TRT and Tendonitis - Elevated E2

Pharma / TRT Testosterone Replacement
1

Long time lurker - first time posting…

I had been on TRT via pellet insertion for a couple of years with good results. About 2 month after an insertion last year, I developed severe tendonitis in my achilles tendons after running a short distance. Shortly thereafter, it affected both elbows and eventually my wrists and even my fingers. I was doing weight training 3-4x a week and just thought that my tendons were strained and were not keeping up with the muscle development. I never thought of a correlation between the trt and the tendonitis. I went through a couple months of physical therapy on my elbows and I needed cortisone in both to finally end the issue. I would imagine that the pellets wearing off over time helped whatever was the cause.

I do remember my T being over 1500, but that is all I remember about labs. I was not as educated on the matter then and I was trusting that these MD/idiots knew what they were doing.

Earlier this year I decided to stop the pellets and seek out an MD to write for trt via injection. Here are my baseline labs that my new MD ordered and the answers to the questions from the sticky:

5/22/2014
Hematocrit 42.9 % 37.5 - 51.0
Testosterone,Free and Total
Testosterone, Serum 425 ng/dL 348 - 1197
Free Testosterone(Direct) 7.0 Low pg/mL 7.2 - 24.0
LH 4.7 mIU/mL 1.7 - 8.6
FSH 9.0 mIU/mL 1.5 - 12.4

-age 51
-height - 5’9"
-waist - 31 in
-weight - 167
-describe body and facial hair - moderate hair, none on back, shave every 2 days, more body hair on T
-describe where you carry fat and how changed - always carry around waist, more lean since trt with a little stubborn belly fat.
-health conditions, symptoms [history] - occasional A fib.
-Rx and OTC drugs, any hair loss drugs or prostate drugs:
Toprol XL 25mg daily
Propecia 1mg daily (15 years)
Aspirin 81mg daily
Magnesium 200mg 2x a day
Fish Oil 2-4G a day
Vit D w/Sea Iodine 10,000IU daily

-describe diet - balanced 40/40/20 split of protein/carbs/good fats
-describe training - weights 3-4x a week, some light cardio 2-3x a week.
-testes ache - ached a long time ago when I first started propecia 15 years ago but not since
-how have morning wood and nocturnal erections changed - some morning wood since trt started, not much before.

After the above labs, the new MD prescribed:

Test Cyp 100mg IM weekly
Hcg 250 IU every 3 days

I felt really good a few weeks after starting. Libido strong, workouts strong and just a general sense of well being. After 2.5 months, I repeated my labs. These were taken 7 days after my injection:

Hematocrit 46.4 % 37.5 - 51.0
Testosterone, Serum 1096 ng/dL 348 - 1197
Free Testosterone(Direct) 19.6 pg/mL 7.2 - 24.0
Estradiol, Sensitive 23 pg/mL 3 - 70

He asked how I felt, which was great at the time. I questioned the high TT since that was 7 days after and represent a trough, and he said he was happy since the FT was in a “good spot”.

Over the next few weeks I noticed my hair thinning and a few weeks after that, the onset of the tendon pain. It was slight at first, hitting my achilles again, the the shoulders, elbows and wrist. It has gotten so bad that I feel horrible after sleeping all night and it takes a while to loosen up. This in a person who is in very good shape and never experienced anything like this.

I decreased my total dose of T to 80mg a week, and split it up between 2 doses. That was 2 weeks ago. I ran some labs on my own a few days go, 2 days post injection:

TSH 4.290 0.450-4.500 uIU/mL
T4,Free(Direct) 1.35 0.82-1.77 ng/dL
Triiodothyronine,Free,Serum 3.0 2.0-4.4 pg/mL
Hematocrit 46.5 37.5-51.0 %
Testosterone, Serum 979 348-1197 ng/dL
Estradiol 50.1 HIGH 7.6-42.6 pg/m

So I am at a bit of a loss. Is the elevated E2 causing this issue, or is it the T running too high? Or is it something else? Since I feel good when I start trt and then over time, I run into issues, I get the feeling that I have always been running too high and I am paying the price for running high again.

Any help would be greatly appreciated.

Thanks!

2

I had bad tendon pain with low e2 but yours was high. Your Thyroid is certainly having some problems.

