Water Retention

Pharma / TRT Testosterone Replacement
1

Hello T-Nation Patrons!

I work with several clients undergoing TRT and one of the biggest complaints is the excess subQ water. Many of the clients looking to improve their physical appearance- the water retention tends to “thicken” the skin and soften their overall look.

Outside of mild diuretics (which I don’t advise long term unless a serious condition exists) I’m having trouble finding a solution.

Ive made recommendations to maintain low sodium in the diet, drink plenty of water, and take in a moderate amount of caffeine; are there other safe methods that athletes have used?

Are there particular micro-nutrients that contribute to / aid in removing excess water?

I appreciate any feedback.

Dr.DT

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Do your patients use estrogen control?

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Ive been reading quite a few posts on this forum and other athlete forums, and the anti-estrogen protocols I’ve seen aren’t typical for TRT.

In fact, many of medications described are more commonly used among female patients for various OB related issues.

Notwithstanding, Id be interested in any feedback.

Dr.DT

4

THis should be moved to the TRT forum.

OP. Read the stickied threads in the TRT forum. This is a rather simple ‘problem’. Aromatase Inhibitor should be used.

But in many cases ‘water retention’ is simply fat. If your clients arent contest lean than their water retention is not affecting their appearance nearly as much as their bodyfat level is.

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[quote]Dr.Bigleo wrote:
Ive been reading quite a few posts on this forum and other athlete forums, and the anti-estrogen protocols I’ve seen aren’t typical for TRT.

Dr.DT

[/quote]

And please be careful with statements like this. You are opening yourself up to ridicule because its clear that you havent done more than 10 minutes of research on this.

Typical =/= optimal. As a general statement, most doctors are in the dark when it comes to optimal drug protocol for men on TRT.

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[quote]Dr.Bigleo wrote:
Ive been reading quite a few posts on this forum and other athlete forums, and the anti-estrogen protocols I’ve seen aren’t typical for TRT.

In fact, many of medications described are more commonly used among female patients for various OB related issues.

Notwithstanding, Id be interested in any feedback.

Dr.DT

[/quote]

Bodybuilders who take testosterone will use an aromatase inhibitor (AI) like arimidex, aromasin or letrozole to control estrogen related side effects (water retention among them) while on cycle. They are very effective and would likely solve your clients’ problems.

I don’t know much about TRT, but I’d hazard a guess that doctors would be reluctant to prescribe ancillary drugs for the sole purpose of improving a patients physique. You can buy AIs legally in liquid form from various research chemical companies.

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Thank you Bone for the feedback.

Most clients are 50+ years of age, so bodyfat is an issue too.

You are absolutely right about common knowledge base among physicians as it relates to the optimal drug protocol for TRT- especially concerning the “aesthetic” related issues like mild edema.

This is precisely why I thought this type of forum would be a good resource. Ill review the ‘stickied’ posts in the TRT area.

Thank you again,

Best.

Dr.DT

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Elevated E2:
inability or weak ability to loose fat
moody/depressed/low energy/apathetic/intolerant/short tempered
ED and performance problems, even with high TT & FT
increased problems of or risks of HPH
increased SHBG leading to lower FT

E2 blocks T at androgen receptors.

If E2 is in the mid thirties or higher, response to TRT can be poor. E2=22mg/ml seems to be near optimal from a libido and fat loss point of view. Many feel transformed when on TRT and then an AI is added.

For every 100mg of injected T ester, 1.0mg anastrozole is typically needed.

Do the reading and take note of “anastrozole over-responders”.

Weekly T injections make E2 worse as a response to the high T peak levels.

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Thank you for your input Overstand,

Especially with patients suffering from LowT the goal really is to improve the quality of life. I believe Bone made a valid point about in saying Typical =/= optimal, and Im not going to pretend for a moment that the knowledge base in this arena isnt lacking among most physicians (myself included).

