33, Low T, Trying to Find Cause and Best Treatment Option

[ddillon]

Age: 33
Height: 6’00”
Waist: 34
Weight: 225, ~25% BF per Bioelectrical Impedance
Body Hair/Facial Hair: Average, definitely not a full bearded lumberjack.
Carry Fat: Gut
Health Conditions: Adult ADD, Broken Collar Bone that Never Calcified
RX: 25mg Adderall XR, never used prostate or hair loss drugs. Did do a few cycles of Accutane in high school. Use Viagra/Cialis 2-3 times a week. Creatine at ~5 g daily. Vaporizer with Nicotine daily.
Lab Results: See Below
Diet: 1500-200 calories Monday through Friday. 2500-300 on the weekend.
Training: 5X5 2-3 times a week for the last year. Weight trained since high school.
Teste Ache/Fever: No.
Morning Wood: Less frequent the last few years.

Initial Lab Results 2/4/2016, 10:00 A.M. (Blood Test)
Free Test: 71.1 pg/mL (Ref Range 30-140)
Testosterone: 331 ng/dL (Ref Range 200-730)
Albumin: 3.8 d/dL (Ref Range 3.2-5.0)
SHBG: 32 nmol/L (Ref Range 11-80)

Recent Lab Results 3/18/2016, 9:00 A.M. (Blood Test, Will Update as Additional Results Received from Lab)
fT3: 2.9 pg/mL (Ref Range 1.71-3.71)
fT4 (FT4_6): 1.06 ng/dL (Ref Range 0.69-1.55)
LH: 5.1 mIU/mL (Ref Range 0.6-12.1)
FSH: 2.6 mIU/mL (Ref Range 0.9-11.9)
PTH Intact: 28.2 pg/mL (Ref Range 12-80)
Total Calcium: 9.7 mg/Dl (Ref Range 8.5-10.5)
Ionized Calcium: 1.23 mmol/L (Ref Range 1.11-1.33)
PSA: 0.47 ng/Ml (Ref Range 0.07-4.00)
TSH: 1.92 uIU/mL (Ref Range 0.35-4.94)
VIT D: 27 (Ref Range 30-96)
Glucose: 99 mg/dL (Ref Range 65-115)
Urea Nitrogen: 18 mg/dL (Ref Range 5-24)
Creatinine: 1.4 mg/dL (Ref Range 0.6-1.5)
EGFR: 58.7 mL/min/173 (Ref Range >60)
EGFR AA: >60 mL/min/173x1.21 (Ref Range >60)
Sodium: 147 mmol/L (Ref Range 133-149)
Potassium: 4.6 mmol/L (Ref Range 3.5-5.1)
Chloride: 108 mmol/L (Ref Range97-110)
Carbon Dioxide: 26 mg/dL (Ref Range 22-33)
Calcium: 9.6 mg/dL (Ref Range8.3-10.3)

C-Reactive Protein: 0.5 mg/dL (Ref Range 0-1.0)
Prolactin: 8.0 ng/mL (Ref Range 2.8-15.6)
Estradiol: 23.0 pg/mL (Ref Range 11-44)
ESR: 10 mm/hr (Ref Range 0-20)
LD: 161 IU/L (Ref Range 100-253)

I am waiting on the additional test results that needed to be sent to another lab and will update the post when I receive them. Pituitary MRI scheduled for this weekend and bone density scan tomorrow.
Body temperature is at 98.6 first thing in the morning per an in ear thermometer, was at 100.7 after getting out of the shower today.
Diet is pretty clean M-F, lots of protein, healthy fats, low glycemic carbs via vegetables and whole grains when I eat carbs.
A little background on me. I have never used any steroids or performance supplements outside of whey and creatine. Trained since I was in high school with weights and still do. Noticed at about 28 years old some mild ED, worsened with age. Sex drive has been a lot lower the last year or two. I am shooting for 1500-1750 calories a day during the week but weight is really slow to come off. I started having trouble focusing at work a few years ago and received a prescription for Adderall XR, wondering if this is the brain fog discussed by others with low T. I’m a tax CPA with my own firm but I do not feel overly stressed, I’ll be curious to see the cortisol test results. Up until mid-20’s to late 20’s I never felt any of the symptoms associated with low T. Started feeling them a few years ago bit only recently made the connection with low T, hence the recent lab tests above.
Getting married in November and shooting for kids shortly after, so I was initially very hesitant to consider using TRT. After some research I am open to the idea but want to ensure I do not affect my ability to have kids, so assuming hCG would be in the cards. Ideally I would like to get my T levels up naturally and have been researching the HPTA restart protocol with hCG to Nolvadex per K Sman’s sticky. Noticed that my Vitamin D is low so I will be looking for a supplement, any recommendations are welcome.
Any help identifying whether I’m primary, secondary or thyroidal is very much appreciated. This forum has a lot of great info and I’m glad to have a resource to help me learn how to best deal with these issues. Thanks in advance for any input.

