PCP or Specialist for TRT

[Tim1985]

I am trying to decide whether to use my PCP for TRT or whether it would be better to find a Endocrinologist, Urologist or go to something like a Universal Men’s Clinic and was hoping to hear some feedback on member’s personal experiences.

I just started reading up on TRT myself so I am not sure what to look for when evaluating a doctor.

I had some recent BW that only tested for total testosterone (was 270) and plan to get additional lab work to get an expanded panel as listed in the “Finding a TRT Physician“ sticky.

[Couchlock]

Phenycycladin?

[Tim1985]

Primary Care Physician

[FreshStart]

I can only tell you from my experience, but my PCP wouldn't administer TRT and he referred me to an endocrinologist. Although my endo had been practicing for 40+ years and was near retirement, he knew jack shit about TRT. He prescribed a very outdated and painful regiment of an intramuscular injection every two weeks using a needle that would have been more fitting to use on a horse.

I found this board and realized how bad the medical advice was from the endo. Searching for a solution I came upon Defy Medical out of Florida (I live in New York and most of their customers are not local to their office). My doctor and the consultation were both fantastic. To start I had to have a physical from my PCP and a bunch of bloodwork. There was a slight delay getting an appointment as a new patient of about 3-4 weeks. It could have been faster than that but I wanted to see one of the MD's on staff and not the Physician's assistant. The only annoying thing was that they needed every piece of labwork to be finalized before they would schedule the appointment (my PCP pulled the wrong Estradiol test and so the Defy Doc sent a prescription to be done out of Labcorp and this process took an extra week). The costs of setup were pretty reasonable (I think it was about $250 plus the bloodwork and PCP visit), and the costs of regular consults are also fair (about $200-250 every 6 months once you are an established patient - I'm gonna meet every 3 months for the first year until everything is dialed in). The meds themselves come in the mail from a compounding pharmacy and ran me about $500 for a 3-5 month supply including new needles. Next time I'll buy the needles elsewhere because they charged a hefty price. The $500 also included Thyroid medicine which you may or may not need. The consultation with the doctor was supposed to be an hour but we were on the phone for about 90 minutes for no extra charge. He really spent time answering my questions. If you decide to work with them do your homework beforehand so you can ask a lot of questions.

They switched me to much more frequent injections (every other day subcutaneously which are painless) and also put me on HCG and an aromatase inhibitor. He also prescribed NatureThroid which is a natural dessicated thyroid medicine instead of the synthetic hormone that docs usually prescribe.

It has only been about 6 weeks but I feel dramatically better. It was an easy decision for me because my insurance was only going to pay for the office visit to see the endo and wouldn't cover the medication, labwork or supplies. I think that bloodwork issued by my PCP will be okay for insurance since I've already hit my deductible. If your insurance will cover TRT and your budget is tight, it may be worth staying with whatever doc they will pay. But if you can't find a doc that meets your needs you'd almost be better off not starting TRT. I'd wholeheartedly endorse Defy. I feel good about my decision and confident that my new doc will help me.

[Tim1985]

I already had to pay for the additional panels out of pocket so I’m not very optimistic that my insurance is going to cover it. Does Defy let you chose who you purchase your Test through?

[FreshStart]

I'm not sure - that's a good question to ask them. I know that when I bought Test C originally I called around and found that Walmart had the best price for a 10cc bottle of 200mg which was around $150. I got it from Defy for about 15 dollars less.

[kelkel]

Defy is one of, if not the most reputable clinic out there. That said, you're still always better with a knowledgeable doc that you can meet with face to face and develop a relationship with if at all possible. The doc's title means absolutely nothing, unless you can find one who has their A4M Certification which is always a plus. They just need to know hormones. It's really not rocket science like some make it out to be.

Just start making some calls to local docs and see if they'll treat based on symptoms, not numbers on a chart and if they'll allow self injections along with HCG and an AI if needed. You should not need to make an appointment to do this, just get a nurse on the phone as you don't want to waste their time or yours. Hormone replacement is not expensive if done correctly.