I am familiar with Arimidex for the treatment of certain glandular disorders in boys and men ,like gynecomastia,hence,I don’t think its that far of a stretch to use any of these breast cancer/menopause medications for LowT patients experiencing symptoms of aromatization.

To keep this in perspective there was only two clients that complained of the edema- specifically speaking about a “thickness” and “softness” in the waist line- which is why I used their language in the original post.
Again, the goal is to improve the quality of life, and if the bloating is uncomfortable, than I don’t see why this wouldn’t be a suitable treatment- I am far more comfortable with an AI than I am a diuretic.

As I read through the various posts, the dosage administered for the treatment of LowT patients would probably be quite laughable to most athletes. I don’t by any means want to state that this is the absolute guideline for treatment, but for those who are treated via testosterone injection, a dosage of 200mg’s every ten days is quite common, so, I am somewhat surprised that aromatization would be the culprit here, but that’s why I thought it prudent to reach out in forum like this one-

I appreciate everyone’s input.

Dr.DT

10

aromatase can be a problem that is why most here constantly push for detailed blood tests PRIOR to starting any treatment or starting on AI. Plus even without aromatase problems going a 10 day rollcoaster of levels starting too high then dropping too low (per the injection literature itself) just seems crazy, why would you want to subject anyone’s body to that variation? feel good for 3-4 days, then feel terrible for 3-4 days, then repeat. even if your body can handle the additional stress, how long will it be before that stress takes a toll of your overall health?

Testosterone also interacts with cortisol function. More T drives higher utilization of Cortisol. If your body can’t produce enough cortisol then that can cause additional problems like hypothyroidism and imbalances with Aldosterone. We know that increasing cortisol helps regulate aromatase.

water retention (and inability to absorb transdermal medications) are one potential symptom of hypothyroidism.

low Aldosterone = low salt/bad electrolyte imbalance can also cause water retention. there seems to be a correlation between Low Cortisol and Low Aldosterone. decreasing salt intake or having low aldosterone can lead to water retention, higher BP, and increased heart rate.

I had water retention and swollen ankles + high BP 140/95 and high resting heart rate of 90-100 that I always attributed to high E, but then found out I had low Aldosterone. I started taking 1-2 teaspoon of sea salt daily (coarse salt tossed to the back of the throat and chugged a full glass of water). Then my water weight dropped, my ankles stopped swelling, I stopped sweating when it was slightly warm, my BP dropped to 116/80, resting heart down to 76, etc.)

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“testosterone injection, a dosage of 200mg’s every ten days is quite common”

Is malpractice, once you understand the issues.

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[quote]KSman wrote:
“testosterone injection, a dosage of 200mg’s every ten days is quite common”

Is malpractice, once you understand the issues.[/quote]

Quoted for truth. My endo wants me to do 200mg every 14 days. I’m on day 12, and I’m barely able to function due to low energy and tiredness - and I’ve been oversleeping the past 6 days (averaging about 3 hours more sleep than usual). I’ve been feeling ‘exhausted’ since day 6. If it weren’t for the meds (Welbutrin + Cymbalta), I’d probably be suicidal.

Definitely switching to 50mg twice/week (every ~3.5 days) starting this Wednesday, and maybe even switch to EOD if that doesn’t do it.

13

[quote]KSman wrote:
“testosterone injection, a dosage of 200mg’s every ten days is quite common”

Is malpractice, once you understand the issues.[/quote]

Think of it this way - if you were trying to do pain management, would you tell someone to take a 10 day dosage of Vicodin all at once? If they survived, they would still be in pain for the remaining 8 days. Spreading out dosages to EOD/E3D only makes sense. Unfortunately, many doctors do prescribe the “load and blast” treatment and then we have to figure out that it doesn’t make sense and adjust accordingly.

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Hello Everyone!

Yikes! I didn’t think I would be knocked for malpractice here!

PureChance- I appreciate your input and will order Aldo/Renin test to look at other causes if the symptoms become more severe/persistent.

