TRT Jungle - What to do now?????

Discussion in 'Men's Health Forum' started by TheOldFart, Jun 8, 2009.

  1. TheOldFart

    TheOldFart Member

    I have been reading this excellent forum for some time now and just joined. I will apologize in advance for my first post being so long. Some basic info I am 64 years old and had signs of low T starting about 2 years ago. I didn't think much of the mild ED and loss of strength, but then depression, mood swings and loss of libido started about 18 months ago. I did web searches for these symptoms and discovered that it sounded like low T, so I brought it up with my doctor at my next appointment. He agreed that is what it sounded like and tested my total T. Unfortunately he did not test all the other things like LH, FSH, E2, etc. Here is my history.

    I started to take 50 mg of DHEA daily February 2008. I have also taken 320 mg of saw Palmetto and 500 mg of nettle root extract for my BPH, which has helped the BPH a lot. I also take zinc, copper and a bunch of other vitamins and minerals.

    All tests at Quest except E2 at local lab.

    May 2008
    DHEA-S = 450 (25-95 for age group) Seems like good place to be.
    Total T = 304 (250-1100) Low even though in lab range.
    Dr agreed that it should be at least 500 for someone my age and started me on androgel 5 gm.

    July 2008
    Total T = 357 (250-1100) Still low
    Free T % = 2 (1.5-2.2)
    Free T = 69 (35-155) Lower than it should be.
    E2 = 25.6 (20-56) - Good

    Depression was better, but not much change in anything else.

    Upped Androgel to 7.5 gm.

    November 2008
    DHEA-S = 617 (25-95 for age group) Too high.
    Total T 277 (250-1100) Not good at all.
    Free T % = 3 (1.5-2.2)
    E2 = 46.5 (20-56) Getting too high.

    I was feeling no better or even a little worse. I had read about Testim having better absorption, so I asked the Dr to switch me to Testim 10 gm. I also reduced DHEA to 25 mg and started to take 200 mg of Source Naturals DIM.

    February 2009
    Total T 644 (250-1100) Things are looking up.

    I had been feeling better for a couple of months and my ED was better, but not gone as 2 years prior when I was 62. I had none until 2 years ago.

    Annual physical May 2009
    DHEA-S = 232 (25-95 for age group)
    DHEA = 99 (61-1636)
    Total T = 862 (250-1100) Testim is really working.
    Free T = 179 (35-155) High.
    Free T % = 2 (1.5-2.2)
    E2 = 57.2 (20-56) Too high.
    DHT = 132 (25-75) Too high.

    So it seems like I need to lower my Free T and DHT and of course, try to get E2 into the 20-30 range. Here are the changes I have made:

    I think that the DHEA is converting to E2, so I have stopped taking DHEA.
    I have cut the Testim to 7.5 gm daily.
    I have added another 160 mg of saw palmetto to try to bring DHT down.
    I have added 6 mg of progesterone cream at night, as it is a 5 alpha reductase inhibitor and possibly a weak AI.
    I have stopped the Source Naturals DIM and started on one tablet of Indolplex DIM and 750 mg of TMG.

    I have been on this for just over 2 weeks now and ED is worse and libido is down. I guess I've screwed something up. My guess is the progesterone cream is at fault, as I tried that a few months ago and it hurt libido, so I stopped. Normally 25 mg of viagra would do wonders for the ED and 50 mg would bring me back to my younger years :), but now neither seem to work. :(

    Any thoughts and suggestions would be greatly appreciated.
  2. xray9

    xray9 Junior Member

    I was in a similar situation. I started taking an aromatase inhibitor, arimidex (Anastrozole), to lower E2. I started with 1 mg a day for two weeks to bring E2 down quickly and now take take 1 mg twice per week, Monday & Thursday, the day after my 2/week 500 i.u. hcg injection. The results have been nothing short of fantastic, hot flashes and bloating are gone and libido / nocturnal erections have returned. IMO anyone on TRT should be also be on HCG and Arimidex. You may also want to keep an eye on prolactin levels which affect libido and can be controlled with cabergoline.
  3. JanSz

    JanSz Junior Member

    I had 69th birthday few days back.
    I know first hand about depression when TT=300
    I am now on shots but androgel was raising my TT and I had to use it for years because I was not able to get a doc who would give me script for injectable T.
    Well, I was much less informed, so I did not pushed too hard, just used avodart to get my high DHT in check.

