Likely Starting TRT Soon

Pharma / TRT Testosterone Replacement
1

Hi everyone. Thanks to all of those who put so much information on here for others to learn from. Here’s my story…

44 years old.
6’ 2"
40" waist
290 pounds (most are surprised it is so high. I thought I “carried it well” because i don’t look flabby, but I am learning about visceral fat
normal (?) facial hair. I can grow a beard without much trouble. Slightly thinning on the top of my head
I have gained weight in my belly, waist, and butt
Only long term health issue has been controlled high BP
I take amlodipine and lisinipril for BP, occasionally Advil for headache
I had a vasectomy about 12 years ago. Fertility is not a concern.
As far as diet goes, I probably over eat, but not a lot of sweets, etc. nothing I would consider extreme one way or another
I used to work out and eat healthy, following the Body for Life type regimen, but its been several years since then. I don’t exercise a lot now, but have a fairly physically active job, moving a lot, lifting, etc
No testes issues pain wise, but I do have a vericocele on the left
No morning wood, no libido, much weaker erections than in the past. I almost never initiate sex with my wife, but can get in the mood if she initiates.

I had a check up with my Primary Doc a few weeks ago, and based on my answers to some “quality of life” questions, she suggested having my Testosterone levels checked. Here are the applicable results from my first labs on 11/13/12:

FSH 8.0 (1.6-8.0)
LH 0.4 (1.5-9.3)
Total T 319 (250-1100)
Free T 76.7 (35-155)

I had a complete urine and blood workup. I initially left it out of this post, but maybe there is something important that is “in range” but not optimal, so I added it her as an edit:

CHOLESTEROL, TOTAL 180 125-200 mg/dL
HDL CHOLESTEROL 57 > OR = 40 mg/dL
TRIGLYCERIDES 98 <150 mg/dL
LDL-CHOLESTEROL 103 <130 mg/dL (calc)
Desirable range <100 mg/dL for patients with CHD or diabetes and <70 mg/dL or diabetic patients with known heart disease.
CHOL/HDLC RATIO 3.2 < OR = 5.0 (calc)
NON HDL CHOLESTEROL 123 mg/dL (calc)
Target for non-HDL cholesterol is 30 mg/dL higher than LDL cholesterol target.
GLUCOSE 114 H 65-99 mg/dL Fasting reference interval
UREA NITROGEN (BUN) 19 7-25 mg/dL
CREATININE 1.14 0.60-1.35 mg/dL
eGFR NON-AFR. AMERICAN 78 > OR = 60 mL/min/1.73m2
eGFR AFRICAN AMERICAN 91 > OR = 60 mL/min/1.73m2
SODIUM 136 135-146 mmol/L
POTASSIUM 4.5 3.5-5.3 mmol/L
CHLORIDE 104 98-110 mmol/L
CARBON DIOXIDE 22 21-33 mmol/L
CALCIUM 9.6 8.6-10.3 mg/dL
PROTEIN, TOTAL 6.9 6.2-8.3 g/dL
ALBUMIN 4.5 3.6-5.1 g/dL
GLOBULIN 2.4 2.1-3.7 g/dL (calc)
ALBUMIN/GLOBULIN RATIO 1.9 1.0-2.1 (calc)
BILIRUBIN, TOTAL 0.7 0.2-1.2 mg/dL
ALKALINE PHOSPHATASE 61 40-115 U/L
AST 14 10-40 U/L
ALT 18 9-60 U/L
HEMOGLOBIN A1c 5.6 <5.7 % of total Hgb
TSH 1.75 0.40-4.50 mIU/L
T4, FREE 1.3 0.8-1.8 ng/dL
The current lot of free T4 reagent available from the
manufacturer produces results that are approximately
9% higher than previous reagent lots. Please interpret these results accordingly
URINALYSIS, COMPLETE
COLOR YELLOW
APPEARANCE CLEAR
SPECIFIC GRAVITY 1.019 1.001-1.035
PH 5.5 5.0-8.0
GLUCOSE NEGATIVE
BILIRUBIN NEGATIVE
KETONES NEGATIVE
OCCULT BLOOD NEGATIVE
PROTEIN NEGATIVE
NITRITE NEGATIVE
LEUKOCYTE ESTERASE NEGATIVE
WBC NONE SEEN < OR = 5 /HPF
RBC NONE SEEN < OR = 3 /HPF
SQUAMOUS EPITHELIAL CELLS NONE SEEN < OR = 5 /HPF
BACTERIA NONE SEEN NONE SEEN /HPF
HYALINE CAST NONE SEEN NONE SEEN /LPF
CBC (INCLUDES DIFF/PLT) KS
WHITE BLOOD CELL COUNT 8.0 3.8-10.8 Thousand/uL
RED BLOOD CELL COUNT 5.05 4.20-5.80 Million/uL
HEMOGLOBIN 15.4 13.2-17.1 g/dL
HEMATOCRIT 46.7 38.5-50.0 %
MCV 92.5 80.0-100.0 fL
MCH 30.5 27.0-33.0 pg
MCHC 33.0 32.0-36.0 g/dL
RDW 13.3 11.0-15.0 %
PLATELET COUNT 207 140-400 Thousand/uL
ABSOLUTE NEUTROPHILS 5304 1500-7800 cells/uL
ABSOLUTE LYMPHOCYTES 2088 850-3900 cells/uL
ABSOLUTE MONOCYTES 528 200-950 cells/uL
ABSOLUTE EOSINOPHILS 56 15-500 cells/uL
ABSOLUTE BASOPHILS 24 0-200 cells/uL
NEUTROPHILS 66.3 %
LYMPHOCYTES 26.1 %
MONOCYTES 6.6 %
EOSINOPHILS 0.7 %
BASOPHILS 0.3 %
IRON AND TOTAL IRON KS
BINDING CAPACITY
IRON, TOTAL 71 45-170 mcg/dL
IRON BINDING CAPACITY 349 250-425 mcg/dL
% SATURATION 20 20-50 % (calc)
FERRITIN 182 20-380 ng/mL KS
PSA, TOTAL 0.8 < OR = 4.0 ng/mL KS
This test was performed using the Siemens
chemiluminescent method. Values obtained from
different assay methods cannot be used
interchangeably. PSA levels, regardless of
value, should not be interpreted as absolute
evidence of the presence or absence of disease.

