Almost one year on TRT... struggling to find balance

[readyforchange]

So I've posted a few times around here. Started TRT last September, so right around 10 months as of now.

It has been a journey, for sure.

If I'm being honest, I've felt "ok" or "bad" more than I've felt good, but it's been better than pre TRT overall, so that's worth something.

I'm with Defy and will have a follow-up consult coming up soon, and would appreciate feedback sorting out what exactly I should seek from them. I'm fairly frustrated at the moment, because despite having a few times where I felt really good, it's always fallen apart after a few weeks (had a good month in January, that was the longest time where I felt good consistently).

I'm trying to figure out some kind of pattern as to what's working and what's not because Defy has changed up my protocol each time I've consulted with them (every three months, so I've had 3 consults with them).

I'm posting my labs below along with how I felt at the time plus what my regimen was at the time. Anyone who is able to see a pattern or help me identify how I can optimize things better is appreciated:


11/28/17
Protocol (original they put me on): 80mg test + 250 iu's HCG + .25 anastrozole every 3.5 days.

Labs:
Testosterone (total): Above 1500
Testosterone (free): 40.4
Estradiol: 49.9
SHBG: 54.2
DHEA: 323

How I was feeling: Best way to describe it: irritable and "PMSing." Fatigue. Struggle to get up in the morning and got really tired in the afternoons/evenings to where I wanted to go to sleep after supper. I notice some testicular shrinkage as well and scrotum hugging up tighter to my body.

After a consult with Dr. Caulkins, he changed protocol to decrease test to 70mg + 500 iu's HCG + .125 anastrzole every 3.5 days and added 25mg DHEA every day.

I still regret this a bit, because we changed SO MUCH at once that I feel it may not have been the best choice. But, the month or so after this change, I felt better than I ever have on TRT and had an almost month long stint where I felt like myself again for the first time in a LONG time.

Unfortunately, when February hit, things started to fall apart. I got to a point where I was extremely tired + very high anxiety/rapid heart rate at night and felt like I was out of breath really quickly while exercising.

I did my 30month follow up labs and here's what they showed at this time:


2/21/18
Testosterone (total): 1143
Testosterone (free): 32.3
DHT: 63
Estradiol: 27.7
SHBG: 34.8
DHEA: 776

When I had my consult with Defy, they were very surprised to hear I felt horrible, saying my numbers looked dang near perfect -- other than the higher DHEA. They attributed my negative symptoms to that and had me stop it.

I'm still confused about this one... why was I feeling so bad with numbers that appear to be good? Could a high DHEA really throw everything off so much that, despite good T and E numbers, I still felt bad?

After this consult, they switched me to 100mg test + 350 iu's HCG + .125 anastrozole every 3.5 days, where I'm currently at.

I still don't feel great, have more bad days than good (in terms of fatigue), and have ongoing anxiety that I've never had prior to TRT.

I pulled my E2 a few weeks ago to see where it was at and it came back at 52... which seems to be my never-ending battle despite being young (31), lean (around 12% bodyfat) and eating a diet 80% whole, unprocessed foods and exercising 3-4 times per week.

I'm kind of at a loss as where to go with this because I feel like I've tried numerus regimens and each of them tend to work for a little while and then go into a downward spiral after a few weeks.

Could HCG or anastrozole be an issue for me? Have we just been changing so many variables that it's been impossible to nail down what's working and what's not?

Any input is appreciated.

 

[HealthMan]

So I've posted a few times around here. Started TRT last September, so right around 10 months as of now.

It has been a journey, for sure.

If I'm being honest, I've felt "ok" or "bad" more than I've felt good, but it's been better than pre TRT overall, so that's worth something.

I'm with Defy and will have a follow-up consult coming up soon, and would appreciate feedback sorting out what exactly I should seek from them. I'm fairly frustrated at the moment, because despite having a few times where I felt really good, it's always fallen apart after a few weeks (had a good month in January, that was the longest time where I felt good consistently).

