Need Help & Advice - First Post

Hello, long time lurker here making first post. Tried to provide all relevant info and blood work. Sorry for long post.

Background
I am a 36-year-old morbidly obese man. I currently weigh 396 pounds and am 5’11. I will be having a dexa scan soon to determine my body fat percentage. On December I weighed 521 pounds. I had type two diabetes and severe hypertension that was poorly controlled by three medications. I’ve dropped this weight very quickly by making a major change to my diet and beginning to exercise. I had never worked out in my life before December.

I’ve got a very long way to go, but some things have improved. I no longer have type two diabetes. My blood pressure is now well controlled by one medication. Before December I could barely walk and climbing a flight of stairs was like attempting Everest. Now I am much more mobile. I exercise regularly six days a week. Currently I walk one to two miles in the morning, in afternoon do one hour of elliptical training or hiking, and one hour of high rep low weight circuit training, and 30-40 minutes of swimming laps. I do this six days a week rotating between muscle groups.

Medical Issues and Medications:
· Morbid Obesity
· Hypertension (controlled by medication Lisinopril 40 mg)
· Gout (controlled by medication Uloric 80 mg)
· Severe Depression and Insomnia (take Wellbutrin 300, Trazodone 200, Effexor 150). See psychologist once per week, psychiatrist once per month.
· Nighttime incontinence/frequent urination – (treated by Vesicare 5 mg)
· Severe visual problems related to night vision and glare. Have seen ophthalmologist, neuro-ophthalmologist and neurologist. Had MRI, visual field testing, detailed eye scans and photo study. No real findings. Suggested might be due to medications or abnormal migraines.
· Low testosterone (Endocrinologist prescribed 200 mg Testosterone Cypionate every 14 days by self injection).

Nutrition:
· Work with a nutritionist – have phone consults every week.
· Cut out juices, refined sugars, fast food, regular soda.
· Currently consume 2600 calories over 6 meals per day. I eat a lot of vegetables, clean protein, small portions of low glycemic carbs.
· Two meal replacement shakes per day.
· Roughly 40:40:20 macro breakdown.

Supplements:
· Fish Oil
· Multivitamin
· Probiotic
· ZMA
· Digestive Enzymes
· Vitamin D 5000 iu

Blood work:
May 26^th: PCP blood work plus Testosterone level

Test Name	Test Value	Reference Range
Total Cholesterol	178	125-200
HDL Cholesterol	39	>=40
Cholesterol/HDL Ratio	4.6	<=5.0
LDL Cholesterol Calculated	99	<130
Triglycerides	181	<150
Protein Total	7.7	6.1-8.1
Albumin	4.4	3.6-5.1
Globulin	3.3	1.9-3.7
Bilirubin Total	0.5	0.2-1.2
Bilirubin Direct	0.2	<=.2
Alkaline Phosphatase	35	40-115
AST	29	10 to 40
ALT	49	9 to 46
WBC	9.1	3.8-10.8
RBC	4.91	4.2-5.8
Hemoglobin	13.3	13.2-17.1
Hematocrit	41.1	38.5-50
MCV	83.7	80-100
MCH	27.2	27-33
MCHC	32.5	32-36
RDW	16.2	11 to 15
Platelet Count	282	140-400
MPV	9.6	7.5-12.5
Total Neutrophils %	66	38-80
Total Lymphocytes %	24	15-49
Monocytes %	7.1	0-13
Eosinophils %	2.5	0-8
Basophils %	0.4	0-2
Total Testosterone	106	250-827
Vitamin D	19	30-100
Fasting Glucose	94	65-99
Sodium	136	135-146
Potassium	4.4	3.5-5.3
Chloride	102	98-110
Carbon Dioxide	27	20-31
Urea Nitrogen	15	7 to 25
Creatinine	0.77	0.6-1.35
Calcium	9.9	8.6-10.3
Uric Acid	5.3	4 to 8
TSH	3.96	0.4-4.5
Hemoglobin A1C	5.4	<5.7

PCP Expanded Hormone Testing 6/5:

LH	1.4	1.5-9.3
Testosterone Total	94	250-1100
Testosterone Free	24.7	46-224
Testosterone Bioavailable	48.6	110-575
SHBG	10	10 to 50
Albumin Serum	4.3	3.6-5.1

Endocrinologist Initial Blood work 6/16:

TSH	5.15	0.4-4.5
T4	6.4	4.5-12
T3 Uptake	33	22-35
Free T4 Index	2.1	1.4-3.8
Prolactin	16.4	2 to 18
Cortisol	17.6	4 to 22
IGF-1	67	53-331

Had first injection of 200mg Test Cypionate on 6/29. Second Injection on 7/13.

