51 yr old male started on HRT 3 weeks ago....

[John Galt 3141]

51 yr old male, 5'6", 145 lbs, 22% body fat (all abdominal fat), ultraendurance athlete in cycling/running/triathlons completely healthy all my life. Also a physician in the traditional since (until now). In 2009 started feeling fatigued, low mood, increased abdominal fat, weak. In Dec. 2009 checked my testosterone level Total 524 (250-1100 ng/dl) Free 61.6 (35-155 ng/dl). Assumed was ok. Continued to feel worse as the yrs went by...assumed work related stress, lack of sleep, etc. This past month hitting rock bottom...wake up in morning with aches/pains/severe fatigue/low mood/irritability. I did further workup on myself:
May 2012 results no treatments in place:
Testosterone Total 544 (240-940)
Free 11 (9-30) A DROP OF 80% FROM DEC. 2009 LEVEL.
FSH 4.0 (0.7-11.1)
LH 5.4 (0.8-7.6)
Progesterone 0.2 (0.3-2.9)
Prolactin 6.7 (2.1-17.7)
Estradiol 12.3 (13.0-50.0)

TSH 6.1 (0.4-4.0) HIGH
T3 116.6 (90-200)
Free T3 2.8 (2.4-4.5)
FT4 1.1 (0.9-1.8)
T-uptake 1.1 (0.7-1.3)
ATPO 67.2 (0-677)

Insulin 2.0 (2.0-6.0)
IGF-1 104 (for 50 yr old 210-307)
Cortisol mid afternoon 9.7 (4)
DHEA-s 0.7 (0.8-5.6) LOW
SHBG 53 (10-57)
PSA 0.6 (<4.0)
CRP 0.3 (<8.0)
Uric acid 3.8 (3.4-7.0)

Hepatic fxn panel completely normal
Basic electrolyte panel normal
Cr 1.0 (0.7-1.2
BUN 19 (6-20)
CBC panel completely normal
WBC 4.6 (4.0-10.0)

HDL 50 (40-135)
Total chol 181 (125-199)
LDL 117 (10-129)
Trig 99 (30-149)

Hgb A1C 5.3 (4.2-5.8)

Went to HRT clinic, seen by nurse who runs it with physician who blindly signs his prescriptions: Prescribed and started 2 weeks ago..

Testosterone cypionate/proprionate/ethanate 200mg/ml 1.0 ml/wk oil im
Arimidex 0.5 mg twice per week
Danazol 20 mg sl bid
DHEA 20 mg qam sl
niacin 500 mg qhs slow release
Semorelin 30 iu qhs sq
Thyroid bulk T3 SR 14 mcg po bid
Pregnenolone 20 mg sl qam

Concerned about going from taking routine vitamins to this regimen the rest of my life. Is this all necessary?
Should the thyroid function be treated first to see if testosterone function returns to normal?
Should HCG be added to regimen? (Will T therapy casue low LSH leading to testicular atrophy/pain?)
If testosterone treatment necessary are im injections best source at this time?

Still feel awful but only 2 weeks therapy. Know takes time.
Thanks for any comments.

[spywizard]

is all that covered by your insurance company??? or are you buying yourself?? and yes on the hcg..

did they check your gh levels?

looks like a good recommendation actually..

[steroid.com 1]

Did you say you are a Physician?

Did any of these panels concern you:
TSH 6.1 (0.4-4.0) HIGH
T3 116.6 (90-200)
Free T3 2.8 (2.4-4.5)
FT4 1.1 (0.9-1.8)
T-uptake 1.1 (0.7-1.3)
ATPO 67.2 (0-677)

You feel like you do because you have Hypothyroidism.

The thyroid is intimately associated with every function of your body, hormonal and otherwise. And keep in mind, hypothyroidism mimics hypogonadism in several of its effects...that's why you feel like you do and why you thought you were low T!

TSH is through the roof! Low T4 and conversion to T3 low as well.

You need to get your Thyroid checked by a specialist and get a diagnosis.

These are also of concern:
IGF -1 104 (for 50 yr old 210-307)
There's a reason why this is low and could very well be related to your Hypothyroidism. IGF-I deficiency is associated with neurodegenerative disease, cardiovascular diseases, heart failure, and shorter life span...so be aware.

Estradiol 12.3 (13.0-50.0)
This is low and another contributing factor...also know that E2 status can have a direct effect on IGF-1 serum levels as well.