[kelkel]

I'm not sure - that's a good question to ask them. I know that when I bought Test C originally I called around and found that Walmart had the best price for a 10cc bottle of 200mg which was around $150. I got it from Defy for about 15 dollars less.

Yet Costco had had it for around $40 before......

[FreshStart]

Yet Costco had had it for around $40 before......

I'll have to call them to see what the current price is. I always forget that Costco has a pharmacy. Thanks kelkel.

[TRA]

I would go to someone who does a lot of TRT and does it well. So that makes the odds about 1/1000 you can find a good doc.
Read up so you know TRT really well, pick Kelkel brain and listen to the vets here - they have more knowledge than 99% of docs on this subject because it just isn't taught in medical school.
I personally don't like endo's if you're in the US because they understand endrocrinology but not in the context of TRT. For example, you can feel like crap with total test level of say, 400 on TRT, and they think because you are in the normal range you are good. My TRT doc runs men in the 1100s with pellets because she knows that is where we feel best.
Urologists tend to be pretty good, and you can look into Aveed with them as well.
Read up and educate yourself. Good luck!

[Youthful55guy]

Similar experience and advice from me. It's a craps shoot to find a PCP knowledgeable in male HRT. However, some of them are open to being educated by the patient, and they are worth their weight in gold. Here's a synopsis of my experience (going on 6 years):

1) I saw a PCP I no longer go to. He did not do the proper labs. Only ran total T and said I was fine, but was more than willing to write me a script for antidepressants. I declined and moved on. I knew there was something messed up with my hormones, but was not educated enough in the clinical aspects of endocrinology to know what was wrong (even though I have a Master's degree in reproductive endocrinology and my dissertation dealt with hypothalamic-pituitary- gonadal interactions).

2) I found a Low T clinic about a 45 minute drive away and made an appointment. They did some lab work and even took my insurance. They ran more complete labs and diagnosed my problem as high (very high) SHBG, which was causing low Free T, even though I have excellent Total T for a guy my age (going on 55 at the time, hence the name). They agreed to treat me by jacking up my total T high enough to saturate the SHBG so that enough T spilled over into Free T. However, they would not give T to go and they would only do weekly injections. So I was stuck on this outdated protocol with a 45 mile cord attached. BUT, I did feel a whole lot better. Actually, I'd describe it as a fricken overnight miracle. They gave me a "secret blend" compounded T and it must have had a slug of T-prop in it. I got my shot about 2:00 PM. Started feeling something in the evening before bed, and then woke up feeling 20 years younger. However the weekly grind of making a 90 mile round trip to get my fix got old fast, and the weekly shot never lasted more than 5 to 6 days before I began to feel a return of symptoms. Also, I had a 2 week European vacation coming up and really needed to find a doc that would let me self-inject.

3) I found a very highly rated and well known TRT doc (the kind that lectures regularly at A4M conferences to other TRT docs. He was about a 2 hour drive, but I decided to go for it. He cost an arm and a leg and did not take insurance, but he knew his stuff! That was about 5 years ago. He got me on pretty much the same protocol I am on today and I see no reason to change. I stayed with him for about 2 years while my new PCP monitored my progress. After 2 years, she saw how good I was doing and I then approached her to take over my protocol. She agreed and that's where I am today.

[kelkel]

Great story ^^^. I went through several myself until landing a great Uro.

[Obs]

I'm not sure - that's a good question to ask them. I know that when I bought Test C originally I called around and found that Walmart had the best price for a 10cc bottle of 200mg which was around $150. I got it from Defy for about 15 dollars less.

Damn. I pay like $35 for ugl... I wouldn't trade.