I'm trying to figure out some kind of pattern as to what's working and what's not because Defy has changed up my protocol each time I've consulted with them (every three months, so I've had 3 consults with them).

I'm posting my labs below along with how I felt at the time plus what my regimen was at the time. Anyone who is able to see a pattern or help me identify how I can optimize things better is appreciated:


11/28/17
Protocol (original they put me on): 80mg test + 250 iu's HCG + .25 anastrozole every 3.5 days.

Labs:
Testosterone (total): Above 1500
Testosterone (free): 40.4
Estradiol: 49.9
SHBG: 54.2
DHEA: 323

How I was feeling: Best way to describe it: irritable and "PMSing." Fatigue. Struggle to get up in the morning and got really tired in the afternoons/evenings to where I wanted to go to sleep after supper. I notice some testicular shrinkage as well and scrotum hugging up tighter to my body.

After a consult with Dr. Caulkins, he changed protocol to decrease test to 70mg + 500 iu's HCG + .125 anastrzole every 3.5 days and added 25mg DHEA every day.

I still regret this a bit, because we changed SO MUCH at once that I feel it may not have been the best choice. But, the month or so after this change, I felt better than I ever have on TRT and had an almost month long stint where I felt like myself again for the first time in a LONG time.

Unfortunately, when February hit, things started to fall apart. I got to a point where I was extremely tired + very high anxiety/rapid heart rate at night and felt like I was out of breath really quickly while exercising.

I did my 30month follow up labs and here's what they showed at this time:


2/21/18
Testosterone (total): 1143
Testosterone (free): 32.3
DHT: 63
Estradiol: 27.7
SHBG: 34.8
DHEA: 776

When I had my consult with Defy, they were very surprised to hear I felt horrible, saying my numbers looked dang near perfect -- other than the higher DHEA. They attributed my negative symptoms to that and had me stop it.

I'm still confused about this one... why was I feeling so bad with numbers that appear to be good? Could a high DHEA really throw everything off so much that, despite good T and E numbers, I still felt bad?

After this consult, they switched me to 100mg test + 350 iu's HCG + .125 anastrozole every 3.5 days, where I'm currently at.

I still don't feel great, have more bad days than good (in terms of fatigue), and have ongoing anxiety that I've never had prior to TRT.

I pulled my E2 a few weeks ago to see where it was at and it came back at 52... which seems to be my never-ending battle despite being young (31), lean (around 12% bodyfat) and eating a diet 80% whole, unprocessed foods and exercising 3-4 times per week.

I'm kind of at a loss as where to go with this because I feel like I've tried numerus regimens and each of them tend to work for a little while and then go into a downward spiral after a few weeks.

Could HCG or anastrozole be an issue for me? Have we just been changing so many variables that it's been impossible to nail down what's working and what's not?

Any input is appreciated.

Without going into much details. A lot of people here have done better with less. I would try a much lower dosage and see how you feel (specially given the symptoms you mentioned).
I have used as much as 180mg / week and now I am at 100 mg / week a feel so much better.
High dosages can put the things into overdrive. Again not going into details but I think it would be worth trying. A lot of people that dont feel good in high dosages find out that lower dosages make them feel much better. Maybe you are one of those people.

 

[readyforchange]

Forgot to mention: I'm highly suspicious of HCG as a cause of the anxiety/rapid heart rate feeling I've had during my time on TRT. When I first started, they had me injecting HCG the day BEFORE Test and I would always notice especially high anxiety/rapid heart rate that day.

Also, when they increased my HCG from 250 to 500 twice per week and decreased test from 160 to 140 (total per week), my E2 went from 50 to 69. It would seem like HCG caused a lot of aromatization, but unfortunately, this is also when they added the 25mg DHEA that sent my DHEA to the 700's, which I've heard can cause excess aromatization, so it's hard to tell where the blame should fall.

I'm tempted to drop the HCG, because I feel l may also be able to get by without an AI on just Test, and despite fertility or aesthetics not really being an issue, I've heard that can cause negative effects down the road, so not sure what to do.

