Should I Try a Restart?? Clomid or Tamoxifen?

Pharma / TRT Testosterone Replacement
1

Hi everyone. This is a great site and full of great information. I would like some guidance with my case.

I am an obese 40 year old. This pass fall I went to a prostate screening that was being offered. My dad has prostate cancer so I am higher risk. I’ve never had any problems with my prostate (and now I know why). They also tested my testosterone level. It was 94 (range 300-700). Wham, hit me across the head with a 2 x 4, I had no idea!

History:
About 3-4 years ago my joints would hurt/ache. My hands, elbows, and knees were the main areas. I started taking Aleve. I had to take 6 pills a day to control the aching. I went to my doctor and she ordered the following test on 01/23/08:

Sed rate 4 mmol/hr (0-14 mmol/hr)
Rheumatoid factor <40 IU/ml (<40 IU/ml)
ANA value 0.21 Negative (<=0.89, Negative)

I went and saw an rheumatoligist. He didn’t think I had arthritis, but ordered the following labs on 04/14/08:

Comprehensive Metabolic Panel
Glucose 86 (65-99 mg/dl)
BUN 22 (7-25 mg/dl)
creatinine 1.01 (0.50-1.30 mg/dl)
bun/cr ratio 22 (6-22 calc)
sodium 138 (135-146 mmol/L)
potassium 4.2 (3.5-5.3 mmol/L)
chloride 103 (98-110 mmol/L)
carbon dioxide 25 (98-110 mmol/L)
calcium 9.4 (8.6-10.2 mg/dl)
protein, total 7.3 (6.2-8.3 g/dl)
albumin 4.7 (3.6-5.1 g/dl)
bilirubin, total 0.4 (0.2-1.2 mg/dl)
alkaline phos 67 (40-115 U/L)
AST 24 (10-40 U/L)
ALT 31 (9-60 U/L)

CBC
WBC 6.9 (3.8-10.8 thous/uL)
RBC 5.67 (4.20-5.80 Mill/uL)
hemoglobin 16.9 (13.2-17.1 G/dl)
hematocrit 49.5 (38.5-50.0%)
(rest normal)

TSH, 3rd gen 3.03 (0.40-4.50 mIU/L)
T-4 free 1.2 (0.8-1.9 mg/dL)

testing from 11-19-09
Lipids
cholesterol, total 155 (125-200 mg/dL)
HDL 39 L (>= 40 mg/dL)
LDL 98 (<130 mg/dL)
triglycerides 89 (<150 mg/dL)

Comprehensive metabolic panel
glucose 87 (65-99 mg/dL)
BUN 23 (7-25 mg/dL)
creatinine 0.92 (0.79-1.33 mg/dL)
sodium 135 (135-146 mmol/L)
potassium 4.3 (3.5-5.3 mmol/L)
chloride 100 (98-110 mmol/L)
carbon dioxide 24 (21-33 mmol/L)
calcium 8.5 L (8.6-10.2 mg/dL)
protein 6.7 (6.2-8.3 g/dL)
albumin 4.1 (3.6-5.1 g/dL)
(I can’t find page 2)

I started Testosterone therapy on Nov 1, 2010. The first dose was great! 50mg test-cyp. 1 week later 100mg dose. I couldn’t wait the 2 weeks for the next dose so I started dosing 100mg weekly. I never felt as good as the 1st dose.

I started anastrozole 0.25 mg daily in December. Tried some clomid and didn’t see that it helped much. In January started HCG 500 Units 2 doses before testosterone. After a couple of weeks changed to every other day.

labs from 12-30-10
Lipid panel
cholesterol, total 160 (125-200 mg/dL)
HDL 34 L (>= 40 mg/dL)
LDL 108 (<130 mg/dL)
triglycerides 90 (<150 mg/dL)

comprehensive metabolic panel
glucose 89 (65-99 mg/dL)
BUN 19 (7-25 mg/dL)
creatinine 1.09 (0.78-1.34 mg/dL)
sodium 141 (135-146 mmol/L)
potassium 4.1 (3.5-5.3 mmol/L)
chloride 105 (98-110 mmol/L)
carbon dioxide 27 (21-33 mmol/L)
calcium 8.9 (8.6-10.2 mg/dL)
protein 6.6 (6.2-8.3 g/dL)
albumin 4.2 (3.6-5.1 g/dL)
bilirubin 0.4 (0.2-1.2 mg/dL)
alkaline phosphatase 50 (40-115 U/L
AST 22 (10-40 U/L)
ALT 29 (9-60 U/L)
Hemoglobin A1c 5.7 (<5.7 % of total Hgb)
TSH, 3rd gen 2.05 (0.40-4.50 mIU/L)