[VTX1800]

I can say Defy hands down. I live close to their office so I go in for physicals and such. They actually care about you, they know what you are going through. They saved my life when I moved here in 2013. No PCP, Endo, Uro, or HRT would continue my previous A4M doctors protocol; hcg, Cyp, anastrozole. Go for A4M certified doctors, Defy, Telemeds,
Etc. Or local weight loss, hormone therapy centers. I have a tumor in my Pituitary Glad,
Now at 34 years of age, It was hard to find proper medical care. I did luck out and found a PCP to administer 200mg/ml of Test Depo, just so I wouldn’t be cold turkey, he just didn’t know
Anything about TRT and HCG. It’s a roll of the dice, unless you have previous paperwork to send over toDefy. They will take care of you! Good luck, best Wishes

[Tim1985]

Thanks for the advice guys. My PCP told me this afternoon that my total test level of 270 is still within the normal range and blamed my symptoms on the antidepressants I’m on. He at least agreed to get the additional BW panels I asked for so I’m heading back in Monday for the blood draw. Will post the numbers from the extra panels as soon as I get them. My PCP is definitely not going to be who I use for TRT so Defy is looking more and more like the route I’m going to go.

[Youthful55guy]

Thanks for the advice guys. My PCP told me this afternoon that my total test level of 270 is still within the normal range and blamed my symptoms on the antidepressants I’m on. He at least agreed to get the additional BW panels I asked for so I’m heading back in Monday for the blood draw. Will post the numbers from the extra panels as soon as I get them. My PCP is definitely not going to be who I use for TRT so Defy is looking more and more like the route I’m going to go.

I think this is the first we've hear that you are taking antidepressants. Yes, they can mess with T levels, libido, and cause ED. I suspect that there are a lot of guys out there being misdiagnosed with depression, when in fact they actually have low T or low Free T (i.e., high SHBG). Docs seems to be willing to hand antidepressants out like candy to treat the symptoms of depression, but dig their heals in when it actually comes to treating a potential cause of the depression with TRT. As I mentioned in my story above, my first PCP was more than willing to prescribe me an antidepressant rather than dig to the root of the problem by testing for Free T.

You may find that when you get on a good TRT protocol that you may be able to wean yourself off of the antidepressants. Then again, it may not have anything to do with low T. You will have to make that decision based on your own experience.

[Tim1985]

Here is the results of my additional blood work:

Total Test: 328 (range: 264 - 916)
Free Test: 11.1 (range: 8.7 - 25.1)
DHEA: 295.8 (range: 138.5 - 475.2)
SHBG: 34.8 (range: 16.5 - 55.9)
Estradiol: 18.1 (range: 8 - 35)
LH: 2.8 (range: 1.7 - 8.6)
TSH: 2.17 (range: 0.45 - 4.5)

Here is the results of my initial blood work (non fasting):

White Blood Cells: 7.3
Hemoglobin: 13.7
Hematocrit: 42
Platelet Count: 268
MCV: 94.8
Glucose: 101
Total Cholesterol: 207
HDL: 60
LDL: 119
Triglycerides: 135
BUN: 17
Creatinine: 1.1
AST: 23
ALT: 24
Total Bilirubin: 0.4
Albumin: 4.7
Alkaline Phosphatase: 66
Sodium: 138
Potassium: 4.1
Calcium: 9.6
Carbon Dioxide: 27
Vitamin D: 32.1
Vitamin B-12: 628
Folate: 17.48
Iron: 67
Ferritin: 130.8
Total Test: 273.1

[Youthful55guy]

Your T values are on the low side but not horribly low. I suspect the antidepressants have a lot to due with your symptoms, especially if they are sexual in nature.

I ran across an interesting article in Men's Health that discussed results of a T study you might be interested in reading. Here's is an excerpt with a link to the article:

In fact, a 2012 study published in The Aging Male found that after 12 months of testosterone therapy, the percentages of guys with moderately severe to severe depression symptoms decreased from 17 percent to 2 percent. And more recent research also backs that up: "The largest randomized control trial for T was just completed a year ago, called the T Trials, and it showed that men who received T had a greater improvement in mood than men who received placebo," notes Dr. Morgentaler.