 

[ERO]

I would drop the HCG entirely for 6 week and see how you feel. You can always add it back in later if you feel it helps.

 

[FeelingLost]

I sure like Healthman's suggestion on low dose and your idea as well.
What if you get permission to experiment.
Keep the HCG prescript but stop taking it and only go back to it if your balls start having issues like pain or they are pulling up tight against your body.
Ask if you can reduce your T dose keep your current script but reduce your weekly dose besure to stay at that amount for at least 5 weeks they assess your feelings. Find the T level where you feel like something is missing.
On your AI With a current Estradiol: 27.7 that is about perfect so if you drop your T dose stop the AI and only take it if you feel bitchy.

Anyway that is what I would do. You can buy mini blood test from DiscountedLab. I do little blood test TT FT and E2 all the time to see how my numbers are going.

Also have you looked at other health issues that might be causing these feeling? Thyroid, Cortosol. Do your other blood numbers look good Iron ferritin?

 

[Systemlord]

The protocols have been too aggressive and changing too many variables at a time, I prefer not to start out on all three Test+HCG+AI, test only and maybe an low dose AI if pre-TRT labs indicate in range estrogen together with low T.

You seem sensitive to estrogen, anytime it's high you seem to get anxiety with causes increased heart rates. Drop the HCG. High estrogen causes me anxiety and increase heart rates as well.

 

[readyforchange]

I agree with you it *seems like I'm sensitive to estrogen and HCG is setting that off leading to the anxiety and high hear rates. My pre-trt E2 was 19, so definitely NOT high. However, my SHBG was 60+ pre TRT (now down to 34), so that may have contributed to the low T.

It seems like there's some back and forth on HCG. Jay Campbell says if not for fertility or cosmetics, why do it? I have two kids and already had a vasectomy, so that's obviously not a concern. Cosmetics? My wife says she doesn't care, so I don't really care. I know Rand Mcclain has also expressed HCG as optional.

But then there are guys like Dr. Crisler who say the "wheels will fall off" without HCG and others who say you're voluntarily enducing organ failure by allowing testicles to shut down completely, so that fear has stopped me and I'm not sure what to think.

On the other side, I have my concerns about long-term AI use, so it's kind of like deciding where to roll the dice: no HCG and try to get off AI, dealing with potential negatives of complete shutdown or continue trying to manage E2 and keep HCG, rolling the dice on long-term AI usage.

I'm 31, so will (hopefully) be on this stuff for a long time, if I'm lucky enough to live a long life, so I'd hate to do something now that causes damage down the road.

Is reversing testicular atrophy/shutdown a simple thing to come back from by adding HCG back in a few months down the road, if warranted?

I plan to wait the month or so it takes to get with Dr. Saya instead of going with one of their other doctors/np's, so maybe just hash this out with him.

The protocols have been too aggressive and changing too many variables at a time, I prefer not to start out on all three Test+HCG+AI, test only and maybe an low dose AI if pre-TRT labs indicate in range estrogen together with low T.

You seem sensitive to estrogen, anytime it's high you seem to get anxiety with causes increased heart rates. Drop the HCG. High estrogen causes me anxiety and increase heart rates as well.

 

[Dr Justin Saya MD]

I agree with you it *seems like I'm sensitive to estrogen and HCG is setting that off leading to the anxiety and high hear rates. My pre-trt E2 was 19, so definitely NOT high. However, my SHBG was 60+ pre TRT (now down to 34), so that may have contributed to the low T.

It seems like there's some back and forth on HCG. Jay Campbell says if not for fertility or cosmetics, why do it? I have two kids and already had a vasectomy, so that's obviously not a concern. Cosmetics? My wife says she doesn't care, so I don't really care. I know Rand Mcclain has also expressed HCG as optional.

But then there are guys like Dr. Crisler who say the "wheels will fall off" without HCG and others who say you're voluntarily enducing organ failure by allowing testicles to shut down completely, so that fear has stopped me and I'm not sure what to think.