Endocrinologist blood work one week after 2^nd bi monthly injection - 7/20/17:

Ferritin	115	20-345
Iron	46	50-80
TIBC	347	250-425
Transferin Saturation	13	15-60
FSH	1.2	1.6-1.8
Testosterone	268	250-827

Hormone Replacement:
By late May many things had improved related to my initial weight loss; however, still had zero libido, severe depression and very little energy. Primary care physician ordered initial testosterone level, and then follow up labs. Low LH combined with complex new eyesight issues led PCP to think I had a pituitary tumor. Had MRI with and without contrast – no tumor found. Findings were an undersized pituitary. Was referred to endocrinologist.

Endocrinologist is well-respected MD who is in his seventies and has practiced for forty plus years. However, he seems to not do very much HRT. Did hormone blood work and then prescribed Testosterone Cypionate 200mg every fourteen days by self-administration.

Have done two injections so far and had blood work one week after second injection. Doctor is pleased with results. Doctor will not change dosage, or allow more frequent injections until next appointment in six months. Will not prescribe HCG or an AI.

Goals:
· Continue weight loss. Ultimate goal weight 175 pounds. For now, would be thrilled to get below 300 in next 6-8 months. This may be too optimistic given that every pound gets harder.
· Get off of as many medications as possible.
· Find right doctor and plan for hormone replacement.

Questions:
· I’ve lurked on this website for a long time. From comparing what is posted here to my doctor’s responses to my questions, it seems that my doctor knows very little about HRT. Do you agree, or does the fact that I am still morbidly obese change what would normally be prescribed?
· Should I change doctors and if so are there any that you could recommend in Suffolk County on Long Island NY (Port Jefferson)?
· If I stick with current doctor should I change schedule of injections to once or twice per week at lower doses? Or should I play by his rules for six months?

I appreciate any advice you can give and for reading such a long post. You guys are a phenomenal resource. I’m not thin skinned; nothing you say will offend me. I know I have a really long way to go.

awesome post my friend and good to see the lifestyle choices you are making listed above I don't have any advice but wish you luck on your journey and will follow your progress if you post/share it

Quote:

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Originally Posted by FreshStart

.
Questions:
· I’ve lurked on this website for a long time. From comparing what is posted here to my doctor’s responses to my questions, it seems that my doctor knows very little about HRT. Do you agree, or does the fact that I am still morbidly obese change what would normally be prescribed?
· Should I change doctors and if so are there any that you could recommend in Suffolk County on Long Island NY (Port Jefferson)?
· If I stick with current doctor should I change schedule of injections to once or twice per week at lower doses? Or should I play by his rules for six months?

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Beside nutrition and exercise, the obesity may be linked to the diagnosis of an underdeveloped pituitary. Not much you can do about that, so control the things you can control. HRT being one of them.

To be honest, the protocol he put you on is out of the stone age. You will constantly have hormonal swings and that's not good. YES, I highly recommend that you keep the total dose, but change the dosing schedule to twice per week or E3D. That will deliver the same amount of T, but at a much more constant level in your body. Make sure testing is done at the time just prior to your next injection. You may want to discuss this change with your doctor so that he/she is not surprised with the follow up lab results.

Changing doctors is up to you, but you want one that will work with you and not just prescribe TRT cookbook style. If you do stick with him, I would not stay on that 2 week stone age protocol. It's a recipe for disaster.

I also notices a lot of your other labs being at the low end, particularly SHBG. I believe that your E2 is probably also low since it generally follows T levels. As the T levels increase, E2 should also increase and this will be good for you, as it may help drive up your SHBG. SHBG is an important protein to help protect T from liver metabolism. This will help to increase your total T and serve as a buffer for the release of Free T. You want most of your labs to be in about mid-range.

