Starting TRT: Treatment options

[overvolting]

I've done a bunch of research and I'm familiar with the HPT axis and the treatment options including:
clomiphene, test cypionate, HCG, pellets, gels etc.

My question is, now the time has come to pull the trigger I'm being offered almost anything I want as a treatment option. Am I making the right choice with test cyp + HCG and is the protocol I'm being offered decent?

I'm 40yo, in good shape, exercise 3-4 times a week with hiit and weights and was feeling tired, difficulty gaining muscle, ease in gaining fat and low libido. I have no other illnesses and am not on any medication except for vitamins and I had my GP do a battery of blood tests, everything came back either good or great, except for testosterone and I'm slightly anemic.

First set of tests oct 2018:
total test 389 ng/dL, range >280
shbg 30 nmol/L, range 13-90
albumin 4.0 g/dL, range 3.4-5.2

free test, calculated: 300 pmol/L, range >200
test, bioavailable: 189 ng/dL, range > 130
estradiol by TMS 27.6 pg/mL, range 10-42
estrone 33.9 pg/mL, range 9-36
total estrogens 61.5 pg/mL, range 19-69

TSH 1.84 uIU/mL range 0.3-4.5

Hemoglobin A1C, vitamin b12, vitamin D, cholesterol and lipids, salts, creatinine, glucose, phosphatase and a battery of others all normal to good.

Second set of tests December 2018:
Prolactin 11 ng/mL, range 4-15
FSH 4.2 mIU/mL, range 1.4-18.1
LH 5.0 mIU/mL, range 1.7-8.6

total test 337 ng/dL, range >280
shbg 37 nmol/L, range 13-90
albumin 3.5 g/dL, range 3.4-5.2

free test, calculated: 238 pmol/L, range >200
test, bioavailable: 132 ng/dL, range > 130

Iron serum / plasma 49 ug/dL, range 50-170
TIBC 236 ug/dL, range 250-430

My GP refered me to an endocrinologist, who said and I almost quote:
"You're a young guy and I can see that you can grow a beard so you don't have low test. Low test would be less than 50 or 100 ng/dL. I'll give you some viagra. I don't want to do it, but I'll leave you a prescription for clomiphene."

Immediately I knew that treatment option was going to suck because he didn't know what he was talking about. Research on here and pubmed showed that clomiphene does raise test levels but almost nobody feels better...

Next I went to a Men's Health clinic at a major city nearby. They basically offered me anything I want:
Gels, pellets, HCG monotherapy, test cyp, test cyp + HCG. The guy first recommended HCG monotherapy because I might want to have another kid in 3 years, I told him, sure but I don't even have a partner right now and that I'd prefer test cyp + hcg. He said most people do feel better on that than HCG alone and to give them 3+months notice of when you wanted to try for a child since it takes that long for them to do anything to get fertility up again.

I asked for both protocols, to evaluate.
HCG mono: 1000-1500 units 3x / wk
Test cyp + HCG: 500 units 2x / wk HCG and I forgot to ask amount of test cyp doh. I can ask at the next meeting but I got the impression they would let me work with them to select the dosage / wk and pick what levels to be at.

They took labs including test, estrogen, PSA. They did a rectal and prostate exam (yeah that was fun).

My 2nd appointment at the Men's health is in 10 days and they said they'd go over my labs and give me my first shot of test cyp and hcg and get me started, then on my 3rd appointment they would teach me how to do it myself. They said I can expect to pay about $40/mo for the test and about $75/mo for the HCG (would be about $200/mo for the HCG monotherapy). They would see me more frequently at first, then drop it to every 3-6 months once things are dialed in and same for bloodwork.
They said they don't manage estrogen unless it becomes a problem and that most men don't need it, but if they do they start with 0.5mg anastrazole 2x wk usually.

I've also got an appointment with an urologist at the same hospital as the endocrinologist, but that's 20 days from now, so if I go with the men's health clinic, I will already be on treatment.

What do you guys think?

 

[Systemlord]

The endocrine society defines low testosterone below 300 ng/dL and even this is thought to be too low by most experts.

Endocrinologist don't usually specialize in TRT and usually forcing you to figure your own case out as the endocrinologists tend to be of no help. It's doubtful any insurance would cover TRT above 300 ng/dL, going private would be your only option.

A good protocol for you would be two injections per week when your SHBG level is taken into account, often once weekly injections is far from optimal for most men.

When I was diagnosed with low testosterone I was full blown anemic, climbing stairs and doing everyday things was like climbing the peaks of everest, so I know exactly what you are talking about.

This clinic actually sounds pretty good and I believe they will be a lot more helpful than your endocrinologist, no way are you getting TRT above 300 ng/dL under insurance.

 

[Vince Carter]

Of what you've written the "mens health clinic" sounds like your best bet.

