Still not dialed in after 2+ years on TRT. Labs included. Help?

[Someguy]

I'm a Defy patient and waiting for my appointment with Dr. Saya in a month or so. I'm feeling pretty bad and hoping to get some suggestions and answers from the community here or maybe from Dr. Saya if he's around and sees this.

I've been on TRT for over 2 years now, with Defy for around 10 months. I'm 38, 6' tall, 195 pounds and in very good shape. Not sure on body fat % but I have a flat stomach, no love handles, and visible abs when I flex. No other health problems, work out 5x/week.

I've kept a log of everything related to my TRT treatments. Here is some history of my dosages, lab results, and how I felt.

9-21-15 After 4 weeks on 100mg Test 2x/week, 100 IU HCG/day, 0.25mg Anastrozole 2x/week:
Total T: 1237
Free T: 43.8
Estradiol: 20 on injection day, 24 the next day.
Notes: This is from a while back with another doctor, before I started with Defy. I'm including it because this is the best I've felt. I still had occasional issues and certain days of the week seemed better than others, which is why my doc and I kept tweaking things.


6-30-16 After 4 weeks on 56mg Test EOD, 125 IU HCG every day, 0.1mg Anastrozole every other day:
Total T: 1266-1438 (trough and peak)
Free T: 32 - 32.6
Estradiol: 16.3 - 33.5 (big swing from one day to the next!)
Felt pretty good, still some brain fog and ED. Needed 10mg of Cialis/day to function when I used to only need 5mg/day. Still noticing that I feel much better on some days than others, even with EOD injections.

In an attempt to get more stable E2 levels day to day, my anastrozole was switched from 0.1mg every other day to 0.05 every day. The results can be seen below. In a nutshell, I felt much worse and got very bad ED, even with Cialis.


8-22-16: After 4 weeks on 56mg Test EOD, 125 HCG every day, 0.05 mg Anastrozole every day (0.05, NOT 0.5)
Total T: 1291-1350
Free T: 27.9-28.6
Estradiol: 28.6 in morning before T injection, 30.1 same day, 6 hours later, after taking T and Anastrozole, 35.5 next morning (before taking Anastrozole).
Result: Feel bad. Brain fog, forgetful, bad mood, bad ED even on 10mg Cialis/day. I feel and function noticeably better (still not great) from 8-30 hours after taking my T shot, then go downhill again until it's time for the next one.


so...

Should I have a good mood and good erectile function at TT: 1291-1353, FT: 27.9-28.6, and E2: 28.3-35.3 ? Is an E2 level around 35 enough to cause symptoms with total T so high, or should I be looking at other possibilities?

While my total testosterone was always between 1200-1400 at the time of my labs, my Free Testosterone dropped from 43.8, to 32, to 28 as time went on - all at the same Total T levels. Any ideas why this would happen? The main changes in my routine seem to be splitting testosterone and anastrozole doses up into smaller, more frequent doses which somewhat correspond to the drop in free T to total T ratio. Are either of these things that might affect free T? What else might affect it? It's a pretty significant drop and I'm wondering if my free T level is why I'm feeling worse now.

At this point, at TT: 1291-1353, FT: 27.9-28.6, and E2: 28.3-35.3 I'm still having problems. Where should I go from here? Is the problem likely my lower free T level, or my E2 level of around 35? Which should I focus on?

Any advice would be appreciated.

 

[Loki]

Have you ever had your DHT checked?

 

[Vince Carter]

have you had your SHBG pulled...could explain the drop in Free T.

 

[Someguy]

The only SHBG and DHT results I have aren't recent. They're from before the results shown in my original post. The results were:

8-27-2014 - SHBG: 41 (just before starting TRT. T level was 261).

3-31-2015 - SHBG: 51 (on TRT, but prior to the results listed above.) TT was 1285, FT was 25.4, E2 was 45, DHT was 816 (range 112-955)

6-30-2015 - TT: 1435, DHT: 691 (range 112-955)


Is it normal for SHBG to change while on TRT? What could cause it? I assume I want a lower SHBG number in order to get more Free T from the same amount of Total T, correct?

 

[Loki]

The only SHBG and DHT results I have aren't recent. They're from before the results shown in my original post. The results were:

8-27-2014 - SHBG: 41 (just before starting TRT. T level was 261).

