Doctors: Can HRT trigger severe hypogonadism?

[drkinsey]

Doctors take a look at the questions at the bottom of the page:

I am a 49 year old male who was referred to an endocrinologist last summer based on the following clinical findings: afternoon fatigue, osteoporosis, (bone density at 2.3 standard deviations below the mean), and diminished libido.

My free T and total T were measured on four different occasions over a period of 60 days last fall. The total T was consistently in the 350 to 400 range irrespective of the test method employed direct RIA or Equilibrium Dialysis. However, the free T was highly dependent on the test method. Free T measured using Equilibrium Dialysis was always in the middle of the reference range (47 - 244 pg/ml). In contrast, when measured using the direct RIA method, the free T was always about 20 percent below the reference range low end of the reference range (9.5 43 pg/ml). As I previously stated in my post regarding lab reference ranges, the direct RIA method has a strong negative bias when total T is in the low normal range and SHBG is very low. (My SHBG was 19 on all four tests.) The following lab tests (December 8 , 2005) are included for reference:

Total T = 398 (350 890)
Free T by Equil. Dialysis = 146 (47 244)
Free T by direct RIA = 7.0 (9.5 43)
SHBG = 19
LH = 3.4; FSH = 1.6)
Estradiol = 18.8
Height = 71; Weight = 180; Body Fat = 11.5 %
Chest = 46 inches; Waist = 32; Bicep = 16.5 inches

Based on the clinical findings and the RIA free T measurements, my endocrinologist put me on a very low dose of Androgel 2.5 g. What happened during the next 6 months was nothing short of surreal.

Within two weeks I began to notice major body changes: rapid loss of muscle mass and significant atrophy; large accumulation of fat deposits in the hip, pubic, and inner thigh areas; and sagging upper arms. I contacted the doctor but he insisted that these changes were visual disturbances. The physical deterioration continued, and by the end of the fourth week I was reporting the following symptoms:
Pain in the hip and femur bones
Hot flashes in the middle of the night
Fatigue beginning shortly after noon, and becoming progressively worse until the next Androgel dose
Apathy, lethargy, and an inability to make decisions
Severe depression
Depersonalization and derealization (an alteration in consciousness where familiar objects and time are distorted and the person becomes an outside observer of his own mental processes the perception the person is in a theatre observing himself perform on stage)

Over the next 8 weeks, I became bed ridden and was not able to work or care for my family. I reluctantly returned to the endocrinologist for a follow- up visit. Here are the results:

Free T by direct RIA = 1.7 (9.5 43)
Vitamin D, 25 OH = 11 (25 80))
Weight = 154; Body Fat = 33.8 %
Chest = 36 inches; Biceps = 12 inches
Significant loss of muscle mass in thigh; excessive fat deposits; mushy look and feel

He increased the dose, and after 8 weeks my total T measured one hours after dosing was 609 (245- 1836), my free T measured using RIA was 20 (12.4 to 40), total estrogen was 157 (range less than 130), and my weight was 170. There was some improvement in upper (but not lower) body composition. I felt some improvement in the morning, but became very fatigued, lethargic, and irritable by 6 pm every day. The endocrinologist said that my total E was normal and that the symptoms I was reporting are not related to my hormone levels (You are at the right level for this dose of medicine.) At this point, I decided to go to a doctor who specializes in HRT but is not an endocrinologist. (In other words, this treatment is not covered by my insurance.)

My new doctor told me to discontinue the Androgel and to follow his standard protocol:

Testosterone pellets (four 75 mg pellets)
Testosterone cypionate injections 50 mg per week
Deca Durabolin 200 mg per week
hCG 500 units every two days
B12 and B6 injections every 10 days
2000 units liquid Vitamin D every night
1000 mg Magnesium every night

After four weeks, my weight has gone up to 180 pounds (BF = 29.6 %), and my upper body composition has improved due to extensive bodybuilding workouts. But my thighs have large deposits of fat tissue, with no muscle tone whatsoever, despite the fact that I am concentrating my workout on lower body exercises. I have not had any follow-up blood work,

Doctors (1) I need to understand how (i.e. the mechanism) a small dose of exogenous testosterone could trigger what appears to be a case of severe hypogonadism.

(2) What can I do, if anything, to return my muscles to a pre- HRT state.

 

[pcgizzmo]

Doctors take a look at the questions at the bottom of the page:

I am a 49 year old male who was referred to an endocrinologist last summer based on the following clinical findings: afternoon fatigue, osteoporosis, (bone density at 2.3 standard deviations below the mean), and diminished libido.