    Good that Testim is raising your TT.
    Cutting testim to 7.5gram/day looks like good move.
    With that move you may get all three into better place, FreeT, DHT & E2.

    About DHEAs, you want to be in high end of youtfull range or even slightly over.

    There is possibility that you will have to use arimidex.
    At this moment you do not know really your E2 level.
    There is a recomended test at Quest for E2 for men, (below).
    At the moment you are doing good, but you can do much better.

    Your testicles are shut, you have to bring them back to action.
    You know very little about your other health areas, need to investigate them.
    Since you responded porly to Androgel your thyroid and Adrenals are suspect.

    You are 64. I do not know your insurance and $$ situation.
    Next year you will be eligible for Medicare, if it is in similar shape as today you may have to wait till next year with my suggestions.
    I will give you a long list of tests that cost me about $6 out of pocket.
    I do it about once a year or 1.5.

    Now you should add hcg to your protocol.
    HCG will keep your testis in shape and will make them produce not only (some) testosterone but also other goodies that you are now missing.

    HCG-shot=250iu EOD (Every Other Day)

    Use these syringes, at least at the begining, so you know how good syringes work.

    BD Ultrafine II U-100 Insulin Syringe 31 Gauge 3/10cc 5/16inch Short Needle--1/2 Unit Markings 100/b at
    BD Ultrafine II U-100 Insulin Syringe 31 Gauge 3/10cc 5/16inch Short Needle--1/2 Unit Markings 100/b Price: $27.80
    HCG may cause your testiss to produce testosterone, keep it
    You want to use a lots of HCG, but not too much because it raises E2.
    If you have to, reduce Testim not HCG
    Do not go over 500iu/EOD, but daily injections are even better than EOD

    HCG is prescription medicine.
    You need script for it.
    When you buy it at pharmacy usually you are not able to get anything less than 10000iu package.
    That is a problem. HCG hardly last 30 days, most people hate to throw out unused medicine.
    Using old HCG you are getting into guessing game.
    HCG can be had over internet, much less expensive, no script.
    I like 1000iu, 1500iu or at the most 2000iu packages.

    I have given you minimal dose (250iu/EOD) depending on your response, eventually you may end up at 500iu (my current dose).

    Testicles need time to recover.
    After 3 months on HCG do blood tests below, post them here in tabulated fashion, we will take it from there.

    That list on the bottom have ICD-9 codes, they make insurance pay.
    Most of them may apply to you.
    That list is posted also on page 32 post #44 on my thread here:
    Jan's BloodTest April13/2007 - Page 2

    There is also explanation there of what those codes describe.

