What is the Protocol???
Warning for Men on TRT: Low Ferritin is Bad
- Thread starter ipi
- Start date
Raising ferritin FAST (a how-to, not a question)
Hi all, I started TRT in 2001 and have been giving blood over the years and have always had issues with recovering my ferritin. Long story short, I got tired of waiting for others to do the research, so I did it myself, created a protocol, hired a hematologist in May 2021 who thought it could...
www.excelmale.com
Absolutely works.
Well, I have a completely unscientific anecdote with an N of 1 and too many variables to make this meaningful, but I thought I would report the following out of interest. Maybe we can get some volunteers to validate my observation?
Summary:
- I have had fatigue for over a year (sometimes debilitating)
- TRT during this time was been mostly cream or Xyosted
- Recently, consistently on cream 100 mg scrotal AM and 50 scrotal PM
- Levels starting about a year ago (when fatigue started) have generally a fair bit higher than my prior TRT experience, as I used Natesto a lot in the past, prior to cream
- I have done a big workup and I narrowed down culprit to two possible variables:
- low ferritin (lowest measurement was 18), or
- obstructive sleep apnea (Had in house test. Results show mild apnea with a total AHI around 10. Supine around 19).
- Started CPAP about six weeks ago (still adjusting to it)
- Recent ferritin (8/30) before CPAP was 18 (didn't have H/H drawn at that time)
- Advised by sleep doc to try iron to raise ferritin (reduce restless leg syndrome)
- decided to try it, but also knew I had to check labs for erthryocytosis
- Did iron 65 mg a day for two weeks and checked labs four hours after AM cream dose. They were very concerning.
- Ferritin up to 56 (prior measurement was 18)
- But H/H = 18.2/55.3
- test 988
- Stopped iron and cream immediately (one week ago)
- Started Natesto as soon as I stopped cream
- Knew I may have to donate, but just wanted to wait at least a week and recheck labs, just to see the trend. Wanted to know if reducing test and adding variability in levels would nudge things in the right direction
- Labs done a week later show huge increase in ferritin
- Ferritin all the way up to 116 (from 56 to 116 in one week)
- Unfortunately, HCT only down to 54.7
As I said in my disclaimer above, I realize this is highly anecdotal and there may be numerous variables at play. But, I have checked ferritin 5 times in the last six months. The three levels prior to iron and prior to the above Natesto break have never been above 45. So, this level seems significant.
Take home point: Maybe stopping your TRT regimen and using Natesto for a week is enough to let your ferritin recover on its own???
I still feel like I gotta go donate some damn blood because my Hct is still 54.7. And, I really don't like Natesto long term. But, I'd certainly be willing to do it periodically if it worked at least as well as the Vorck protocol.
So, anyone out there on the iron/ferritin/trt hamster wheel, feel free to try this for a week and report back here!
MegaTurd
Member
We’ve had very similar experiences! I’m a long time TRTer (15 years). My ferritin has been chronically low for years and it’s been challenging to raise it while on T. Every time I’m on low dose injections my HG/HCT creeps up to the >17/>50 range. My HG/HCT is perfectly normal off T. I tried to raise my ferritin dosing heme iron supps on Kyzatrex and within 4 weeks I was having all kinds of high HG/HCT symptoms. My blood numbers were the highest I ever seen them (higher than they’ve ever been on cypionate) and my ferritin didn’t budge.
The only way I’ve been able to raise my ferritin in the past is when I’m completely off T or on Natesto. I’m currently back to reconsidering a Natesto run. Low ferritin (iron deficiency without anemia) is as bad symptomatically if not worse than being hypogonadal. I’m seeing more and more long time TRTers having issues with intractably low ferritin levels.
I’ve been on Natesto many times since I began using it in 2017. I exp practically none of the side effects that plague me on other forms of exogenous T. My only issue has been the lack of spectacular looking numbers on it. I’m certainly not a roob as I acknowledge that numbers aren't everything and Natesto hits the body differently than other modalities but I still let those numbers screw with my head and the moment anything feels remotely off I blame the Natesto and switch to something else. There have been times on Natesto when I’ve felt fantastic but despite that I’ll let a random 370ng/dl, 30 min after dosing convince me that I’m undertreated on Natesto.
I have a theory that for some and possibly I’m one of them, that bucket of T poured into the circulation after dosing Natesto is immediately soaked up by hungry androgen receptors. Perhaps I have more free androgen receptors avail than some. It’s either that or after 7 years I’ve just had shit luck capturing my true peak (greater than 470… my highest on Natesto) or… I’m really not absorbing Natesto well. If you look back through the studies there were plenty of guys pulling lowish numbers on Natesto and despite that many felt great symptomatically. I bumped into another guy on Natesto the other day who doesn’t pull spectacular numbers on Natesto who claims he feels as good as he ever did if not better than he did on injections. He’s another 10+ year TRTer who had issues with HG/HCT.
Anyway… any updates? Are you still on Natesto? How’s your ferritin?
This is interesting to hear that someone else out there has made similar observations as me! I sometimes think I am a unicorn.