Based on my low LH levels, my doctor wanted me to make an appt with an endocrinologist. From what I have learned on forums like this, i knew I needed to find a doctor that knew what was going on in this field of medicine. I found a doc here in my area who has been called “an internationally known expert” in this field. After reading some of his thoughts on the subject that I found online, I thought that he seemed like a good one to see. I had my first visit with him on 12/21/12. Actually, most of my exam was with an assistant, who thought my primary issue might be sleep apnea. When the doctor I searched so hard to find finally saw me, he all but dismissed the sleep apnea idea. He said my initial blood tests showed that my Twas in range but low. He was concerned with my LH level, especially since LH and FSH generally rise and fall together. He said 0.4 was abnormally low. He ordered labs and a brain MRI to rule out a pituitary or hypothalamic tumor. He also wanted to run a second set of T labs, including FSH, LH, free/bioavailable/total Testostone, and Prolactin. Here are the result from the blood test on 12/22/12:

FSH 7.0 (1.6-8.0)
LH 0.3 (1.5-9.3)
Total T 327 (250-1100)
Free T 71.2 (35-155)
Prolactin 6.2 (2.0-18.0)
Bioavailable T 155.7 (110-575)
SHBG 15 (10-50)
Albumin 4.8 (3.6-5.1)

I know now i should have asked to have estrodiol included, but didn’t then. Monday I get my pituitary MRI, and my next visit to the doctor is Feb 1. I think some sort of therapy is in the works, but I am wondering if, since my LH level is apparently a major issue, he will recommend HCG instead of T.

Any input is appreciated. Thanks.