    1 --------- Comprehensive Metabolic Panel w/EGFR
    2 --------- Hepatic Function Panel (10256X)
    3 --------- VAP TM Cholesterol Test (10270X)
    4 --------- CBC w/ diff/PLT
    5 --------- Iodine, iodide Panel - (2503)
    6 --------- Selenium
    7 --------- Copper, serum
    8 --------- Zinc
    9 --------- Magnesium
    10 --------- Phosphate
    insurance may not pay($57.75) 11 --------- C-Reactive Protein (CRP), Highly Sensitive, CSF - (17401X)
    12 --------- Fibrinogen
    insurance may not pay($191) 13 --------- Homocysteine, cardio
    14 --------- Lipoprotein (A) Lp(A)
    15 --------- Iron and Iron Binding Capacity (7573X) - (356N)
    16 --------- Iron, Total (571X) - (24984P)
    17 --------- Ferritin (457X) - (22764P)
    18 --------- Transferrin (891X) - (30346P)
    19 --------- Folate, RBC & Hematocrit - (1768N)
    20 --------- Hemoglobin A1c (496X) - (45484P)
    21 --------- Hemoglobin, Plasma (514X) - (7211P)
    specify 22 --------- VITAMIN SCREEN
    specify 23 --------- VITAMIN B PANEL 2 - (9067)
    24 --------- Vitamin D, 25-Hydroxy, LC/MS/MS - (17306X)
    25 --------- t3, Total (859X)
    26 --------- T4, Total (Thyroxine)
    27 --------- T3, Free
    28 --------- T4,Free
    29 --------- T3, Reverse (967X)
    30 --------- Ultrasensitive TSH
    31 --------- Thyroid Peroxidase and Thyroglobulin Antibodies (7260X)
    32 --------- Insuline, serum
    33 --------- IGF Binding protein-3
    34 --------- igf-1
    35 --------- DHEA Sulfate 402X
    36 --------- Aldosterone
    37 --------- ACTH, Plasma
    38 --------- Cortisol Binding Globulin (Transcortin) (37371X)
    39 --------- Cortisol AM/PM
    40 --------- prolactin - (746X)
    41 --------- Progesterone, LC/MS/MS 17183X
    42 --------- Pregnenolone, LC/MS/MS (31493X) 28373P
    43 --------- Androstenedione, LC/MS/MS - (17182X)
    44 --------- Estradiol, Ultrasensitive, LC/MS/MS (30289X)
    45 --------- Estrone, LC/MS/MS (23244X)
    46 --------- Testosterone, Free, Bio/Total (LC/MS/MS) Code: 14966X
    47 --------- Dihydrotestosterone (204X)
    48 --------- Ceruloplasmin (326X)
    49 --------- Coenzyme Q10 (198268)
    250.00 ----- 257.2 ----- 780.79
    250.01 ----- 272.4 ----- 788.41
    255.4 ----- 601.9 ----- 253.3
    783.9 ----- 780.4 ----- 255.8

    My own Goals
    DHEAs(500-640)mcg/dL(13.55-17.34)mol/L------------------major player, 95% time overlooked
    Pregnenolone(> 100ng/dL)
    Estradiol, Ultrasensitive(25-29)pg/mL
    Estrone, LC/MS/MS (23244X)
    do not use Anastrozole if possible or minimize its use
    BATest(342, 460-575)ng/dL------------stay around 342 if you need AI to control E2
    DHT(60-90)ng/dL (I am active when it gets over or under this range)
    RT3 in lower half of range, TotalT3 in upper 1/3 range
    FreeT3~400pg/dL or higher if TotalT3 not reached
    Body temperature (97.8 - 98.2F) (36.56 - 36.78C); (36.6-37C)(97.9-98.6F)
    Last edited: Jun 9, 2009
  4. saw palmento does not lower serum DHT and can increase estrodial in some men
    Progesterone in a male should be added in form of TD pregenonlone
    Personally you are playing russian roulette by listening to these hormone experts on the internet
    If you are on
    west coast - Dr mariano is excellent recommendation
    East cost - My self and DR O
    Mid west - Dr John Crisler is also highly recommended and also great comtributor to male HRT as well
    REduce dhea to 10 mgs 2 times a day just to keep it in your system to get the benefits but also avoid the side effects of elevated e2
    I would also look at estrogen metabolites to see if you really need the DIM
    I suspect that you are undermethylated and highly suggest genova male hormone profile covered by many PPO for a reasonable price.
    Dhea can aggravate prostate issue may want to look into 7 keto dhea.
    also examine your adrenal cortisol salvia and thyroid completely. Thyroid goes hidden because alot of dr's do not know how to properly access it.
    Since being a medical consult for dr's that are interested in learning more about preventitive medicine are inquiring about how to properly interpret thyroid labs. Dr's that i have worked with have had dramatic improvement in clinical response.
    Since reading the article presented by Dr M about thyroid it really has made a huge impact on improving the quality of life of may people.
    Last edited: Jun 9, 2009
  5. TheOldFart

    TheOldFart Member

    I appreciate the extent of the responses so far and I have some comments and perhaps questions.

    The first relates to DHEA. I have read in several places where it is best to have DHEA-S at levels where they were at when in our 20s. I have read this in books and articles on the web. However, I have never seen a study where it has been shown that there is any benefit from this. I was taking DHEA in response to these books and articles and my doctor saw no problem in this. I doubt that he has ever investigated this, but he is always willing to look at the information that I show him. I did locate these 2 study reports last month. This one addresses DHEA-S levels vs. mortality in men and women in the age range of 65 to 76, which is where I will be next year. This shows no benefit from having a high DHEA-S level and in fact shows benefit from being in the 61 to 144 mcg/dl range. Of course, it doesn't address quality of life, just mortality.

