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Messages - Dr. John Crisler

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2
So I understand that you want a certain ratio of T3 to RT3. But what is that optimal ratio and what causes it to tip one way or the other.

You want it as low as possible. 2:1 or lower. I've had Hashimoto's for almost 20 years. My wife has had Hashimoto's for over 20 years, and my son has congenital hypothyroidism. My grandmother had Graves, my sister had Graves and got RAI (big mistake). Make sure you're converting properly, if not, you might want to add some T3 but not too much. It's easy to overdo T3 and blow out your adrenals, but adding T3 can reduce your RT3 a lot. Also consider taking some zinc and selenium.

What do you mean by "blow out your adrenals"?

In my experience (with myself and family), if we do too much T3 (like Cytomel) to where our TSH gets suppressed to almost nothing, and if the adrenals aren't supported, they wear out / crash over time. Cortisol starts trending down after a year or two of being on T3. This happened to me in 2008 and it took a couple years for my adrenals to come back. It happened to my wife twice. The first time was in 2004, and then again a couple years ago. Only this time her adrenals were so bad that her AM cortisol was 4! I think partly due to this adrenal "fatigue" (doctors don't like to acknowledge that condition exists), she got a disease that's so rare there are only 300 known cases. She got eosinophillic fasciitis. Now she's on long term high dose prednisone, which really sucks. My advice is to never touch T3 unless you have a T4 to T3 conversion problem (which my wife definitely has). Carefully monitor and support your adrenals if you have to go on T3.
I use T3-only in a number of cases. As always, it depends on the case.

Not addressing Adrenal Fatigue over time can cause total collapse with, or without, adding T3.

3
I recall reading somewhere that it can drop your T to near castrate levels. Is that true, or bs?

In the article referenced by the Dr. Crisler:

Quote
The researchers found that, after taking the drug for 28 days, testosterone in the blood dropped to castrate levels for all three doses. “Castrate levels” refers to the target range of testosterone in the blood after chemical or surgical castration and is usually defined as 50 nanograms per deciliter.
...
“Normal testosterone in a man is anywhere from 350 to 1,100 nanograms per deciliter,” said Dr. Seth Cohen, an assistant professor of urology at NYU Langone Health, who was not involved in the study. “And they got these guys down to 13 nanograms per deciliter.
...
But due to the study’s small sample size, more research is needed to evaluate the potential side effects of the drug in the general population, Cohen said.

“Nine participants had decreased libido, which is not small,” he said. “When you put that on a large, multimillion-person basis, you have a huge portion of men running around with very low libido.”
...
“The very important point here is that despite having those low levels of testosterone, the steroid that is given in this prototyped male pill provides the androgen activity in the man in all the other parts of their body,” Page added.

I wondered on this last point if this stuff aromatizes to give you the missing estradiol. But the Wiki article says no:

Quote
Because DMAU suppresses testosterone levels and by extension estrogen levels in men but has no estrogenic activity of its own, it may pose a risk of symptoms of low estrogen levels such as sexual dysfunction (e.g., decreased sex drive, reduced erectile function) and osteoporosis. Reduced sexual function and decreased bone mineral density have been observed with the closely related medication trestolone, which has low estrogenicity similarly to DMAU.
THANK YOU for your astute observation!

4
MALE BIRTH CONTROL PILLS: This is a REALLY bad idea.

http://ktla.com/2018/03/20/male-birth-control-pill-a-step-closer-to-reality-as-study-finds-experimental-contraceptive-is-safe/

Yes, and Thalidomide was “safe and effective” as treatment for nausea during pregnancy, too. If you don’t know that story, I’m sorry for what you are about to learn when you search it.

And progestins (synthetic progesterone) were “safe and effective” for women as Hormone Replacement Therapy, too. AND infinitely preferable to those horrible “bioidentical hormones” (AKA natural progesterone) the Age Management Medicine doctors constantly push on the population.

….until it became unavoidably obvious progestins cause heart attacks, strokes, and cancer. By the way, bioidentical progesterone does not.

The same can be said of the various endocrine disrupting substances constantly assaulting our bodies. Pesticides, preservatives, plasticizers, insecticides, etc. They usually mimic estrogen (and so are called “xenoestrogens”), but what they all do is powerfully disrupt our natural hormonal pathways. As we learn more and more about how our bodies work, the best practitioners of Interventional Medicine are working to serve those natural pathways. Restore, replace, and optimize. It’s how the body not only regulates itself, it’s how we develop, and maintain life, in a changing environment. This is the foundation to my “Backfilling the Pathways” treatment protocols. But what is frighteningly unique about the toxic substances previously mentioned is they are so powerful they escape the standard Pharmacological axe “The dose makes the poison”. Often even miniscule amounts can induce horrible outcomes. And often they are stored—and so accumulate—in the body.

Since the ultimate goal in restoring health is making things as natural as possible, how on earth can a powerful endocrine disrupter such as this Frankenstein DMAU NOT cause serious complications? They specifically mention hormonal pathway disruption in the article, as if it’s a good thing. Have we learned nothing?

