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Messages - Cataceous

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Is your doctor ok with less frequent injections? Why would he care if the total dose per week is the same?

Welcome! Your numbers are suggestive of secondary hypogonadism. It's hard to predict what any given urologist will do, but here are some things he should do: Measure testosterone a second time to confirm it's low. This should be done around 8-10 am. In addition, prolactin and estradiol should be tested. Other possible tests are discussed here. The thyroid hormones are worth checking to ensure there's not concomitant hypothyroidism.

The point of the extra testing, aside from confirming hypogonadism, it to rule out treatable underlying causes. For example, either elevated prolactin or elevated estradiol can cause hypogonadism. If your hypogonadism is idiopathic, i.e. with unknown causes, then you would likely be given the option of testosterone replacement therapy. Typical options include transdermal testosterone and testosterone injections. I would urge you to look into testosterone nasal gel as a first-line treatment. The name brand is Natesto, and Empower Pharmacy also makes a version that is less expensive. Conventional TRT is more likely to cause side effects, especially testicular atrophy and infertility. This is due to the complete suppression of your own testosterone production. The nasal gels have the large advantage of adding on to your own production instead of replacing it. This allows your body to function more like normal than if the whole HPTA feedback system is shut down.

Ok, it sounds like the elevated antibodies don't necessarily mean there's a problem, particularly with the free thyroid hormones looking ok.

"... some people may be positive to TPO antibodies, but they do not have a thyroid condition."[R]

Do you have a free T3 measurement? SHBG? The latter could be used to help estimate free testosterone. The direct free testosterone test is too inaccurate to use. However, with such low total testosterone it would take very low SHBG to suggest a reasonable level of free testosterone. I'd want to understand the significance of the thyroglobulin antibody results.

If you do opt for TRT I'd encourage you to consider a testosterone nasal gel product for starters, either Natesto or Empower Pharmacy's generic version. Although the delivery method isn't the nicest, these products have a big advantage in that they don't crush your HPTA activity. Regular TRT typically sends LH and FSH to near zero, along with other useful upstream hormones. Testicular atrophy is a common side effect, along with infertility. Some men have problems with libido and/or sexual function that are possibly a result of this disruption.

I wouldn't worry too much about the vitamin D. The danger zone is below 20 ng/mL. Without much justification testing companies jacked up the bottom of the normal range by 10 ng/dL. You could supplement with 1,000-2,000 IU per day as insurance.

I don't know much about low ferritin—except that it can occur in guys on TRT who use blood donations to manage hematocrit.

I use 0.3 cc, 31 gauge, 5/16" U-100 insulin syringes. These can have markings down to 0.005 mL, depending on the brand. If your testosterone ester has the typical 200 mg/mL then your dose resolution is 1 mg, which would rarely be inadequate. There is some evidence that reducing peak testosterone helps with reducing hematocrit. Subcutaneous injections are a little better for this than IM because the slower absorption smooths out the peaks and troughs a little. The dose size and frequency are still the most important factors. The SC-specific product you're referring to is Xyosted, which contains testosterone enanthate. Because the formulation lacks benzyl alcohol the half-life is double that of typical products, so most guys can get away with injecting once a week.

If you were going with injectables I'd recommend starting with daily or EOD doses of testosterone cypionate or enanthate. You'd adjust the dose to attain midrange free testosterone. Free testosterone must be measured by an accurate test—e.g. equilibrium dialysis—and/or calculated by measuring SHBG along with total testosterone.

If you don't get polycythemia with topical testosterone then it's almost certainly possible to dose injections in a way that doesn't cause such problems. In the worst case this means daily micro-injections of a cypionate/propionate blend. Injections have the advantages of greater consistency and control, along with little risk of transference. I'd also assume they cost considerably less than a name brand such as Androgel.

How is the availability of the 1.62% product?

I don't know how hCG increases libido. The variations in testosterone may help. The restoration of other hormones such as progesterone could also be a factor. In addition, the activation of LH receptors may have a role. "LHCGR have been found in many types of extragonadal tissues, and the physiologic role of some has remained largely unexplored. Thus receptors have been found in the uterus, sperm, seminal vesicles, prostate, skin, breast, adrenals, thyroid, neural retina, neuroendocrine cells, and (rat) brain."[R]

The fact that you're having erection problems in spite of taking PDE5 inhibitors could point to a functional issue with the penis. It would be interesting to see how you respond to PT-141. If you can't get to 100% with this drug—at least while trying to sleep—then it's almost surely not related to hormones. Not that I'm recommending it—PT-141 is so strong it's a bit scary. I worry about potential long-term effects.

Interesting. Have you also tried supplementing with arginine or citrulline?

"There were no differences between the levels of SHBG between visits or between treatments (Figure 4A). The apparent increase in the amount of SHBG in the enclomiphene citrate group after 6 months of treatment as compared with the testosterone gel group was not statistically significant (P = 0.091)."

Oral Enclomiphene Citrate Stimulates the Endogenous Production of Testosterone and Sperm Counts in Men with Low Testosterone: Comparison with Testosterone Gel

First time I've seen that mentioned. I'm also not aware of a broader testosterone shortage, though there are occasional complaints about the absence of a particular brand.

What's been getting attention is the shortage of hCG caused by FDA's reclassification of it as a biologic. This effectively banned compounding pharmacies from selling it until they get special licensing. The reduced supply has made even the brand-name products harder to get and more expensive.