On the other side, I have my concerns about long-term AI use, so it's kind of like deciding where to roll the dice: no HCG and try to get off AI, dealing with potential negatives of complete shutdown or continue trying to manage E2 and keep HCG, rolling the dice on long-term AI usage.

I'm 31, so will (hopefully) be on this stuff for a long time, if I'm lucky enough to live a long life, so I'd hate to do something now that causes damage down the road.

Is reversing testicular atrophy/shutdown a simple thing to come back from by adding HCG back in a few months down the road, if warranted?

I plan to wait the month or so it takes to get with Dr. Saya instead of going with one of their other doctors/np's, so maybe just hash this out with him.

If you haven’t spoken to me yet, please do schedule your next consultation with me for review.

You mentioned in a previous post that through your experience HCG may have provoked anxiety and rapid heart rate symptoms. Here’s a pearl of wisdom for the community and a less known fact - HCG is very similar in structure to TSH (thyroid stimulating hormone)...so similar in fact that there appears the possibility of cross-reactivity with TSH receptors (obviously more pronounced the higher the HCG dosage/serum levels):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3111156/

With those specific symptoms, you may do well to do a trial of stopping HCG to see if anything changes (for better or worse).

 

[readyforchange]

If you haven’t spoken to me yet, please do schedule your next consultation with me for review.

You mentioned in a previous post that through your experience HCG may have provoked anxiety and rapid heart rate symptoms. Here’s a pearl of wisdom for the community and a less known fact - HCG is very similar in structure to TSH (thyroid stimulating hormone)...so similar in fact that there appears the possibility of cross-reactivity with TSH receptors (obviously more pronounced the higher the HCG dosage/serum levels):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3111156/

With those specific symptoms, you may do well to do a trial of stopping HCG to see if anything changes (for better or worse).

Dr. Saya,

I will definitely schedule with you for my next consult. My struggle is, do I drop the HCG now, wait 4-6 weeks and THEN do labs and a consult with you, or do labs for current regimen and then talk about adjustments.

It's just hard when I know I feel crappy on current regimen (anxiety/rapid heart rate have been ongoing and lethargic feeling/fatigue consistent), so it almost seems like a waste to do labs for current when a trial of stopping HCG seems like a good idea.

In terms of HCG being similar to TSH, would this be exacerbated in an individual who was trending toward hyperthyroid to begin with? My TSH has always been on the low side (.77), I was very skinny growing up and had trouble gaining weight even through my 20's, etc.

 

[1Draw]

Based on your symptoms, I would have a full thyroid panel ran with FT4,FT3, Reverse T3, and antibodies Your TSH is low which may or may not be an indicator.

https://www.restartmed.com/thyroid-symptoms-men/

 

[Dr Justin Saya MD]

A trial of stopping HCG and then labs and subjective assessment at time of consult would be of clinical value.

 

[FeelingLost]

HCG (Half life 2 days) - Steady state in 10 days. I would think all HCG would be out of the body and E2 stable in no more than 2 weeks.
This should only effect E2 not TT or FT. Only if you change your T amount would you have to wait 5 weeks.

 

[readyforchange]

Stopped HCG and anastrozole last Sunday, so going on 8 days with just 50mg of test cyp every 3.5 days (Sunday morning/Wednesday evening).

We'll see how it goes. So far, I'm feeling better overall, but still have some of the anxiety/rapid heart rate and still some fatigue. Overall, I'd say I feel a 6 or so out of 10 in terms of energy, libido, mood, and initiative to get things done. (Which is better than the 3 or 4 I felt a few weeks ago).

I think it's too early to blame the HCG or anastrozole, as the slight increase in mood, energy, etc. I'm feeling could just be due to improved T to E ratios.


The thing I keep going back to is last December-January I hit a "sweet spot" for 4-5 weeks while on 70mg test, 500 IU's HCG, .25 anastrozole and 25mg DHEA every 3.5 days.