3-31-2015 - SHBG: 51 (on TRT, but prior to the results listed above.) TT was 1285, FT was 25.4, E2 was 45, DHT was 816 (range 112-955)

6-30-2015 - TT: 1435, DHT: 691 (range 112-955)


Is it normal for SHBG to change while on TRT? What could cause it? I assume I want a lower SHBG number in order to get more Free T from the same amount of Total T, correct?

I would get a more recent DHT test, to me this has been the most powerful hormone for mood, libido, etc... I don't think high/low SHBG is good or bad... You just make adjustments to your protocol... Also you might look into Gene's Nitric stack for your ED. It works well in combination with the Cialis....

 

[Dr Justin Saya MD]

Loki took the words out of my mouth. There are some guys who get LESS conversion to DHT when T levels are more stable/consistent...it's an ironic, yet harsh reality (this is why *some* - not most - guys actually FEEL better with larger less frequent injections...ie once weekly...but there are other issues at play as well).

Given the discordance in how you feel compared to your (known) lab results, I agree a DHT, SHBG, prolactin check would offer some more insight at this point...this is where we begin to dig deeper. Possible neurotransmitter issue at play in these scenarios as well. Could do a trial of L-tyrosine 500mg BID to see if a little dopamine push perks things up.

 

[Loki]

Loki took the words out of my mouth. There are some guys who get LESS conversion to DHT when T levels are more stable/consistent...it's an ironic, yet harsh reality (this is why *some* - not most - guys actually FEEL better with larger less frequent injections...ie once weekly...but there are other issues at play as well).

Given the discordance in how you feel compared to your (known) lab results, I agree a DHT, SHBG, prolactin check would offer some more insight at this point...this is where we begin to dig deeper. Possible neurotransmitter issue at play in these scenarios as well. Could do a trial of L-tyrosine 500mg BID to see if a little dopamine push perks things up.

Would L-tyrosine be beneficial to all or only on a selective basis? I'm down to try anything ....

 

[Dr Justin Saya MD]

Would L-tyrosine be beneficial to all or only on a selective basis? I'm down to try anything ....

Never say never, but I've never seen any harm done to a patient through a trial of L-tyrosine appropriately dosed. Some experience and receive the dopamine benefit, some don't.

 

[Loki]

Never say never, but I've never seen any harm done to a patient through a trial of L-tyrosine appropriately dosed. Some experience and receive the dopamine benefit, some don't.

I'm all for a trial... Who should I email or how do you want me to handle?

 

[Dr Justin Saya MD]

I'm all for a trial... Who should I email or how do you want me to handle?

L-Tyrosine is actually an OTC supplement. You can pick it up at a supplement store or Amazon. I suggest a reputable brand such as Jarrow, Life Extension, etc.

 

[Loki]

L-Tyrosine is actually an OTC supplement. You can pick it up at a supplement store or Amazon. I suggest a reputable brand such as Jarrow, Life Extension, etc.

Ok, thanks (and you could have sold me something ).... Any dosing recommendations ?

 

[Dr Justin Saya MD]

Ok, thanks (and you could have sold me something ).... Any dosing recommendations ?

500mg twice daily.

 

[Someguy]

Loki took the words out of my mouth. There are some guys who get LESS conversion to DHT when T levels are more stable/consistent...it's an ironic, yet harsh reality (this is why *some* - not most - guys actually FEEL better with larger less frequent injections...ie once weekly...but there are other issues at play as well).

Given the discordance in how you feel compared to your (known) lab results, I agree a DHT, SHBG, prolactin check would offer some more insight at this point...this is where we begin to dig deeper. Possible neurotransmitter issue at play in these scenarios as well. Could do a trial of L-tyrosine 500mg BID to see if a little dopamine push perks things up.

Thanks Dr. Saya and everyone for replying. Dr. Saya, I have an appointment scheduled with you for September 27. Is there anything you can recommend for me to try between now and then to try to get back on track? I'd rather not wait until the 27 to start feeling better if at all possible. Should I change my T or anastrozole dosing frequency? Start taking L-tyrosine?

My Prolactin came in at 8.5 (range: 4-15) on 7-1-2016.

