogenic due to lack of knowledge...oh some weekend medical terminology banter!

Does iatrogenic neuronal necrosis exist? I think I may have some from that encounter.

That legitimately cracked me up BTW.

 

[Holden]

I believe Dr saya commented saying he receives offers for him to pay to be listed in those rankings. I wouldn't put much faith in them. I've always wondered how you can rate a doctor objectively. A doctor who gives out high doses of painkillers will have a high patient satisfaction rating and measuring patient health disincentivizes the doctor from taking sticker patients. There's really not a good way to do so AFAIK.



I had a urologist tell me injectable testosterone is bad for the liver and confuse "iatrogenic" with "idiopathic". Truly had no words at that point.

I don't disagree that doctors can give advice that is not optimal, which is why I'm on this board to see if I can move toward gaining any more clarity in the various words of advice I've received from traditional doctors and from "TRT doctors".

From folks reading this, who do you think are the top 3 doctors in the USA in the world of TRT + Urology + Endocrynology? I say all 3 because several "TRT" Dr's I've run across don't measure IGF-1 for example; also several don't have good answers for sex drive; many "TRT" doctors also try to push Sermorelin to increase human growth hormone but have no answer when asked about the studies linking high IGF-1 levels to cancer in older adults. Urology because many say T will increase prostate size in older adults, but how much of that is normal, due to age vs due to cancer vs due to testosterone, how do you know? Endocrynology because these hormones are interrelated. Who are the top 3 docs in the USA that know this space inside and out? Many great Primary Care physicians, but then they focus on diabetes, thyroid maybe, CVD, but I was with one recently and asked him to measure my Estrogen and he said he wouldn't know what to do even if he got the results, so he refused to.

I have tried to contact Dr Saya just to ask if he'd be a good fit, and since I have recent labs ask if I can I pay for a consult, but only received an email from an associated saying that he's booked until late Dec early January. No time for a 1 hour consult. hmm, must be really really busy. I probably want to make a decision before then given my pellets are wearing off. So sounds like he cannot help at this point.

Who are the Top 3 in the USA? Or does no one really know because there is so many differing "opinions" on therapy?

 

[johndoesmith]

I don't disagree that doctors can give advice that is not optimal, which is why I'm on this board to see if I can move toward gaining any more clarity in the various words of advice I've received from traditional doctors and from "TRT doctors".

From folks reading this, who do you think are the top 3 doctors in the USA in the world of TRT + Urology + Endocrynology? I say all 3 because several "TRT" Dr's I've run across don't measure IGF-1 for example; also several don't have good answers for sex drive; many "TRT" doctors also try to push Sermorelin to increase human growth hormone but have no answer when asked about the studies linking high IGF-1 levels to cancer in older adults. Urology because many say T will increase prostate size in older adults, but how much of that is normal, due to age vs due to cancer vs due to testosterone, how do you know? Endocrynology because these hormones are interrelated. Who are the top 3 docs in the USA that know this space inside and out? Many great Primary Care physicians, but then they focus on diabetes, thyroid maybe, CVD, but I was with one recently and asked him to measure my Estrogen and he said he wouldn't know what to do even if he got the results, so he refused to.

I have tried to contact Dr Saya just to ask if he'd be a good fit, and since I have recent labs ask if I can I pay for a consult, but only received an email from an associated saying that he's booked until late Dec early January. No time for a 1 hour consult. hmm, must be really really busy. I probably want to make a decision before then given my pellets are wearing off. So sounds like he cannot help at this point.

Who are the Top 3 in the USA? Or does no one really know because there is so many differing "opinions" on therapy?

I've only consulted Dr saya myself so can only speak from experience about him, having said that it's hard to rate other doctors that I haven't consulted. There are other trt patients I've spoken to who have consulted other well known trt physicians, Dr Rand McClain comes to mind as I've heard good things about him and Dr John Crisler as well.

To say who the top doc is, is so difficult as it's subjective.

Not sure why you weren't able to book s consult for early Jan, it's not that long, especially with the holidays complicating operating hours. I'd give a call back and book an appointment if it were me, as that's exactly what I did.

 

[Dr Justin Saya MD]

I have tried to contact Dr Saya just to ask if he'd be a good fit, and since I have recent labs ask if I can I pay for a consult, but only received an email from an associated saying that he's booked until late Dec early January. No time for a 1 hour consult. hmm, must be really really busy. I probably want to make a decision before then given my pellets are wearing off. So sounds like he cannot help at this point.

Holden - my schedule is indeed booked out...and the Holidays make it even worse. We do have a wait list for no-show appts if you're flexible with appt timing. If you wanted to proceed to a consult with me, the Clomid would keep you afloat in the meantime and also offer some useful data/talking points if you had another round of labs prior to our discussion when we can fully assess the totality of your case.

I would venture to say that any physician in this space who's worth their weight would likely be backed up a few weeks on their schedule...especially at this time of the year. McClain, Crisler, Shippen, Gordon are good ones you could check with.

 

[Holden]

Holden - my schedule is indeed booked out...and the Holidays make it even worse. We do have a wait list for no-show appts if you're flexible with appt timing. If you wanted to proceed to a consult with me, the Clomid would keep you afloat in the meantime and also offer some useful data/talking points if you had another round of labs prior to our discussion when we can fully assess the totality of your case.

I would venture to say that any physician in this space who's worth their weight would likely be backed up a few weeks on their schedule...especially at this time of the year. McClain, Crisler, Shippen, Gordon are good ones you could check with.

Thanks Dr Saya, that makes sense. How can I ensure the consult would be with you? The email response I had referred to (from one of your staff) said an ..."evaluation would be with one of our doctors or physician assistants".

Thanks,

-H

 

[Holden]

@johndoesmith - you had asked if I have other lab results to post them here. I'll try uploading these screenshots and see if this works. This is meant to be a summary of the more pertinent tests but I have more tests as well, just need to figure out the best way to get them up here. The "100 Days Post Pellet Insertion" was 7 days ago so I'm at about 107 days or 3 1/2 months post insertion.

@Dr Saya - yes I'll get another set of full tests per your associate's email before I see you to talk about best way forward. Net/net I'm 53 yrs old with 3 kids under 4 yrs old so need to be in top health through my 80's, balancing odds of CVD, Diabetes, Cancer, Dementia and every other age related illness out there.

 

[Dr Justin Saya MD]

Thanks Dr Saya, that makes sense. How can I ensure the consult would be with you? The email response I had referred to (from one of your staff) said an ..."evaluation would be with one of our doctors or physician assistants".

Thanks,

-H

Any patient can always request me specifically upon scheduling their appt.