    Dehydroepiandrosterone Sulfate and Mortality in Elderly Men and Women -- Trivedi and Khaw 86 (9): 4171 -- Journal of Clinical Endocrinology & Metabolism

    Here is another study that showed the relationship to DHEA intake to how it affects many of the other hormones.

    Mary Ann Liebert, Inc. - The Journal of Alternative and Complementary Medicine - 6(1):91

    Unfortunately, not having a subscription, I cannot get the entire study report. However, it did show that men taking either 50 mg or 100 mg of DHEA daily had significant increases in DHEA-S, DHEA, androstenedione, free T, estrone and E2. However, it did not affect the levels of total T and DHT.

    I guess these studies both make me wonder about the benefit of high DHEA-S levels in older men and if taking DHEA is the reason that my DHT, total T and E2 are above even the lab ranges by a significant amount.

    The next is whether saw palmetto lowers DHT. I have found information of studies which say that it has no effect on DHT, but there seems to be controversy on that. Since I have been taking saw palmetto for years and I have high DHT, I am inclined to believe that it has no or little effect on DHT. Howeve, the combination of saw palmetto and nettle root extract have improved my BPH. When I was using progesterone cream with 6 to 10 mg of progesterone in it several months ago, I did have further improvements in BPH. However, it did kill my libido and made my ED worse. When not taking it my ED is mild and libido is good. That makes me believe that progesterone cream does affect DHT, but without testing with and without taking it I can't know for sure.

    I have read recommendations on several boards about what tests should be run and I understand the need for many of them. However, getting insurance to pay for them and finding a doctor to interpret them is a problem. I have heard many discussions on Dr. Mariano, Dr. Crisler and Dr. Shippen on various boards and know that they are well respected in this field. I have not heard of a Dr. O, so I would appreciate knowing who he is. I live in NY state.

    The problem is that doctor and travel costs are a problem because of the cost and no insurance coverage for these doctors. The expense is beyond what we can afford in light of my retiree medical insurance costing me over $13k per year, my wife having cancer (seemingly got it all during surgery) and us being retired. Perhaps next year when we go on Medicare, although I will probably still end up in an HMO with a Medicare advantage plan.

    I also read this discussion earlier this year by Dr. Mariano on progesterone.

    I will try to absorb all the information that you have given me over the next few days and try to get more information and see if there is any additional advice on this post. Again, thank all of you for replying in such detail.
  6. Dr O is the MD that has helped many people on here that had complex medical problem. Him and I work together to find the cause of the problem starting with lifestyles, poor nutrition, proper sleep patterns, intestinal imbalances, stress management. We focus first on the adrenals and thyroid then sex hormones. If the person is over certain age and is low in T then sex hormones will be addressed according to each indivdual case. Shippen is great but he is winding down his business and getting ready to retire. Dr O and I have several clients from him that are extremely pleased with their T and e2 levels but are still felling not right. dr Shippen is a good dr as he will admit that he does not know something. He encourages people to seek areas where he is not strong in. That I admire in the man tremendously. We have alot of people that have been to the top drs in the United states with out resolution as one thing is that we are extremely opened minded focusing on other areas dr's do not.
  7. TheOldFart

    TheOldFart Member

    I stopped the progesterone right after I first posted 4 days ago. After 2 days ED was again almost gone. Morning erections were back, so I took 25 mg of viagra just to be sure and went back to bed. I wouldn't have needed it. Wife woke up and started kissing and fondling and I was ready to go, just 10 minutes after taking the Viagra. This morning no Viagra and no problem at all. Not completely back to normal, but almost. Progesterone must be an effective 5-AR inhibitor. No more progesterone for me. She is also going to try not taking it, as she has been using it after having her ovaries removed 3 months ago. She can't use estrogen because of the ovarian cancer (very early stage and grade). I don't know if progesterone inhibits DHT in women or if DHT does much for their libido, but it is worth a try. :D
  8. pmgamer18

    pmgamer18 Member

    Bottom line here and I am 65 just got over heart bypass sugary been on TRT for 27 yrs keep your Total T up into the upper 1/3 of your labs range and keep your estradiol down between 10 to 30 best at 20 if SHBG is mid range lower then keep estradiol at 15.

