Protocol Question

Pharma / TRT Testosterone Replacement
1

Let me start by saying I’ve read the stickies and also used the search function. I’m undecided which of the following protocols would be best for me to start with. I’ll soon be starting trt again. Previously my protocol was 125mg T enanthate once per week IM for 6 months followed by 1500iu HCG twice per week for 6 weeks. This was not a good protocol as I experienced peaks and troughs during the T cycle, and the HCG cycle was a nightmare (suspected high E2 and/or low T). I want to do things properly this time so I’d really appreciate your opinions on which of the following protocols would be best. I’d like to have stable levels, feel good, avoid high E2 and keep my balls full. I also want to keep things as easy and simple as possible, hopefully avoiding having to use an AI. I can’t afford HCG 250iu EOD but can afford 250iu twice per week.

The protocol options:

Option A)
62.5mg Test E IM + 250iu HCG SQ Monday, 62.5mg Test E IM + 250iu HCG SQ Thurs/Fri.
*I’m thinking T+HCG on same days makes it easier and more convenient, but is it better to do on different days? If so, day before or after?

Option B)
125mg Test E IM Monday, 250iu HCG SQ sat, 250iu HCG SQ Sunday

Option C)
125mg Test E every 5 days - not sure what the best HCG protocol would be to go with this?

Thanks in advance.

2

I can’t speak to the HCG as I don’t use it but you would be best served splitting your dosage into 2 x per week @ like E3.5D. So Monday night and Friday morning. If you go sub Q you might even get to lower your dose to 50mg x2 and get the same bang for your buck.

Do you have any lab results from your prior stint?

3

Protocol A is best, however SHBG will dictate injection frequency which you do not have and if SHBG is lower neither of these protocols will work.

4

Thanks for the replies. I did try Test E subQ for a while too and didn’t like it. Doctor has advised against it due to higher chance of being aromatased into E2 in fat tissue.

Can anyone give input as to HCG? Best to take same day as T injection, or on day before or after?

The following tests were done at the end of May this year, the day before injection:

Haemoglobin 146 g/L (130-175)
HCT 0.43 (0.38-0.50)
MCV 86 fL
Neutrophils 2.1 /nL
Lymphocytes 1.7 /nL
Monocytes 0.3 /nL
Eosinophils 0.1 /nL
Basophils <0.1 /nL
Platelets 173 /nL

TSH. 2.3 mU/L (0.5-4.0)
Free t4 15.9 pmol/L

FSH 5 U/L (2-12)
LH 6 U/L (2-9)

I didn’t have oestradiol tested this time but recently had results of 52 and 39 in previous months (pmol/L)

Prolactin 352 mU/L (86-324)

Testosterone 14.2 nmol/L (12.0-31.9)

(Previous testosterone results were 8.1 on HCG and 18.6, 18.7 on trt. 11 before starting any trt. )

SHBG 20 nmol/L (15-48)

CRP <1 mg/L (<5)

Ser. Osmo 299 mmol/kg (275-300)

Sodium 146 mmol/L (135-145)
Potassium 5.1 mmol/L (3.5-5.5)
Chloride 104 mmol/L (95-110)
Urea 6.2 mmol/L (3.0-7.5)
Creatinine 95 umol/L (60-110)
eGFR >90 mL/min/1.73m2 (>89)
Bicarbonate 30 mmol/L (20-32)
Total bilirubin 6 umol/L (4-20)
ALP 52 U/L (35-110)
Gamma GT 17 U/L (5-50)
ALT 34 U/L (5-40)
Total protein 68 g/L (66-83)
Albumin 40 g/L (36-47)
Globulin 28 g/L (26-41)
Total calcium 2.43 mmol/L (2.15-2.55)
Corr. Calcium 2.43 mmol/L (2.15-2.55)
Phosphate 1.12 mmol/L (0.8-1.5)
Magnesium 0.89 mmol/L (0.7-1.05)

Testosterone 14.2 nmol/L (12.0-31.9)
SHBG 20 nmol/L (15-48)
Albumin 40 g/L (36-47)
Calculated FTe 392 pmol/L (260-740)

(taken the week before:
Testosterone 11.6 nmol/L (12.0-31.9)
SHBG 14 nmol/L (15-48)
Albumin 49 g/L (36-47)
Calculated FTe 311 pmol/L (260-740))

Cortisol 0810 Hrs 309 nmol/L

Growth hormone <0.1 ug/L
Growth hormone <0.3 mIU/L

IGF-1 Liaison 26 nmol/L (15-43)

5

You have lower SHBG so twice weekly may fail, my SHBG is 16-18 and don’t respond well to TRT injecting twice weekly. Once you begin TRT it will lower you already low SHBG. Thyroid labs are inadequate, your doctor is cutting corners or doesn’t understand the importance of testing Free T3, the only active thyroid hormone that’s responsible for metabolic rates.