I have pulled labs a few times after Natesto and numbers are typically pretty low - maybe near 500 or so. My guess is that we are not seeing the peak. Or, it is altogether possible some guys don't need high levels to feel good.
As of now, I am not on Natesto. Like you, there are times I feel great on it, but in general, if I use it, I tend to convince myself that I feel under treated. It is possible that in the back of my head, I have some subconscious awareness of the numbers I have seen, but my brain is telling me that I feel... lackluster? I also tend to get annoyed by the nasal build up after a while. So, although I have found myself using it here and there, I also find myself migrating away from it. In fairness, I have not had a long run of Natesto use in a long time, and I think that is when it works the best - after you have committed to it.
I think it's a great tool for times when you want to transition from A to B. You can use Natesto to get symptom relief while some ester is clearing. Having discovered my ferritin issue, I would fully be inclined to do the same as I did before - allow my system to rebuild ferritin stores via using Natesto for a while. I can't validate this experience was legitimate, but I strongly suspect it was.
Meanwhile, I very much agree with you on iron deficiency without anemia being worse than being hypogonadal. I have struggled mightily for about 1.5 years with all kinds of crap I never had before (horrible fatigue, brain fog, depression, physically feeling weak) and after extensive efforts, I am pretty sure low ferritin is the cause of (with apnea being a possible alternative cause or contributing factor). The onset of the symptoms started about three weeks after starting scrotal cream, and I can verify that scrotal cream gets my levels MUCH higher than anything else. So, the timing makes sense.
As of now, I am back to using cream and taking a small risk by using iron supplements. I got my H/H back to normal with a donation. I happen to have a migraine condition and use candesartan as a preventative. I had not been on it for a long time, but resume recently. It has an added benefit of reducing the likelihood of elevating my hematocrit. My hope is that this plus being diligent with CPAP will keep my HCT under control. I also reduced my cream dose from twice a day to once a day, which will also allow me to continue this regiment without jacking up my HCT.
I plan to monitor labs closely and will report back here. Please do the same if you don't mind!
MegaTurd
Member
Agree, agree, agree!
It’s really hard to pull a 370 on Natesto and not conclude that you’re undertreated despite feeling pretty good thanks to the endless messsging on every corner that T numbers are everything! I know it’s the reason I’ve bailed on Natesto more times than I’d like to admit. I do keep a journal (something I’d advise everyone on T to do) and I can identify many times over the years when I was on cruise control with Natesto and I was feeling pretty fantastic.
Jelly nose fatigue is real! I do find however once I get past the first month it’s more and more built into my routine and I no longer consider it a burden just like I’d never consider regular bathing or tooth brushing one either. You have to get a Navage and use it regularly, particularly at the end of the day before bed. That 10-12 hour jelly break really helps. It also helps to wipe the applicator with an isopropyl alcohol wipe to help keep it hygienic and prevent nasal infections.
Sadly, I can’t point to any other modality that doesn’t crush my ferritin other than Natesto. Androderm worked pretty well for me. Unfortunately, it’s no longer manufactured.
Just an anecdote but it seems like the longer I’ve been on T, the more my body has forgotten how to process iron properly. Sometimes I wonder if there is some permanent damage. My ferritin after 15 years on T is the lowest it’s ever been and it seems like it’s harder and harder to raise these days. I’ve suffered with all of the horrible symptoms attributed to low iron and they all suck. I hope you’re able to raise yours without turning your blood into sludge.
The idea of pumping sludge for years/decades scares the crap out of me. Earmuffs for those who want to whip out the tired trope of people happily existing at higher altitudes pumping sludge. No question in my mind it’s harmful to not only the vasculature but also the heart and all of the organs fed by that sludge supply. It’s another reason why Natesto is so appealing. My Hemoglobin and hematocrit are ~15/46 on Natesto… right where I’d want those numbers to be.
It’s really hard to pull a 370 on Natesto and not conclude that you’re undertreated despite feeling pretty good thanks to the endless messsging on every corner that T numbers are everything! I know it’s the reason I’ve bailed on Natesto more times than I’d like to admit. I do keep a journal (something I’d advise everyone on T to do) and I can identify many times over the years when I was on cruise control with Natesto and I was feeling pretty fantastic.
Jelly nose fatigue is real! I do find however once I get past the first month it’s more and more built into my routine and I no longer consider it a burden just like I’d never consider regular bathing or tooth brushing one either. You have to get a Navage and use it regularly, particularly at the end of the day before bed. That 10-12 hour jelly break really helps. It also helps to wipe the applicator with an isopropyl alcohol wipe to help keep it hygienic and prevent nasal infections.
Sadly, I can’t point to any other modality that doesn’t crush my ferritin other than Natesto. Androderm worked pretty well for me. Unfortunately, it’s no longer manufactured.
Just an anecdote but it seems like the longer I’ve been on T, the more my body has forgotten how to process iron properly. Sometimes I wonder if there is some permanent damage. My ferritin after 15 years on T is the lowest it’s ever been and it seems like it’s harder and harder to raise these days. I’ve suffered with all of the horrible symptoms attributed to low iron and they all suck. I hope you’re able to raise yours without turning your blood into sludge.