Backing up a bit, it’s very clear to us what happens when testosterone is lowered; by any cause. Now they want us to do that on purpose?

Here’s the unavoidable fly in the ointment for this drug: it’s a progestin. We already know what progestins do to women. We also know what is bad for the breast tends to be bad for the prostate. And we share the cardiovascular system. Let that sink in.

Now, who wants to be a guinea pig?

5
Ferritin is an iron storage protein. Yours is so low it is hurting you.

At the time they drew the sample, you had some iron in your blood. That is what they measured.

Ferritin can be falsely elevated, as in inflammation.

6
Testosterone, Hormones and General Men's Health / Re: 20 yo Male Low T
« on: March 16, 2018, 03:07:51 am »
My testosterone in August when I was 19 was 200 ng/dL, and I didn't do anything about it. I feel good and have been putting on muscle fine (230 bench in August to a 260 bench now, which is somewhat slow now that I think about it). I was 158 lb in August at 5'7'', which is somewhat lean for me: I'm 168 now and the 10 pounds is not all muscle.

Should I check my T again? What else should I check? Free T? 200 seems really low, but I feel fine, but maybe I could feel insanely good. Unless my T is abysmal I probably won't do TRT. What non TRT methods do you recommend to increase T?

How noticeable is 200 ng/dL vs 400 vs 600? If my T is 400, should I still actively try to increase it? Is it possible that if I feel good and am putting on muscle, then increasing my T won't have a dramatic effect, even if my T is as low as 200?
It looks like you're not broken--there's nothing to fix.

Rejoice.

7
Please keep in mind you follow Clomid therapy by testing T and also LH/FSH.

All three are variable throughout the day.

8
Having low, or lower E, with high or higher SHBG, is a bad combination.

See how your Free T is barely in range, and with Total T where it is? The same thing is happening to your E.

9
Testosterone, Hormones and General Men's Health / Re: Trt thoughts
« on: March 10, 2018, 05:26:20 pm »
HCG is only beneficial to a TRT protocol (although there are always rare individuals who react badly to anything).

I don't know if you need an AI or not. But IF you do, they are effective and safe, if used properly.

10
Testosterone, Hormones and General Men's Health / Re: SHGB levels
« on: March 07, 2018, 07:42:20 pm »
Following up on James' final point, I see anxiety in guys with low(er) SHBG and high Free T.

11
Testosterone, Hormones and General Men's Health / Re: Pregnenlone
« on: March 07, 2018, 02:33:32 am »
If a patient (male or female) is suffering anxiety, I will start them on PREG sustained release 30-50mgs before bed. If they can take that without grogginess in the morning, add an AM dose.

I use DHEA in virtually all my TRT patients. A few don't respond well. OTOH, some tell me it changed their lives.

Indeed my friend.

Our dearly missed PeakT often professed that he considered the DHEA that I prescribed for him during our first consultation to be a missing piece to his HRT puzzle. In fact, he described the decrease in anxiety he experienced with the addition of DHEA to be as life-changing as his TRT itself.
Well, you sure did a lot for him, then. During the two lunches I had the honor of sharing with Curt last November, I detected NO anxiety whatsoever. He was as chill as they come.

Curt spoke very highly of you in that conversation, Dr. Saya.

12
Testosterone, Hormones and General Men's Health / Re: SHGB levels
« on: March 07, 2018, 02:30:22 am »
With low SHBG total testosterone you'll obviously have lower total testosterone. Free testosterone is normal without TRT... in the mornings. By the evening you are lucky to have any testosterone left. In my experience the most common complaint with low SHBG guys is little to none sex drive. And that TRT barely ever works as expected.

Why do you think sex drive is low and expectations aren’t meant?  Wouldn’t high free t be an advantage?   Is it because of estrodial issues?

There are a couple of potential answers. 

1.) Free SHBG plays a role in intracellular AR signalling. The rate of glucuronidation and time before effluxion of a free testosterone molecule that has entered a cell is mediated by intracellular SHBG brought into the cell via the megalin receptor. This phenomenon is tissue specific, and some cells produce their own SHBG internally to achieve this result.

2.) Free SHBG also plays a role in extracellular signalling.  A receptor, known as SHBG-R, binds to free SHBG which then "catches" various steroid molecules to complete a signalling pathway believed to be related to C-AMP.  There is a pinned post regarding this phenomenon, and Dr. Crisler wrote an article about it. 

3.) SHBG fluctuations alter the hepatic metabolic clearance of testosterone, but do not significantly alter that of estradiol.

4.) SHBG has sole control of the free-to-bound estradiol ratio, but the lowest affinity for estradiol.  Fluctuations in SHBG therefore have a greater effect on FE2:TE2 than on other free hormone fractions.