Day in and day out we see doctors failing miserably at thyroid treatment and testing, a common denominator is only testing TSH and Free T4 (in Europe) and informs us to knowledge and that it is lacking. Reverse T3 can block Free T3, TSH of 2.5 isn’t optimal, closer to 1.0 is optimal. So if I asked you where you thyroid free hormones levels were, you would say doctor didn’t test for them and I’ll ask why not?

I’m seeing big fluctuations in SHBG (14-20) which is telling me your thyroid is struggling and you will see SHBG fluctuate when thyroid hormone output changes and thyroid output should be consistent, TSH is unreliable at diagnosing thyroid problems. You can have low Free T3 and high Reverse T3 and TSH in range. You can have thyroid labs in range and have thyroid dysfunction, few doctors can spot thyroid problems and shockingly know very little within their own field of medicine.

Your doctors is wrong and doesn’t stay updated with the latest studies which is hardly shocking anymore, injecting SQ has been shown to decrease estrogen, if anything I’ve seen guys try SQ and estrogen is very low. HCG can increase estrogen more so than injecting test SQ, injecting HCG together with Test and estrogen blocker is best since E2 will rise as a result of Test+HCG.

Prolactin may be causing problems with testosterone, lowering testosterone and making you look like a guy with testicular failure when in fact prolactin is the problem. An MRI is needed.

I recommend 25mg EOD, HCG EOD, the AI taken with injections since the AI blocks estrogen within 24 hours, by hour 50 the half life of the AI is reached and is less effective.

6

I appreciate your reply. As mentioned, 250iu HCG EOD is not an option for me unless absolutely necessary as it is too expensive.

I have just obtained some more recent blood test results. These were taken when I was off trt. Hopefully this can give a more complete picture:

26/6/18
Testosterone 17.1 nmol/L
SHBG 18 nmol/L
Albumin 40 g/L
Calculated FTe 506 pmol/L
Prolactin 286 mU/L
FSH 5 U/L
LH 5 U/L
Oestradiol 81 pmol/L
TSH. 3.9 mU/L
Cholesterol 4.7 mmol/L
Triglycerides 1.7 mmol/L
HDL cholesterol 1.3 mmol/L
Cholesterol/HDL 3.6
Non HDL-Chol. 3.4 mmol/L
LDL Cholesterol 2.6 mmol/L

Thoughts?

7

Your TSH is all over the place, 3.9 is not good at all and a lot of progressive doctors believe thyroid is in trouble when TSH reaches 2.5. A Total T of 492 and an SHBG of 18 isn’t bad by any means unless SHBG is lower do to low thyroid function which is what I’m seeing. Low thyroid function will see SHBG decrease and lower thyroid hormones slows down every cell in your body.

Once you start taking thyroid medicine SHBG will increase and Total T will see an increase while Free T will see a decrease. Free T is the hormone that makes the magic happen, so TRT will likely be needed as well. Oestradiol is good, but would likely be a little higher is T status was improved.

Hopefully your endo will not play the numbers game and realise thyroid is struggling.

8

Interesting, I was pretty sick with the flu when the tests were done on 26/6/18, I wonder if that could have affected the TSH? One month prior it was at 2.3 and before starting TRT last year it was on 1.3 and then 1.9. Does have me a little worried so I will keep an eye on that one. Thanks so much for your help.

I gave up seeing endocrinologists, as I saw the two “best” ones where I live and were hopeless! Eg. One of them started me on 250mg test E once a fortnight with no HCG and refused to test my E2, the other I saw for a second opinion said all my levels were fine (testosterone of 11) and said I should go on antidepressants instead. I did some research and found a doctor on the other side of the country who flies across the country to see patients and is more knowledgeable on trt, although he’s a GP not an endo. He did explain that blood tests can vary a lot day to day. I’ll try and get TSH tested again after starting back TRT.