I’m very comfortable with the info on the AI, and will try those as first solutions.

Without sounding like a total idiot on the subject- We do a blood panel before we setting up an apt. and dosing schedule. We use a dosing index that outlines how much to administer to bring the patients range back to optimal(600-800 ng /dl )Again…the indexes notation of optimal NOT my own!

I’m reviewing the chart right now, and the index ranges from 180mg/10 days to 400mgs every 14 days. I’d like to say 80% of the patients are treated at the level of 200mgs per visit, with visits every 10 days or so.

As I stated, this is probably laughable to most athletes.

The type of testosterone we use is esterfied, and according to the reference card, is active 24-36 hours after administration, with a half life between 10-12 days.

I’m not at all wanting to be argumentative here- Ultimately,this is a learning opportunity for me. And, in the spirit of that, what I don’t understand is why (if the medication has time released properties spanning nearly 22 days) a dosing schedule of every 3-5 days would be more optimal?

Wouldn’t this lead to a higher accrual of free Testosterone in the blood, and perhaps more non-beneficial side effects?

If I am wrong- Fine. I will use the good feedback to discuss with other DOE’s and perhaps adjust patient treatment accordingly. I certainly wouldn’t want patients to think of the treatment in terms of “load and blast” by any means.

Aside from the recent edema complaints, most patients have had nothing but stellar feedback since starting the treatment.

Akaji- I encourage you to discuss this with your GP. LowT absolutely can illicit these types of side effects, but something more serious can also be going on. A basic blood/urine test would be enough to provide a 30 thousand foot view of any alternate causes.

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[quote]Dr.Bigleo wrote:

As I stated, this is probably laughable to most athletes.

The type of testosterone we use is esterfied, and according to the reference card, is active 24-36 hours after administration, with a half life between 10-12 days.
[/quote]

What would be laughable would be the dosing schedule. Most popular esters are test cypionate and test ethanate, which have half-lives of around 6-7 days. Even if the half-life of the ester you are using is 10-12 days, your patients would be at half their T levels after that time than they were at on day one. Does it still make sense to dose every 2 weeks?

If at all possible, train your patients to self-inject.

Glad to have you on board.

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Hello Again,

Testosterone Cypionate 200mg/ml is the only form of injectable testosterone that we use in the clinic. I’m sure that manufacturer or brand would not make a difference, but for the purpose of this conversation we use the product from a company called Watson Laboratories.

I’ve scanned the pamphlet and taken a screen shot of the page outlining the recommended dosage/ schedule. You’ll see what I’ve mentioned is what is recommended (not that I’m saying that its optimum by any means as mentioned in earlier posts)

PCDude, your comments, and others comments, are very sensible.

This forum has proved to be a great resource. I will share with colleagues as the topic arises.

I’m going to make a point to engage in more detailed dialogue with all lowT patients, increasing frequency of/ and dosages as it makes sense, as well as, utilize AI’s as a part of treatment.

Thank you everyone who participated! Ill be sure to check back and share patient feedback in the coming month.

Best,

Dr.DT

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To be blunt, my GP is a douchebag, and I’m looking for a new one. For the past 6 years he’s told me that the only way I’ll ever feel better is to exercise and lose weight. For the past 6 years, I’ve tried. I’ll spend about a month on a normal diet (and I mean normal - what I see everyone around me that is healthy eats - not a crash diet or anything stupid like that), and keep with exercise for most of that time, and by the end of that month I am literally one bad day away from suicide.

As for my other note, about ‘if it weren’t for the meds, I’d be suicidal’… turned out that, even with the meds, I ended up being suicidal by the end of the day. I took 4mg Xanax (4x the dose my doc recommended) and slept for the next 19 hours (1 PM to 8 AM). I still feel like shit, but at least I don’t want to kill myself… or, at least, I don’t have the energy to kill myself. Heh.

