Ask Dr Rand McClain

[1Draw]

A very detailed and reply. Many thanks Dr. McCain!

 

[ta406]

Hi Dr. McClain,

I have a question regarding cortisol. I have had a saliva test that shows that my cortisol levels are high. Especially at night which I believe causes me to wake up in the early a.m. hours and its next to impossible to fall back asleep. I am 5' 9", 210lbs, 13% body fat My diet is clean and weight train 4x a week.

I am on trt. I get frequent blood work and try to maintain my testosterone and estrogen levels at healthy levels. I donate blood every few months, both because my RBC slowly increases and because my dad needed a few blood transfusions to keep him alive after an illness so I understand how important donating is. I have had my thyroid checked and my doc said everything looked good. I have tried, meditation, mindfulness and more natural supplements and combinations of supplements than I can count. Nothing really seams to work. I was recently reading that low doses of Propranolol may help to combat this. Do you think this is something worth exploring or would you happen to have any other suggestions? Thanks

 

[OMI100]

Dr McClain,
Magnesium question.
O.K. Based on comments here, and Vince's thread, I have been looking into magnesium.
https://www.excelmale.com/forum/showthread.php?2992-1-Mineral-for-Everything-Magnesium
I had a Mag, RBC test ran with the following results 5.6 (4.2-6.8)
BTY I had already started using some Mag Bisglycinate (200mg/day) for a week or 2 prior to the test but I stopped taking any supplimate a few days before the blood test.
Based on reading here on Excelmale, and elsewhere, the general view is that you want to be at the top of range or even a bit higher.
Can you comment on what you feel is an optimal level for Mag.
I have also been looking at types of Mag supplements and there seems to be 2 basic methods for get your Mag levels up, oral and TD.
There is one manufacture that adds MSM to the TD Mag spray. I am guessing that the MSM should help the movement of the Mag into the skin and body.
Can you comment on the pros and cons of both methods.
Thanks,
omi

 

[lexer]

Hi Dr Rand. I have a question regarding DHT. When i inject 100 mgs of testosterone cypionate per week, the following few days my dht goes well over 150, i know the day after the injection it does. A week later just before my next injection my dht is 90 ( range 35-80 ). When my total T ( natural) is only 340, my dht is 38. Would it make sense to inject smaller amounts of T every monday and thursday at 45 mgs in order to reduce those high spikes in DHT ? Would doing so cut down the chances of hair loss and prostate issues? I somehow believe that it is the day after and the following few days after an injection when DHT spikes above the high level of normal when all the negative dht side effect can occur.. what is your opinion? Im thinking smaller/ frequent T injections would reduce those high dht spikes?
what is your opinion on using very low dose finasteride, breaking a 1mg tab in half (.5 ) and using finasteride at small dosages every monday wed and friday in order to reduce dht but minimize possible finasteride side effects by lowering dht too low?
thank you Dr....l

 

[Rand McClain DO]

Many thanks for the in-depth replies to my concerns and putting things in a common sense perspective.

According to the authors of a clinical trial https://clinicaltrials.gov/ct2/show/NCT01769157 , L-carnitine and thyroid hormone tended to antagonize reciprocally in human body. This is obviously a conundrum for anyone who is hypothyroid but that has benefited from taking L-carnitine. By the way, here are the papers regarding thyroid hormone suppression of L-carnitine:
https://www.ncbi.nlm.nih.gov/pubmed/15591013
https://www.ncbi.nlm.nih.gov/pubmed/11201848

Given the above, do you still think the reported suppressive effects can be "overridden" by thyroid replacement dosage adjustment?