Cortisol mid afternoon 9.7 (4)
High...were you stressed?

DHEA-s 0.7 (0.8-5.6) LOW
Points to Thyroid again.

SHBG 53 (10-57)
Almost at top of reference range; binding to Testosterone lowering both Free and Bio Available Testosterone.

You need to see a Endo on your Thyroid right quick and don't take any meds till you get a diagnosis.

[John Galt 3141]

Spywizard,
IGF-1 is the growth hormone level=low. Have high deductible but cost reasonable from my compounding pharmacy.
Gdevine,
I suspect I have Hashimoto's disease....symptoms fit. Yes, always stressed...work,family, lack of sleep unfortunately. Am working on seeing endocrinologist ASAP.
Yes , I am an anesthesiologist. I see the workups that the local primary care physicians do and not very impressive. I am becoming very, very wary of traditional medicine....causes as much or more harm than good. Thanks for responding, I have been following your post and you seem very knowledgeable.

[kelkel]

Totally agree with the hypothyroid aspect GD speaks of as well as the need for HCG. It would have been great to remedy that first and see where you ended up before making the leap into TRT. That said, I would have liked to see you go with a more reasonable starting dose of T and titrate up as needed based on labs. 200 is a high end dosage in the TRT world, even with 30% being ester. 100 would have been more reasonable as well as possibly waiting until labs before adding an AI, unless negative sides occur, as you are obviously low. Adding one compound at a time allows you to learn more of what each compound does for you along the way and makes adjustments easier.

Very interesting to see the Danazol prescribed to suppress your high shbg level. We have been speaking of that here within the past few days on another thread. Also just by increasing your T you will suppress your shbg level. Side bar-add Vit D to your protocol as well as it will naturally help with shbg levels. Guarantee your low. OTC is fine or a script for Drisdol which is only once a week.

The protocol they've put you on does appear to cover all the bases but like most clinics, do not really address the root cause. They are, after all, a business. Welcome to the forum Doc. We are all here for different reasons and there is a wealth of knowledge here to be gained from the varied opinions of the members. Take some time and read the sticky threads at the top of the forum as they will really bring you up to speed. Gead GD's thread on HCG since you asked about it.

Again, welcome! Stick around and let us know your progress/decisions along the way...

[steroid.com 1]

Spywizard,
IGF-1 is the growth hormone level=low. Have high deductible but cost reasonable from my compounding pharmacy.
Gdevine,
I suspect I have Hashimoto's disease....symptoms fit. Yes, always stressed...work,family, lack of sleep unfortunately. Am working on seeing endocrinologist ASAP.
Yes , I am an anesthesiologist. I see the workups that the local primary care physicians do and not very impressive. I am becoming very, very wary of traditional medicine....causes as much or more harm than good. Thanks for responding, I have been following your post and you seem very knowledgeable.

Hasimoto's disease is very much a high probability...as well as Adrenal Fatigue.

Make sure you find a Doc who totally understands hormone repla***ent protocols in men. There are a lot of Endo's out there who don't know squat and could really end up hurting you. Guys like Dr. John Crisler are the class of Physician's who "get it" Doc.

Only want the best for you man

[bass]

totally agree with GD and Kel! your test levels were not low enough to put you on TRT, however your TSH stands out like a sore thumb! thats probably where you main problem is, thyroid. definitely need an MRI.

[John Galt 3141]

Kelkel, your right in that my measured Vit D level was low despite supplementation with 1000 iu qd. Have upped the dose. Did read threads on HCG and that's what brought it to my attention. Have scheduled an appointment with the best "traditional" endocrinologist in our area but I have no idea how tuned in he is to all this...will let you know. I'm very interested to find out myself. I've gotten more of an education in endocrinology in the past week reading through this forum than I ever did in medical school, and I went to very good schools. It's a shame when you think of it.

[kelkel]

Doc check the links in the Finding a TRT Physician sticky and you may find someone in your area with expertise in TRT. There's some other info in that thread that may help you speed up the process. The title "Endo" does not mean they know TRT. I knew more than my first endo did regarding TRT for that matter. Call and ask if they will treat you along Crisler's protocols. They say yes, your probably good to go. Good luck sir! Keep us posted.

[ecdysone]

Just to reiterate, like kel said, 200 mg test/week is excessive for someone of your age/test level.