My free T and total T were measured on four different occasions over a period of 60 days last fall. The total T was consistently in the 350 to 400 range irrespective of the test method employed direct RIA or Equilibrium Dialysis. However, the free T was highly dependent on the test method. Free T measured using Equilibrium Dialysis was always in the middle of the reference range (47 - 244 pg/ml). In contrast, when measured using the direct RIA method, the free T was always about 20 percent below the reference range low end of the reference range (9.5 43 pg/ml). As I previously stated in my post regarding lab reference ranges, the direct RIA method has a strong negative bias when total T is in the low normal range and SHBG is very low. (My SHBG was 19 on all four tests.) The following lab tests (December 8 , 2005) are included for reference:

Total T = 398 (350 890)
Free T by Equil. Dialysis = 146 (47 244)
Free T by direct RIA = 7.0 (9.5 43)
SHBG = 19
LH = 3.4; FSH = 1.6)
Estradiol = 18.8
Height = 71; Weight = 180; Body Fat = 11.5 %
Chest = 46 inches; Waist = 32; Bicep = 16.5 inches

Based on the clinical findings and the RIA free T measurements, my endocrinologist put me on a very low dose of Androgel 2.5 g. What happened during the next 6 months was nothing short of surreal.

Within two weeks I began to notice major body changes: rapid loss of muscle mass and significant atrophy; large accumulation of fat deposits in the hip, pubic, and inner thigh areas; and sagging upper arms. I contacted the doctor but he insisted that these changes were visual disturbances. The physical deterioration continued, and by the end of the fourth week I was reporting the following symptoms:
Pain in the hip and femur bones
Hot flashes in the middle of the night
Fatigue beginning shortly after noon, and becoming progressively worse until the next Androgel dose
Apathy, lethargy, and an inability to make decisions
Severe depression
Depersonalization and derealization (an alteration in consciousness where familiar objects and time are distorted and the person becomes an outside observer of his own mental processes the perception the person is in a theatre observing himself perform on stage)

Over the next 8 weeks, I became bed ridden and was not able to work or care for my family. I reluctantly returned to the endocrinologist for a follow- up visit. Here are the results:

Free T by direct RIA = 1.7 (9.5 43)
Vitamin D, 25 OH = 11 (25 80))
Weight = 154; Body Fat = 33.8 %
Chest = 36 inches; Biceps = 12 inches
Significant loss of muscle mass in thigh; excessive fat deposits; mushy look and feel

He increased the dose, and after 8 weeks my total T measured one hours after dosing was 609 (245- 1836), my free T measured using RIA was 20 (12.4 to 40), total estrogen was 157 (range less than 130), and my weight was 170. There was some improvement in upper (but not lower) body composition. I felt some improvement in the morning, but became very fatigued, lethargic, and irritable by 6 pm every day. The endocrinologist said that my total E was normal and that the symptoms I was reporting are not related to my hormone levels (You are at the right level for this dose of medicine.) At this point, I decided to go to a doctor who specializes in HRT but is not an endocrinologist. (In other words, this treatment is not covered by my insurance.)

My new doctor told me to discontinue the Androgel and to follow his standard protocol:

Testosterone pellets (four 75 mg pellets)
Testosterone cypionate injections 50 mg per week
Deca Durabolin 200 mg per week
hCG 500 units every two days
B12 and B6 injections every 10 days
2000 units liquid Vitamin D every night
1000 mg Magnesium every night

After four weeks, my weight has gone up to 180 pounds (BF = 29.6 %), and my upper body composition has improved due to extensive bodybuilding workouts. But my thighs have large deposits of fat tissue, with no muscle tone whatsoever, despite the fact that I am concentrating my workout on lower body exercises. I have not had any follow-up blood work,

Doctors (1) I need to understand how (i.e. the mechanism) a small dose of exogenous testosterone could trigger what appears to be a case of severe hypogonadism.

(2) What can I do, if anything, to return my muscles to a pre- HRT state.

Hello! From your screen name and detailed synopsis you are a Dr? I know you are asking for Dr's opinions and I am not one but I will give you what I can tell you and this will also keep your post bumped up high so one of the Dr's here can respond as well. There are a few but sometimes they are busy and it takes a while.

Because of the HPTA when you introduce external testosterone there will be shut down. At what levels and how long it takes for this shutdown to occur I don't think is known. It seems to be different for each person. When Dr's first give Andro Gel the dose is often not high enough to address the amount of T that is being produced as well as make up for the HPTA shut down. Consequently the body stops making T and you are left w/a level that us much lower than what you started with even being on replacement therapy. You are often left feeling much worse than you did before the therapy. It seems that your Dr. did try and adjust the dose once you reported your symptoms but at that point you must have had some other hormonal abnormalities most likely from the tests you showed your estrogen. He said it was normal but the test showed high and high levels of estrogen can diminish the effects of TRT.