With exogenous testosterone administration, FT% increases as SHBG decreases.  This is often mistaken for a positive outcome since free testosterone in otherwise eugonadal males correlates positivity in the literature with lean tissue mass, sexual function and overall wellbeing.  However,  when SHBG is disproportionately low to serum androgen concentration, this effect is offset by an accelerated metabolic clearance rate for testosterone with no similar change in estradiol, less overall AR signalling from accelerated cellular effluxion, an increased rate of aromatization, an increased rate of conversion via other pathways, decreased extracellular signalling at SHBG-R and a deficiency of a primary transport protien for testosterone that is required for serum transit and proportionate target tissue diffusion due the low aqueous solubility of testosterone and the complexity of steroid sensitive extravascular membranes through which testosterone must pass while still protected by a strongly bound protien to reach target tissues intact.
Great point. Combining our respective posts here, as levels rise, SHBG grabs more AND MORE of the T, preferentially over the E.

13
Testosterone, Hormones and General Men's Health / Re: SHGB levels
« on: March 07, 2018, 02:27:47 am »
With low SHBG total testosterone you'll obviously have lower total testosterone. Free testosterone is normal without TRT... in the mornings. By the evening you are lucky to have any testosterone left. In my experience the most common complaint with low SHBG guys is little to none sex drive. And that TRT barely ever works as expected.

Why do you think sex drive is low and expectations aren’t meant?  Wouldn’t high free t be an advantage?   Is it because of estrodial issues?

There are a couple of potential answers. 

1.) Free SHBG plays a role in intracellular AR signalling. The rate of glucuronidation and time before effluxion of a free testosterone molecule that has entered a cell is mediated by intracellular SHBG brought into the cell via the megalin receptor. This phenomenon is tissue specific, and some cells produce their own SHBG internally to achieve this result.

2.) Free SHBG also plays a role in extracellular signalling.  A receptor, known as SHBG-R, binds to free SHBG which then "catches" various steroid molecules to complete a signalling pathway believed to be related to C-AMP.  There is a pinned post regarding this phenomenon, and Dr. Crisler wrote an article about it. 

3.) SHBG fluctuations alter the hepatic metabolic clearance of testosterone, but do not significantly alter that of estradiol.

4.) SHBG has sole control of the free-to-bound estradiol ratio, but the lowest affinity for estradiol.  Fluctuations in SHBG therefore have a greater effect on FE2:TE2 than on other free hormone fractions.

With exogenous testosterone administration, FT% increases as SHBG decreases.  This is often mistaken for a positive outcome since free testosterone in otherwise eugonadal males correlates positivity in the literature with lean tissue mass, sexual function and overall wellbeing.  However,  when SHBG is disproportionately low to serum androgen concentration, this effect is offset by an accelerated metabolic clearance rate for testosterone with no similar change in estradiol, less overall AR signalling from accelerated cellular effluxion, an increased rate of aromatization, an increased rate of conversion via other pathways, decreased extracellular signalling at SHBG-R and a deficiency of a primary transport protien for testosterone that is required for serum transit and proportionate target tissue diffusion due the low aqueous solubility of testosterone and the complexity of steroid sensitive extravascular membranes through which testosterone must pass while still protected by a strongly bound protien to reach target tissues intact.
You write SO well!

I would just add increased urinary excretion of T with low(er) SHBG.

The increased Free T from low(er) SHBG more readily crosses the glomerular border in the kidneys, so ends up in the urinal, instead of staying in our bodies. If you are injecting, for instance, 100mg a week of Test cyp, and collect all the urine you make for the week, and then do the same while splitting the dose into two 50mg injections, you will find more urine in the former.

This also happens with rapidly accelerating serum androgen levels. It's as if the body is trying to dump the extra T.

Unfortunately, that does not happen with E as well.

14
Testosterone, Hormones and General Men's Health / Re: Pregnenlone
« on: March 05, 2018, 08:01:03 pm »
If a patient (male or female) is suffering anxiety, I will start them on PREG sustained release 30-50mgs before bed. If they can take that without grogginess in the morning, add an AM dose.

I use DHEA in virtually all my TRT patients. A few don't respond well. OTOH, some tell me it changed their lives.

15
The problem is that none of these things will significantly increase SHBG, and especially not when it is low (outside reference range.)   Not even Clomid.   Not even T3.

The increases to expect are in the  +3-9 nmol/L range for everything that you've mentioned (+30% baseline, max.), and that's assuming you started out with a number that you wouldn't want to increase anyway, such as 35 nmol/L.

Some of the studies are exclusive to women (coffee), or women with PCOS (berberine.)

If we're going to add non-natural substances, it must also include:

oral ethinyl estradiol (avg: +100%)
GTX-758 study drug  (avg: + 500%)
Yes, I've seen the low SHBG not respond to anti-oxidants, Thyroid RT, etc by increasing SHBG much. It would seem they are just so inflamed, or whatever the cause(s), we have to strategize our way around all those free hormones--and increased T excretion in the urine (but not E), as you have astutely pointed out.

OTOH, I've seen many go from mid range to over the top with antioxidants and Thyroid supplementation.

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