On that dosage, I felt "it" for the first time in a long time. My mood, energy, libido, and initiative to get things done was an 8.5-9.5 out of 10 and I remember thinking, "Wow! This is really worth it!"

But then things fell apart mid February. Without changing that protocol, I ended up feeling worse than ever, experiencing similar symptoms to what I have been recently: Extreme anxiety, fatigue/lethargy, no libido.

When I had labs drawn at that time, it got even more confusing because everything appeared good:

Free T: 32
Total T: 1143
Estradiol: 27
DHEA: 700 (HIGH)

The only thing off was the high DHEA. They even ran extra thyroid panels that time and everything looked normal.

Has anyone experienced numbers that look near perfect, but still end up feeling horrible? Why did that regimen work so well for 4-6 weeks and then crash?

Could a DHEA that high cause these negative symptoms and over-run the positive I would've gotten from the other aspects (test, HCG, AI) being optimal?

 

[Gman86]

Stopped HCG and anastrozole last Sunday, so going on 8 days with just 50mg of test cyp every 3.5 days (Sunday morning/Wednesday evening).

We'll see how it goes. So far, I'm feeling better overall, but still have some of the anxiety/rapid heart rate and still some fatigue. Overall, I'd say I feel a 6 or so out of 10 in terms of energy, libido, mood, and initiative to get things done. (Which is better than the 3 or 4 I felt a few weeks ago).

I think it's too early to blame the HCG or anastrozole, as the slight increase in mood, energy, etc. I'm feeling could just be due to improved T to E ratios.


The thing I keep going back to is last December-January I hit a "sweet spot" for 4-5 weeks while on 70mg test, 500 IU's HCG, .25 anastrozole and 25mg DHEA every 3.5 days.

On that dosage, I felt "it" for the first time in a long time. My mood, energy, libido, and initiative to get things done was an 8.5-9.5 out of 10 and I remember thinking, "Wow! This is really worth it!"

But then things fell apart mid February. Without changing that protocol, I ended up feeling worse than ever, experiencing similar symptoms to what I have been recently: Extreme anxiety, fatigue/lethargy, no libido.

When I had labs drawn at that time, it got even more confusing because everything appeared good:

Free T: 32
Total T: 1143
Estradiol: 27
DHEA: 700 (HIGH)

The only thing off was the high DHEA. They even ran extra thyroid panels that time and everything looked normal.

Has anyone experienced numbers that look near perfect, but still end up feeling horrible? Why did that regimen work so well for 4-6 weeks and then crash?

Could a DHEA that high cause these negative symptoms and over-run the positive I would've gotten from the other aspects (test, HCG, AI) being optimal?

Have you had cortisol tested? My DHEA levels have always been high-very high, without supplementing any DHEA. So i’ve done quite a bit of research on why DHEA levels can be elevated. And from my understanding, cortisol and DHEA have an inverse relationship. If DHEA is really high, usually cortisol is low. Low cortisol symptoms can mimic a lot of low testosterone symptoms.

 

[Kirk001]

Just a thought... I would focus on that period when I felt great. What meds was I on? Had they reached steady state or were they decreasing/increasing concentration? Get those half-life/steady state numbers and break out a spreadsheet to try to determine what were the concentrations of all your various meds in your body during that period. Maybe you need to aim for those concentrations at steady state in the future. Something to think about.

 

[Renman23]

As a Career finance guy, after reading your posts, i think you could benefit from applying 6 sigma concepts to your protocall. In 6 there are 5 steps. Define, measure, analyse , improve, control.

My thought is you may benefit from :
1, Defining what your goals are in TRT. How you were feeling before you started, what your goals you wished to achieve. (i.e. Libido, mood, weight, strength.. etc)
2. You have your blood work , you can also note your other goals and note them , daily, Whats my mood, whats my weight, libido, gains in gym. Additionally you should log in your book, EXACTLY what you took and when. That way
3. Analyse you can review perhaps weekly monthly and KNOW what you are doing and how your measurable's are tracking. This will also make it much easier for your doctor to help dial you in. that way
4. You can improve your processes. Become more consistent with what works and what DOESNT. for
5. Control.... Which is what we all want.

