Tertiary hypogonadism (Hypothalamus) Treatment

[Tiffer]

Hi All,
I will try keep this as short as possible.
As long as I can remember I have been lethargic and battled to get up in the morning. I also suffered from anxiety, moodiness and sleep issues. I have tried antidepressants etc with little effect. I normally use caffeine pills etc to get me going. I am 42 now.
So in late 2011 my GP ran tests and said I had low test (TT 223) and low vitamin D. She gave me the test cream but this didn’t work. She then gave me a Nebido test shot (1000mg) and I felt great. Problem was after that my nuts shrank and I had pain in one.
She then recommended an endocrinologist who ran tests and identified that I had Tertiary hypogonadism (Hypothalamus). He put me on clomid and after a while my TT was at 769. He then had to add Femara as an AI to reduce my E2. After a few months on clomid he said I should stop and that we had ‘rebooted’ my system. Fast forward almost 2 years and my low test symptoms are as bad as ever – my TT is now 323.
I want to start long term HRT and am going to see a doc on Friday. I have played with some options below – any advice or correctiions would be much appreciated.
Tiffer

Bloods:
15 November 2011 (1st Test)
Total Testosterone 224.78 ng/dl
Free Testosterone 64.84 pg/ml
SHBG 13.70 nmol/L
DHEA-S 274.54 ug/dl
S-Cortisol 9.42 ug/dl
S-PSA 0.79 ng/mL

10 September 2012 (After Clomid)
Total Testosterone 769.45 ng/dl
Free Testosterone 242.36 pg/ml
Estradiol (E2) 54.22 pg/ml
SHBG 15.40 nmol/L
DHEA-S 376.38 ug/dl
LH 8.90 mIU/mL
FSH 14.30 mIU/mL

10 March 2014
Total Testosterone 322.77 ng/dl
Free Testosterone 91.35 pg/ml
Estradiol (E2) 20.16 pg/ml
SHBG 15.70 nmol/L
S-Prolactin 5.10 ng/mL
DHEA-S 322.51 ug/dl
Vitamin D 25 41.60 ng/mL
S-TSH 1.03 uIU/ml
S-Cortisol 5.72 ug/dl
Insulin 9.20 uIU/ml

The clomid definitely worked, but these are the options I am considering:

Clomid 25mg every 2 days
Arimidex (Anastrozole) 0.25mg every 2 days

OR

50mg Testosterone enanthate/cypionate every third day
0.25mg Arimidex every third day
500IU HCG every third day

And on last thing - I found these target levels - are these reasonable?

Total Testosterone 800-1000 ng/dl
Free Testosterone 250-300 pg/ml
Estradiol (E2) 20-30 pg/ml
SHBG 10-30 nmol/l
DHT 60-70 ng/dl
Prolactin 2-3 ng/ml
DHEA-S ~300 ug/dl
Vitamin D >30ng/ml

 

[theheat]

I'm not sure what your reference ranges were (mine were 46-224), but you have a higher free T than me (70) and I have a TT of 719. Your SHBG it perfect at 15. I'm not sure what your bioavailable T numbers are, but I would shoot for over 350.

You definitely need to to something as your current numbers aren't great. You could try Clomid again, as it worked before, but you'll eventually be in the same boat in another year, and I wouldn't want to stay on Clomid long term. The second option looks good, or something like 100mg Cyp a week, 1/4 tab Adex 2x week, and 250 IUs HCG 2x week. That isn't a bad option if you don't plan on having kids and you don't mind pinning for the rest of your life.

What are your lifestyle habits like now? Are you getting enough sleep, adequate nutrition, low alcohol consumption, low stress, lifting heavy, minimizing endurance training, taking zinc + D3, etc? Just make sure you're doing everything you can to optimize your own T before you commit to TRT...

 

[Tiffer]

I don't mind pinning but might want another kid - would the HCG in the second option not keep your fertility going?
My lifestyle could probably improve but it's not too bad - I think I have had low test for ages.

 

[theheat]

The HCG would preserve your fertility.... I wouldn't do the TRT if you're thinking about having kids.

 

[Alpin]

So you were on clomid for 2 months @ 25 mg per day?
Any neg side effects from the clomid?
Using DIM while on clomid is said to reduce estrogenic sides....

 

[Alpin]

Careful with the A.i. while on low dose E3D T.
It lowers estradiol quicker it seems when you are putting exogenous T in your body. I have used a similar protocol with sucess. 60 mg T E3D and HCG 350-500 I.u. E3D.
I used Adex 0.25 mg E3D. ...
I noticed loss of libido with it....especially when I lowered HCG to 350 I.u.

 

[Alpin]

I'm not sure what your reference ranges were (mine were 46-224), but you have a higher free T than me (70) and I have a TT of 719. Your SHBG it perfect at 15. I'm not sure what your bioavailable T numbers are, but I would shoot for over 350.

You definitely need to to something as your current numbers aren't great. You could try Clomid again, as it worked before, but you'll eventually be in the same boat in another year, and I wouldn't want to stay on Clomid long term. The second option looks good, or something like 100mg Cyp a week, 1/4 tab Adex 2x week, and 250 IUs HCG 2x week. That isn't a bad option if you don't plan on having kids and you don't mind pinning for the rest of your life.

What are your lifestyle habits like now? Are you getting enough sleep, adequate nutrition, low alcohol consumption, low stress, lifting heavy, minimizing endurance training, taking zinc + D3, etc? Just make sure you're doing everything you can to optimize your own T before you commit to TRT...

His SHBG is not perfect. Its low. Range is usually between 16-53 nmol/l. Low SHBG could mean you will convert more T into estradiol easier. Also gels dont work as well in low SHBG guys. E3D shots are better.

 

[Tiffer]

The doc actually initially prescribed 100mg per day clomid to start! I had nausea, constipation, hot flushes and was emotional. I then went down to 50 mg EOD and the sides pretty much went away. My E2 did spike and he then added an AI called Femara.

 

[Alpin]

The doc actually initially prescribed 100mg per day clomid to start! I had nausea, constipation, hot flushes and was emotional. I then went down to 50 mg EOD and the sides pretty much went away. My E2 did spike and he then added an AI called Femara.

Be very careful with femara.....it is strong he should not be prescribing it to you when Arimidex is a better option.
So 25mg a day went well with you?
No sides like depression or mood issues.
You could even go 12.5mg ED and stay on it long term.

 

[Tiffer]

Thanks I will push for Arimidex and probably the low dose Clomid as I can't recall sides when I went lower. Then see how it goes. Should I start the Arimidex straight away with the Clomid?

 

[Alpin]

I would not start an A.I. blind like that off the bat on clomid. You need labs showing high Estradiol or at least high Estradiol symptoms before using an A.I.
What dose for clomid were you most comfortable with?

 

[Tiffer]

I went down to 50mg EOD after bad sides on the 100mg PD and that seemed ok. I was thinking of starting slow as it will be long term and going 25mg EOD. So from what you are saying I should prob have arimidex handy and do bloods after 6 weeks and if my E2>30 pg/ml take 0.25mg EOD Arimidex. What are the typical high E2 sides - my E2 went to 54 last time I tried Clomid but I wasn't that aware or informed of what to look for.

 

[Alpin]

Sounds like a plan. Typical high E2 sides are but are:
Insomnia, anxiety, water retention, increass in bp(could be mild), . Keep in mind some sides are the same as low E2.

 

[Tiffer]

Ok great - thanks for the help I will let you know how it goes!