I don't have enough DHT results to compare, but a quick review of my lab history over the past 2 years shows a general trend of less frequent testosterone injections yielding a greater amount of Free T with the same amount of Total T. As injection frequency increases Free T / Total T ratio goes down. Of course there are other variables changing over that time period as well, so who knows...

Another issue of note is that I feel a LOT worse after going from 0.1mg Anastrozole EOD to 0.05mg Anastrozole ED. There were no other changes in my protocol. Details below:

6-30-2016: After 4 weeks on 56mg Test EOD, 0.1mg Anastrozole EOD, 125 IU HCG ED. Felt pretty good, but not completely clear headed. Only slight occasional ED on 10mg Cialis per day.
Labs: TT: 1266-1438; FT: 32-32.6; E2: 16.3-33.5

**Changed from 0.1mg Anastrozole EOD to 0.05mg Anastrozole ED to try to reduce day-to-day E2 fluctuation. All else the same. Took labs after 4 weeks on new protocol**

8-22-2016: (After 4 weeks on 0.05 Anastrozole daily) : Bad brain fog and concentration, negative mood, poor libido, bad ED even on 10mg Cialis per day.
Labs: TT: 1291-1353; FT: 27.9-28.6; E2: 28.3-35.3

I'm kind of at a loss because based on the lab results I'm not sure why I feel so much worse after the change from 0.1mg Anastrozole EOD to 0.05mg Anastrozole ED.

Any suggestions for things I could try before my Sept. 27 appointment would be greatly appreciated. Thanks for all you do!

 

[Dr Justin Saya MD]

Thanks Dr. Saya and everyone for replying. Dr. Saya, I have an appointment scheduled with you for September 27. Is there anything you can recommend for me to try between now and then to try to get back on track? I'd rather not wait until the 27 to start feeling better if at all possible. Should I change my T or anastrozole dosing frequency? Start taking L-tyrosine?

My Prolactin came in at 8.5 (range: 4-15) on 7-1-2016.

I don't have enough DHT results to compare, but a quick review of my lab history over the past 2 years shows a general trend of less frequent testosterone injections yielding a greater amount of Free T with the same amount of Total T. As injection frequency increases Free T / Total T ratio goes down. Of course there are other variables changing over that time period as well, so who knows...

Another issue of note is that I feel a LOT worse after going from 0.1mg Anastrozole EOD to 0.05mg Anastrozole ED. There were no other changes in my protocol. Details below:

6-30-2016: After 4 weeks on 56mg Test EOD, 0.1mg Anastrozole EOD, 125 IU HCG ED. Felt pretty good, but not completely clear headed. Only slight occasional ED on 10mg Cialis per day.
Labs: TT: 1266-1438; FT: 32-32.6; E2: 16.3-33.5

**Changed from 0.1mg Anastrozole EOD to 0.05mg Anastrozole ED to try to reduce day-to-day E2 fluctuation. All else the same. Took labs after 4 weeks on new protocol**

8-22-2016: (After 4 weeks on 0.05 Anastrozole daily) : Bad brain fog and concentration, negative mood, poor libido, bad ED even on 10mg Cialis per day.
Labs: TT: 1291-1353; FT: 27.9-28.6; E2: 28.3-35.3

I'm kind of at a loss because based on the lab results I'm not sure why I feel so much worse after the change from 0.1mg Anastrozole EOD to 0.05mg Anastrozole ED.

Any suggestions for things I could try before my Sept. 27 appointment would be greatly appreciated. Thanks for all you do!

I would try the L-tyrosine. If you are who I think you are based on the clinical story, we've suspected all along that you were "E sensitive" in the sense that you are likely going to do better with TIGHT control of estrogen...however the question remains WHERE to set that bar for tight control. The E2 is now tightly controlled within a tight range, but may not be your optimal range.

It's looking more and more like you are going to be a guy that does better with either a slightly HIGHER estradiol or a slightly LOWER estradiol (again with tight control to minimize fluctuation) than what most consider normal/optimal. We can head "up" or we can head "down" from here to rule out/in which you respond better to. You felt good previously with E2 at ~20-24 (although once weekly shots and other variables different). You felt good some days and bad some days when E2 fluctuated in a range 16 - 35 (the question is were the "good" days closer to 16 or closer to 35). You're now more tightly controlled with E2 consistently 27-28, but this appears to not be your sweet spot (assuming E2 is the issue, more likely than not assuming your DHT comes back okay - I would check this before our consult).