 

[Vince]

We do have a couple of Clinics that advertise on this site, you may want to check them out. Have you considered trying low dose clomid, 12.5 mg every other day.

 

[S1W]

Crazy...my pre-TRT numbers were almost identical to yours - both sets, too. And same age, physically fit, similar symptoms, etc. I even had a physician tell me years ago when I asked to get my levels tested, "well you have a beard so clearly there is no reason to test your testosterone" and he flat out refused to order the tests.

Anyway, a few thoughts for your situation:

- If you think you might want to have kids in a year or two, don't bother going on TRT now (yes even if you include HCG).

- If you do choose to start TRT, I would recommend starting with T only - no HCG or anything else. 20% compounded cream or injectable testosterone. Get that part of the equation dialed in (which can take a long time to do) and then consider whether or not you want to add something like HCG.

- My GP referred me to an endo. The endo sucked. I then tried a local naturopath who was actually pretty decent for a non-TRT specialist doc but still had pretty limited knowledge on the subject. I eventually ended up with one of the clinics that are site sponsors here. Having been through all of that, I'd recommend you just go with one of the site sponsors right out of the gates and save yourself some frustration.

 

[overvolting]

Thanks everyone for the replies.

I considered clomid and the pubmed results indicate that they raise test but don't help with symptoms.

I don't have a partner to have another child with (trying to go through a divorce) so if I do choose to have another child I'd have to meet the right person and get to know them, it won't be for another 3-6 years most likely. I don't want to hold off on TRT until then.

Systemlord, why do you say my SHBG levels indicate I should split my test dose to 2x per week instead of 1x per week? They're near the mid of the range?

S1W, why go on T only? I don't want my testes to atrophy and I'd like to keep my leydig cells alive in case I want to come off or boost my fertility 3-6 years from now. Wouldn't the best course be to dial everything in with test cyp and HCG right off the bat and keep my testes ready to go if I need them in a few years? I've seen at least a few examples of people who started directly with test + HCG and were able to dial in very quickly.

I will definitely consider switching to one of the clinics here, but for now I have local options and I think during the dial in period, it helps that they can see me in person and do physical exams.

I'm thinking 200mg test cyp 1x/wk and 500 iu HCG 2x/wk to start with.

 

[Systemlord]

HCG can complicate dialing in your TRT protocol as it increases estrogen production, some men have mood problems and a host of other symptoms on HCG forcing to question what's causing the mood problems HCG or your TRT dose.

Testosterone binds to SHBG which is used to determine a TRT protocol, lower SHBG men find multiple injections per week to work best, midrange to higher SHBG men find less frequent injections is necessary.

200mg per week is too much for most men, I feel optimal at 80mg weekly.

 

[madman]

Thanks everyone for the replies.

I considered clomid and the pubmed results indicate that they raise test but don't help with symptoms.

I don't have a partner to have another child with (trying to go through a divorce) so if I do choose to have another child I'd have to meet the right person and get to know them, it won't be for another 3-6 years most likely. I don't want to hold off on TRT until then.

Systemlord, why do you say my SHBG levels indicate I should split my test dose to 2x per week instead of 1x per week? They're near the mid of the range?

S1W, why go on T only? I don't want my testes to atrophy and I'd like to keep my leydig cells alive in case I want to come off or boost my fertility 3-6 years from now. Wouldn't the best course be to dial everything in with test cyp and HCG right off the bat and keep my testes ready to go if I need them in a few years? I've seen at least a few examples of people who started directly with test + HCG and were able to dial in very quickly.

I will definitely consider switching to one of the clinics here, but for now I have local options and I think during the dial in period, it helps that they can see me in person and do physical exams.

I'm thinking 200mg test cyp 1x/wk and 500 iu HCG 2x/wk to start with.

Save yourself the trouble and forget the Men's Health clinic.....200 mg/week is too high of a starting dose for trt especially once weekly!

Look into Defy which many on here use.

 

[trt reznor]

Overvolting, if there's one thing I've learned here is that its much easier to start with a conservative dose first, rather than start too high, have side effects, then try to figure out what's causing it and back off of your dosages. Such a pita. I would think half of what you're thinking might be ok. 100mg test split into two injections, 250iu hCG 2x a week. You have to give yourself a good 5 weeks to level out and balance before you know if that dosage is right for you. E2 seems to be the hardest hormone to control. You can have a TT of 1500, and if your E2 is too high you won't reap any of the benefits.

I'm just a guy that's been researching TRT for several years, and this is just my take. But like I said, if there's anything I've seen in the way of universal good advice here, it's to start with a conservative amount. Best of luck!

 

[fifty]

Agree that 200mg/wk is too much to start with.

Hopefully your clinic will let you inject yourself. Going in for injections would get old real quick.