I also noted that your IGF-1 levels suck. You may want to consider asking your doctor to also prescribe HGH therapy. Given your medical condition and your very low IGF-1 levels, you may be able to get it covered by insurance (it's very expensive). Additional tests may be required to confirm the low GH diagnosis to satisfy insurance. Check into their requirements before you go down that path.

Congrats on the Weight Loss!! Great job!! I take Lisinopril too. A side effect of some medications is that they dry you out. Should try Dry Mouth mouth wash and Eye Drops to keep your eyes moist. Eye drops may help with the focus.

I agree your Test dosing is better done weekly. Split into two doses. Usually 100 to 150mg split into two.

I had an after thought about your situation. Since you know through MRI that you have an underdeveloped pituitary gland, and your labs are consistent with this diagnosis, you might be at risk for many other hormones being out of balance. The pituitary produces numerous hormones, many of which control other glands to produce their own hormones. Hence, it's been called at times the "Master Gland".

Just one example, I am willing to bet that if you tested your pregnenolone and DHEA levels that they would be low. The pituitary helps regulate production of these hormones in the testicles and adrenals through the release of LH. You know your LH is low, so there's a trickle down effect. Trickling down even more, pregnenolone and DHEA are important precursor hormones to many, many steroid hormones (including testosterone). The following diagram is a very simplistic view of the steroid hormone cascade.
Attachment 170087

You can supplement with pregnenolone and DHEA if your state allows the sale of them. As far as all of the other effects of having an underdeveloped pituitary (e.g., GH, IGF, etc.). You probably need consultation with a hormone expert with experience in this type of treatment.

Quote:

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Originally Posted by matt thebeard

awesome post my friend and good to see the lifestyle choices you are making listed above I don't have any advice but wish you luck on your journey and will follow your progress if you post/share it

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Quote:

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Originally Posted by jwh7699

Congrats on the Weight Loss!! Great job!! I take Lisinopril too. A side effect of some medications is that they dry you out. Should try Dry Mouth mouth wash and Eye Drops to keep your eyes moist. Eye drops may help with the focus.

I agree your Test dosing is better done weekly. Split into two doses. Usually 100 to 150mg split into two.

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Thank you both for your words or support. JWH you are so right about the drying out effects of multiple meds. Combined with trying to restrict liquids pre bedtime, I wake up and my mouth is sand. I After chugging 1-1.5 liters of water I feel ok. But even then after brushing my teeth and mouthwash my mouth still feels gross throughout the day. I'm definitely going to try some of the dry mouth products - I ordered biotene to start.

Quote:

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Originally Posted by Youthful55guy

Beside nutrition and exercise, the obesity may be linked to the diagnosis of an underdeveloped pituitary. Not much you can do about that, so control the things you can control. HRT being one of them.

To be honest, the protocol he put you on is out of the stone age. You will constantly have hormonal swings and that's not good. YES, I highly recommend that you keep the total dose, but change the dosing schedule to twice per week or E3D. That will deliver the same amount of T, but at a much more constant level in your body. Make sure testing is done at the time just prior to your next injection. You may want to discuss this change with your doctor so that he/she is not surprised with the follow up lab results.

Changing doctors is up to you, but you want one that will work with you and not just prescribe TRT cookbook style. If you do stick with him, I would not stay on that 2 week stone age protocol. It's a recipe for disaster.

I also notices a lot of your other labs being at the low end, particularly SHBG. I believe that your E2 is probably also low since it generally follows T levels. As the T levels increase, E2 should also increase and this will be good for you, as it may help drive up your SHBG. SHBG is an important protein to help protect T from liver metabolism. This will help to increase your total T and serve as a buffer for the release of Free T. You want most of your labs to be in about mid-range.

I also noted that your IGF-1 levels suck. You may want to consider asking your doctor to also prescribe HGH therapy. Given your medical condition and your very low IGF-1 levels, you may be able to get it covered by insurance (it's very expensive). Additional tests may be required to confirm the low GH diagnosis to satisfy insurance. Check into their requirements before you go down that path.

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Quote:

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Originally Posted by Youthful55guy

I had an after thought about your situation. Since you know through MRI that you have an underdeveloped pituitary gland, and your labs are consistent with this diagnosis, you might be at risk for many other hormones being out of balance. The pituitary produces numerous hormones, many of which control other glands to produce their own hormones. Hence, it's been called at times the "Master Gland".