It seems like you made the right move by going to an anti-aging Dr. It has been my experience and many many people on this board that endo's do not know how to administer TRT. I can't comment on pellets and injections at the same time. I have never heard of anyone doing both but maybe your Dr. wants you to do injections until the pellets take effect. It sounds like you are in the right hands. If your muscle issues were the effect of low T then they should come back w/time and continued therapy and workouts. Muscles have what is known as muscle memory and they rebound pretty quickly given proper stimulus. As far as the fat deposits it really sounds like to me that you had high E2 maybe for a while. This to can be taken care of given time, proper diet, training and therapy.


Paul

 

[pmgamer18]

Paul gave you all that you needed to know I am not up on doing pellets and shots. When I was first put on pellets I was not on enough of them crashed in 4 weeks. All I can say to you is to go slow don't over do it. Your T levels have been down for some time and you need to get leveled off at up to 1/3 of your labs range for both Total and Free T also keep your E2 Estradiol down between 10 to 30 best at 20. Doing this your body will start to undo the damage done by low T. Over doing it will pull you back down. Hell I would not do weights until your leveled off for some time.

 

[drkinsey]

Hello! From your screen name and detailed synopsis you are a Dr? I know you are asking for Dr's opinions and I am not one but I will give you what I can tell you and this will also keep your post bumped up high so one of the Dr's here can respond as well. There are a few but sometimes they are busy and it takes a while.

Because of the HPTA when you introduce external testosterone there will be shut down. At what levels and how long it takes for this shutdown to occur I don't think is known. It seems to be different for each person. When Dr's first give Andro Gel the dose is often not high enough to address the amount of T that is being produced as well as make up for the HPTA shut down. Consequently the body stops making T and you are left w/a level that us much lower than what you started with even being on replacement therapy. You are often left feeling much worse than you did before the therapy. It seems that your Dr. did try and adjust the dose once you reported your symptoms blettingut at that point you must have had some other hormonal abnormalities most likely from the tests you showed your estrogen. He said it was normal but the test showed high and high levels of estrogen can diminish the effects of TRT.

It seems like you made the right move by going to an anti-aging Dr. It has been my experience and many many people on this board that endo's do not know how to administer TRT. I can't comment on pellets and injections at the same time. I have never heard of anyone doing both but maybe your Dr. wants you to do injections until the pellets take effect. It sounds like you are in the right hands. If your muscle issues were the effect of low T then they should come back w/time and continued therapy and workouts. Muscles have what is known as muscle memory and they rebound pretty quickly given proper stimulus. As far as the fat deposits it really sounds like to me that you had high E2 maybe for a while. This to can be taken care of given time, proper diet, training and therapy.


Paul

Thanks, Paul. Unfortunately, my doctor let me suffer for 12 weeks, effectively putting me in a severely deprived state without justification. (His philosophy is to see a patient every 3 or 6 months even though the patient has not achieved an adequate level). I will never visit an endocrinologist again. You guys on this message board are great.

 

[marianco]

Because of the HPTA when you introduce external testosterone there will be shut down. At what levels and how long it takes for this shutdown to occur I don't think is known. It seems to be different for each person. When Dr's first give Andro Gel the dose is often not high enough to address the amount of T that is being produced as well as make up for the HPTA shut down. Consequently the body stops making T and you are left w/a level that us much lower than what you started with even being on replacement therapy. You are often left feeling much worse than you did before the therapy.

I like Paul's explanation.

At certain doses, usually lower doses, TRT can result in lower testosterone levels than baseline. It is evident in the prescribing guidlines for Androgel itself.

Transdermal testosterone can cause a large increase in Dihydrotestosterone (DHT). DHT can cause fat accumulation - unlike Testosterone. It may give secondary sex characteristics and helps libido, but excessive amounts has its downsides.

I would question the need for Testosterone pellets, testosterone cypionate, HCG, and Deca all at once. I highly doubt that an anti-aging doctor would chose Deca. Be that as it may, hopefully things turn out well.

 

[HeadDoc]

I don't have much to add to any of the above. In the 4+ years I've been around the TRT forums, I've heard from only one guy who did well on pellets. The concoction that you were placed on makes no sense to me. Perhaps you complained of joint pain and muscle wasting? Do you have AIDS? The TSH is high. I'd keep an eye on the thyroid.