From <https://www.menshealth.com/health/testosterone-therapy-effects/slide/4>

[TRA]

Your T values are on the low side but not horribly low. I suspect the antidepressants have a lot to due with your symptoms, especially if they are sexual in nature.

I ran across an interesting article in Men's Health that discussed results of a T study you might be interested in reading. Here's is an excerpt with a link to the article:

In fact, a 2012 study published in The Aging Male found that after 12 months of testosterone therapy, the percentages of guys with moderately severe to severe depression symptoms decreased from 17 percent to 2 percent. And more recent research also backs that up: "The largest randomized control trial for T was just completed a year ago, called the T Trials, and it showed that men who received T had a greater improvement in mood than men who received placebo," notes Dr. Morgentaler.

From <https://www.menshealth.com/health/testosterone-therapy-effects/slide/4>

I've never felt anything so horrible as the mental anguish and depression when my test levels were <100. I didn't know at the time and had not known for likely over a year. I had incredibly low test levels before ever considering AAS and was on TRT before ever cycling. Now I can tell without fail when my test levels are below 700-750. And I guarantee there are men out there on a host of anti-depressants for this very reason. Good post.

[kelkel]

I ran across an interesting article in Men's Health that discussed results of a T study you might be interested in reading. Here's is an excerpt with a link to the article:

In fact, a 2012 study published in The Aging Male found that after 12 months of testosterone therapy, the percentages of guys with moderately severe to severe depression symptoms decreased from 17 percent to 2 percent. And more recent research also backs that up: "The largest randomized control trial for T was just completed a year ago, called the T Trials, and it showed that men who received T had a greater improvement in mood than men who received placebo," notes Dr. Morgentaler.

From <https://www.menshealth.com/health/testosterone-therapy-effects/slide/4>

And virtually no one's better than Dr. Morgantaler.

[Tim1985]

For anyone that was on antidepressants prior to TRT, how long did you wait to taper of your meds to see if your depression was caused by your low T?

[TRA]

For anyone that was on antidepressants prior to TRT, how long did you wait to taper of your meds to see if your depression was caused by your low T?

What is your TRT regimen? If twice a week injections with test cyp, if it were me, I would do it based on lab values of test levels.
Do you know what level your doc is shooting for? Mine was fairly knowledgeable regarding TRT (not e2, haha, but test) and ran me in the upper limits of normal. I didn't feel good at less than 700, and worse exponentially as I got below 500. I was not on anti-depressants but certainly qualified.
So, I would take a step-wise approach:
1) determine goal test level
2) monitor labs and once there, under guidance of prescribing doc begin taper

The caveat is of course whether the goal test level is sufficient. So it isn't a straightforward situation. The goal would be to have a one time trial at taper so you can see, and avoid bouncing back and forth on and off the meds. Not sure if that helps but maybe you can post up the goal level here and get some feedback.

Do you have any test you can use on your own if your doc is satisfied just to get you in the range of normal, even if low?

[FreshStart]

For anyone that was on antidepressants prior to TRT, how long did you wait to taper of your meds to see if your depression was caused by your low T?

I am in this exact situation and won't be doing this for at least a year to get into an established long term protocol. And only if my doctors are all on board.

I can tell you that my doctors had found a combo of 3 medicines that were treating my depression to a point of being able to function again before I started TRT. My depression was very severe and I have a bad history of compulsive behavior in many forms. There is significant family history of mental illness, suicide, addiction and other compulsive behaviors so I'm going to be very careful about when to reduce.

I can tell you that TRT has dramatically improved my depression and mood. Now a few months into TRT and two months into new better protocol I feel substantially different than I did before. My mood had not really improved when on the meds prior to TRT, but what had changed was my ability to function and do things. TRT has taken this to a new level and my mood has substantially improved. Prior to TRT but with meds I also had short cycles (1-3 weeks) of depression that were bad but not as bad or as deep as without meds. I haven't had one of these cycles since being on the new protocol.