Just one example, I am willing to bet that if you tested your pregnenolone and DHEA levels that they would be low. The pituitary helps regulate production of these hormones in the testicles and adrenals through the release of LH. You know your LH is low, so there's a trickle down effect. Trickling down even more, pregnenolone and DHEA are important precursor hormones to many, many steroid hormones (including testosterone). The following diagram is a very simplistic view of the steroid hormone cascade.
Attachment 170087

You can supplement with pregnenolone and DHEA if your state allows the sale of them. As far as all of the other effects of having an underdeveloped pituitary (e.g., GH, IGF, etc.). You probably need consultation with a hormone expert with experience in this type of treatment.

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YouthfulGuy thank you very much for going through my labs and post with such attention. It's very helpful. I called my endocrinologists office and switched my appointment for 4 months instead of 6 (I have a 5 month supply of Test) so if makes sense to have appt before supply runs out so I can switch docs if need be.

I plan to take your advice and begin doing injections twice a week starting in two weeks (I pinned a full 200 mg today because I want a little more time to educate myself before changing protocol). I'm also going to insist that the endo does significantly more bloodwork than he was planning to do before our appointment. And I'm going to press him to try to get my other hormones tested in more detail.

I doubt that I am going to stick with this endo long-term but my insurance makes switching a little difficult. I have great in network coverage at this one hospital and medical center, but out of network it is going to be significantly more expensive. There are other younger endos that I can see in network but this guy is the chief so I have a feeling others aren't going to want to overstep him and be more aggresive. If I need to go somewhere and pay cash so be it. I'm lucky to be able to afford it. One thing I've learned since January is that it's not worth obsessing over the cost of something that will make you feel better and be able to enjoy life. The cost of being sick and depressed is far higher.

I'm going to also look into what you said about pregnenolone and DHEA. I understand what you are talking about in a general sense but I want to have a much better picture of how these various hormones signal and interact.

Do you know anything about thyroid function? I was looking at older bloodwork that I posted which was from early January and what jumped out at me was my TSH level. On January 5 my TSH was 3.27. On May 26 it was 3.96. On June 16 it was 5.15. Although the June 16 T3 and T4 labs are "in range" it seems like an accelerating TSH level that goes up by 57% in 5 months might warrant attention. The doc said that he thinks the level could be artificially inflated because I started eating sushi in mid may and that seaweed has high iodine content. My nutritionist said that that was crap - that nori doesn't have much iodine only kelp which isn't used in sushi. Combined with my depression, and a strong family history of hypothyroidism (mother and sister have taken Synthroid for 30 + years) I'm curious if I should be on a low dose?

Thanks again for your time and detailed answers.

Biotene is good. ACT makes a dry mouth mouth wash too that's pretty good. They also have a dry mouth spray which might be good to have on your night stand. Xylitol gum is a type of gum for dry mouth. You can do a search for it on Walmart.com

If you're constantly waking up with very bad dry mouth, you may be snoring a lot in your sleep. A sleep study to rule out Sleep Apnea is a good idea.

Yeah, make sure they add DHEA, Pregnenolone, and Estradiol - Sensitive to your next Blood Work.

If your Insurance covers TRT In-Network, I would stay In-Network. As long as they let you self-inject you can adjust your dosing any way you want.

I am not well versed on the Thyroid, but an increase of 50% in less than 6 months is something to definitely look into. You could always stick with your current Endo for TRT. Take a look at the younger guys and pick the one that knows the most about the Thyroid, also it gives you a leg in the door if you decide to move your TRT over too them too.

A good book you can pick up at the Library is called "Stop the Thyroid Madness", they have a good website too.

I noticed your Vitamin D level is low. It's very common nowadays. You should talk to your Doctor about it. If they won't prescribe something it's very easy to buy on-line.