The idea of pumping sludge for years/decades scares the crap out of me. Earmuffs for those who want to whip out the tired trope of people happily existing at higher altitudes pumping sludge. No question in my mind it’s harmful to not only the vasculature but also the heart and all of the organs fed by that sludge supply. It’s another reason why Natesto is so appealing. My Hemoglobin and hematocrit are ~15/46 on Natesto… right where I’d want those numbers to be.
Nelson Vergel
Founder, ExcelMale.com
Thanks for sharing! Do you mean candesartan can reduce the likehood of elevating hematcrit?
We had reports on losartan.
Good to see these search results:
Candesartan, an angiotensin II receptor blocker (ARB) used to treat hypertension and heart failure, has been associated with hematological effects, particularly a decrease in hematocrit levels.
Hematological Effects of Candesartan
Hematocrit Reduction
Studies have shown that candesartan can cause a small but significant decrease in hematocrit values:- In controlled clinical trials, patients treated with candesartan experienced a 7-8% decrease in hematocrit compared to control groups
1
. - A reduction of approximately 0.5 volume % in hematocrit was observed in patients treated with candesartan alone
3
.
Other Hematological Changes
Along with hematocrit reduction, candesartan has been associated with:- Decreased erythrocyte (red blood cell) count
1
3 - Reduced hemoglobin concentration (approximately 0.2 g/dL decrease)
3 - Decreased reticulocyte count
1 - Reduced erythroid cell count in bone marrow examinations
1
Mechanism of Hematological Effects
The primary cause of the anemia induced by candesartan treatment is thought to be:- Increased renal blood flow
- Subsequent decrease in erythropoietin production
1
Clinical Significance
While these hematological changes are generally small, they can be clinically important in some cases:- Anemia, leukopenia, and thrombocytopenia have been associated with withdrawal of patients from clinical trials
3
. - Healthcare providers should monitor hematological parameters, especially in patients with pre-existing anemia or other blood disorders.
Comparison with Other Antihypertensives
A comparative study between ARBs and calcium channel blockers (CCBs) found that:In conclusion, while candesartan is an effective antihypertensive medication, it can cause modest reductions in hematocrit and other hematological parameters. Regular monitoring of these values may be necessary, especially in susceptible patients.
Nelson Vergel
Founder, ExcelMale.com
You may reference the table provided in the search results for a comparison of ARB medications and their effects on red blood cells and hematocrit. The table shows data for several ARB medications, including candesartan, losartan, valsartan, telmisartan, irbesartan, olmesartan, and eprosartan.Based on the available data, we can make the following observations:
- Candesartan appears to have the most significant effect, with a 7-8% decrease in both red blood cell count and hematocrit levels.
- Irbesartan shows a 2.5% decrease in hematocrit, though its effect on red blood cell count is not specified.
- Eprosartan is associated with a decrease in hematocrit in around 4% of patients, specifically those showing a greater than 20% decrease.
- For losartan, valsartan, telmisartan, and olmesartan, specific quantitative changes in red blood cell count and hematocrit are not provided in the table.
@Nelson Vergel, I was not totally clear. The short answer is "yes" - my hope is that candesartan can help keep hematocrit in check. When I said I use it as a preventative, I meant for migraines. But, my hope is that I get the added benefit of reduced hematocrit.
I have read reports of other ARB's showing a reduction in hematocrit, so I assumed candesartan would do the same. I have not personally read any studies on candesartan specifically, but I have seen some passing references to its ability to reduce hematocrit. So, your reference is much better than mine.
@MegaTurd (great name), have you been able to identify a ferritin threshold below which you feel symptoms? I have not because the concept is somewhat knew to me. I will be watching this over time. That said, I went through a sleep study (part of my fatigue workup) and my sleep doctor identified my ferritin as low. This can cause restless leg syndrome (which can cause poor sleep), and I believe she wanted me to get my ferritin above 100 ng/ml, for what it's worth.
MegaTurd
Member
Thanks buddy! Gotta love the Decepticons and yes I still have the sense of humor of a 5 year old so…
Based on the research I have done, I’m targeting a ferritin of 100 ng/ml. Anything below 50 can be problematic. I’ve experienced restless leg, Koilonychia, extreme fatigue, itching without a rash and low mood (iron is necessary for neurotransmitter synthesis among other things) with ferritin ranging between 19-50.
Best way to raise ferritin is to switch to a T modality that doesn’t suppress hepcidin 24/7 or drives up RBC production… something like Natesto while going all in on the cow meat and ensuring you’re topped off on the other vitamins necessary for iron absorption and storage.
Remember that using heme iron is the absolute worst way to raise ferritin on TRT. When you ran the Ferritin Protocol, how did you fare?
I know you weren't asking me, but I tried it x5 days and saw no benefit and no change in ferritin. I was fairly diligent with timing, but not perfect. Probably biggest criticism would be not timing perfect around food intake.
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