Thats what im, planning to do with mine.

It works for Amazon and GE, why not my health? LOL.

Good luck with your progress.!

 

[readyforchange]

That's kind of what I'm leaning towards trying to work out with Dr. Saya at my next consult.

Something about that protocol worked GREAT, initially at least. But for some reason, after 5-6 weeks something then became WAY off because I ended up feeling aweful. I should have tried to get through it and search more for what was off instead of making the drastic changes I ended up making.

The only glaring thing off was the 700+ DHEA level from the 25mg they had me taking daily. Not sure if that could have a significant negative side effect or not, considering my T and E numbers looked great despite that super high DHEA.

Currently have been on just 10mg test cyp (every 3.5 days) for 2 weeks, so the HCG and Anastrozole should be out of my system if I understand that correctly, and while I feel "ok", I'd say it's a 6 or so out of 10, so I don't think HCG and/or the AI were as big of a negative factor as I may have thought, especially considering I felt my best when on both (and the highest doses of both that I've been on over the past year at that).


Thanks for your input.

Just a thought... I would focus on that period when I felt great. What meds was I on? Had they reached steady state or were they decreasing/increasing concentration? Get those half-life/steady state numbers and break out a spreadsheet to try to determine what were the concentrations of all your various meds in your body during that period. Maybe you need to aim for those concentrations at steady state in the future. Something to think about.

 

[readyforchange]

This is really great advice, thanks! I've started tracking better with a daily log of how I feel and keeping better track of what I'm taking.

As a Career finance guy, after reading your posts, i think you could benefit from applying 6 sigma concepts to your protocall. In 6 there are 5 steps. Define, measure, analyse , improve, control.

My thought is you may benefit from :
1, Defining what your goals are in TRT. How you were feeling before you started, what your goals you wished to achieve. (i.e. Libido, mood, weight, strength.. etc)
2. You have your blood work , you can also note your other goals and note them , daily, Whats my mood, whats my weight, libido, gains in gym. Additionally you should log in your book, EXACTLY what you took and when. That way
3. Analyse you can review perhaps weekly monthly and KNOW what you are doing and how your measurable's are tracking. This will also make it much easier for your doctor to help dial you in. that way
4. You can improve your processes. Become more consistent with what works and what DOESNT. for
5. Control.... Which is what we all want.

Thats what im, planning to do with mine.

It works for Amazon and GE, why not my health? LOL.

Good luck with your progress.!

 

[readyforchange]

One thing worth noting: I've seen guys around here posting about how "it's easier to start low and go up in dosing than start high and try to go lower", I would DEFINITELY agree with that sentiment at this point.

A month ago, was advised to drop test dosage from 140mg/week to 100mg/week to combat E2 that is persistent and man this has been a rollercoaster.

A few years ago, prior to TRT and when going through a very intense and stressful life stage, I battled really bad anxiety, to the point where if I didn't pop a valium in the evening, I'd wake up with a panic attack in the middle of the night.

I'm experiencing that again now -- originally thought it might be HCG because I've had anxiety-like symptoms when including that in my regimen, but nothing like what I'm currently feeling with this big drop in test dosage. I saw in another thread someone suggested decreasing (falling) levels of androgens can initiate anxiety, depression, etc., it definitely seems to be true in my case.

In the past 2-3 weeks, I've had 3-4 panic attacks in the middle of the night (and feel like I'm on the verge of one most of the day), and that's more than I've had in the previous 2-3 YEARS.

 

[PixelFree]

I haven't read your whole thread, but your experience is consistent with mine.

I was on therapy for over a year, and felt crap the whole time.

In the end, I realised my natural T was just fine (I just wanted it to be 'amazing'), and have felt much better just being natural and getting my body fat down.