I have had suicidal thoughts since I was 13 (I’m now 23), but they usually behave more like intrusive thoughts (a la OCD); never before have they manifested in such a strong desire as they did last night. I am fairly convinced that it is due to the testosterone shot - or, rather, the withdrawal effect after the testosterone has left my body. It was my first shot; I never felt better from it, and by day 3 or 4 I felt myself getting more tired, by day 6 I was exhausted and I noticed my depression was getting massively worse. The night of day 12 (last night), I was closer to suicide than I have ever been before - even when I held a knife to my throat and threatened to kill myself in front of my parents when I was 16.

I’ve had urine tests, blood tests, etc., and my GP always insisted that everything was fine. My TSH is 2.99 and total testosterone is 141-153 (tests @ 10 AM, then @ 8 AM), though, and I exhibit all of the side effects of both hypothyroidism and hypogonadism - so why wasn’t that ever looked in to? Because he did things ‘by the book’, and treated only based on labwork, not symptoms, not behavior. So forgive me if you feel I’m being too harsh, but fuck doctors who go by the book, including my endocrinologist. If I had been prescribed testosterone injections every other day or every three days, I don’t think I’d be in this predicament.

1 Like
18

[quote]Akaji wrote:

To be blunt, my GP is a douchebag, and I’m looking for a new one. For the past 6 years he’s told me that the only way I’ll ever feel better is to exercise and lose weight. For the past 6 years, I’ve tried. I’ll spend about a month on a normal diet (and I mean normal - what I see everyone around me that is healthy eats - not a crash diet or anything stupid like that), and keep with exercise for most of that time, and by the end of that month I am literally one bad day away from suicide.

As for my other note, about ‘if it weren’t for the meds, I’d be suicidal’… turned out that, even with the meds, I ended up being suicidal by the end of the day. I took 4mg Xanax (4x the dose my doc recommended) and slept for the next 19 hours (1 PM to 8 AM). I still feel like shit, but at least I don’t want to kill myself… or, at least, I don’t have the energy to kill myself. Heh.

I have had suicidal thoughts since I was 13 (I’m now 23), but they usually behave more like intrusive thoughts (a la OCD); never before have they manifested in such a strong desire as they did last night. I am fairly convinced that it is due to the testosterone shot - or, rather, the withdrawal effect after the testosterone has left my body. It was my first shot; I never felt better from it, and by day 3 or 4 I felt myself getting more tired, by day 6 I was exhausted, and by day 8 I noticed my depression getting noticeably worse. The night of day 12 (last night), I was closer to suicide than I have ever been before - even when I held a knife to my throat and threatened to kill myself in front of my parents when I was 16.

I’ve had urine tests, blood tests, etc., and my GP always insisted that everything was fine. My TSH is 2.99, though, and I exhibit all o the side effects of hypogonadism - so why wasn’t that ever looked in to? Because he did things ‘by the book’, and treated only based on labwork, not symptoms, not behavior. So forgive me if you feel I’m being too harsh, but fuck doctors who go by the book, including my endocrinologist. If I had been prescribed testosterone injections every other day or every three days, I don’t think I’d be in this predicament.[/quote]

If this is too harsh for you, just ignore it. But seriously dude? You can’t eat and exercise like a normal person for a month without wanting to kill yourself? That’s pathetic. You’re on a website filled with people who follow strict diets and exercise rigorously every single day. You aren’t going to find any sympathy here.

I agree that test c should be administered e3d, but 200mg of test cyp once is no where near enough to shut you down. Test C/E take weeks before you “notice” any kind of effect at all. Further, it’s fairly obvious when somebody has hypogonadism. If your bloodwork is normal, the problem is not your hormones, it’s in your head.

Sounds to me like you are overweight and depressed. Instead of blaming your doctor/hormones/every medical condition under the sun for your problems, why don’t you grow the fuck up, stick to a diet and get the results you want?