    I use my wood to gage my Estradiol and take arimidex doing .25 mgs every 2 to 3 days some days I need an extra dose to keep it down. If my wood stops most of the time it my estradiol going down to low. So i just stop the arimidex until wood comes back that day I go back on it but do less.

    Estradiol changes a lot so I keep a log on what I am taking and how I am feeling my BPH is all gone after yrs of problems. Just keeping estradiol down my heart Dr. has me doing cialis everyday I cut a 20 mgs pill in half this helps my heart BP and keeps my wood up.

    At your age make dam sure you heart is good low T for a time can cause problems.
  9. zkt

    zkt Member

    I`m trying to see the big picture here. You are obviously well read and paying attention to your bodily responses to changing doseages of the many effectors that you are taking.
    You dont mention psycholigical factors. Libido is mostly in the head. I must recommend that you simplify your situation. The estrogen moidifying supplements are at best marginally effective - same for the 5-reductase inhibitors.
    Use T, hcg and aromatase inhibitator while keeping an eye on thyrod hormone levels and you might be ok.
  10. TheOldFart

    TheOldFart Member

    I finally got back the results of my blood test today and they were not as expected. Here are the changes that I have been doing over the past 2 months.

    Decreased Testim from 10 gm daily to 7.5 gm daily
    Stopped taking 25 mg of DHEA daily
    Increased saw palmetto from 320 mg to 480 mg daily
    Switched from plain DIM to one Indolplex DIM daily

    Here are the changes in my blood test results from May till 2 weeks ago. I had both blood tests done at the same time. I put on Testim at 6 am and had blood drawn at 10 am. The only difference was that the test done in May was a fasting test because of the lipid profile done that day.

    Total T - (250-1100) - Quest - 862 > 268
    T % - (1.5-2.2) - Quest - 2 > 2
    Free T - (35-155) - Quest - 179 > 50
    DHT - (25-75) - Quest - 132 > 76
    E2 - (<20-56) - Local lab - 57.2 > <20
    DHEA-S - (25-95) - Quest - 232 > don't have results

    OK, so how can my total T drop from 862 to 268 by just reducing my Testim dose from 10 to 7.5? I have been on T gel for over a year now, so I can't believe that my body just stopped making T between the 12 and 14 month points. In any case, I was only at 304 before I started on TRT. It is interesting that I was at 277 after 6 months on androgel, but I never got above 357 on Androgel. I was also at 644 an Testim 10 mg just 6 months ago and that was not a fasting test. How could a 25% lower dose drop my T by almost 70%?

    I have an appointment with my doctor for next Tuesday. I will stop the DIM and go back to 10 gm of Testim, but that is all until I get the DHEA-S results. I don't know what is taking so long to get that.

    My morning and night time erections have been variable for a while now. Some mornings they are great and others they are non existent. Unfortunately, I didn't note what it was on the day of my blood tests.

    Does anyone have any thoughts on this and/or suggestions.
  11. AlexanderDenmark

    AlexanderDenmark Junior Member

    Did your doc really say that your Test shoulid be around 500 at your age?

    I'm 22 and my test is around 500. Don't feel good to say to least.
  12. TheOldFart

    TheOldFart Member

    Yes, when I was first tested 14 months ago and I was at 304, he said that I should be at least at 500 at my age of 64. However, he did say that if I felt good at a lower number that would be more important than the T level. That is what Dr. Shippen says too. He thought that I was fine at 644 and he did not think I was too high at 862. The reason that I dropped back to 7.5 gm was because both of us thought that my high T level might be part of the reason for my high E2. Dr. Crisler says that often when E2 is high, it is because T is too high for that particular person. In addition, DHT at 132 was definitely too high and we thought it might be because of the high T.
  13. zkt

    zkt Member

    Sorry I dont have time to give you the time you need right now. But at first glance it seems that your aromatase enzyme is too high. Consider arimidex. Maybe 0.25/w to start. Reply or PM to remind me of this.