Based on those bloods, do you think I’m OK with option A?

Thanks again for your help, really appreciated!

9

TSH is thyroid stimulating hormone and is secreted by the pituitary gland to stimulate the thyroid to produce thyroid hormones, so TSH isn’t actual thyroid hormones. You need to be checking Free T3, Reverse T3 and antibodies. These could be why TSH is fluctuating so wildly, because Free T3 could be fluctuating. When Free T3 goes down, TSH goes up as seen in your latest 3.9 score.

No I personally don’t think option A is is the best option, smaller injections (25mg) EOD is going to serve you better especially after SHBG decreases after the first few months of TRT.

10

The possible thyroid issues have only occurred after stopping trt in April. My experience with trt last year was positive, other than feeling tired on day 6 before weekly injection. Do you think coming off trt could have messed up the thyroid? Or is it likely the TSH was high because I had the flu?

11

Your right at the limit for TSH, ranges are .5 - 4.5, if doctor isn’t concerned with a TSH of 3.9 find another doctor. I mean how bad do you have to let things get before taking action? You don’t wait till the ship is underwater to make your escape.

Feeling tired on day 6 indicates injections are too far apart, I felt the same injecting twice weekly and on day 3 I felt a slight crash. TRT can have a positive effect on thyroid, each time I increase test dosage my T3 uptake changes and I feel hot and temperatures are elevated higher than 98.6 degrees, in effect I’m becoming almost hyperthyroid for a couple of weeks.

Having the flu can increase Reverse T3 because the body is under stress, the body is slamming on the brakes metabolically. Thyroid hormone Free T3 drives metabolic rates or body temperatures. I don’t think stopping TRT can cause thyroid issues, think it’s one of the reason that made you seek TRT.

My TSH never fluctuates more than .7 - 1.1.

12

Sorry mate I don’t full understand the last sentence…

I first started trt due to all the common symptoms plus low test of 11. Trt made me feel a world better but had to stop for the past 4 or so months. I do want to make sure my thyroid is healthy, but I find it quite confusing. Doesn’t help that I live in Australia where trt knowledge is almost non existent. I’m seeing Dr Z now, who is my last resort in Australia. There are no other options. Frankly, I’ve gotten more help from these forums from most medical professionals I’ve seen, thanks to kind folks like yourself.

13

Hi @systemlord I just saw my Dr. They weren’t concerned about TSH as it was under 5.5. T4 historically was within range, 19 and 14. I explained I have read TSH should be under 2 ideally, but the Dr didn’t seem fussed, and who am I to argue with a doctor… Is what it feels like. I explained my oral morning and arvo temperatures have been consistently low, around 36c but again, Dr wasn’t fussed. I’m giving up on thyroid for now, but the Dr did say I can test thyroid again after my T levels out. I’m only on week 3 of trt so in a few months I can test again.

This is an issue Australia is far far behind in so I doubt I’ll find a Dr who is up to date and agrees with T Nation about thyroid sticky stuff.

This was my GP, not my TRT prescribing Dr. I’m hoping .y trt doc will seriously look at my thyroid.

So far I’ve gone through GP, TRT dr, and two endocrinologists and none of them are concerned about my thyroid.

I’m hoping I feel better after week 6 or so of trt. I’m currently injecting 62.5mg T Enanthate IM every 3 days, with 250iu HCG day before each injection. Low SHBG. Thanks for your help. I’d be interested in your thoughts.

14

TSH is NOT actual thyroid hormones, I’ve seen guys with a normal TSH and Free T3 below ranges. Unless these doctors make an effort to stay updated they will continue being ignorant until their carriers fizzle out and they become irrelevant.

I think ridiculous that you haven’t ever had thyroid hormone testing, waiting for TSH to go out of range before checking thyroid hormones is insane.

It would be like testing LH to determine a testosterone without actually testing Total T or Free T to determine a testosterone deficiency. LH stimulates the testicles to produce testosterone, doctors check Total T. TSH stimulates the thyroid gland to produce thyroid hormones, doctors check thyroid hormones. Simple concept really.

It’s makes you wonder what doctors are actually learning in medical school.

15

I know right? It shouldn’t be that hard to understand…

I have had t4 tested in the past, not recently, but it was within normal range.