[KSman]

Can you get oral temperatures?

You are definitely a bit estrogen dominant now, relative to T levels.

TSH=1.92 may be a problem.
Do you use iodized salt and/or vitamins that list iodine+selenium?

2nd post of 1st forum topic:

• advice for new guys
• things that damage your hormones
• protocol for injections
• finding a TRT doc

FSH is typically the better indicator that LH, so you seem secondary. Prolactin is not the cause.
One can be primary+secondary to varying degrees.

fT3 looks good
fT4 is a bit below midrange

Find 5,000iu Vit-D3, tiny oil caps. Take 25,000 for first 5 days, 5,000iu thereafter

Agree that ADD could easily have been low-T brain fog. Note that low thyroid function can have similar effects.

Blood pressure?

Might be interesting to try: Scientists Discover Way to Jumpstart Bone's Healing Process | URMC Newsroom

Also see: Teriparatide - Wikipedia
Does not seem to be any side effects.

Boron, manganese, and some other trace elements are important for bone health.
You need calcium and magnesium.
Any muscle cramps? that is low magnesium.
Serum calcium levels are meaningless as body will dissolve bone to maintain serum calcium levels.

Testosterone is important for bone health. The collagen matrix is bones is a protein structure and an anabolic state is important.

[ddillon]

Thanks for the quick response KSman.

I don’t have an oral thermometer but will pick one up next time I’m at the store.

I use iodized salt and take a daily multi vitamin with 150 mcg Iodine and 55 mcg Selenium. Would you recommend additional supplementation?

I picked up D3 oil caps from Costco today at lunch and will start your recommended dosage.

I do not remember my blood pressure, but it has been within the healthy range but close to the high the last few times I’ve been to the doctors.

I have chewed through the stickies but will need to work through them a few more times before it all makes sense, especially now that I have some solid blood work to compare.

I found a TRT doctor at UW that I will be meeting with in May. In the interim my general practitioner admits he is not trained in TRT issues but has been open to my research so far and is willing to work with me. He is willing to prescribe the hCG and Nolvadex needed for your HPTA restart protocol; do you think I would benefit from that? Doesn’t seem like it could hurt.

For the collar bone I’m going to make an appointment to get it reset and pinned after my wedding. I’ll read up on your links in the meantime.

I appreciate all of the time you spend putting information on these forums. With a lack of good doctors familiar with these issues having a good resource for self education is invaluable.

[KSman]

ADD meds might increase BP.

Adderall | Physical

In the long run, Adderall creates a spectrum of risks and changes to brain function similar to stimulants that are abused. Would be good if you felt OK without it. But perhaps best to get TRT/restart issues behind you.

Globulin?
Total proteins?

[ddillon]

I fell OK with it as I believe the risk of side effects are pretty low from what I have read. Ill update you with the additional test results as soon as they are in.

[ddillon]

Just received some additional test results from my 3/18/2016 blood work as follows:

DIHYDROTESTOSTERONE (DHT): 351 pg/mL (Ref Range 112-955)
FREE TEST: 75.2 pg/mL (Ref Range 30-140)
TESTOSTERONE: 306 ng/dL (Ref Range 200-730)
ALBUMIN: 4.1 g/dL (Ref Range 3.2-5.0)
SEX HORMONE BND GLOB nmol/L (Ref Range 11-80)

Seems to confirm original low testosterone results were not an anomaly.

MRI and bone density scan results should be in within a week.

[ddillon]

KSman,

I got squeezed in by my TRT doctor early and will be seeing him on Wednesday. After reading up more on the forums, I am a lot more open to the idea of TRT. I get the feeling it is unlikely I will get my T levels up with an HPTA restart. Do you think there is any benefit to holding off on TRT while I wait for the Iodine and Vitamin D supplements to do there thing?

[ddillon]

So my appointment went well with my TRT doctor and I have been prescribed the following:

40mg Test Cyp 3 times a week IM (120 mg per week)
333 iu HCG 3 times a week (1000 iu per week)
.25 mg Anastrozole 2 times a week (.5 mg per week)

I appreciate this site as a resource as my doctor originally wanted to put me on shots once a week. I expressed my concern about peaks in T levels and was able to persuade him to get on board at 3 times per week. Come to find out that he does E3D as well.