3

TSH 4.290 0.450-4.500 uIU/mL [Very high]
T4,Free(Direct) 1.35 0.82-1.77 ng/dL [OK}
Triiodothyronine,Free,Serum 3.0 2.0-4.4 pg/mL [LOW]

You have some form of hypothyroidism, please follow the lead in the first paragraph of the advice for new guys sticky. I know that you are a good reader, so that is the direction. Note iodine, body temperatures, fT3 and rT3 and respond here.

You seem to have high SHBG that is exaggerating your TT

Your 5-alpha reductase inhibitor drugs will kill libido and for some is a hormone train wreck.

High T does not cause tendon pain and high E2 does not either. Something else may be the cause.

Try for 250iu hCG EOD. But note, that a few guys will get high T–>E2 in there testes from these low doses of hCG, not explanation available for that. If anastrozole as suggested does not get E2 in the 20’s, you have this hCG problem and then need to try very small does of hCG or quit. SERM’s may have similar problems for you if that is the case.

And E2 is a train wreck, ask for 1mg anastrozole per week. Take 1/2mg when you inject.

Do you have these labs?
CBC
AM cortisol
DHEA-S
AST/ALT

More in other stickies, sorry for been terse, its late here.

Tag me in the KSman is here sticky when you have info here for me.

4

Hey KSman here are the rest of my labs as requested…

BUN 22 6-24 mg/dL 01
Creatinine, Serum 1.20 0.76-1.27 mg/dL 01
eGFR If NonAfricn Am 70 >59 mL/min/1.73 01
eGFR If Africn Am 81 >59 mL/min/1.73 01
BUN/Creatinine Ratio 18 9-20 01
Sodium, Serum 139 134-144 mmol/L 01
Potassium, Serum 4.1 3.5-5.2 mmol/L 01
Chloride, Serum 102 97-108 mmol/L 01
Calcium, Serum 9.1 8.7-10.2 mg/dL 01
Phosphorus, Serum 2.8 2.5-4.5 mg/dL 01
Protein, Total, Serum 6.2 6.0-8.5 g/dL 01
Albumin, Serum 4.6 3.5-5.5 g/dL 01
Globulin, Total 1.6 1.5-4.5 g/dL 01
A/G Ratio 2.9 HIGH 1.1-2.5 01
Bilirubin, Total 0.5 0.0-1.2 mg/dL 01
Alkaline Phosphatase, S 62 39-117 IU/L 01
LDH 141 0-225 IU/L 01
AST (SGOT) 24 0-40 IU/L 01
ALT (SGPT) 19 0-44 IU/L 01
GGT 9 0-65 IU/L 01
Iron, Serum 138 40-155 ug/dL 01
Cholesterol, Total 178 100-199 mg/dL 01
Triglycerides 47 0-149 mg/dL 01
HDL Cholesterol 68 >39 mg/dL 01
According to ATP-III Guidelines, HDL-C >59 mg/dL is considered a
negative risk factor for CHD.
VLDL Cholesterol Cal 9 5-40 mg/dL 01
LDL Cholesterol Calc 101 HIGH 0-99 mg/dL 01
T. Chol/HDL Ratio 2.6 0.0-5.0 ratio units 01

CBC With Differential/Platelet
WBC 4.0 3.4-10.8 x10E3/uL 01
RBC 5.01 4.14-5.80 x10E6/uL 01
Hemoglobin 15.8 12.6-17.7 g/dL 01
Hematocrit 46.5 37.5-51.0 % 01
MCV 93 79-97 fL 01
MCH 31.5 26.6-33.0 pg 01
MCHC 34.0 31.5-35.7 g/dL 01
RDW 12.3 12.3-15.4 % 01
Platelets 136 LOW 150-379 x10E3/uL 01
Neutrophils 52 % 01
Lymphs 40 % 01
Monocytes 7 % 01
Eos 1 % 01
Basos 0 % 01
Neutrophils (Absolute) 2.1 1.4-7.0 x10E3/uL 01
Lymphs (Absolute) 1.6 0.7-3.1 x10E3/uL 01
Monocytes(Absolute) 0.3 0.1-0.9 x10E3/uL 01
Eos (Absolute) 0.1 0.0-0.4 x10E3/uL 01
Baso (Absolute) 0.0 0.0-0.2 x10E3/uL 01
Immature Granulocytes 0 % 01
Immature Grans (Abs) 0.0 0.0-0.1 x10E3/uL 01
Comp. Metabolic Panel (14)
Carbon Dioxide, Total 24 18-29 mmol/L 01

DHEA-Sulfate 320.5 71.6-375.4 ug/dL 01

Cortisol - AM 13.1 6.2-19.4 ug/dL 01

Oral temps 98.6 during day / 97.7 AM AM in bed.