CBC
WBC 4.4 (3.8-10.8 thous/uL)
RBC 5.36 (4.20-5.80 Mill/uL)
hemoglobin 16.1 (13.2-17.1 g/dL)
hematocrit 48.0 (38.5-50.0%)

02-11-11 lab results
Cortisol (saliva)
AM 6.1 (3.7-9.5 ng/ml)
noon 1.2 (1.2-3.0 ng/ml)
PM 1.2 (0.6-1.9 ng/ml)
night 0.5 (0.4-1.0 ng/ml)

estradiol 12 (12-56 pg/ml)
testosterone 777 (400-1200 ng/dl)
T/SHBG ratio 1.8 (0.7-1.0)
DHEAS 158 (70-325 ug/dL)
SHBG <15 L (15-50 15-50 mmol/L)
PSA 1.4 (<0.5-4 ng/ml)
free T4 1.0 (0.7-2.5 ng/dL)
free T3 2.8 (2.5-6.5 pg/ml)
TSH 1.6 (0.5-3.0 uU/ml)
TPO 13 (0-150 IU/ml)
Vit D, 25-OH, D2 <4 <4 if not supplementing ng/ml)
Vit D, 25-OH, D3 29 32-100 ng/ml
Vit D, 25-OH total 29 32-100 ng/ml
Last testosterone of 100mg dosed 1 week before bloodwork.

No additional lab work was done before starting testosterone.
symptoms before TRT:
no energy, social withdrawal, testes and penis shrinking, balls never have hung, loss of libido, wife not interested in sex & I didn’t care, morning wood-what is that?, some nocturnal erections, I have a goatee and would shave every other day, small amount of hair on chest, pubic hair, hair on arms and legs, dry skin, hair was becoming like straw, brittle nails. Married for 17 years with 4 pregnancies. Kids ages 15, 12, 8. Been treating depression/anxiety for 10 years, worse in last year.

Since starting TRH, the libido has improved. Having thoughts that I never remember having as prominent before. I want sex twice a day and wife is freaking out, what to do about her. Some morning woods now. HGC has helped reduce the shrinking balls, but has not increased too much, still not much hanging. I am feeling 90% better, but not 100%.

Age 40
height 5’10"
weight 285 at last appointment,
40 inch waist
Health issues–sleep apnea, Hypertension, depression/anxiety, allergies
current drugs: lisinopril, hctz, citalopram, wellbutrin, naproxen, flexamin, zyrtec, vit d (was 2000 iu/day, now taking 4000 iu/day since last lab), added a b-complex since last labs, testosterone 30 mg every other day, hcg 500 units every other day, anastrozole (was 0.25 daily, now every other day).

Questions:
Can TRT help with the thyroid? TSH has impoved, hair not as dry and skin not as dry.
Dr called today and recommended seeing an endrocrinologist due to aderinal issue noticed in last lab. Does anyone else see an issue?

Would like to see HANs, but PA too far away.

2

Are you injecting 500 UI HCG every other day?

That’s a lot and you can desensitize your LH receptors. Did you read the injection sticky?
You can also cause an E2 spike.

If you tried clomid during TRT it wouldn’t help much. Are you primary or secondary?

Your TSH at 3 is a red flag. How’s your iodine intake?

3

Yes, TRT helps with thyroid for some. Read the advice for new guy sticky if you have not already.

Read the KSman has a thyroid problem post - iodine, what is in your salt shaker?

Did doc put you on a salt restricted diet?

Check waking body temp and temps during the day.

Is there a statin drug in your list of drugs?

Take DHEA, fish oil, CoQ10

Check ferritin [hemochromatosis], PSA, CRP, homocysteine and !!! rT3 !!!

check for Lyme disease

Your drugs can be causing problems. You may have started some drugs because of T, iodine, thyroid or cortisol problems. Hopefully you can reduce your Rx drugs.

Citalopram - Wikipedia ← try to get off of this

http://www.rxlist.com/zyrtec-drug.htm ← can increase BP

Blood pressure?
Pulse rate?

Adrenal fatigue is from too many stresses on the body. This can be events, accidents, surgeries, crisis, gum disease, gut flora problems, crones disease, ulcerative colitis, any chronic inflammation of infection.

dose hCG at 250iu EOD

4

[quote]KSman wrote:
Read the KSman has a thyroid problem post - iodine, what is in your salt shaker?
–For some reason, the salt is non-iodine, bought some fresh iodined salt last night.

Did doc put you on a salt restricted diet?
–no

Check waking body temp and temps during the day.
–will start

Is there a statin drug in your list of drugs?
–no and total cholesterol runs around 160.

