TRT and Thyroid journey - fatigue since TRT start. [Labs Included]

[Creatine]

Hello Everyone:

Hoping to get your opinion and perhaps referral to a doctor who would consult over the phone.

I'm 35, male, 5'10 (178 cms), 155 lbs (70 kg), not obese or fat, of average fitness.

Medical History:


2013, age 30: No health problems. Got a regular check-up done. Nothing was flagged. Lab reports attached.

2016, age 33: ED symptoms. Took Cialis 10mg for the first time and it worked like a charm. Erection lasted 3 days! Great.

2017, age 34: ED worsened. Upped to Cialis 20mg. But effect would wear off in less than 24 hours. Got concerned, went to a Urologist in Manhattan, New York. He pulled Testosterone, Prolactin, E2 etc and said everything is normal and that everything is in my head. I need to relax and reduce stress.

2018 March, age 35: Feeling low energy and reduced cognitive abilities. Like mental fog. Also in terms of ED: Cialis now completely stopped working for me. I took 30mg of Cialis (3x my dosage from 2016!) and effect would last only a couple of hours. And even then it'd be a semi erection.

I happened to be traveling to INDIA where you can walk-in to labs and get any tests done without doctor's referral.

• Testosterone came out as 140!! Super low.
• Thyroid TSH : 5.75, higher than range

Went to an Endo in India and he said:

• -> You've subclinical hypothyroidism. Ordered test for antibodies and when that came out negative, he said, it is not an autoimmune disease, it is only slightly outside range so no medication needed.
  
• -> Testosterone: you've low T and I'll prescribe a single shot of Sustanon (Testosterone) 250mg.
  

I read forums and thought that wasn't a wise protocol. So, I didn't take it. Instead, I started self-medicating as follows:

• 1. Thyroxine 125mcg
• 2. Nolvadex 25mg EOD

I did this for 6 weeks until 2018 June.

June 2018, age 35: Felt better energy, better mood, improved mental clarity. Figured because I'm self medicating, I should re-do labs to see if I'm dosing correctly.
TSH was almost ZERO. So, I reduced dosage to 100mcg down from 125.

Testosterone had improved to 400s. But no changes in ED. Still dead penis.

I stopped Nolvadex. And instead, I added T-gel (1% Cernos) to my routine. But it was too much (15ml) amndinconvenient. I did it for 2 weeks and got tested again. T had now increased to 700+! GREAT NEWS. And My ED symptoms had reduced somewhat. I woke up with semi-erection. Some life was coming back to my penis and I thought that's progress.

Anyway, because it was inconvenient, I decided to take injections. And took a shot of 250mg Sustaon Testosterone.

Woke up next day with no morning wood and also feeling very drowsy, low energy. I waited a couple of days and same thing, still fatigue.

So, I went and got tested again.

July 2018, age 35, 3 days after T injection: T had gone up to 800+. Good news. But E2 had also gone to 47. So, perhaps that was causing ED. Cialis didn't help either. But this time I also got SHBG pulled. And it was LOW (13ish).

I looked at my lab report from 2013 (that's the only other time I had gotten SHBG pulled) and it was 15 at that time too. But in 2013 I had no ED, no energy, mood or mental fog issues. I felt perfectly healthy. and my T was only in 300s in 2013.

So, I kept reading forums and learned that low SHBG is NOT good for TRT protocol.

So, I'm now confused as to where to go next from here.

It seems like:
1. I should continue Thyroid medication of 100mcg per day as that definitely did help with a lot of things.
2. But TRT - I'm unclear. Where to go next?

Some options in my head but I don't feel confident taking any of the routes:
Option 1: Switch back to T gel daily. I can get compounding pharmacy prescription for a higher potency gel (say 5-10% potency) so I've to apply a lot less. Applying 3ml per day vs applying 15ml per day is a huge difference.

Option 2: Because I keep reading that injections is way to go, people feel better and gel stops working at some point, how about I inject a long ester T with some AI? For eg: Testosterone Undec 200mg every week + 25mg Aromasin E3D + HCG  250 iu injection E3D. (HCG to preserve fertility). Would that work?
So, basically, it looks like my self-medication for Hypothyrodism is fine and I need to continue it. But I'm lost on TRT.


Summary of all labs attached.

[Cataceous]

Typically it's recommended to first get thyroid issues under control before tackling testosterone. There are some other tests you might add to rule out some treatable reasons for hypogonadism: http://www.peaktestosterone.com/Testosterone_Tests.aspx

With lowish SHBG, topical testosterone or frequent injections may be preferred. Serum testosterone should not be pushed too high due to potential problems with estradiol. AI use may be necessary.

Low-dose Clomid therapy is another possibility for treatment. Some guys here have preferred it over Nolvadex.