Using half of that SQ (0.25 cc every 3.5 days with a insulin syringe) will serve you better and should suppress your SHBG into a better range.

Skip the Danazol and hold off on the Arimidex until you get some more hormone labs a couple weeks from now.

Most of here favor getting one endrocrine system under control before screwing with another

[HRTstudent]

Concerned about going from taking routine vitamins to this regimen the rest of my life. Is this all necessary?

absolutely not....

but you went to a clinic who makes most of their money by writing prescriptions, I'm being honest.

why start someone on an AI before you know if they need it? that's foolish. it's easy to remedy IF they need it, but many don't. not only that, but your estradiol was tested at very very low.

same thing with danazol, that's just crazy to start you on that.

honestly, I would start out on JUST testosterone and take it from there. thats pretty much what Dr Crisler does and you can be damn sure he is a specialist in this field with a lot of experience and education...

it just bothers me that people would take you from nothing to a plethora of prescription drugs when probably 98% of your results are going to come from 1 drug - testosterone. for you personally, you need to check into your thyroid though as well.

nothing wrong with fine-tuning down the road, but at least you'll know what you need or don't instead of taking it all and, of course, taking the possible long term risks of it too. not to mention the cost.

[Bill_boy2005]

absolutely not....

but you went to a clinic who makes most of their money by writing prescriptions, I'm being honest.

why start someone on an AI before you know if they need it? that's foolish. it's easy to remedy IF they need it, but many don't. not only that, but your estradiol was tested at very very low.

same thing with danazol, that's just crazy to start you on that.

honestly, I would start out on JUST testosterone and take it from there. thats pretty much what Dr Crisler does and you can be damn sure he is a specialist in this field with a lot of experience and education...

it just bothers me that people would take you from nothing to a plethora of prescription drugs when probably 98% of your results are going to come from 1 drug - testosterone. for you personally, you need to check into your thyroid though as well.

nothing wrong with fine-tuning down the road, but at least you'll know what you need or don't instead of taking it all and, of course, taking the possible long term risks of it too. not to mention the cost.

I looked at an HRT clinic when I was looking to go beyond my urologist. Their "suggested" meds were a lot like what he posted above. A lot more than I needed for damn sure. I am damn glad I went with Dr. Crisler instead. The HRT clinic was effectively going to lifelong cycle me.

[steroid.com 1]

Kelkel, your right in that my measured Vit D level was low despite supplementation with 1000 iu qd. Have upped the dose. Did read threads on HCG and that's what brought it to my attention. Have scheduled an appointment with the best "traditional" endocrinologist in our area but I have no idea how tuned in he is to all this...will let you know. I'm very interested to find out myself. I've gotten more of an education in endocrinology in the past week reading through this forum than I ever did in medical school, and I went to very good schools. It's a shame when you think of it.

John - Most of us here work (as in patient) with either Physician's who are on the cutting edge of Testosterone Repla***ent Therapies for men or we are self taught through our own study and due diligence of the science and sharing of experiences like we do here in this great forum.

The type of Endo science you were taught in med school didn't cover this as it wasn't even out there yet...it's relatively new...and why so few specialists.

I do understand it's now becoming a bit more common in Med School and in time most PCP's, Endo's and Euro's will have practical understanding on how to practice TRT especially because the drug companies want to sell more drugs!

In fact, my Doc used to be a an anesthesiologist here in South Florida but was so fascinated with this new science he went to Harvard Medical School and was trained in the latest most up to date forms of hormone repla***ent and management in men.

Check out The American Academy for Anti Aging Medicine (A4M) most every practitioner here is a specialist in TRT for both men and women...Physician's on the cutting edge!

What gets me John, in all of this, is that Medical Doctors who swore an oath will put men into protocol's without understanding even the basics of medicine half life let alone understanding HPTA suppression and the mechanisms behind it and won't allow men to use hCG because it's a "fertility drug" or an aromatase inhibitor to control E2 because it's a "cancer drug"...like you said...it's scary.

[ecdysone]

deleted

[steroid.com 1]

To be honest, I'm not much of a fanboy of many of self-proclaimed TRT docs (I wouldn't want to tell you why), but as just another health care professional, I tell you what Dr. John: self diagnosing Hashimoto's without any antibodies to thyroid binding proteins, etc. is a shot in the dark. Mind you, you could be dead on, but I just prefer the conservative approach, so take a deep breath (no pun intended) and see what a real expert (not me) can offer you.