 

[Albert]

There is a formula that was published on another list (I think Ernie Nolan had the formula I'm think of) and I cannot remember all of it, but your weight from my memory you should have 500 to 600 mg of pallets.

It appears to me that you where under dosed, like Phil was.

Ok, found it, read on.

Dr. R. Don Gambrell, Augusta GA says his patients have trouble getting to the high normal level of 800-1000 using the shots patches and creams.
The therapy giving the greatest success and patient benefit is hormone pellets inserted under the skin every 4 months with no day to day or weekly patient involvement.

The formula he uses is more than the compounding pharmacy recommends.
Subtract 30 pounds from the total weight and for every 10 pounds give the patient a 75mg pellet with a max of 20 pellets.
This is 1500mg that lasts for 120 days and means a daily amount dissolving directly into the blood stream of 12.5mg/day.


Later,
Albert.

 

[drkinsey]

I don't have much to add to any of the above. In the 4+ years I've been around the TRT forums, I've heard from only one guy who did well on pellets. The concoction that you were placed on makes no sense to me. Perhaps you complained of joint pain and muscle wasting? Do you have AIDS? The TSH is high. I'd keep an eye on the thyroid.

No, I do not have AIDS. I lost a huge amount of muscle mass. Prior to HRT, I weighed 180 pounds (11.8 percent BF). After 3 months of androgen deprivation, my weight dropped to 154 (33.8 percent BF). That is a huge amount of muscle loss (and a huge increase in body fat). The net lean body mass LOSS is 58 pounds.

Incidentally, my new doctor is an anti-aging specialist; he is truly one of the best.

 

[pcgizzmo]

No, I do not have AIDS. I lost a huge amount of muscle mass. Prior to HRT, I weighed 180 pounds (11.8 percent BF). After 3 months of androgen deprivation, my weight dropped to 154 (33.8 percent BF). That is a huge amount of muscle loss (and a huge increase in body fat). The net lean body mass LOSS is 58 pounds.

Incidentally, my new doctor is an anti-aging specialist; he is truly one of the best.

That is a HUGE loss. I am 36 and my testosterone was below 200 for at least two years and I did not lose anywhere near that amount of muscle. Really strange if you ask me. It almost sounds like you did have some type of wasting disease. (I know you didn't) I just wonder what it was that made you lose so quickly. Did you continue to workout at all during the 3 months or was that pretty much a lost cause? Have you had your cortisol checked? I would say maybe hyperthyroid but HeadDoc said your TSH was high. I did not see that in your tests but those are the two things I can think of off the top of my head that can cause pretty good loss of muscle.

Paul

 

[drkinsey]

That is a HUGE loss. I am 36 and my testosterone was below 200 for at least two years and I did not lose anywhere near that amount of muscle. Really strange if you ask me. It almost sounds like you did have some type of wasting disease. (I know you didn't) I just wonder what it was that made you lose so quickly. Did you continue to workout at all during the 3 months or was that pretty much a lost cause? Have you had your cortisol checked? I would say maybe hyperthyroid but HeadDoc said your TSH was high. I did not see that in your tests but those are the two things I can think of off the top of my head that can cause pretty good loss of muscle.

Paul

Most of the loss occured during the first 4 weeks after starting HRT. I tried to work out on several occasions, but found that working out actually made me feel worse.

My endo only measured free T and vitamin D after 90 days. Neither TSH nor cortisol were measured,. ( I am not sure why headdoc inferred that my TSH was not optimal.) During my "hellacious" 90 days in the deprived state, I developed a strange intolerance to cold temps and a strong aversion to being touched.

But the most troubling physical symptoms (in addition to severe depression, depersonalization, and impaired mental function) were the hot flashes, bone pain, and high blood pressure (with migraine headaches) that occured at night in January.

I was too sick to help myself. My wife wanted to help me but didn't know where to begin. I should have ordered my own blood tests (through LabSafe) to prove to the doctors that my hormones levels had crashed. I knew better, but I was too paralyzed to act. Although I have no data to back up by assertion, I honestly believe that my testosterone had approached the zero state during those critical 4 to 6 weeks. (My free T, measured by the endo after 90 days on HRT, was extremely low.)

 

[pmgamer18]

You should call Dr. John at www.allthingsmale.com he to me is one of the best on this I am sure he can get your back to normal. I have seen 7 Endos in the last 22 yrs. and not one was any dam good on low T. Also Read Dr. John's TRT: A Recipe for Success and his HCG update tell him I sent you.

 

[HeadDoc]

sorry to cause any confusion, I was reading another thread that included a TSH.