Site sponsor Defy Medical is an excellent choice for someone to manage your treatment, with phone consultations and prescriptions shipped from compounding pharmacies. Prices are reasonable, but you must deal with insurance yourself if you even have coverage for this.

[Creatine]

Thanks @Cataceous

Typically it's recommended to first get thyroid issues under control before tackling testosterone. There are some other tests you might add to rule out some treatable reasons for hypogonadism: http://www.peaktestosterone.com/Testosterone_Tests.aspx

My Thyroid is now under control, I believe. I've been on Thyroxine since early April and levels are now stable and dosage is now fixed at around 100mcg.
As for Hypogonadism root causes: I eliminated most causes.  In fact, when my doctor prescribed me Sustanon 250mg Testosterone injections, I didn't take it right away. I waited 3 months to first deal with Thyroid and try to increase T with Nolvadex/Clomid. I feel like Thyroid medication (Thyroxine) did have some positive impact but still in the lower normal range.

With lowish SHBG, topical testosterone or frequent injections may be preferred. Serum testosterone should not be pushed too high due to potential problems with estradiol. AI use may be necessary.

Low-dose Clomid therapy is another possibility for treatment. Some guys here have preferred it over Nolvadex.

I don't mind taking AI like Aromasin or Arimidex but I really prefer to not inject more than once a week. Twice a week is manageable but I travel quite a bit and I'd end up missing some shots every now and then. Once a week, I feel like I've a higher likelihood of compliance.

Does low-ish SHBH really make it necessary for me to inject multiple times a week? There is no way around it?

Also, I suppose, I'd still need to inject HCG couple of times a week? The way I understand it is that HCG is primarily to preserve fertility and prevent major testicular atrophy. So, if you miss shots here and there, it is not a deal breaker. But if you miss your T shots, it'd have noticeable impact. So, I feel like once a week of T shot is something I can manage. Same with HCG.

Site sponsor Defy Medical is an excellent choice for someone to manage your treatment, with phone consultations and prescriptions shipped from compounding pharmacies. Prices are reasonable, but you must deal with insurance yourself if you even have coverage for this.

I'll call them. I don't have insurance so it doesn't matter. I'll wait to hear more opinions/suggestions so that when I call Defy I've some options to discuss.

[mrmagoo2010]

https://www.ncbi.nlm.nih.gov/pubmed/29942726

what do we think about this study?

[oldolylifter]

https://www.ncbi.nlm.nih.gov/pubmed/29942726

what do we think about this study?

Not much, n=1.  It's simply a case presentation.  The authors could review the difference between correlation and causation.

[Creatine]

https://www.ncbi.nlm.nih.gov/pubmed/29942726

what do we think about this study?

I'm taking T4 (synthetic t4 called Thyroxine), not T3.

[Cataceous]

...
Does low-ish SHBH really make it necessary for me to inject multiple times a week? There is no way around it?

Also, I suppose, I'd still need to inject HCG couple of times a week? The way I understand it is that HCG is primarily to preserve fertility and prevent major testicular atrophy. So, if you miss shots here and there, it is not a deal breaker. But if you miss your T shots, it'd have noticeable impact. So, I feel like once a week of T shot is something I can manage. Same with HCG.
...

The interplay between testosterone esters, dosing frequency and SHBG is not an exact science. So you can't say for sure what will or won't work before you try it. However, it's likely that the maximum injection frequency is going to give you the best chance of success. In the case of Sustanon the shorter esters are potentially going to be a problem, causing fluctuations in hormone levels with weekly injections, a possibility mentioned in the Wiki article. In fact the article says that pure esters may be a better choice for stability.

Yes, hCG should be injected at least twice a week. Dr. Crisler advocates daily injections. There may be more to hCG than fertility and avoidance of testicular atrophy. It's possible the LH receptors elsewhere in the body do some useful things for us. Subjectively, a number of guys have said that TRT alone wasn't very good until hCG was added.

[Creatine]

Thanks.

In my head, what seems to make most sense is this:


Thyroid: Continue Thyroxine 100mcg ED morning

TRT: Low SHBG makes it necessary to dose T more frequently, so following TRT protocol:

1 ml of T-Gel (compounded 15%) ED morning transdermal application on shoulders, neck, arms, upper back
+
HCG 500 IU twice a week (if I miss some shots because of travel, no big deal)
+
AI Arimidex .25 mg EOD or Aromasin 25mg E2D

Does it sound reasonable?

I suppose HCG will also add to T levels as it'd stimulate testes to produce.

[cujet]

I have Hashimoto's, (autoimmune thyroid disease) and near nil T.

It's been a hell of a struggle to feel well. TSH in particular, is not a viable indicator of thyroid levels in my case. I must have T4 and Free T3 levels above the halfway mark, and better yet, at the 2/3 position in the lab range. TSH, as you know, IS NOT a thyroid hormone.