To go up on estradiol is simple, do a trial of stopping the anastrozole. To go down we would need a slight dosage adjustment on the anastrozole. We can discuss both during consult. For now would try the L-tyrosine and get DHT checked (note this lab takes a particularly long time to return results...sometimes up to a week).

 

[Someguy]

I would try the L-tyrosine. If you are who I think you are based on the clinical story, we've suspected all along that you were "E sensitive" in the sense that you are likely going to do better with TIGHT control of estrogen...however the question remains WHERE to set that bar for tight control. The E2 is now tightly controlled within a tight range, but may not be your optimal range.

It's looking more and more like you are going to be a guy that does better with either a slightly HIGHER estradiol or a slightly LOWER estradiol (again with tight control to minimize fluctuation) than what most consider normal/optimal. We can head "up" or we can head "down" from here to rule out/in which you respond better to. You felt good previously with E2 at ~20-24 (although once weekly shots and other variables different). You felt good some days and bad some days when E2 fluctuated in a range 16 - 35 (the question is were the "good" days closer to 16 or closer to 35). You're now more tightly controlled with E2 consistently 27-28, but this appears to not be your sweet spot (assuming E2 is the issue, more likely than not assuming your DHT comes back okay - I would check this before our consult).

To go up on estradiol is simple, do a trial of stopping the anastrozole. To go down we would need a slight dosage adjustment on the anastrozole. We can discuss both during consult. For now would try the L-tyrosine and get DHT checked (note this lab takes a particularly long time to return results...sometimes up to a week).

Thanks! I'll start the L-Tyrosine now.

I think I'm the guy you think I am. We've discussed that I'm extra sensitive to swings in E2, to general E2 level, and also that I'm very sensitive to HCG and slight changes in HCG dosage cause big changes in Total T.

My latest labs (while on 0.05 anastrozole ED) actually show E2 ranging from 28-35 from one day to the next. Maybe trying lower E2 first is a better bet? Does it make sense to change my anastrozole dose now to see how I'm feeling by our next appointment? If so, what daily dose should I try in order to target E2 in the low 20s?

Thanks again for all of your help.

 

[ERO]

500mg twice daily.

I am going to try this as well since TRT has been a 5 year disappointment for me so far.

 

[Dr Justin Saya MD]

I am going to try this as well since TRT has been a 5 year disappointment for me so far.

Certainly give it a shot ERO. I had a note to myself that we were planning on discussing neurotransmitters during our next chat.

 

[Dr Justin Saya MD]

Thanks! I'll start the L-Tyrosine now.

I think I'm the guy you think I am. We've discussed that I'm extra sensitive to swings in E2, to general E2 level, and also that I'm very sensitive to HCG and slight changes in HCG dosage cause big changes in Total T.

My latest labs (while on 0.05 anastrozole ED) actually show E2 ranging from 28-35 from one day to the next. Maybe trying lower E2 first is a better bet? Does it make sense to change my anastrozole dose now to see how I'm feeling by our next appointment? If so, what daily dose should I try in order to target E2 in the low 20s?

Thanks again for all of your help.

There are a number of guys that feel "best" with E2 levels in the 15-25 range regardless of how high T is or T:E ratio. We can aim for it with continued micro-dosed anastrozole on a continued daily basis as this has given you relatively tight control. Given your response to this point that would approximate a dosage of 0.08mg of anastrozole DAILY. Please email [email protected] with this message/response and staff will forward to me for authorization. This should give us enough time to gauge your response by the time of our consult, but I would suggest a repeat T and E2 check close to that time so we have both subjective and objective data to discuss.

 

[ERO]

Certainly give it a shot ERO. I had a note to myself that we were planning on discussing neurotransmitters during our next chat.

Thank you Dr. Saya. The Nuvigil worked as a stimulant but had no effect on my TRT experience, so I am hoping the L-Tyrosine will have some effect. I have my fingers crossed

 

[Vince Carter]

On Tyrosine...>I think that it's worked wonders for me, not a miracle but I'm better than I was. I use the N-Acetyl or NALT variety that is supposed to cross the blood-brain-barrier better or more efficiently. I pair that with Mucuna powder twice per day at about 1-1.5g of NALT and about a 1.4tsp of Mucuna powder.