2

I just read my initial post and realized I didn’t really list any symptoms. The things that led my PCP to suggest a T test were that I have almost no libido whatsoever. My favorite evening activity has more to do with my recliner than my wife. My self confidence has gone down. I get tired of hearing myself answer “I don’t care” whenever someone asks my opinion. I can’t see to come up with any long term goals, plans or desires. I have almost no energy by the time I get home from work to do anything. There is nothing I am passionate about anymore. I just feel like a ship floating on the water and don’t have any way to direct my course.

3

Low LH: Do your testes and scrotum hang properly or getting pulled up?

LH and FSH usually move together.

You appear to have a prediabetic state

  • GLUCOSE 114 H 65-99 mg/dL Fasting reference interval
  • HEMOGLOBIN A1c 5.6 <5.7 % of total Hgb
  • check fasting insulin
  • check homocysteine
  • check E2 estradiol

Insulin resistant and low T are seen together in “metabolic syndrome” aka “syndrome X”. TRT can improve insulin sensitivity and BP. But you need to avoid TRT creating elevated E2.

Ask your wife if you snore. Do you think that you sleep well?

Post your waking oral waking body temperature and also mid afternoon.
Do you use iodized salt or have iodine in vitamins - used for how long

You feel hungry 2 hours after dinner and then eat? That hunger can be a misinterpretation of heart burn from a hiatal hernia. Those are common in the population, not causing problems for many. Been overweight is a large risk factor. You have heart burn?

CV health:

  • DHEA 25mg if needed, test DHEA-S
  • 5000iu vit-D3 tiny oil caps, can get at Walmart
  • high potency B complex multi-vits with minerals and iodine
  • 1000mg vit C
  • 400iu natural source Vit-E
  • fish oil caps, flax seed/oil and nuts for EFA’s
  • TRT

Have you read any of the stickies?

4

Yes, I have read all of the stickies. Some twice. I started taking my temperature today and will post the results after a few days to check for consistency. I have started looking for iodine supplements locally, but so far all I have found is either in a multi-vitamin or in Kelp supplements. I checked our salt, and we mostly use non-iodized kosher salt.

As far as I can tell, everything seems to hang normally. No bunching or pulling up in normal conditions.

I am aware that LH and FSH should run similarly. That is something that has been confusing for me.

My wife says I do not snore all that much, but I do mumble and groan a lot. I don’t sleep all that well, but it is primarily due to shoulder pain that keeps me turning from side to side. She says she has never noticed excessive snoring or sleep apnea actions.

I did not know that amlodipine sometimes caused gyno. I didn’t see where tha article explained why that was, but I will talk to the doc about that.

The only time I experience heartburn is related to certain foods, like tomato based sauces. Interestingly enough, not from spicy foods, garlic, etc. I do eat sometimes before bed, and if I wake up in the middle of the night I sometimes feel hungry.

My Endo talked about the pre-diabetic issue and the metabolic syndrome, but said he thought things would look better if we ended up doing TRT. I have never had high glucose before in any prior lab tests.

I have looked forward to your reply. Thank you for all of the info and help you provide here.

5

Thanks for the info. I’ll try to answer as you asked the questions.

As far as how their hanging, e erythema seems to be normal. I don’t know that they’re ever pulled or bunched up.

I’m aware that the LH and FSH should move together. I think that is one of the first things I wonder about when I got my first set of labs back - even before I knew that 319 was lower than optimal. My Endo is requesting the pituitary MRI for that reason. I have that done Monday.

He and I also discussed the glucose and metabolic syndrome issue. This is the first time I have ever had my glucose come back high. He didn’t see the need to retest for it, however. He said if I started T therapy it would probably help that and my BP, and we would look at it again then.

I’m going to call him next week and see if I can get E2 tested so I have those results to go with the others when I have my next appt with him Feb 1st.

I was not aware of the amlodipine and gynecomastia link. I might ask grab out that, but after doing some more research beyond wiki, it seems that is very rare.