One other issue of concern regarding L-carnitine is some recent data which shows that in the gut it transforms to TMAO which has some cardiac toxicity: https://www.ncbi.nlm.nih.gov/pubmed/25636076

Thyroid optimization is a big focus of mine right now (long time struggling with this). I recently tried adding some T4 to my 1 grain natural desiccated thyroid and I felt worse and my rT3 increased. I cannot seem to get my ferritin levels up no matter how much iron I take, for one, as I know how important that is for thyroid function. I feel I have been and still am chronically under-dosed, but it's a catch-22 at this point when increasing thyroid replacement with either NDT or T4 may backfire if there are other possible imbalances making replacement work against me (on a side note, I have already tried both T3 and T4 monotherapy as well as T3 added to NDT). In addition, I have a genetic methylation defect (MTHFR C677T +/+) and am taking various supplements to support proper methylation, however, it would be great to get some insight with respect to supplement navigation. Even guys like me that have a lot of knowledge still need a coach.

As far as consideration of TRT, one huge hold-back is that I suffered from an "idiopathic" DVT that presented out of nowhere back in 2012 and have been on anticoagulant prophylaxis (Xarelto 10mg qd) since 2014. I am at a standstill of what to do or not to do next, as I have not been able to determine the cause of the thrombophilia in the first place (had every test under the sun to date and we cannot determine whether it's familial, acquired, or a combination). I am not even sure if I should remain on an anticoagulant and most hematologists aren't of any help since they really only treat existing pathologies (all are also oncologists). I am looking into getting with a research facility with a major university for a more extensive workup and evaluation to determine the etiology, but even then, I may reach a dead end. While it may not change my direction whether to use TRT or not, at least knowing the cause would put things in perspective. I don't know if Clomid would make any difference with respect to this.

Would you consider your practice and treatment approach to be in the realm of functional medicine?

Again would appreciate your thoughts.

Hi Marco,
Your questions are a bit too extensive to tackle in a forum setting and without more information. However, a few comments:
Please note that the clinical trial you reference re L-carnitine posts no study results. The papers you reference re suppression of thyroid hormone really do not support same. A cursory review of the literature speaks to the theory, but even one of your references demonstrates that L-carnitine might be beneficial for patients with hypothyroid.
Re cardiac effects of L-carntine, yes, there are studies demonstrating its conversion to TMAO, but others showing its beneficial effect on atherosclerosis and AGE. Bottom line at this point (and most points): if it appears to help you without any negative SE's/consequences, use it.
Being homozygous for MTHFR, I would recommend supplementing with a specific supplement designed to help you metabolize folic acid (http://catalog.designsforhealth.com/L-5-MTHF). I would also hesitate to supplement with progesterone.
Lastly, if no obvious culprits can be found for your DVT (hence idiopathic), and it has resolved, I would not remain on anticoagulant therapy. Less common causes (no coagulopathy) for DVT still can occur so "treating" a undiagnosed coagulopathy with an "anticoagulant" long-term is akin to treating a resolved rare bacterial infection with long-term broad spectrum antibiotics. Again, without access to your complete medical information, and not being your physician, I am not providing specific medical advice to you - simply general commentary.

 

[Rand McClain DO]

Hello Dr. McClain:

As somewhat of a follow-on to the question that Vince posed, have you ever seen a case of actual TRT success in guys with low SHBG? I am talking SHBG in the teens. That is where my SHBG is and TRT to me feels like I am injecting water or in the case of topical T, using a generic hand lotion. When I say "success" I don't mean nice numbers on blood work - I mean things like a decent libido, maybe some ability to gain a little muscle and lose a bit of fat and some additional energy.


Thank you,

Hi ERO,
Yes, I see successful TRT in guys with low SHBG most if not all of the time. I typically however do not waste resources measuring SHBG as a general rule. I look directly to the free hormones (and of course to the patient first and foremost!).

 

[OMI100]

Dr. McClain,
I would like to add to Lexer's question:
Would dutasteride be an acceptable alternative to finasteride, with out the unwanted effects the finasteride can have?
Thanks,

omi

 

[Rand McClain DO]

Hi Dr. McClain,

I have a question regarding cortisol. I have had a saliva test that shows that my cortisol levels are high. Especially at night which I believe causes me to wake up in the early a.m. hours and its next to impossible to fall back asleep. I am 5' 9", 210lbs, 13% body fat My diet is clean and weight train 4x a week.