My mental clarity is also unlike anything I can remember from my adulthood. I am self employed and I've worked both harder and significantly smarter since being on TRT without noticing it. I have heard a tremendous amount of feedback from clients indicating that I sound and am acting differently (better) than I had before.

I am also going through a pretty significant life and lifestyle change so piecing out how much is due to TRT and how much is due to significant weight loss and improvement in self image would be difficult. But I truly think the protocol I'm on now has significantly helped.

[Tim1985]

Successfully found a new TRT doc that is A4M certified. Night and day difference between the other doctors I met with and he treats based on symptoms not a set number. He decided to start me with 25 mg/day of Clomid for 25 days then 5 days off. Will run that for 3 months then pull labs and decide where to go from there. Since my wife and I are not sure whether we are finished having kids, he thought this was a better place to start.

Depending how I respond to the Clomid or if I decide to get snipped, he will then switch me over to Test. He wasn’t against me taking HCG in addition to Test but seemed like it would only be if I pushed for it (I plan to).

He also told me to pick up Dr Morgantellers book “Testosterone For Life” which has been a good read and matched up with all the sticky’s I’ve read on this forum.

If anyone has past experience with starting on just Clomid, I’d be interested to know what your Test levels increased to and how long you stayed on that treatment before switching to Test?

[kelkel]

Happy for you Tim! Let us know how the clomid therapy works out for you please. Seems like a long time to wait for BW though?

[Tim1985]

Been awhile since my last update. My most recent labs in Feb showed:

total test = 812.7 (range 250 - 1,100 ng/dL),
free test = 133.9 (range 46 - 224 pg/mL)
FAI = 79.1 (range 23 - 130)
SHBG = 35.6 (range 10 - 50 nmol/L)
estradiol = 77.5 (range <40 pg/mL)

Since my estradiol was high, he started me on 0.5 mg arimidex, twice weekly. I still take 25 mg of clomid daily for 25 days then 5 days off. Now that my son was born, he is gona switch me over to injections next month but he is still fighting me on taking HCG. I don’t think he is gona budge so I have been in contact with Defy and can get a HCG script through them.

My overall health is night and day different - mental clarity, energy and libido are back to normal. Also broke through a plateau at the gym and started making strength gains steadily over the last three months.

While I know Clomid therapy isn’t for everyone, it has been a great start to my TRT. For anyone with low T, on the fence with injections, pellets or cream, ask your dr about starting off with clomid. My insurance company won’t cover shit but with GoodRx I pay $4 at Walmart for a two month supply.

[Youthful55guy]

Been awhile since my last update. My most recent labs in Feb showed:

total test = 812.7 (range 250 - 1,100 ng/dL),
free test = 133.9 (range 46 - 224 pg/mL)
FAI = 79.1 (range 23 - 130)
SHBG = 35.6 (range 10 - 50 nmol/L)
estradiol = 77.5 (range <40 pg/mL)

Since my estradiol was high, he started me on 0.5 mg arimidex, twice weekly. I still take 25 mg of clomid daily for 25 days then 5 days off. Now that my son was born, he is gona switch me over to injections next month but he is still fighting me on taking HCG. I don’t think he is gona budge so I have been in contact with Defy and can get a HCG script through them.

My overall health is night and day different - mental clarity, energy and libido are back to normal. Also broke through a plateau at the gym and started making strength gains steadily over the last three months.

While I know Clomid therapy isn’t for everyone, it has been a great start to my TRT. For anyone with low T, on the fence with injections, pellets or cream, ask your dr about starting off with clomid. My insurance company won’t cover shit but with GoodRx I pay $4 at Walmart for a two month supply.

Sounds like you are in good hands. Happy for you. I would push for the HCG though.

[kelkel]

Glad you're doing better! Be careful with that much adex though. In my opinion half of that would be a better place to start.

[APIs]

OP, do not allow anyone to disparage your use of antidepressants. Internet opinions expressed here should hold -Zero- value to you in this regard. The decision to halt them should be based on consultation between you and your Doc. It's just really bad practice for people on here to be bashing these meds. Some people do require them & there's nothing wrong with it...