As I mentioned, the assistant thought about sleep apnea in my exam. I called my wife from the doctors office and she said I don’t really snore that much and never stop breathing that she has noticed in 5 years. She said I do moan and mobile, as if I’m talking in my sleep. I don’t sleep well, but that is due more to shoulder pain and I toss back and forth to relieve the pressure.

I started taking temps today and I will post them after a few days to establish some consistency. I checked and we use mostly kosher or sea salt, no iodized table salt. I looked in a couple of stores today but can’t find iodine supplements locally. I guess if my temps are low I will go www to find those.

I don’t really have heartburn unless I eat something with a tomato sauce. Interestingly, spicy foods, garlicky foods, etc don’t bother me. I don’t get hungry after dinner unless I am up late, but if I wake up in the middle of the night I sometimes go looking for something in the fridge.

I will take your advice on the CV supplementation.

Yes, I have read all the stickies. Some more than once.

Thanks for the input. I have looked forward to your posting on my situation. You provide a wealth of information on here to many people and we appreciate it.

6

“amlodipine sometimes caused gyno” Side effects are listed, the mechanisms are not.

When things like this happen, often what happens is that the liver’s ability to clear estrogens causes them to rise and that lowers T. There is a spectrum of severity, some times mild, sometimes worst. In a few cases, gyno can result. That rarity does not in any way suggest that the underlying effect is rare or un-common. When these things occur, there may be other drugs or preexisting liver conditions/tendencies that make those affected susceptible. The take away point is the mechanics of such effects

The evening eating is a major problem that you need to overcome. Do not discount the hiatal hernia as a possible factor. Hiatal hernia - Wikipedia

Large meals cause problems with pressure and alcohol affects the function of the lower esophageal sphincter (LES) Esophagus - Wikipedia

If you take a proton pump inhibitor and you then feel less inclined to eat in the evening, that suggests that the ‘hunger’ is an acid reflux driven sensation. When you eat you also wash the acid down and get relief and reward for that behaviour.

7

My doctor called today with my MRI results. He said they didn’t see anything definitive, but there might be (not visible on all views) a 3mm microadenoma on my pituitary. He didn’t seem to be alarmed, but did say I could come in and pick up my prescription for Test Cyp. He originally said it would be 1 ml injections of 200 mg/ml every two weeks. I told him about the information I had found here and asked if I could do one week injections at a maximum. He agreed to write the script for .5 ml every week. He said after 6 weeks we would do blood tests again. I asked if we could check E2 then, since we hadn’t done so previously. He agreed that it would be worth looking at.

When I picked up the prescription, I asked the nurse to give the doctor some information I had printed. It was Dr. John Crisler’s protocol. I asked if she would give it to the doctor so we could discuss it at my next vist on Feb 1. He also gave me orders for more blood tests to include Insulin Like Growth Factor 1, Cortisol, and ACTH.

When I picked up the prescription, he had also included scripts for 18 ga syringes. When I took it to the pharmacy, I told them I didn’t want those syringes and asked for 29 ga insulin syringes. The pharmacist said I would have a hard time drawing into those and suggested other options. I ended up getting a couple of singles in different sizes to try them out. The T was in 1ml vials. Next time I will ask my doctor to specify bigger vials as it seems I will have a hard time getting everything out of these little vials without wasting some, and will have that problem every other time I inject with such small vials.

I gave myself my first injection tonight of .5 ml of the 200 mg/ml solution. I used a 23 ga 1" needle on a 3 ml syringe. I injected into my right glute muscle and it was very tolerable. I am thinking about splitting my next dose into two .25 ml injections next week. If I did my first one tonight (Wednesday), would Sunday and Friday next week by ok, followed by subsequent Monday/Friday dosing?

I will post my lab results when I get them back in the next week or so.

I have been taking my temperature. It has been pretty consistent waking about 97.4 and getting to 98.4 to 98.6 later in the day. I left my records at the office today, but I will post the specifics with the labs in a few days.