Drugs like Armour can drive TSH way down, even with T4 and Free T3 below lab range!

I've read that high E2 can also affect thyroid levels negatively. Requiring a higher thyroid dose.

In addition, I found that using Testosterone creme positively affects libido.

I've also found that Testosterone drives down my already low AM Cortisol to well below normal. (ACTH is near nil) and I must take a small AM dose of Prednisone.

Bottom line: I like my Testosterone levels below 800, T4 mid range or higher and Free T3 mid range or higher. Nothing else matters.

[Cataceous]

...
1 ml of T-Gel (compounded 15%) ED morning transdermal application on shoulders, neck, arms, upper back
+
HCG 500 IU twice a week (if I miss some shots because of travel, no big deal)
+
AI Arimidex .25 mg EOD or Aromasin 25mg E2D

Does it sound reasonable?

I suppose HCG will also add to T levels as it'd stimulate testes to produce.

You'll want to run this by a doctor, but the general idea is reasonable. Here are some caveats: Some guys get good results with topical testosterone, but others do not. There can be issues with absorption, and sometimes DHT is pushed too high. So be prepared with plan B in case it doesn't work out. A typical starting dose for transdermal testosterone is 50 mg/day. Going with three times this may not be wise if your goal is to keep serum levels on the lower side to accommodate low SHBG. I'd try to hold off on the AI until you're stabilized. Then, if it still seems necessary, I would start with much lower doses until you establish your sensitivity to the drug. As an example, for me a dose of only 50 mcg (0.05 mg) anastrozole every other day can reduce estradiol by 20 pg/mL.

[Cataceous]

There are conflicting opinions on whether transdermal testosterone is appropriate with low SHBG. The author of this thread just linked to this interesting thread at ATM, in which Dr. Crisler says

For instance, gels are the WORST way to deliver T (outside of a SL prep, perhaps) with low SHBG. Its resultant wide swings--extremely desirable for others--causes issues for these poor chaps.

What would be best? SubQ injections, QOD. I know...I know...that can be bothersome.

This could be resolved with a study contrasting the pharmacokinetics of transdermal testosterone in low- and high-SHBG individuals.

See also: http://www.peaktestosterone.com/forum/index.php?topic=13367.msg120207#msg120207
https://www.excelmale.com/showthread.php?10804-Low-SHBG-T-Gel-along-with-Injected-T-has-Helped-Somewhat/page1

[Joe Sixpack]

Drugs like Armour can drive TSH way down, even with T4 and Free T3 below lab range!

Interesting comment.  That's exactly what happened to me. 

[Creatine]

...
1 ml of T-Gel (compounded 15%) ED morning transdermal application on shoulders, neck, arms, upper back
+
HCG 500 IU twice a week (if I miss some shots because of travel, no big deal)
+
AI Arimidex .25 mg EOD or Aromasin 25mg E2D

Does it sound reasonable?

I suppose HCG will also add to T levels as it'd stimulate testes to produce.

You'll want to run this by a doctor, but the general idea is reasonable. Here are some caveats: Some guys get good results with topical testosterone, but others do not. There can be issues with absorption, and sometimes DHT is pushed too high. So be prepared with plan B in case it doesn't work out. A typical starting dose for transdermal testosterone is 50 mg/day. Going with three times this may not be wise if your goal is to keep serum levels on the lower side to accommodate low SHBG. I'd try to hold off on the AI until you're stabilized. Then, if it still seems necessary, I would start with much lower doses until you establish your sensitivity to the drug. As an example, for me a dose of only 50 mcg (0.05 mg) anastrozole every other day can reduce estradiol by 20 pg/mL.

I did get my DHT tested and it is quite high. Just above range. I've hereditary MPB as well. But I do not wish to take Finstraide. I'd live with receding hairline - doesn't bother me as much.

As for low SHBG vs 50mg dose: I'm confused here. I understood that because of low SHBG, a lot of testosterone remains "free" and hence gets flushed out by the liver. So, if I took 250mg dose (injection) once a week, there would be so much free or unbound T, that most of it will get flushed out in a day or two. So, I won't have any T remaining in my system after couple of days. So, it is important that I take another dosage of T to replenish the flushed out T.

So, if I took 150mg dosage a day of which only about 10% or 15mg gets absorbed as it is transdermal. Then in a week, I'm absorbing 105mg of T. And my level everyday will be more or less steady because I'd be replenishing whatever T was cleared out.

But if I were to take 105mg as a one-time injection per week, then it won't provide me with steady level. Because within a couple of days of taking injection, the unbound/Free T will be flushed out. And I'd have 5 days remaining before my next shot. So, my T levels will decline significantly over these 5 days.

So, I suppose 15mg (absorbed. Meaning 150mg, not 50mg, applied) is what makes sense?