  14. Progesterone is going to fee e2 pathways not good and will not help lower dht
    Saw palmento will not lower serum DHEA.
    With testosterone I would switch to compounded gel it will help reduce e2 due to decreases surface area which is needed for testim
  15. TheOldFart

    TheOldFart Member

    My update (#10) shows that my E2 is now below the lower measuring limit of the lab used. Why would I want to add arimidex or change to compounded gel if I am already too low now that I have added Indolplex DIM? The thing that confuses me is why would my total T drop from 862 to 268 and free T from 179 to 50 with just dropping my Testim dose from 10 gm to 7.5 gm? I believe that the analysis of the blood was done at the same Quest lab both times, but I will check when I see my doctor tomorrow.

    I am not using progesterone. I stopped after less than 2 weeks of use, as my libido went to near zero. I haven't used it for 6 weeks before my blood test.

    I'm not sure about the effects of phytoestrogens. Studies in post menopausal women have shown that phytoestrogens lower E2, but not as much as mine dropped. Since E2 is about the same in post meno women as it is in men, I would think it would do the same for men. Some studies have shown that phytoestrogens lower T in men, but not a lot. However, I don't see how phytoestrogens would affect T levels in men who are using exogenous T.
  16. zkt

    zkt Member

    Sorry but I hadnt read the entire post, updates and comments, and still havent. Obviously you wouldnt do anything to lower E if is already too low. Neither would you need to take DHEA if on T.
    Why not just try too keep it simple? Do the T, and arimidex if needed, and lose all the other stuff? The pathways and especially interreactions of the various hormones really arent all that well understood in the first place. My advice after running my own therapy successfully for 2 years, reading hundreds of studies and a few medical texts, is to follow the KISS principle.
  17. TheOldFart

    TheOldFart Member

    BAsically that is what I am thinking of doing.

    - Take Testim back up to the 10 gm that seemed to work and helped my ED and libido.
    - Stop DHEA.
    - No soy except for small amount of soy isolate powder in my whey protein shakes.
    - Still take 1/2 of an Indolplex DIM tablet. Remember that my E2 was high before the soy isoflavones. However, it could have been the DHEA that caused it. There was a study that showed that DHEA converted to E2 in men. Actually, there were 2 studies, but they were at 50 mg. I have not found any that show what happens at 25 mg.
    - Keep taking saw palmetto, as I have been taking it for about 10 years and it has helped my BPH even before the low T symptoms began. BPH was getting worse before SP and then it slowly got better. I don't want to risk it getting worse again.
  18. zkt

    zkt Member

    Excellent! The BHP is another matter tho. Assume you test PSA and DRE at least yearly. SP is ok but Terrazosin is better. If you have hypertension is inhibits the NE at the alpha2 receptor as a plus but doesnt lower BP if NE isnt an issue.
  19. TheOldFart

    TheOldFart Member

    I have an annual physical and have a PSA annually and sometimes a DRE at 6 months. Oh joy. :) My PSA has been steady at 0.77 to 0.88 for years, except for one 0.53 last year. My doctor said that I am perhaps his most stable patient. It was at 0.82 in May at my physical. I have hypertension and have been on an ACE inhibitor for probably 20 years. I use fosinopril.
  20. zkt

    zkt Member

    Yea hypertension, its brought up way too infrequently here and it is very important to keep the BP in the normal range.
    You really might benefit from the selective alpha blockers unless you also have renal hypertension, in which case the ACE or ARB are the best choice. You could also titrate the ACE down and add some AB. This might also help the BPH. But then if youre ok on the SP and BP is ok- dont fix it if it aint broke. GP`s are supposed to know all the fine points of the hypertension drugs but many dont. You seem well informed and that will definitely effect your treatment sooner or later. The more you know the better off you wil be especially in the good ol USA- 37th in world healthcare and still falling. But thats another rant. LOL
    One more thought- I`ve been working on teaching the wife to do the DRE- it seems to be a bit more fun that way!
    We are about the same age btw.