- I re-read your supplements list and see that you are taking Vitamin D already. :)

[QUOTE=FreshStart;7313134]Do you know anything about thyroid function? I was looking at older bloodwork that I posted which was from early January and what jumped out at me was my TSH level. On January 5 my TSH was 3.27. On May 26 it was 3.96. On June 16 it was 5.15. Although the June 16 T3 and T4 labs are "in range" it seems like an accelerating TSH level that goes up by 57% in 5 months might warrant attention. The doc said that he thinks the level could be artificially inflated because I started eating sushi in mid may and that seaweed has high iodine content. My nutritionist said that that was crap - that nori doesn't have much iodine only kelp which isn't used in sushi. Combined with my depression, and a strong family history of hypothyroidism (mother and sister have taken Synthroid for 30 + years) I'm curious if I should be on a low dose?
QUOTE]

I agree with your Endo that eating high iodine foods will not increase your TSH, if anything it should have the opposite effect. interestingly, TSH is one of the hormones produced by the pituitary, so it seems to be functioning in that regard. TSH is produced by the pituitary in response to low T4/T3 levels. The thyroid produces T4 (which is short for a long name that indicates the hormone has 4 iodine atoms attached to it). However, T3 is the much more active form of the hormone and it is made from T4. If you have high TSH (anything above about 3), it is a very good indication that your thyroid is not functioning properly and not producing enough T4. We know the problem is at the thyroid and not pituitary level because your TSH is high. The pituitary is trying to tell the thyroid to make more T4, but it's either not getting the signal or it's just not capable of producing enough T4 to feedback negatively on the pituitary to decrease TSH levels. High TSH is a symptom of the problem, not the problem itself.

With a TSH over 5, you really should be considering thyroid hormone supplementation. It will probably help with the obesity too because your metabolism must be very low. Supplementing with thyroid hormone will probably help that. I also suspect that the depression issue is linked to both the low thyroid hormone and low T, as deficiency of either hormone is linked to depression. Having both of them out of range only increases the risk of depression. You may want to consider a medication adjustment as your get these hormones within healthier levels.

great to see the progress you have made, diet, lifestyle, and a genuine interesting in bettering yourself.

Youthfull55 has some great points, he is very knowledgable, these guys keep impressing me every time
I read a post such as yours with multiple medical issues...
there advice is to instill much thought.
I will add a few suggestions or ideas that came to mind.
your 200 mgs every 2 weeks does suck... at the min once a week if anything,
as you say you are going to do more research on multiple injections, I still havent
jumped on the E3D routine, but I didnt like the 2 week protocol. not to sure how
much it would throw your bloodwork out at once a week, but it would make T levels more stable,
you must feel pretty down before your shot, just remember to do bloodwork the morning of your shot,
before shot...
the explanation of the relationship between thyroid and pituitary was bang on, again, theres always
something youre gonna learn on here... I agree with youthful55s explanation of t3 t4 levels....yours do seem
to be a little low, at bare min they should be midrange, the ranges they give are ridiculous, they should be used to reference
midrange, but a doctor only looks and says .."youre in range" weather your at the low end or the high end,
TSH on the rise is not good, and even if youre just over, they wont usually prescribe meds yet, mine had to hit 12,
even though I was told I had hashimotos disease...press this issue with your doc, as was said, your metabloism
is probably slow and a contributing factor to obesity. have you had your thyroid antibodies checked?

good luck withh your journey/battle, you are taking the right steps, your health can only get better

A couple more thoughts:

Your prolactin is way high and that can be problematic for T. Even on TRT, it will be problematic if E2 gets out of range. High E2 + high prolactin can lead to a case of gynecomastia. If for some reason progesterone spikes or you start throwing in some AAS with progestin like activity, your at risk of a REALLY BAD case of gynecomastia (e.g., begin lactating). So, consider talking to your doc about this and at the very least monitoring it. Obesity is linked to high E2 in men because fat cells are loaded with aromatase enzyme, the more fat, the more the conversion of T to E2. So if you go on TRT, and T levels rise as they should, E2 may spike.

Your cortisol levels are high. However, this may resolve as your other hormones come back into range. Best to monitor it.

Per one of my previous posts, your IGF-1 (Somatomedin C) levels suck. This means inadequate Growth hormone production and/or low IGF binding protein 3. You might want to consider requesting a script for HGH, but this is very expensive, so it's best to have it covered by insurance if you can get it. With your numbers, chances are good for coverage if it's within plan. IGF-1 is a marker of growth hormone production. GH is very much involved with metabolism, so low individuals with low GH are often morbidly obese. HGH supplementation treats the problem, not the symptoms (obesity).

