Dr. Visit - What Should I Request?

Pharma TRT
61

Have an appointment with a TRT doctor this Friday. Here are my latest labs, any thoughts would be appreciated. I was coming off of a cold at the time alos.

WBC 3.9 (4.0-10.5 k/mm3)
RBC 4.85 (4.7-6)
Hemoglobin 14.5 (13.8-17.2 gm/dl)
Hematocrit 41.3 (42-52%)
MCV 85.2 (78-100fl)
MCH 29.9 (27-31pg)
MCHC 35.1 (32-36 g/dl)
RDW-SD 39.9 (35.1-43.9fl)
RDW 12.9 (11.5-14.5%)
Platelet count 255 (150-450 k/mm3)
MPV 9.8 (6-10.8 fl)
Neutrophils 68.8 (40-75%)
Lymphocyte 16.6 (20-50%) - low on every test last 5 years
monocytes 10.4 (0-12%)
Eosinophil 3.6 (0-5%)
Basophil .3 (0-2%)
Neutrophils # 2.7 (1.5 -6.6k/mm3)
Immature Gran. 0.0 (0-.2)
Lymphocyte # .6 (1-3.5)
Monocyte # .4 (0-1)
Esoinophil # .1 (0-.7)
basophil # 0 (0-.1)

CMP
glucose 101 (70-110)
blood urea nitrogen 26 (10-20 mg/dl)
creatinine 1 (.6-1.3)
sodium 140 (130-145)
potassium 4.2 (3.5-5.1)
chloride 107 (98-107 meq/l)
carbond dioxide 23.1 (21-32)
anion gap 14.1 (10-20)
calcium 8.9 (8.5-10.1)
total protein 7.8 (6.4-8.2)
albumin 4.1 (3.5-5.8)
ast/sgot 17 (1-35)
alt/sgspt 44 (30-65)
alk phos 100 (50-136)
bilirubin total .3 (0-1)

Lipid Profile
Cholestrol 219 (110-220mg/dl)
Triglycerides 65 (30-200 mg/dl)
HDL 61 (35-65)
LDL 145 (88-130)
CHOL risk ratio 4

TSH 1.5 (.35-5.5 uiu/ml)
PSA .53 (0-4 ng/ml)
LH 3.9 (1.7-8.6)
Free T3 3.6 (2-4.4)
25 OH VIt D 76.8 (32-100)
DHEA-S 150.6 (160-449 ug/dl)
IGF-1 287 (115-307 ng/ml)
Total T 539 (249-836)
% Free T 15.3 (9-46)
Test F+W Bound 82.5 (40-250)
Hemoglobin A1C 5.9 (4-6% non-diabetic) (6-8% controlled diabetic)
Cortisol 12.63 (4.3-22.4 ug/dl)
E2 32 (ND-39.8)

waiting on free cortisol/transcortin measures and also another saliva cortisol 4x test

Stopped DHEA and Preg 2 weeks prior to this test, no trt for 2+ months

Working long hours now and feel absolutely horrible, complete zombie.

Did the prednisone taper (and was on DHEA and Preg) and felt alot better then. This blood work was around 2-3 weeks after finishing the prednisone taper.

Thanks for any comments.

62

You can make your own T. Maybe not enough.

What else were you taking before and during the 10 days? DHEA? Diet changes? Lifestyle changes?

63

DHEA and Pregnenelone. Part of it fell on the end of xmas break (low stress - little work). the last five days were long hours, higher stress (as are the last few weeks).

64

prednisone taper didn’t work…new results:

Different Lab - Labrix.

Morning 12.14 range (5.1-40.2) optimal range ((18-35))
Noon 2.97 (2.1-15.7) ((6-12))
Evening .51 (1.8-12) ((4-8))
Night 1.43 (.9-9.2) ((2-6))

Is it ok to try and boost cortisol via Preg, while taking cortef?

65

Have you read Wilson’s book?

Prednisone is very repressive. A healthy normal male would recover, you need to be managed better.

You need to support your adrenals. Yes, take pregnenolone. A little 2% OTC progesterone might be helpful too, while giving your adrenals a rest with cortisol. Hopefully you can taper off of cortisol later.

66

Yes,

I think I will be requesting some HC and then doing Preg/Prog/DHEA…maybe through a compounding pharmacist?

Any thoughts of oral vs. cream? I didn’t absorb androgel well, so absorption may be an issues?

I’ve read with oral you need the micronized lipid matrix products?

Thanks for the help.

67

Dr appointment went well…waiting for my treatment plan.

Doc mentioned (told him trying to conceive) that he might do T injections for 3 weeks, then hcg only the 4th week. Hadn’t heard of this before. Any comments on that?

Has anyone had luck with Progesterone for adrenal issues? My tested out lowish. thanks.

68

Got my CBG measure back. I’ll copy my adrenal/saliva history:

Saliva Test 10/10
Cortisol
Morning 5.5 (13.0-24.0 nM)
Noon 5.0 (5-8 nM)
Afternoon 1.6 (4-7 nM)
Nightime 2.1 (1-3 nM)
Cortisol Sum 14.2 (23-42)
DHEA-S Average 1.7 ng/ml (2-10)
Total Cortisol / DHEA-S Ratio 8.4 (5-6)

**Felt terrible here. No energy, none.

Blood Work Dec 10, 2010Cortisol Response to ACTH
Cortisol 16.25 (4.3-22.4 ug/dl) 9 am
ACTH 21.2 (7.2-63.3 pg/mL)
30 min 23.02
60 min 30.07
Range: 4.3-22.4

**Showed endo saliva results. Discredits them. Orders Stim test. Results are fine. Let’s just monitor you. Last time i will see him.