Dude, he didn't self diagnose...he just made a statement as to what it may be and nothing more than that...and he may be right, who knows till he gets the right tests.

He's already stated he has an apt with a top Endo now...

If you're not a fan-boy of self proclaimed TRT Docs who are you a fan of...a 79 year old GP in Lincoln NE? LOL

[Vettester]

Wow!! I'm just getting caught up on this great thread! John, welcome to this forum. As you've already discovered, you're interacting with a great group of people here.

When I read through your nicely written opening post, I just figured the plan of action from your doctor was going to be strictly directed at your thyroid condition. Granted, it wouldn't hurt to have a better free test level, which can be achieved with some SHBG management. HPTA looks pretty healthy with GnRH production, but that will vanish soon enough with your new therapy. I don't quite get the doctor's rationale on this one, but that happens once in awhile at this place LOL.

Anyways ... Welcome once again, and I definitely agree with what the others are telling you. Seriously, 1mg/wk of AI and your E2 is already low?? Hmmm, it leaves me stymied!

[keep fightin]

you guys are keepin this thread lively, love it! weighty matters being discussed here and the only little thing I can contribute is bump your Vit D way up! I bet you could supp 5,000 iu a day and still not be in a upper quartile range

[John Galt 3141]

Comments on my saliva cortisol test and what to do about it, if anything?
1.3-3.0 hr after waking= 2.0 (18-19)
3.0-6.0 hr post waking= 5.0 (5.0-8.0)
6.0-9.0 hr post waking= 27.0 (5)
9.0-15.0 hr post waking= 2.0 (1.0-3.0)

Of note was feeling extreme fatigue when waking up in morning
also, 6.0-9.0 right in the middle of my stressful workday
Thanks

[chrishansen83]

Hi and welcome!

Apparently, your problem is not "Low T".

Therefore, putting you on TRT seems like a bad idea.

You have to know, that those clinics (like every business venture) are primarily interested in making money, so be really careful about what they offer you and always check if that could solve your problem.

Unfortunately, you have to be one step forward of the doc.

Yes, I know, it's ridiculous - nonetheless this is they way life works.

It looks like the doc. tried to handle all your symptoms, but not the underlying cause - all the fancy, although incredibly useful stuff he ordered you to take proves this.

I'd LOVE to take what you have, except the Testosterone and Arimidex.

I have as well 500ish T level (cause of low LH), with low cortisol, I can relate to you .

The strange thing is, your body is atm. (OK, before TRT) in a hormonal equilibrium / homeostasis and for most Low T guys that means the body somehow compensates for the low T production capability - typically lowering SHBG.
That homeostasis is a P.o.S., because you feel like sh!t and can barely go through life, but it's a survival mechanism indeed.

Your current lab values do not make any sense in the sex hormone / steroid view (DHEA low, SHBG high, WTF?), so there must be something else going on, that's why you have to dig into the thyroid issue and fix the cortisol problem ASAP - there is no way around.

Very interesting the use of sermorelin, the doc. either wanted to fix the cortisol with this, or just really wanted the $$$, sermorelin raises the GH levels a bit for a long time, unfortunately you would be better off with GHRP-6 in the morning it seems like.
GHRP is around 50 USD for a month, subQ inj., I think you can buy it anywhere in the US.
The best is to combine the two - that could fix the cortisol and you might feel better in a matter of days - of course it's hard to tell if you keep encountering stress during the days.

Yours is indeed a really complex problem.

What I see is that you are doing two, different approaches to hormonal health:

- TRT (Test. + Arimid.)
- natural hormone rebalance (all the other stuff)

I do not want to give you advice, but if I'd be you, I'd stop the Test + AI and would go with the natural route first (preg. + T3 would likely help a lot and fast).

You are 51, so going TRT could not be a big deal for you, I'm just 28 that's why I'd go natural. TRT is for life, there is no way back.

I hope you can pick a really good doc. you can trust.

Your cortisol levels are pure BS, no wonder you feel like you do.

I have to ask you:

Do you have dark under-eye circles and any kind of skin disease (seborrheic dermatitis or eczema)?

Do you look and feel like a zombie even after a couple of hours of waking up?

I took daily 10000 IUs of Vit. D before for months without any effect - I suspect Vit. D does nothing for you as long as your cortisol is in the wrong.


Good luck!