Time until effects: The sedating effect should be rapid. I recommend dosing at bedtime. Effects on mood should become apparent within days, though may fade somewhat over time. Effects on aromatization should also be stabilized within days. I'm not sure how long it takes for downregulation of estrogen receptors. I would guess days to weeks. Stabilization of effects on libido and sexual function may take weeks to months.

Testing: I would test serum progesterone after one to two weeks of supplementation. At that point titrate the dose up or down to target the desired serum level. With bedtime dosing I would test in the mornings. This should give somewhat of an average of your daily levels. After the first test and dose adjustment I would wait at least a month and then retest progesterone. Also test estradiol, and ideally testosterone and SHBG. It might also be useful to look at DHT and prolactin. Do you happen to have baseline values for any of these latter hormones? After the second test you can again adjust the dose as needed.

Don't be disappointed if you don't see a large reduction in estradiol. Progesterone is not that strong of an aromatase inhibitor. However, the overall reduction in estrogenic activity should push you in the right direction with respect to ameliorating symptoms. If the second set of tests didn't require a large dose adjustment then you could wait another one to two months before making a final evaluation, which could include another test of serum progesterone and an assessment of how much, if any, you've improved with the therapy. If results are still unsatisfactory—and estradiol is still high relative to testosterone—then I would consider adding in anastrozole.

Self-testing is possible and affordable in many states if you don't have a cooperative doctor and/or insurance company.

Treatment duration: If you experience good results with one or both drugs then you will want to continue indefinitely, testing levels twice a year or so to ensure no significant changes. It's not so likely that either drug is going to cure the underlying issue. I think you said you'd already lost a significant amount of weight, which is otherwise a common avenue for reducing aromatization. Occasionally there are reports of AI use leading to prolonged reduction in estradiol even when treatment is discontinued. Presumably your continued testing would pick up something like this, with unexpected later reductions in estradiol and/or the estradiol/testosterone ratio. Then you might be able to at least taper the doses to some extent.

Transference: There's not as much concern with progesterone as with testosterone, regarding contamination of others. However, it would still be wise to minimize the possibility. You do not need to wash your clothes separately. If they are washed in warm water with detergent then negligible amounts will remain.

Most likely your estradiol really is quite high, but in some cases the estradiol test you used can be fooled by high levels of C-reactive protein and falsely report high estradiol as a result. One way to check is to use a different estradiol test that doesn't have this shortcoming. You seem to be using Quest Diagnostics for your testing. Therefore the test you want is this one.

Arimidex (anastrozole) and progesterone are both reasonable treatment options, either singly or used together. I view progesterone as a little safer because it is endogenous. But it's important to monitor hormones and titrate doses with either treatment.

I suggest avoiding oral delivery with progesterone. Results can be less predictable because of significant metabolization into other substances. This leaves injections or transdermal delivery. I've had good luck with both methods, though I prefer the precision of injections. With respect to transdermal products, I particularly like the ones that are simply progesterone in coconut oil. These may not be absorbed quite as well as multi-ingredient creams, but I like the relative purity, and I still had good absorption with scrotal application. You can even buy these products over-the-counter. For example, there's the Progestelle brand available on Amazon. I would start low, with 5-10 mg in a transdermal product. Figure the rate of absorption may be about 10%. I would target midrange serum levels for starters, around 0.75 ng/mL.

Progesterone helps reduce estrogenic activity by at least two mechanisms. It's a mild aromatase inhibitor, which can slow production of estradiol, leading to lower levels. In addition, progesterone downregulates estrogen receptors. This means there are fewer receptors and therefore less overall responsiveness to estrogens such as estradiol. Progesterone may help with your sleep. In my case starting supplementation increased quality sleep by about an hour each night. Expect a positive effect on mood, especially in the beginning. The improvements may tempt you to dose higher, but try to avoid this. Higher levels can degrade memory and mental sharpness, and also cause other problems.

I would try progesterone alone for a few months. Only if you're still having problems clearly linked to estrogen would I then proceed to use anastrozole in addition. Anastrozole is quite strong, so it is wise to micro-dose from the start, and increase slowly and only if clearly needed. Reasonable starting doses are around 0.25-0.5 mg per week. It's tricky to split a 1 mg tablet appropriately, but you can dissolve a tablet in 10 mL of vodka and dose by volume. I've used this technique to take as little as 0.025 mg (25 micrograms) of anastrozole daily. You're looking for the smallest dose that gives you reasonable results. In addition to total estradiol, you need to monitor the ratio of estradiol to testosterone. The normal range for this is about 0.3-0.6%. You don't want to stray much from this if possible. Your current ratio is 1.2%. You knew that the absolute level of estradiol is high, but this shows that estradiol is unusually high relative to testosterone as well.

That total estrogen is puzzling, and worth further investigation. However, with estradiol in range I don't think aggressive treatment is warranted yet. I would retest to measure fractionated estrogens via mass spectrometry. This test gives the individual components of total estrogen: estriol, estrone and estradiol. The other estrogens are considerably weaker than estradiol, with estriol about 100 times less potent, and estrone about 10 times less potent.

That's a ridiculously high dose of anastrozole and almost surely would be unhealthy. Even 0.25 mg spread out over a week lowers my estradiol by 20 pg/mL or so. The ratio of estradiol to testosterone probably has independent importance. Yours is already towards the lower end of a normal range 0.34% (0.3-0.6). You do not want to lower this further.

I do think a dose reduction is a good idea. Unless athletic performance is a priority over long-term health I believe it's advisable to keep free testosterone in range and no higher than what our individual prime natural level was.

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