Thyroid - after reading the stickies, and having OK temps, I am unsure how to address the elevated TSH. Few notes - I did have a benign thyroid cyst a few years ago but it was aspirated and I am checked annually. Nothing new there. I also take about 2000 mcg a day of Sea Iodine. But that is a low dose. My temps seem fine. Can you please advise a plan?

E2 - MD agreed to .5mg weekly of anastrozole. He feels that 1mg/week is too high for me right now. I will split the dose twice a week. How long until I do f/u on e2 levels?

He also agreed to hcg 250u EOD.

High TT - I have the DHEA and AM Cortisol as requested (above)

The tendonitis is still baffling me. If you search the net you will see many cases where trt seems to have caused this. Some do say they improved at a lower test dose. I guess time will tell after running 80mg a week for a bit. I do feel better (mood, libido etc) at 80 than 100, but it could be psychological.

I am open to any suggestions.

Thanks!
Bob

5

It is odd that I am not familiar with TRT and tendonitis

Your E2 should level out in 2-3 weeks. That dose will probably not get you near E2=22pg/ml unless you are an anastrozole over-responder.

Your additional labs look great. Lipid profile is very good [WOW].

Do you think that you were once iodine deficient. Your 2mg/day is certainly adequate [or more] from a maintenance point of view.

Body temps are good. So if you were to experiment with more iodine, you would not see much of a guiding change there.

So we are back to the high E2 and expected lower FT and elevated SHBG. These will need to be watched as you get E2 dialed in. But I would not rush that testing as SHBG will take time to respond.

How are you feeling these days?

6

I had severe Achilles’ tendon pain and still do from E2 being driven to low with Femara. I stopped the femara and pain improved but did not totally go away. Just had blood work last week and E was 51. Still waiting for the pain to totally go away. When the pain started my E was 5. Worst 8 months of my life. I’m wondering if the pain will totally go away or is there some permanent damage?

7

If there’s an association between TRT and tendonitis I would think it has to do with exercise induced strain. There is the psychological motivation to finally start or increase training as well as a tendency to be overconfident. On top of this testosterone is actually increasing the strength of the muscle fibers, increased hemoglobin delivering more oxygen allowing more endurance and delivering this new power to possibly under conditioned tendons. This is how I see it.

Low E2 is a known cause. Since E2 is the main growth steroid in joints and ligaments perhaps elevated amounts cause pathological growth or possibly ossification.

8

[quote]mbalmr wrote:
I had severe Achilles’ tendon pain and still do from E2 being driven to low with Femara. I stopped the femara and pain improved but did not totally go away. Just had blood work last week and E was 51. Still waiting for the pain to totally go away. When the pain started my E was 5. Worst 8 months of my life. I’m wondering if the pain will totally go away or is there some permanent damage?[/quote]

Femara=Letrozole. I have always stated that letro has a reputation for harshness - read unpredictable dose-respose. I never recommend it. We get spill over from the steroid boys who think that it must be better and more even so.

9

Yeah, I did what you told me KSMAN and stopped the letro. Pain is a little better but is still bad. What’s weird is some days there is no pain at all, zilch, and then…boom! Pain is back full force the next day. Will my Achilles ever be normal again? I’ve been off the letro now for six weeks or more.

10

" I needed cortisone in both to finally end the issue"

Please note that long term use of cortisone like drugs is very catabolic and has been known to lead to weakening of connective tissue. Tendons have snapped!

Healing: look at diet. Fish oil can be helpful.

11

Thank you. I go to my PC today to go over blood work. I’ve had four days in a row now with just mild pain. Seems like they are repairing themselves as my E2 is coming up since stopping Letrozol.

12

Tendons and ligaments require weeks to months to heal unlike muscle which is days to weeks. This is due to a lack of vascularity. Nutrients are required to cross through several cell layers to be made available. You can improve the flow of blood by heating and massaging. Another cool trick is icing to the point of intense pain and then removing the ice. This will cause the arteriolar sphincters to open wide and allow intense blood flow to the area. You can knock a good 30-50% off your recovery time.