I am on trt. I get frequent blood work and try to maintain my testosterone and estrogen levels at healthy levels. I donate blood every few months, both because my RBC slowly increases and because my dad needed a few blood transfusions to keep him alive after an illness so I understand how important donating is. I have had my thyroid checked and my doc said everything looked good. I have tried, meditation, mindfulness and more natural supplements and combinations of supplements than I can count. Nothing really seams to work. I was recently reading that low doses of Propranolol may help to combat this. Do you think this is something worth exploring or would you happen to have any other suggestions? Thanks

Hi ta406,
This is a tough question(s) because it is too complex to answer in a forum setting. Some general comments though that I hope may be helpful:
You say you have to get serial therapeutic phlebotomies (or just volunteer)? If they are therapeutic, then I would question the reason for the H/H increases. Most likely, they are the result of some form of sleep apnea. If you are not getting enough oxygen during sleep, you are going to be in "fight or flight" mode during the night (or whatever time you get your sleep). Being in chronic sympathetic nervous system mode will increase your cortisol levels (at least initially) and if this happens each night, your body will start to "gear up" for this (what I call) "training (hypoxic) in your sleep". What I find in practice is that most patients with sleep apnea will "sleep" (read: remain unconscious) fairly well through the first sleep cycle (four hours) of the night, but will be aware of there sympathetic nervous system response during the second sleep cycle. In addition, if your circadian rhythms are in sync, you naturally begin to produce more cortisol in the early morning hours in preparation for waking and getting busy with your day.
If you are under CHRONIC stress, we find that your cortisol levels flip flop and you begin to produce more at night and less in the morning (just FYI, I typically see a spike in cortisol levels in the morning and by noon or early afternoon these are reduced to almost nil). If one starts TRT, occasionally one can see an initial imbalance in cortisol levels because less of the precursors to T (including pregnenolone, progesterone and DHEA) are being diverted to T and can be used therefore to "overproduce" cortisol. This usual resolves fairly quickly though (weeks if not days).
Supplements that can be used to reduce cortisol are phosphatidylserine (800mg po qday minimum), holy basil, ashwaganda and Relora, to name a few. There is a pretty good formula made by Integrative Therapeutics called "Cortisol Manager" that I have used with patients with success. There are other supplements that can be used such as magnolia bark which activate GABA receptors which can help one relax (and thereby reduce cortisol).
Propanolol is a fairly non-specific beta blocker. It could help reduce sympathetic nervous system stimulation therefore, but could also slow your heart rate too much (and there are other contraindications you need to consider), make you feel depressed, or decrease you BP too much.
I would submit to a sleep study if I were you first and foremost if you experience unexplained elevations in H/H.

 

[Rand McClain DO]

Hi ta406,
This is a tough question(s) because it is too complex to answer in a forum setting. Some general comments though that I hope may be helpful:
You say you have to get serial therapeutic phlebotomies (or just volunteer)? If they are therapeutic, then I would question the reason for the H/H increases. Most likely, they are the result of some form of sleep apnea. If you are not getting enough oxygen during sleep, you are going to be in "fight or flight" mode during the night (or whatever time you get your sleep). Being in chronic sympathetic nervous system mode will increase your cortisol levels (at least initially) and if this happens each night, your body will start to "gear up" for this (what I call) "training (hypoxic) in your sleep". What I find in practice is that most patients with sleep apnea will "sleep" (read: remain unconscious) fairly well through the first sleep cycle (four hours) of the night, but will be aware of there sympathetic nervous system response during the second sleep cycle. In addition, if your circadian rhythms are in sync, you naturally begin to produce more cortisol in the early morning hours in preparation for waking and getting busy with your day.
If you are under CHRONIC stress, we find that your cortisol levels flip flop and you begin to produce more at night and less in the morning (just FYI, I typically see a spike in cortisol levels in the morning and by noon or early afternoon these are reduced to almost nil). If one starts TRT, occasionally one can see an initial imbalance in cortisol levels because less of the precursors to T (including pregnenolone, progesterone and DHEA) are being diverted to T and can be used therefore to "overproduce" cortisol. This usual resolves fairly quickly though (weeks if not days).
Supplements that can be used to reduce cortisol are phosphatidylserine (800mg po qday minimum), holy basil, ashwaganda and Relora, to name a few. There is a pretty good formula made by Integrative Therapeutics called "Cortisol Manager" that I have used with patients with success. There are other supplements that can be used such as magnolia bark which activate GABA receptors which can help one relax (and thereby reduce cortisol).
Propanolol is a fairly non-specific beta blocker. It could help reduce sympathetic nervous system stimulation therefore, but could also slow your heart rate too much (and there are other contraindications you need to consider), make you feel depressed, or decrease you BP too much.
I would submit to a sleep study if I were you first and foremost if you experience unexplained elevations in H/H.