Take DHEA, fish oil, CoQ10
–DHEAS 158 (70-325 ug/dL) do I need more?
–Will fish oil help increase HDL’s?

Check ferritin [hemochromatosis], PSA, CRP, homocysteine and !!! rT3 !!!
–PSA has increased since being on TRT (<1 increase)
–I’ll check about getting the others tested.

check for Lyme disease

Your drugs can be causing problems. You may have started some drugs because of T, iodine, thyroid or cortisol problems. Hopefully you can reduce your Rx drugs.
–I’ve decreased the lisinopril and citalopram. Tried stopping the citalopram but was getting to grouchy. Trying to decrease again.

dose hCG at 250iu EOD
I know, will start going lower.
[/quote]

5

Niacin can raise HDL:

6

You have mood problems from low E2. Take a break from anastrozole and resume in 5-6 days with the new dose, unless you have been there for a while already. Low thyroid levels can also cause your issues.

Fish oil and B-complex will help HDL. B-vits may need to be stronger.

Iodine, read the KSman has thyroid problems thread!
Check body temps.

You have made good progress, you need to deal with some other non-T issues. Adrenals… I asked the right questions…

7

I bought some new salt with iodine this week and replaced all of my salt shakers with the salt that I know for sure has iodine.

I have some body temps for the last few days:
tues. bedtime 97.5
wed wake up 96.8, 3pm 99.0, 6pm 98.4, bedtime 98.3
thur wake up 97.0, 11am 98.4

There is some variance in the temps through out the day. I had Wed off, so a lower stressed day.

Any one else have input on this?

8

Adrenal problems can create erratic body temps.

9

I thought I was on to something by changing the salt to iodized, but I guess not. My morning temps were starting to increase, then the last 2 days they have fallen again.

03/09 96.8
03/10 97.0
03/11 97.1
03/12 97.2
03/13 97.6
03/14 97.3
03/15 97.0

My daily averages have been high of 98.1 and low of 97.3, usually around 97.6.

I have my first appointment with endo on March 23rd.

Anybody have any input on what I should or could be doing? I have a testosterone problem, looking like thyroid issue and maybe cortisol issue also. Could these be the result of a single problem?

10

Well, I had my first appointment with the endo. I thought my PCP had a concern about my cortisol level. The endo was not concerned about my cortisol level at all. He was all concerned about my testosterone. He is wanting to find out if my problem is in my head (pituitary) or my balls. He said that he will find this out by some simple blood test. He ordered some blood work which was a repeat of labs done within the last 3 months so I don’t see that I will learn anything when I go back in 2 weeks.

Maybe he’ll find out something new.

11

Had a follow appointment with my endo for some blood work done 2 weeks ago. He is interested in determining if my low testosterone is primary or secondary. He ran a CMP which was normal.

T4, free 1.1 ng/dl (0.8-1.8)
SHBG 9 nmol/L (9-45)
FSH <0.7 mIU/ml (1.6-8.0)
LH <0.2 mIU/ml (1.5-9.3)
prolactin 9.3 ng/ml (2.0-18.0)
estradiol 24 pg/ml (13-54)
TT 728 ng/dl (250-1100)
FT 231.5 pg/ml (35.0-155.0)

He wants me to go off my hormones for 3 weeks, retest testosterone, lh, fsh.

Is that long enough for things to “normalize” so that he can get the information that he is looking for? Or is this going to be another wasted 3 hour trip to find out that he can’t tell the information that he needs?

I drove 1.5 hours to find out that he didn’t find anything out, that I need to be off the hormones for 3 weeks and retest and see him a week later.

(and this isn’t even why my PCP wanted to see him about)

12

yes going off hormones is a normal ploy. Docs don’t have to suffer with the consequences or feeling like crap for those weeks. Their jobs, relationships, mental well being aren’t put in jeopardy.

you have a broken leg you say… well, why don’t we just monitor the situation for the next month. If your leg is not feeling better by then, maybe we can get another x-ray and see if a cast is warranted. Have fun, I’m off for a cruise. what a load…

if you have blood tests before your started on HRT, then there is nothing new that this is going to show you.

plus he didn’t even run TSH or Free T3 (free T4 is useless by itself).

your TSH says your have a thyroid problem
your previous free T3 says you have a thyroid problem
your body temps say that you have a thyroid problem

your cortisol tests says that your levels are below ideal. you really need an 8am Cortisol blood test to confirm, but it may need to be treated.

your estradiol seems wayyy too low why did you start on arimidex in the first place?why are you continuing with such low E2 numbers.