 

[Cips1975]

Key thing is get your bloods checked and have your Dr dial in your TRT program based off the results and any sides you are having. Just like anything , you have to start somewhere. I started with T levels of 230 , got on 200mg of Test cyp (100mg twice weekly) and bloods came back slightly higher than the top end of the reference range. Dr decreased my dose to 150mg weekly and that got me to 700 ish. Back on 200 mg again and at 830 T levels as of this months blood work. So 150-200mg gets me in the sweet spot.

 

[overvolting]

Awesome, thanks for the feedback. If I hear you guys correctly, start slow, with lower doses and take my time seeing over a period of weeks and checking blood test results, assessing side effects and positive effects, making changes with the supervising physician.

 

[Systemlord]

Awesome, thanks for the feedback. If I hear you guys correctly, start slow, with lower doses and take my time seeing over a period of weeks and checking blood test results, assessing side effects and positive effects, making changes with the supervising physician.

The whole point of starting low is to avoid the unpleasant side effects, see how you feel and change one variable at a time. There are some guys who years later find that they feel better closer to midrange versus high normal levels.

I would be very surprised if 50mg twice weekly didn't see levels above 600.

 

[overvolting]

What does it mean when your SHBG results swing way over to the high end? How does this affect TRT?

Just got the results from the clinic's blood tests taken a week ago at 4pm, the last two tests were at 8:30am:

Now, a few things stand out. This is a different lab, but my previous two SHBG results were 30 and 37 nmol/L and now a few months later I got 79!
Look up a few posts and someone was telling me that I would have to inject 2x/wk because my SHBG was low. What happened... Only changes I can think of are I reduced the amount of Boron I was taking from about 12mg/day to 3mg eod and I also stopped dieting as hard and let my weight stabilize with a bit of meat and carb loading.

I thought it was because of the meat and carb loading but my libido actually had a huge improvement recently. My muscles also got a little but noticeably harder and fuller.

Also my hematocrit came out very low, considering my endurance is pretty decent and I've been doing HIIT in the pool for several months. Estradiol is also higher.

L-minus 7 days before I get my first injections of Test-Cyp and HCG.

 

[trt reznor]

What does it mean when your SHBG results swing way over to the high end? How does this affect TRT?

Just got the results from the clinic's blood tests taken a week ago at 4pm, the last two tests were at 8:30am:
View attachment 6559

Now, a few things stand out. This is a different lab, but my previous two SHBG results were 30 and 37 nmol/L and now a few months later I got 79!
Look up a few posts and someone was telling me that I would have to inject 2x/wk because my SHBG was low. What happened... Only changes I can think of are I reduced the amount of Boron I was taking from about 12mg/day to 3mg eod and I also stopped dieting as hard and let my weight stabilize with a bit of meat and carb loading.

I thought it was because of the meat and carb loading but my libido actually had a huge improvement recently. My muscles also got a little but noticeably harder and fuller.

Also my hematocrit came out very low, considering my endurance is pretty decent and I've been doing HIIT in the pool for several months. Estradiol is also higher.

L-minus 7 days before I get my first injections of Test-Cyp and HCG.

Did you actually start TRT, or is this just your normal labs? I would assume normal since your LH and FSH are still present.

 

[madman]

Did you actually start TRT, or is this just your normal labs? I would assume normal since your LH and FSH are still present.

He stated at the end of his post....".L-minus 7 days before I get my first injections of Test-Cyp and HCG"

 

[fifty]

Few people actually read posts. It’s amazing.

Anyway, it is quite odd that your shbg went up 200%. I don’t think I’ve ever seen that much of a change...especially in only a month(?).

 

[Systemlord]

Certain medications can increase SHBG, if it's not then I have no idea why SHBG increase so dramatically, but a shot in the dark I would say possibly diet and a decrease of boron.

When SHBG increases, Total T increases and Free T decreases, SHBG is made in the liver and Free T3 levels can increase/decrease SHBG levels.

This may or may not change your strategy for a TRT protocol, one large injection or two moderate doses twice weekly. I would start with the latter.

LH is below midrange and so to is Total T, it's safe to say you're suffering from low testosterone. No way can those estrogen labs be the LC/MS/MS sensitive method, ranges are a dead give away.

 

[trt reznor]

amazing

Thanks man! I try

 

[overvolting]

Update:

Started yesterday with 100mg of test cyp (0.5ml) in the glutes. Put in an order for HCG.
Either the placebo effect is very strong or I started feeling the effects within hours. I felt less anxiety and worry and more relaxed and I felt like it's easier to move my body. I was not aware that I was anxious, but when the tension and worry went away I really noticed the difference. I must have been experiencing more hypogonadal effects than I realized.

Slept deeply last night and no night sweats, got morning erection. I feel pretty great overall. It's subtle, but pronounced. Had a great session at the gym and when I left I didn't feel tired as usual. Strength is the same but pump was slightly stronger than usual, appetite is stronger, muscles feel a little denser already.

Also erections improved.