[kelkel]

An API sighting. Hope all is well!

[APIs]

^Hey thanks Kel, life is good. Still a reader here, but no time for much else ;-(

[Tim1985]

Kelkel, what should I be targeting for my estradiol range? I go back in for a follow up and will get them to run BW again. All my dr mentioned was wanting it back below 40 pg/mL

[Youthful55guy]

Kelkel, what should I be targeting for my estradiol range? I go back in for a follow up and will get them to run BW again. All my dr mentioned was wanting it back below 40 pg/mL

It depends on the laboratory, the exact test method, and their own "normal ranges". For LabCorp, using the LC/MS/MS method (the one I recommend), the normal range is 8-35 pg/mL. I usually shoot for the upper 50% to 75% of the range, which is about 22-28 pg/mL. I adjust my anastrozole dose using the Vodke/Eye Dropper method based on labs. I also use nipple reactivity as a guide. Typically, they become less reactive (lifeless) if I go too far. My last test showed an E of 23.2 pg/mL and nipple reactivity has been somewhat diminished. I retesting next week and will make a decision whether to drop my dose from 0.5mg/week (5 drops per day) to 0.4mg/wk (4 drops per day).

[Tim1985]

Since my last post I have had BW done in mid May and on August 1st.

Before my May BW, I was taking 25mg Clomid daily for 25 days and then 5 days off, along with 0.5 mg arimidex twice a week.

May BW results:-
Total Test: 633.2 (down from 812.7 in Jan)
Free Test: 106.7 (down from 133.9 in Jan)
FAI: 63.1 (down from 79.1 in Jan)
SHBG: 34.8 (down from 35.6 in Jan)
Estradiol: 56.8 (down from 77.5 in Jan)

Going into the appointment, I was feeling about as good as I could ever remember and my lebido was back like it was in high school. After going in for my follow up appointment at the start of June, he swapped me over to injections. Script said 200mg injection once every 2 weeks but I inject 50 mg every 3.5 days. He was happy to see my estrogen come down but still said it was high so increased my arimidex to 1mg twice a week.

He also discovered through some genetic testing that I was homogeneous for the MTHFR gene and heterogeneous for the COM-T gene which long story short was the cause of my depression. Had me start taking a supplement called SAM-E and gradually started to taper me off Prozac.

Mid July, I started to notice I wasn’t feeling as good as I have been the past couple months and thought that maybe I bottomed out my estrogen with the increased dose. I went in for follow up BW August 1st and just got the results.

August BW
Total Test: 687.8 (up from 633.2)
Free Test: 160.1 (up from 106.7)
FAI: 94.6 (up from 63.1)
SHBG: 25.2 (down from 34.8)
Estradiol: 56.2 (down from 56.8)

Needless to say I was shocked that doubling the arimidex dose did almost nothing to my estrogen level. Any chance that would be from the big jump in free test? The Dr wants me to start taking 1 mg arimidex three times a week, which seems really high but gona listen to him. Not sure if the changes I’m noticing are from trying to get off Prozac or my hormones still being out of range. Any thoughts on how my estrogen failed to drop when he doubled my dose? Getting frustrated making adjustments and then having to wait weeks/month for follow up BW, while feeling like shit again.

[Youthful55guy]

I don't have any constructive feedback on the estrogen, except to agree that is a lot of Arimedex! Also, it helps if we can see the "normal" ranges for the test. Lavatories vary in terms of normal ranges, so it makes it more difficult to give opinions without knowing where you are within your lab's normal ranges.

It's interesting that your SHBG level came down quite a bit. Makes me wonder if the Prozac was pushing it up. You might want to research whether that is a potential side-effect. The drop in SHBG helps to explain the increased Free T.

[Tim1985]

Total Test range is 250 - 1,100 ng/dL
Free Test range is 46 - 224 pg/mL
FAI range is 23 - 130
SHBG range is 10 - 50 nmole/L
Estradiol range is <40 pg/mL