8

Ok, I have a question. About 5 days into my second shot of T-Cyp at 100 mg/week, I had some swelling in my lower legs and feet. It actually hurt to press or squeeze my calves. Now granted, I had been out of town on a business trip, eaten more than usual share of convention center buffet food, had a few more drinks than usual, and done a lot of standing around or walking, flying on a plane, etc. I’ve seen pitting edema, and it was not that severe. It was just enough to feel it in my socks and shoes, and see it as visible slightly swollen. I thought I had heard that an increase in E might cause that, but I couldn’t find where I had seen it.

I haven’t had any other high E symptoms, like sensitive nipples, mood changes, etc, but at the same time I haven’t seen much of a change in anything since starting TRT, other that a decrease in “brain fog”.

I have 4 more weeks on my initial prescription before I do blood work. If it continues, I will call my doc, but like I said. I wasn’t sure of it was my out of the ordinary activities or our of the ordinary hormones. I was wondering if it more to do with the T shots or my activities. I got home last night, and seem to be a little better today, but has anyone had edema and pain in their legs from T?

9

The problem with injecting in your glutes is needing to avoid the sciatic nerve. It can be affected by nearby inflammation and then your leg will have problems. You need to stop injecting that way, it is archaic and unnecessary.

Insulin syringes of 1/2 and 1 mg will for the same needle have the same filling rates. However, the 1/2 ml syring will inject much faster and you can read the dose easier and be more accurate. Very little waste compared to the large syringes and removable needles. See the protocol for injections sticky. Slow loading times are something that you can live with. Get 1/2" #29 1/2ml [“50iu”] insulin syringes, best price is Sams/Walmart house brand Relion. You do not need a script in most states for insulin syringes.

10

Thanks KS, I’m glad you’re back.

For my second week, I have used a 25ga 1" syringe. It works fine and I feel little pain. Only my first injection was in my glute. Since then have been going into my quad.

That actually brings up a couple of more questions:

A. I just started TRT 2 1/2 weeks ago. My doctor agreed to let me do weekly shots of 100mg T-Cyp, instead of his original recommendation of 200mg every 2 weeks. I want to talk to him about making a transition to 2x/week of 50 mg. Until i talk to him about that, if i start that on my own now, will that influence my labs at 6 weeks enough for him to know I wasn’t following his instructions?

B. After my initial labs, I would like to eventually do subcutaneous daily injections, and I have some 28 ga 1/2" insulin syringes for when that time comes. One of the main reasons is, as you said, it looks much easier to get the right dosage, rather than the 3ml syringe i have been using. Is that enough needle to get into my quads for IM now, or should I stick with the 25 ga 1" until I go SC down the road?

11

I got some more labs back today and I s hoping I could get some insight. Here they are:

ACTH, PLASMA 22 (6-50 pg/ml)
a.m. CORTISOL, TOTAL 19.3 mcg/dl (4.0-22.0)
IGF I LC/MS 125 (52-328ng/ml)
Z-SCORE -0.3 (-2.0-+2.0 SD)

I see that they are all in range, but anything to investigate further?

12

More frequent injections provide smoother levels, but there are more injections and why have any IM muscle damage at all, simply not needed. Can you get insulin needles without a script in your state? If so, its your show.

The lab work will not show anything that the doc would worry about and the lab results will be representative of what is really going on in your body.

The first two indicate good cortisol and adrenal function. Did you do the lab at 8AM?

IGF-1 is a measure of your growth hormone status. A bit low for your age. I would watch this in the future. Might improve as your other interventions take effect.

13

Yes, I can get insulin needles without a prescription here in Missouri. My biggest concern is that the doc will know I am doing something contrary to his advice, stop treating me, and I will have to start over with the whole thing. I know others have done it, but I really don’t want to.

As far as those last tests, yes, it was exactly 8:00 am when the drew the blood. I will see where to things go with the IGF-1. Thanks again.