Regarding the doctor I visited, I am very happy. They have a few offices in the Seattle are and accept insurance. Excluding blood-work co-pays, my treatment will cost less than $200 a year including HCG.

I am going to attempt to dissolve the Anastrozole in vodka and dose more frequently. Hope .5 mg is enough as the stickies recommend 1 mg per week; I’ll find out in 6 weeks when I have my follow up blood-work done.

Pituitary scan came back normal besides a “2 mm focus of relatively decreased enhancement in the left central aspect of the pituitary gland. Pituitary microadenoma is not excluded.” My understanding is that microadenoma’s are not uncommon and many times benign. I’m going to follow up with an endocrinologist to play its safe, especially now that I have started TRT that may cause it to grow(?). A bit worrisome, has anyone else had similar results on their MRI scans?

Bone density scan came back normal per the lab and my TRT doctor said they looked good. I’m not sure how to interpret the report or what numbers would be relevant to post, but if there is anything the gurus here would like to see I can post it.

In addition to the D3 which I loaded up on the first week and now taking 10,000 iu daily, I have started taking an Iodine supplement. The iodine is by Zen Haus at 12.5 mg iodine and 50 mcg selenium daily. No noticed increase in body temps yet, still holding at 98.4-98.6 in the morning.

I’m going to email my doctor about SQ injections of the T as the general consensus her seems to believe that it works as well if not better than IM. Trying to find copies of the studies from Canada to forward my doctor. I figure if my intent is to go SQ, then might as well start now so the blood-work will reflect the delivery method I would prefer moving forward.

Thanks again for all the feedback and support. Let me know if anyone sees any issues with my treatment, has any experience with pituitary microadenoma, or any other general feedback. I’ll be sure to continue to follow up with treatment results.

[KSman]

TRT will not make the adinoma grow.

1/2mg anastrozole will limit where your E2 can go. Next labs can be used for dose adjustment. Be prepared to explain that rational to your doc and the calculations to get the Rx changed.

Sounds like you have a very good doctor situation!

[ddillon]

KSman,

Glad to here TRT wont affect the adinoma, that was an assumption on my end.

When you speak of calculations to get the RX changed, are you referring to adjusting the anastrozole based on the E2 report or adjusting Testosterone injections due to SQ.

I am very happy with my doctor situation, couldn’t recommend them enough. Id provide the clinics name, but I believe that is against forum rules.

[KSman]

It it is a clinic, they probably welcome on-line referrals. Some individual doctors might not. Forum rules do not care.

Example: If when using anastrozole, you get E2=28 and E2=22 is the target, new dose = old dose X 28/22. This works very well because of the linear response of low dose anastrozole as it is a competitive drug.

[ddillon]

Is that calculation based on your experience or is there a sticky/study you could point me to explaining how that works in detail. Id like to have some backup to bring to my appointment assuming an adjustment is necessary.

The clinic is Revive Low T and they have 3 locations in the Seattle area. It takes me about two hours with traffic to get to any of their offices from where I live and they were very accommodating of that. I had two separate sets of blood-work sent to them in advance and they were able to start treatment the same day. I received my prescription at my morning appointment, filled it, and was able to be seen again later in the day to go over how to administer everything which saved me a second trip battling Seattle traffic. As I mentioned above, my insurance will be covering my prescriptions but they work with a compounding pharmacy for patients that aren’t covered and the pricing sounded pretty reasonable.

FYI, I put my weekly dose of anastrozole in a 1ml syringe with a blunt tip by pulling out the plunger, sucked up .75ml of 189 proof Everclear, and it dissolved completely over night. I plan on dosing 3 times a week on the days after injections. God Everclear is horrible stuff. Maybe after tax season I’ll try a nice aged scotch…

[KSman]

A competitive AI drug competes with T at T aromatase reaction sites. If you double the interference you double the effect. That is my theory for low doses where you are modulating T–>E2 and not attempting to stop it. In practice, the results of the calculation produce very good results. Others here have found that calculation works for them. You will not find a clinical paper. This method is described in a few of the stickies.

Leaving everclear in the syringe might make the plunger bind. And vodka works well. No need for super high proof. Just need to overcome anastrozole’s hydrophobia.

[ddillon]

Update 5/9/16

So I have been on TRT for about 6 weeks. Libido increased and ED decreased around week 2. Since then that has reversed to pre-TRT levels. In addition I have gained 10 lbs since I started even though I have been eating less than 2000 calories a day. My weights in the gym are way up, but I doubt the weight gain is all muscle. I feel pretty bloated and am guessing that my Estrogen levels are too high based on the weight gain and libido issues. I had my blood work done today and am following up with my doctor on Saturday.

