Been reading through as many threads as I can in preparation for tomorrow’s visit with the endo. One thread in particular about a SERM challenge caught my eye as potentially being useful. Is this something that I should consider or is more bloodwork needed first?
If SERM increases LH/FSH:
- hypothalamus and pituitary are working
- if T increases, testes are responsive and able [hCG challenge will do this part]
If SERM does not increase LH/FSH:
- top end is broken, pituitary may be damaged from trauma or adinoma.
You need FSH first.
You MUST taper off of a SERM or you could end up worse.
Got some additional bloodwork back that the endo wanted.
E2 - 23 <=63 pg/ml
FSH - 2.4 1.3 - 11.4 mIU/ml
LH - 1.0 1.2-7.8 mIU/ml
Prolactin - 5.0 3.0-30.0 ng/ml
T4 - 8.5 4.4-12.4 ug/dl
T - 254 292-1052
TSH - 0.9 0.5 - 4.7 uIU/ml
His next recommendation is to have a pituitary MRI done. Is this worth doing / are there any alternatives for diagnosing a pituitary tumor? Just asking because it will be ~ $800 out of pocket. Endo isn’t super knowledgable but he is willing to do what I want it seems, or to recommend me to a fertility doc ( may have been a Urologist? I forget ).
Since it’s up to me, I’m not sure what I want to do yet. I’m leaning towards trying clomid.
Prolactin indicates that you do not have a prolactin producing adinoma. Making the MRI more of a long shot.
Thyroid labs are not very deep, but appear good. Body temps good now?
We see a good number of guys here who have hormone levels drop in their twenties. This is probably rare, but this site selects for that. Most of these are secondary hypogonadism without detected adinomas.
It is a tough call. Do you have any reduction in the width of your peripheral vision or any other non-refractive visual field disturbances? The optic nerves can be pressed on by an adinoma.
Your option is a HPTA restart with hCG then SERM [recommend nolvadex, not clomid], or SERM alone. You will have to taper off of the SERM and best to use 0.5mg anastrozole during and cruise on that after. If SERM does not increase LH and FSH, restart will not work. Do not use high dose hCG or SERM and never both at once.
It took forever, but I finally was able to get my MRI. The results are everything is normal.
The doc called me today and wanted to jump into treating with testosterone, even after all of the tests point to secondary hypogonadism. I brought up the SERM challenge, and inquired why that or HCG wouldn’t be better than straight test since I’m secondary.
He said for the past 35 years, he’s always treated low T with testosterone, but he’s open to me sending him some research.
After looking for some studies, I have settled on these.
Hormonal effects of an antiestrogen, tamoxifen, in normal and oligospermic men.
Disparate effect of clomiphene and tamoxifen on pituitary gonadotropin release in vitro.
Hypogonadism as a cause of recurrent muscle injury in a high level soccer player. A case report.
I wish it were him informing me, but at least he’s willing to listen. I feel like I’m well informed, I just don’t know if I’m well-enough informed to provide an effective argument.
“Body temps good now?”
They are still low but I supplemented with the 50mg iodine / daily for 3 weeks, and have been using iodized salt since.
“Do you have any reduction in the width of your peripheral vision or any other non-refractive visual field disturbances?”
no issues here.
I’m in a pretty similar position (secondary, 30) although my thyroid is not quite as good.
What is your digestion like?
How are your stress levels?
How is your sleep?
[quote]KSman wrote:
Your option is a HPTA restart with hCG then SERM [recommend nolvadex, not clomid], or SERM alone. You will have to taper off of the SERM and best to use 0.5mg anastrozole during and cruise on that after. If SERM does not increase LH and FSH, restart will not work. Do not use high dose hCG or SERM and never both at once.[/quote]
Some reset specific questions for those of us who are trying to help our doctors design resets:
1- Can you start AI before or during the hCG. Seems like it might help overall feel but maybe not valuable to the restart itself. He is at a 11:1 ratio of T:E.
2 - What’s the timeframe/max dose on the hCG for this pre-SERM usage? IS 1000IU 3x/week a ‘high dose’?
3 - Why discontinue hCG when you start the SERM ?
4 - Dosage/frequency/length for SERM use?
5 - How frequent 0.5mg anastrozole?
[quote]nomadic wrote:
What is your digestion like?
[/quote]
No problems
[quote]nomadic wrote:
How are your stress levels?
[/quote]
A little stress but nothing out of the ordinary.
[quote]nomadic wrote:
How is your sleep?
[/quote]
I work from home, so no alarm clock and a solid 8-9 hours a night. I’ve never had any sleep issues.
Still waiting for the doc to call, but is there more reason to skip the hCG and go straight to the SERM if my testes are normal size?