Also, another related question:
I keep reading conflicting peices of information. I read that injected T is far superior. People report feeling better on injected T more often than on transdermal T even if the dosage (adjusted for absorption rate) is same. So, this really confuses me. T is T. How can it be different.

I understand that transdermal will convert to DHT slightly higher rate but still, T is T.

Is this just a myth or is this true?

[Flyingfool]

I have Hashimoto's, (autoimmune thyroid disease) and near nil T.

It's been a hell of a struggle to feel well. TSH in particular, is not a viable indicator of thyroid levels in my case. I must have T4 and Free T3 levels above the halfway mark, and better yet, at the 2/3 position in the lab range. TSH, as you know, IS NOT a thyroid hormone.

Drugs like Armour can drive TSH way down, even with T4 and Free T3 below lab range!

I've read that high E2 can also affect thyroid levels negatively. Requiring a higher thyroid dose.

In addition, I found that using Testosterone creme positively affects libido.

I've also found that Testosterone drives down my already low AM Cortisol to well below normal. (ACTH is near nil) and I must take a small AM dose of Prednisone.

Bottom line: I like my Testosterone levels below 800, T4 mid range or higher and Free T3 mid range or higher. Nothing else matters.

TSH is a virtually useless test. The only a tive form is free T3. Free T4 is important to have ample amount to allow conversion into the active free T3

It is extremely common for someone on thyroid meds to remove symptoms to have supressed TSH. For this reason so many Drs under medicate latients because they freak out when TSH gets Supressed.

Most peple to feel well need to have theor free T4 to be at 50% of the range or a bit higher AND free T3 to be at least 50% of the range and many nees to get to the upper 1/3 of the range (66,7% of range) in orser to feel well.

Again most Dr will not increase meds to get both FT4 and FT3 to those levels leaving their patients feeling symptomatic.

As far as the OP with low SHBG, I think injections at least twice if not 3 times a week would be best. Nust take the darn medicine with you when you travel!

[Cataceous]

...
I did get my DHT tested and it is quite high. ...

I'd view this as another reason to prefer injections over transdermal testosterone.

...
As for low SHBG vs 50mg dose: I'm confused here. I understood that because of low SHBG, a lot of testosterone remains "free" and hence gets flushed out by the liver. So, if I took 250mg dose (injection) once a week, there would be so much free or unbound T, that most of it will get flushed out in a day or two. So, I won't have any T remaining in my system after couple of days. So, it is important that I take another dosage of T to replenish the flushed out T.

So, if I took 150mg dosage a day of which only about 10% or 15mg gets absorbed as it is transdermal. Then in a week, I'm absorbing 105mg of T. And my level everyday will be more or less steady because I'd be replenishing whatever T was cleared out.

But if I were to take 105mg as a one-time injection per week, then it won't provide me with steady level. Because within a couple of days of taking injection, the unbound/Free T will be flushed out. And I'd have 5 days remaining before my next shot. So, my T levels will decline significantly over these 5 days.

So, I suppose 15mg (absorbed. Meaning 150mg, not 50mg, applied) is what makes sense?

Also, another related question:
I keep reading conflicting peices of information. I read that injected T is far superior. People report feeling better on injected T more often than on transdermal T even if the dosage (adjusted for absorption rate) is same. So, this really confuses me. T is T. How can it be different.

I understand that transdermal will convert to DHT slightly higher rate but still, T is T.

Is this just a myth or is this true?

The vastly different pharmacokinetics and pharmacodynamics account for some of the different behaviors. Transdermal testosterone is pure testosterone that goes directly through the skin, eventually entering the bloodstream. As such it's free to interact along the way, which includes both aromatization to estradiol and conversion to DHT. Injected testosterone most often has an ester attached. In the case of Sustanon there are four different esters. The esters are hydrophobic, meaning they don't readily dissolve in our (water-based) tissue. Testosterone attached to an ester is not available for use until the ester is removed (cleaved). When a testosterone ester is injected along with its carrier oil, a depot is formed that is dissolved only slowly. The bigger the ester, the more slowly it is dissolved. Only after this absorption does the testosterone ester enter the bloodstream. Once there the ester is separated fairly rapidly, and the testosterone can be put to use.

The longest ester in Sustanon has a typical half life of over two weeks. Even with your low SHBG the half life for you is almost certainly on the order of days. But this may still be short enough to give substantial variation in hormones with weekly injections. Throw in the shorter esters present in Sustanon and you're likely to experience uncomfortable fluctuations. A combination of the absolute testosterone level and large swings can allow free estradiol to elevate, both in absolute terms and relative to free testosterone. This imbalance frequently leads to problems.

To avoid problems with estradiol you should be targeting average or below levels of serum testosterone. The average young guy is making only about 5-8 mg of testosterone a day. This is where the 50 mg starting dose for transdermal testosterone comes from.