I would say think about:

  1. stopping arimidex
  2. confirming your cortisol, free t3, reverse T3, and ferritin numbers (as well as D25-OH just because)
  3. starting on thyroid meds (like armour - stay away from T4only medications)
13

[quote]Tunapancake wrote:
Are you injecting 500 UI HCG every other day?

That’s a lot and you can desensitize your LH receptors. Did you read the injection sticky?
You can also cause an E2 spike.

If you tried clomid during TRT it wouldn’t help much. Are you primary or secondary?

Your TSH at 3 is a red flag. How’s your iodine intake?[/quote]

I have seen it mentioned on this website that 500IU hCG can desensitize LHCG receptors. There is absolutely no evidence that 500IU hCG DOES or DOES NOT induce LHCG receptor endocytosis (theory does not always translate to clinical outcome). Also, if this occurs at this dose (or any dose), it is transient, as the G-protein coupled receptor will be upregulated upon cessation of the factor resulting in excessive stimulation (hCG). If the OP’s doctor prescribed him 500IU qod, he should take 500IU qod, especially if he is interested in fertility. 500IU qod (along with occasional clomid stimulation) has been reported to maintain quality and quantity of sperm for men interested in maintaining fertility on TRT (personal communication). The only acceptable reason to suggest lowering the dose from 500IU qod to 250IU qod is for estradiol control. The above individual, however has a low level of estradiol.

14

[quote]PureChance wrote:
if you have blood tests before your started on HRT, then there is nothing new that this is going to show you.
[/quote]

I just had the one test that showed extremely low test. No further testing was done.

15

[quote]PureChance wrote:
your estradiol seems wayyy too low why did you start on arimidex in the first place?why are you continuing with such low E2 numbers.

I would say think about:

  1. stopping arimidex
  2. confirming your cortisol, free t3, reverse T3, and ferritin numbers (as well as D25-OH just because)
  3. starting on thyroid meds (like armour - stay away from T4only medications)
    [/quote]

My most current E2 is 24 which is the sweet spot.

  1. I’m going cold turkey as of today.
  2. I’ll keep that in mind. I’ll talk to my PCP about those test.
  3. I’ll get all the test completed and talk to my PCP about starting.

Thanks for your input.

16

whoops missed the newest E2… but why did you start on it when you were at 12?

and my thoughts are just my simple opinion (and were based on your original 12 result). i wouldn’t change anything about your protocol without consulting with a doctor.

17

Some of the results from lab work done last week:

TSH 2.80 (0.40-4.50 mIU/L)
T4 free 1.1 (0.8-1.8 ng/dl)
t3 free 3.2 (2.3-4.2 pg/ml)
t3 reverse 25 (11-32 ng/dl)
ft3/rt3 ratio 12.8 (ideal over 20)

iron total 73 (45-1701 mcg/dl)
TIBC 382 (250-425 mcg/dl)
%saturation 19 L(20-50%)

ferritin 22 (20-380 ng/mL)

vitamin b12 708 (200-1100 pg/ml)
folate serum 20.3 (normal > 5.4 ng/ml)

Cortisol 8am 11.4 (4.0-22.0 mcg/dl)

18

I have started taking an iron tablet and vitamin c twice daily due to lower iron levels.

questions–

  1. Do I have an issue with cortisol?

  2. Do I need to take care of the cortisol before dealing with the thyroid, or thyroid first, or does it even matter?

19

good idea on the iron. make sure to keep an eye on your hemocrit and hemoglobin levels while taking iron.

ideal 8am cortisol is 15-20.
under 10 is a definite issue.
under 15 is a probable issue.

Isocort is a great OTC supplement. Each pill contains 2.5mg equivalent Hydrocortisone.
Stopthethyroidmadness.com has some good information on isocort and cortisol supplementation.

fT3 is at the bottom of the ideal range.
rt3 is midish (ideal is 12). fixing your ferritin and cortisol issues should help lower this number.

20

Ok, after a 3 week hiatus from testosterone I had my levels rechecked.

FSH 0.8 (1.6-8.0 mIU/ml)
LH <0.2 (1.5-9.3 mIU/ml)
Total test 86 (250-1100 ng/ml)
Free test 21.1 (35.0-155.0 pg/ml)

From this my endo determined that I must be secondary. Had an MRI and came back “just fine.”

Dr gave me 2 options-- continuing on the testosterone or take clomid for 2 months and retest. I asked if tamoxifen would work better and he said no, just blocks estrogen.

If I wanted to try restarting, is clomid the way to go or would tamoxifen work better?

Would I want to continue taking an AI?

Thanks for your help.