If my doctor ups my testosterone amounts, how would you recommend adjusting the anastrozole for the additional T assuming estrogen is high at my current dosing?

I will follow up with blood results as soon as I get them. I am also curious to see where my thyroid hormones are at, wondering if they may have something to do with the weight gain.

[KSman]

You need to try around 1mg anastrozole for every 100mg T. You were taking 0.5mg for 120mg 42% of suggested and probably well undermedicated. I expained earlier how to calcuate new doses. You probably will need a liquid to refine dosing.

You need to get your doc on board with a target of E2=22pg/ml.

[ddillon]

Thanks KSman, I intend to get my doc on board. He wanted start low and see where the .5 mg gets me.

Update: Although I was pretty sure .5 mg anastrozele weekly wouldn’t cut it per KSman’s recommendations and the stickies, I wanted to follow my doctors advice and ensure he didn’t feel like I was going behind his back. However, after gaining 10 lbs of water weight and losing the benefits felt the first 2 weeks on TRT, I had enough. On Monday I took .5 mg with my injection and another .25 mg today; 5 lbs down in the last 48 hours. I plan on moving forward with 1 mg a week. Hopefully my doctor will be on board and update the prescription after my blood work comes back, otherwise I have ordered some anastozele from a research chemical vendor. I haven’t been able to find an outline of the forum rules, but if there is no objection I can follow up in a few weeks with a review of the vendor I used and potency of the research chemicals on my lab rats. From my research, it seems like there are mixed reviews on research anastrozele.

[ddillon]

Updated Lab results attached and I am a bit surprised. My Estradiol came back at 11.00 pg/mL (REF RANGE 7.6-42.6), down from 23.0 pg/mL (REF RANGE 11-44). The attached blood work was at the .5 mg anastrozole per week and prior to my last post where I started to increase anastrozole dosing. As mentioned in my last post, I was holding a lot of water weight and had ballooned from 226 lb pre-TRT to 236 lb as of Monday morning. After my blood work Monday I performed my injection in conjunction with .5 mg anastrozole and another .25 mg anastrozole on Wednesday with my second injection. Today, Thursday, I weighed in at 225 lb and am holding a lot less water as evidenced by the mirror. I do not feel any of the symptoms of low Estrogen such as achy bones.

I wonder if the swing is due to the different reference ranges for each test, different labs, interaction with the anastrozole and the testing method, or some other reason. It looks like I am an over responder but I am hesitant to bring my anastrozole dosage back down to .5 mg as I would hate to put all that water weight back on. Is low estrogen known to cause water weight gain? Any insight prior to meeting with my doctor on Saturday is appreciated.

[KSman]

FT labwork not done. SHBG responded nicely.

You may be quite sensitive to E2. Bloat is a known issue, but seems to be rare with TRT guys.

How much T are you taking and how?

[ddillon]

I am taking .2 ml of test cyp 200mg/ml on Monday, Wednesday, and Friday IM for a total of 120 mg a week. HCG at 1000 mg a week administered in thirds with with the test cyp shots. Anastrozole was at .5 mg a week in 2 doses with the latest lab work, started taking more this week prior to getting the lab results back but will scale back to .5 mg based on the low E levels reported.

To clarify, is bloat as a known issue due to the TRT or do you think it could be due to low E. My water weight has dropped 10 lbs in the 4 days I increased my anastrozole, but I am guessing my E levels will be even lower now.

I will ask for a more in depth set of labs for my next blood work when I meet with my doctor on Saturday.

[ddillon]

Meet with my doctor today and he adjusted my dosage. Doctor requests injecting 150 mg test over 3 injections per week, up from 120 mg. My latest blood work had my my serum test at 456 ng/DL, so I was hoping for a larger increase in weekly dosing. Does it take a while for testosterone to “build up” in my system? Is adjusting testosterone dosing similar to anastrozole where ideal T levels are divided by current and the factor multiplied by my current dose?

Doctor recommends stopping anastrozole and I will test estradiol on my own dime prior to my 6 week follow up to make sure I don’t swing in the wrong direction. If my estradiol levels rise above ideal I will adjust my anastrozole per KSmans methodology. I read on a few other forums that the liquid chromatography/tandem mass spectrometry estradiol tests are the way to go, but haven’t seen the issue discussed much here. Any opinions?

Finally, if I switch to subq EOD, should I front load a larger then normal dose to compensate for the slower absorption time via subq?

As always, thanks in advance for any input.