14

Remembering those 21g IM pig-stickers–ouch! +1 for SubQ 2x/wk. As for difficulty drawing into 29ga? ha! I use painless 31g 0.5mL without issue…just have to wait a few minutes for them to load up. So you’re prediabetic and obese with GERD? Dunno what you eat, but elimnating grains (refined or whole), sugars, soda and most other bulk carbs in favor of minimally processed foods (meat, fat, fish, nuts, eggs, veggies, fermented dairy, moderate fruit) will probably shut off your GERD like a switch no matter what time of day you eat. And if you’re like me, it’ll also bring your appetite in line with your actual energy expenditure, and you’ll drop the extra weight w/o starving yourself–to a still greater extent, if you remain on TRT with appropriate E2 control.

15

I used to do IM in quads with #29 1/2". And have done that with .5ml as well. If some leaks back to SC, does not matter.

Docs used to be concerned with the burden on the patient of treatment. When injections are so easy and not-uncomfortable with insulin needles, that concern is really not an issue. So when we want to inject more often, then that is changing the perspective away from burden imposed by the doctor. I always advocate that you can and should inject the prescribed weekly dose in whatever manner you choose. The labs will be what they are. The lab results will be higher than at 7 days after a weekly injection. Could a control freak doctor have a problem with that? -perhaps.

16

Hmm. I just left my doctor’s office after 4 weeks on TRT. I’m not sure what to think. I’m a little disappointed in what he said, but I’m also a little relieved on some other things.

I did the first dose of 100mg/ml of T Cyp on Feb 1. I injected .5ml for week one. Starting on the second week, I started doing 2x per week of .25 ml. I didn’t expect he would order labs for another couple of weeks, so I thought I would switch back to 1x per week these two weeks so my labs would be more in line with what he might be expecting, in case he was, as KS put it, somewhat of a control freak.

We talked about any changes i had experienced. I told him i had noticed a slight increase in libido, a definitely higher level of mental clarity, and a slight positive change in energy levels. My erections haven’t gotten any stronger, more frequent, or really changed at all. He said that those things might take up to three months to get where they should be. He did suggest, his words, a cock ring for stamina as some guys develop “leaks” of blood flow that drugs won’t fix. He did say he would give me a Rx for Levitra if I wanted to try that.

When asked, I told him I had been doing weekly injections of .5ml. To my surprise, he said to keep doing that for another three months and then, because I seemed to want to, we would do another set of labs. He really only wants to check a CBC, PSA, and Prolactin level. Because I brought it up, he said we would check T levels, but it was only so I would know where I was! He said my symptoms/experiences were important than T levels in that regards. I think I liked that statement; that he would go by what I told him more than numbers. After explaining why I wanted E2 levels checked, he would include that but didn’t see the reason. He said after a few months estrogen would find a balance based on my T levels, wherever they are. I wasn’t as thrilled with that statement.

He did say he read the Crisler protocol I left. He said he thought some of those points would make minuscule changes that I wouldn’t even notice unless I was looking for them. He said he would go along with HCG if I was interested in fertility. He would also entertain the thought if i was involved in porn, looking to find a new woman that would be freaked out by small balls, or was involved in homosexual sex, because then testicular size mattered. Other than that, he was opposed to it. He was ok with AI if I started developing man boobs, but otherwise probably not.

So I guess the upshot is this… I think I can probably do T injections in whatever manner I choose that works best for me, so long as I stay on the prescribed dose. That’s ok with me. He will dose based more on what I experience and not just because I am “in range”. That’s ok with me too. Anything else outside of that will require a change in doctor, lying, or major lifestyle change lol.

Until then, I guess I am on my own until early May when I get to see numbers. I have been taking 100 mg Zinc over day, the 5000 oil based Vit D caps KS suggested, and a multi vitamin.

17

Actually, should I be taking Zinc without knowing any E2 levels?

18

Does anyone have experience with how well Zinc acts as an AI?

On a related note, and I hope this makes sense to some of you, if I wanted to do some Military Police research online, would the results be trustworthy?

19

If zinc was effective, it would be used…

More to the point, zinc deficiencies may cause problems. Metal atoms are vital in the role of catalyst function in enzymes. That does not lead to more zinc is better. Too much can cause some problems by limiting the absorption of other trace elements.

MP research, that is a very vague statement.

20

I was thinking of anastrazole. My doc seems against writing a Rx.