YouthfulGuy thanks again for your detailed responses. I appreciate very much.

As I mentioned above I'm going to switch myself to twice weekly injections (Monday/Thursday). Should I wait until two weeks from last injection?

Also, I'm going to get different needles and syringes. My doc had ordered 3cc syringes with a 22g 1.5" needle for drawing up and injecting. I'm using outer thighs for shots. First shot was fine. Second one hurt. Third one seemed ok until about 10 hours after injection. There is no redness or sign of infection but there is a lot of pain when I lie down on it. Feels like a small bump down in the muscle that is very sore. The nurse that taught me how to inject and supervised second shot said she thought the 1.5 inch length needles were crazy as was the 22 gauge width.

Since I'll be injecting a quarter of prior volume I was going to get 1 cc luer lock syringes and then two needles for drawing up and injecting. I am very obese and most of my weight is in my thighs hips and butt. I was going to get an 18g 1.5 inch needle for drawing up and then a 25 g 1.5 inch needle for dispensing but I'm wondering if I should switch to one inch length? Do those gauges seem right? Any particular supplier to order from, I was just going to get on Amazon..

Thanks again for all responses.

I realized from one of the replies above that I didn't mention my sleep apnea. I was diagnosed with obstructive sleep apnea about 12 years ago when I was roughly at current weight. I tried CPAP BIPAP and APAP and all of them completely sucked. I really couldn't sleep and at the time was traveling a lot for work so it was even more annoying. I stopped using it.

I definitely still have OSA and it is likely worse than before. I no longer travel much for work and also have different insurance so I qualify for new gear. Had the consultation and waiting for sleep study. There's a very long backlog and so my appointment is in end of November (consultation was in April). Insurance will pay but for now I have to be patient. I'm considering paying cash for one of the dentist fitted appliances but they are expensive (my insurance will only pay after in network sleep study and trying PAP therapy for several months) and don't work well for more severe OSA cases.

Quote:

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Originally Posted by FreshStart

YouthfulGuy thanks again for your detailed responses. I appreciate very much.

As I mentioned above I'm going to switch myself to twice weekly injections (Monday/Thursday). Should I wait until two weeks from last injection?

Also, I'm going to get different needles and syringes. My doc had ordered 3cc syringes with a 22g 1.5" needle for drawing up and injecting. I'm using outer thighs for shots. First shot was fine. Second one hurt. Third one seemed ok until about 10 hours after injection. There is no redness or sign of infection but there is a lot of pain when I lie down on it. Feels like a small bump down in the muscle that is very sore. The nurse that taught me how to inject and supervised second shot said she thought the 1.5 inch length needles were crazy as was the 22 gauge width.

Since I'll be injecting a quarter of prior volume I was going to get 1 cc luer lock syringes and then two needles for drawing up and injecting. I am very obese and most of my weight is in my thighs hips and butt. I was going to get an 18g 1.5 inch needle for drawing up and then a 25 g 1.5 inch needle for dispensing but I'm wondering if I should switch to one inch length? Do those gauges seem right? Any particular supplier to order from, I was just going to get on Amazon..

Thanks again for all responses.

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Can't help you with the OSA, zero experience, only know that it can really mess up sleep patterns and thus T and GH levels.

Regarding the needles, there's really no reason that the T has to go into the muscle. I've seen absolutely zero research that IM T is any better or worse the SC T. I believe this is simply a medical hand-me-down method. IM happens to be the way they started injecting decades ago because they were administering huge doses of an oily substance and for some reason they thought putting it into the muscle would be better than the fat. it might have something to do too with the esters they were using back then. My experience is that T-cyp is completely SC compatible but T-prop is not. I get a huge amount of bruising with T-prop SC but not with T-cyp.

My inclination is to say to you to skip the 1.5 inch needles and the separate draw and inject needles and go straight to one piece insulin syringes to draw and inject. I use 30G 1/2 inch needles very successfully. If you feel you need a slightly longer and bigger needle, I have used a 25G 5/8 inch needle insulin syringe, but I would personally never go back to that after using a 30G.

best of luck

22g to pull and inject?...same needle?...OUCH
at least pull with 22g and change to a 25g min...
it must be a little dull once you put it in the skin.