And one more consideration: if you are taking a 5-alpha reductase inhibitor, consider stopping at least temporarily (especially if these new symptoms coincided with starting same). Finasteride or dutasteride block conversion of progesterone to 5-DHP and 5-alloprogesterone, both of which are very calming metabolites (acting on the GABA receptors).

 

[lexer]

Hi Dr Mcclain
I have a question regarding DHT. When i inject 100 mgs of testosterone cypionate per week, the following few days my dht goes well over 150, i know the day after the injection it does. A week later just before my next injection my dht is 90 ( range 35-80 ). When my total T ( natural) is only 340, my dht is 38. Would it make sense to inject smaller amounts of T every monday and thursday at 45 mgs in order to reduce those high spikes in DHT ? Would doing so cut down the chances of hair loss and prostate issues? I somehow believe that it is the day after and the following few days after an injection when DHT spikes above the high level of normal when all the negative dht side effect can occur.. what is your opinion? Im thinking smaller/ frequent T injections would reduce those high dht spikes?
what is your opinion on using very low dose finasteride, breaking a 1mg tab in half (.5 ) and using finasteride at small dosages every monday wed and friday in order to reduce dht but minimize possible finasteride side effects by lowering dht too low?
thank you

 

[ERO]

Hi ERO,
Yes, I see successful TRT in guys with low SHBG most if not all of the time. I typically however do not waste resources measuring SHBG as a general rule. I look directly to the free hormones (and of course to the patient first and foremost!).

Thank you Dr. McLain. Wow - On this forum and on several other TRT forums, I see guys with very low SHBG like me that pretty much all agree that TRT feels like we are injecting water. Said another way, we really feel no difference pre and post TRT. I have tried every protocol imaginable, except for pellets and those are out of date. What is the secret to your success with low SHBG? I have tried small daily injections, twice weekly, topical Test, Test Prop, Test Cyp, you name it, I have probably tried it. My symptoms are always the same. Very low to no libido, inability to gain any muscle or loose any fat, and I'd like to take a nap every day even though I sleep well at night.

 

[Rand McClain DO]

Dr McClain,my question is, if a person came into your practice complaining of all the Low T symptoms, and you have Blood tests ran that came back good on the T levels, what would be your first suspicion of what else might be wrong that you would check for? I am sure you have seen this before. Thanks for your help.

Good question! Depends upon what "good on the T levels" means. If a patient has T free levels that are on the high end of normal, but still has symptoms of low-T then I would typically suggest reassaying T levels. Sometimes we catch a snapshot of T levels that are not representative. I have seen, eg, free T assays that are high, but suspicious as temporary because total T, DHT, E2, and even H/H are low. I retest and find that the free T "spike" was indeed out of line with the other assays and the second assay shows free t as low (commensurate with the other values). I would also consider other reasons for the patient's signs and symptoms, of course. Thyroid assays, sleep quantity and quality, night v day jobs, prolactin assays, neurotransmitter assays, exercise quantity and quality, and other items (it's a long list) are a few considerations that come into play with T levels as well. In essence, we see a hoof print and look for the horses first and then the zebras and then the unicorns until we figure it out!