Some protocols lead with hCG to “stimulate the testes” and then move into SERM. Some use AI before/during/after. Some go right the SERM. That’s why I’m asking above questions to KSMan 
From what I can tell the hCG up front helps mentally by giving you a little T boost before you enter what seems to generally be a neutral or unpleasant SERM period. Does not seem to be required though.
Also the initial hCG use helps to prove secondary hypogonadism, which is a nice thing to know for sure before you go into the SERM reset.
Edit: What are you resetting from? Most people end up here for some reason - a period of adrenal fatigue, some iodine deficiency, extreme weight loss, constant dieting, hairloss drugs, something toxic in your system, GI problems, etc. I have even heard people speculate that relationship problems are driving them down.
Nothing that I know of. My LH/FSH are very low along with my testosterone, but I don’t know why. My hope is that the SERM restart kickstarts my HPTA. If it doesn’t then I guess my only choice is to do TRT even though I’m secondary? Not sure what other options there are to get my pituitary producing.
[quote]ginter wrote:
Nothing that I know of. My LH/FSH are very low along with my testosterone, but I don’t know why. My hope is that the SERM restart kickstarts my HPTA. If it doesn’t then I guess my only choice is to do TRT even though I’m secondary? Not sure what other options there are to get my pituitary producing.[/quote]
I guess the other choice is long term hCG, but I think the focus should be on figuring out the source of the problem.
Not sure what you were asking, explain and ping KSman is here again.
I’m going to try to talk my doctor into doing a SERM challenge/restart, but I don’t know what I’m trying to accomplish.
Is the plan to do that to see if my HPTA is restored and if not then go on TRT even though I’m secondary? I know that you don’t recommend staying on a SERM longterm, but isn’t there a study of men staying on successfully for 5+ years?
I’m just confused on the next step assuming the SERM restart doesn’t work.
The objective of a restart is to fix a state of secondary hypogonadism.
Staying on a SERM does not fix the HPTA. You are fixed if you can run without it.
If a proper restart does not work, then your option is TRT or hCG mono if that works.
So my endo finally got back to me a few weeks ago and after everything he wasn’t comfortable/knowledgable enough to go any route except T replacement. That’s fine - I would rather have a doc who is on the same page as me and is more knowledgable in this area anyway.
I called the local compounding pharmacy for docs who have prescribed clomid and found a urologist. After seeing him, he is open to using clomid but is wary of tamoxifen. He told me to forward him any research I wanted and he’s going to call me next week.
During the process of gathering the research, I actually think I may be more comfortable with clomid myself. This page in particular,
http://toxnet.nlm.nih.gov/cgi-bin/sis/search/r?dbs+hsdb:@term+@rn+10540-29-1,
scares me a bit. Clomiphene’s page is way better
http://toxnet.nlm.nih.gov/cgi-bin/sis/search/r?dbs+hsdb:@term+@rn+911-45-5
I’m also having a hard time locating the Ghent, Belgium study that compared the effects of clomid and nolva directly, and determined nolva was better. Anyone have a link to this?
Either way, for the people advocating nolva over clomid, what are your comments on it being more carcinogenic than clomid?
HELP!
Since my last post I’ve bounced around to a few different doctors until I finally found one who was willing to prescribe clomid. That was two weeks ago. It definitely has helped my symptoms - I feel a boost in energy and mood - but it hasn’t eliminated them. Either way, I had to stop taking it because it was causing me vision issues - blurring, difficulty focusing, sensitivity to light, etc.
This doctor is impossible to get a hold of, but after a week of trying, a nurse was able to act as a go between and updated him of the situation. I figured he would move me straight to test + HCG now since that is what I discussed with a nurse during the visit, but this other nurse comes back and says the doctor wants to put me on 1mg arimidex daily until my next visit in approx 1 month.
My initial reaction was confusion because my E2 levels were never high - 22 or 23 the last time I got it tested. Am I right in thinking that he’s crazy for wanting to me go on arimidex in the first place and extra crazy for prescribing such a high dose?
Someone is confused.
As to be switched from Clomid to Nolvadex. That should be easy.
Called the nurse back and told him I wasn’t comfortable with arimidex as it wasn’t what we had discussed. He spoke with the doctor again and came back with HCG by itself, which I’m ok with trying. I figure I’ll see how I feel leading up to my followup appt. next month and add T cyp if need be.
My only concern is the amount he’s prescribed - 1500ui 3x/week! I’ve ready on here where people are taking much smaller doses, but usually they are taking it in addition to T. I know desensitization can be an issue, so should I be worried about such a high amount, or is it ok because I’m not taking it with T?
That’s too high.
Go for 250iu EOD
Or
500 3x times a week.
That dose is way too high.
If no AI high dose DIM and clacium d glucarate can help.
For efforts to get a pregnancy, men have been given high amounts of hCG. That can work. For hypogonadism, you need to avoid LH receptor desensitization. And you also need to avoid high levels of E2 that come with high hCG doses.
What kind of doc is this?