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take a look at this graph. It is pretty accurate I believe (and mirrors exactly what 16+ blood tests show for me personally).

let’s say that my personal genetic optimal point for T is the 6 on this graph. Why in world would I want to take a dose that boosts me above my personal optimal point for 4 days and then drops me below ideal for 6 days?

what is my body going to do with that extra T during the first 4 days? try to dump it to DHT or Estradiol? mess up my cortisol levels because of the increased demands placed on my body? how will the demands on my cortisol impact my thyroid which works with cortisol to maintain body metabolism/temperature? what is that extra Estradiol going to do? what about feedback impact on DHEA, etc. etc. etc.

how am I going to feel during the last 6 days as my levels bottom out back where I was before treatment? My higher estradiol will probably still be hanging out causing issues, and how long will the increased aromatase continue until my body realizes it has too little T and decreases it?

now if I take shots every 3 days or every other day, I can provide myself with very stable levels between 5 and 7 (with my hypothetical ideal being 6). Now how will my body react? keeping my levels stable exactly where they need to be.

most docs seem to require shots every two weeks because they see it as a quick easy continuous revenue stream (charging for more office visits). why worry about the actual health of their patients?

Here is a product brochure for one type of injection and in their literature they even show how much the T-levels will swing.

[quote]http://www.pfizer.ca/en/our_products/products/monograph/182
In a randomized cross-over study of six healthy males aged 20-29 years of age, the
pharmacokinetics of a single injection of 200 mg testosterone cypionate was compared to that of a single injection of 194 mg testosterone enanthate. Mean serum testosterone concentrations
increased sharply to 3 times the basal levels (approximately 1350 ng/dl) at 24 hours and declined gradually to basal levels (approximately 500 ng/dl) by day 10.[/quote]

Is having a swing of 800 healthy?!?!?!?? WHY subject your body to that week in and week out? It just doesn’t make any sense.

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[quote]overstand wrote:
If this is too harsh for you, just ignore it. But seriously dude? You can’t eat and exercise like a normal person for a month without wanting to kill yourself? That’s pathetic. [/quote]

Overstand - you are way off base here and need to back up and apologize. Go tell someone with a broken leg that they should just exercise and eat right and they will feel better. How will that work for them? If you have a medical condition (low T, hypothyroidism, etc.) then telling someone to diet is just as effective as leaving them with a broken leg. Wouldn’t you feel like crap after a month of walking around with a broken bone that is not being treated?

Low T, low thyroid, etc. all effect your mood, your drive, your sense of well being. I am glad if you have never had to suffer through any of this, but most of us here haven’t been as lucky.

THIS forum here is specifically here to help people who are going through problems or who are having issue. You are the one who is off base. This here is NOT a body building forum. Yes, the website is about that, but this specific forum is here for the purpose of helping those seeking hormone replacement therapy information, advice, and guidance. NOT bullying.

this is even more BS. It is rarely black and white obvious. Blood tests can only show you show much. There are so many factors that go into treatment and all of the impacts to a huge range of other systems. It is incredibly hard to get on the right plan and get back to 100%. Plus who defines normal? does my ‘normal’ range work perfectly for your exact genetic makeup? let’s say I am great with E2 at 50, but 50 turns you into a basket case. Well, your test is “normal” so it must just be in your head. that is a load of BS. Just because you don’t understand it or agree with it, doesn’t mean that it is not real.

If I have offered help to you in the past I want to apologize, and let you know that I won’t be making the same mistake in the future. This type of behavior is never call for ESPECIALLY on a forum dedicated to help men overcome legitimate issues and the struggles that most of us face. Throwing it into someone’s face is juvenile and immature.

go back to my broken leg example - how great would your advice be in that situation? You break your leg, I tell you to just MAN up and that diet will help. Those of us that post here, and are seeking help have a LEGITIMATE MEDICAL ISSUE just as serious as diabeties or a broken bone, etc. etc. etc.

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