**Go into xmas break and starting to feel better. Went on a prednisone taper, while on preg/dhea after a long xmas break (low stress). Starting to feel pretty good again. Had alot of energy, more than at anytime in the past two years. Very excited at this point.

**About a week or two after the taper and removing preg/dhea (for a blood test as per new Dr) starting to feel bad. Work starts up (long hours / higher stress). Thought the prednisone taper would restart the adrenals, but probably not the case. Right now, feel about as bad as ever have.

Saliva Cortisol Test - Feb 10, 2011
Morning 12.14 range (5.1-40.2) optimal range ((18-35))
Noon 2.97 (2.1-15.7) ((6-12))
Evening .51 (1.8-12) ((4-8))
Night 1.43 (.9-9.2) ((2-6))

Blood Work - Feb 12, 2011
Cortisol 12.63 (4.3-22.4 ug/dl)
CBG 3.0 mg/dL (2.3-3.9)

Started back up on Preg/DHEA -about 2-3 weeks in and no change. Talked to the Dr about HC, but haven’t recieved my treatment plan yet, so not sure what he has in mind. How long is usual for using HC? As in, how long of break do you give the adrenals before tapering off?

What does everyone think of Progesterone? My levels were low. Some recommend it and some say stay away (Dr Crisler).

Thanks.

69

Still waiting to hear back from the Dr. But, the pharmacy called and wanted my insurance info. Said he rx’d T (injection), hcg, anastozole, cortef, and metformin. Don’t know the protocol yet.

When i visited with him he mentioned doing T injections for 3 weeks, then 1 week of hcg. Haven’t heard of this before. Anyone comment on it?

70

Alright, Got my rx’s from the pharmacy, but still need to talk with the Dr again.

Here is the plan (from what i can tell from pharmacy directions):

Metformin: 500mg x 1/day
Cortef: 20-30 mg/day
Test-Cypionate: Inject .8ml (200mg/ml) IM 1x a week for weeks 1-3 of the month
hcg: Inject 500 units Sub Q week 4 of the month
anastrozole: 1mg tablets, says 1-2 tablets per week

Also included: BD 18G needles (to draw T), BD Syringe 25G 1.5", and one small syringe (assuming for hcg).

Questions:
Can you start Cortef at say 20mg? or need to titrate up? STTM says to now you don’t need to titrate up.
What is the dosing schedule for anastrozole? EOD? so break the tablets into 1/4ths? and start at 1mg/wk?
Anyone see the benefit of T for 3 weeks and hcg for 1? Going to talk with him about this.
What/Where is the best way to learn to inject (DR office is several hours away)?

71

anyone?

72

I believe those needles would be for the test.

73

See the protocol for injections sticky. No harm in introducing post drugs in stages, but often no reason to.

My wife’s starting dose for cortef was 20mg and there were no concerns of that nature.

“Anyone see the benefit of T for 3 weeks and hcg for 1?” -do not understand.

Injections: first determine how often you want to inject and SC vs IM, then we can be specific too.

74

KSman,

He has me injecting T once a week, on weeks 1,2,3 of the month. Then one injection of hcg (no T) on week 4. This is what i meant.

75

Oops…that was wrong.

T-Cyp, 1 injection per week, on weeks 1,2, and 3 off the month
HCG, 500 u’s, 3x per week on week 4 of the month.

Should I keep a consistent schedule with cortef or take the initial dose upon waking and then every 4 hours?

Say I wake up at 5 am during the week, and 9 am on the weekends. How does the cortef dosing change?

76

Cortisol levels track waking times/patterns. Take when you wake. Perhaps 20 when you wake and 10 in the early afternoon. You need a declining curve and do not want cortisol interfering with sleep. Start with lower doses of cortef and see how they feel. Do not take more than needed.

That T protocol seems bogus in some ways. Interesting possibilities, but unknown. I suggest that you inject twice a week. How will labs be timed?

77

My gut says just listen to the Dr and try it. He has been in the game a long time. This is what I’ll do for a while.

But, it just doesn’t make complete sense to me. The body wants balance/homeostasis. Why not do the same thing every week?

was around 15-20mg of Cortef this week. Didn’t really feel much difference at all. Didn’t take a dose larger than 5 mg though. 5 - 5 - 5 - 2.5 was the usual dose.

Might bump up to 7.5 or 10 in the am and see how that feels. Have a period of less work and stress coming up, so hopefully the combination will result in regaining some energy/enthusiasm.

78

Take as little cortef as it takes to make you feel better. You do not want to be feeling hyper or stimulated. In time you should be tapering off and not using at all.

A normal curve is highest in the AM then curves down into the evening. Take 60% when you get up and the remainder in the early or mid afternoon. You do not want cortisol interfering with sleep.

I don’t care for that 3-1 protocol. Never seen this done before. You can try it and see how you feel. If testes are not very responsive, you will be in a two week hole. So this will not work for most. With T levels moving, an anastrozole dose will be wrong.

Your HPTA will always be shut down.

When would you do labs?

Injecting once a week does not work well for many, you might be better with twice a week.

79

Haven’t felt better on up 20mg a day yet. worked up to 7.5-5-5-2.5 and nothing. Felt great during the prednisone taper (10mg). Think i need to start my mornings on a higher dose.

80

Going 10 - 5 - 5 - 2.5 and still nothing.

Have felt a little more irritable/depressed than usual the last week or so?