 

[MikeXL]

Dr. McClain
I realize that finasteride and dutasteride both block conversion of progesterone to 5-DHP, 5-isoprogesterone and 5-alloprogesterone, which are important neurohoromones. Can this effect of finasteride and dutasteride be offset or partially offset by taking pregnolone or progesterone in an effort to increase the available substrate to create 5-DHP, 5-isoP and 5-alloP?


Here are the approximate labs of a buddy of mine
Prior to TRT - T = 300; DHT = 20
TRT only - T = 1,300; DHT = 85
TRT and finasteride - T = 1,300; DHT = 30

He did not use finasteride prior to TRT, but if he had, I am sure his DHT would have been single digits. As you can see, his DHT on TRT with finasteride is higher than his DHT was when he had low T. So it seems that the DHT lowering effect of finasteride was more than offset by increasing the DHT substrate (Testosterone)

So, I am wondering if the progesterone-metabolite-lowering effect of finasteride could be offset by increasing the substrate of these metabolite, which in this case would be progesterone/pregnenolone

 

[lexer]

Im a bit disappointed doctor Rand isnt answering our questions regarding DHT ..

 

[ratbag]

Patience is a virtue lexer... I doubt think he spends his days here waiting for questions.

 

[Dr Justin Saya MD]

Im a bit disappointed doctor Rand isnt answering our questions regarding DHT ..

Keep in mind Dr McClain is graciously donating his (scarce) time to answer questions here. In all honesty, I've been pleasantly surprised at the level of detail and thoroughness of his responses. Knowing him, it doesn't surprise me one bit, but I think everyone here should show him nothing but gratitude for his efforts.

 

[lexer]

I agree, dr rand is a very nice man and it is very nice of him to take time to answer questions.

 

[stephanfresco]

HI DR RAND ....thanks again for your answer about my test ai dosage...
-some MD speak about hemoglobin/hematocrit while on trt can be high without risk with a normal platelet count.THE BIG DANGER is high platelet count....is it true?
-does high estradiol make the cbc (hemoglobine hematocrit platelet count) goes higher?
-there is a famous trt doctor who said that 60 to 80mg/ week of testoterone is more than enough and higher dosage are not very recommended cause with the time goes on , the benefit of trt is reduced.My personnal experience is that low dose like 40 MG EVERY 3 DAYS i feel the effect on the libido but nothing special with the energy or capacity TO working out compare with 160 OR 200 MG /WEEK.
what is your your thought about this?

thank you very very much dr rand....

 

[ta406]

And one more consideration: if you are taking a 5-alpha reductase inhibitor, consider stopping at least temporarily (especially if these new symptoms coincided with starting same). Finasteride or dutasteride block conversion of progesterone to 5-DHP and 5-alloprogesterone, both of which are very calming metabolites (acting on the GABA receptors).

Thank you so much for the reply. I do have mild obstructive sleep apnea that I recently got an oral appliance for so hopefully that will resolve that issue. My testosterone is at the top of the normal range so I am also thinking about discussing lowering my dosage with my doctor so I'm optimistic those two things will alleviate my h/h. I only have to donate probably twice a year because of h/h but I donate more often. I do take .25 mg of arimidex 2x a week but if I feel good at a lower testosterone dose, I'm hopeful to get off of that too. i will look into the cortisol lowering supplements that you've listed. Again, Thank you

 

[dnfuss]

Re: Aspirin and HCG

Dr. McClain,

I have read with concern recent studies supporting the antiandrogenic properties of NSAIDs. See, e.g., "Ibuprofen alters human testicular physiology to produce a state of compensated hypogonadism." I noted with particular interest the further study cited in footnote 34 thereto ("Aspirin inhibits androgen response to chorionic gonadotropin in humans").

My current TRT protocol includes 500 IU HCG, administered SubQ q.3.5d., and among other things I am also currently on aspirin, 81 mg q.d. It was not prescribed by my doctor, but I thought it might be cheap insurance given my age and some of my lipid levels.

The latter study above made me wonder if perhaps I should stop aspirin? Or should I not be concerned because the dose I'm on is only approximately 10% of the dose used in the study (800 mg. b.i.d.)?