Treatment options for Hypogonadism

Renholder: Thanks. I re-read the clomiphene abstracts and the links. Even apart from fertility considerations (not an issue for me), this approach seems to have a lot to commend it. My initial labs showed total T levels marginally higher than the test subjects. My free T was pretty low, but the abstracts don’t focus on free T, so its hard to know how I compare to the test groups on that score. Also, I’m older than the test subjects, but clomiphene still seeems worth considering. If my new labs continue to show total T in the 3-350 range and low free T, I’ll ask if I might be a good candidate for the Clomid stimulation procedure. I assume that would be the next step, unless they jump to TRT. Since my symptoms are unabated, I am actually hoping for levels that are low enough to support some kind of intervention — hopefully one that focuses more on symptom reduction than numbers.

Hey meatbuilder,

If you want to learn more and read practical experiences from other people, just google: “Clomiphene as TRT”.

A healthy self-regulated endocrine system is obviously to be preferred instead of having to rely on TRT for life, so I would make sure that even before you try SERM therapy (clomiphene), you rule out other things that may be depressing your testosterone levels.

That can be everything from other diseases and conditions in the body (diabetes, hemachromatosis, etc) to lifestyle issues and mental health. I believe I read a study where overweight people who lost weight actually increased their testosterone levels. Depression can also suppress your testosterone levels.

Then again, you have people who are overweight and depressed BECAUSE they have low testosterone, so it can go both ways. There are also certain natural remedies that may be worth checking out like Maca or Tongkat Ali.

As for the reference ranges, you are right that the perception of what is normal is largely flawed and flat out wrong with many health practicioners. If you see the values sta-kool posted, it is obvious that age is also an imporant part of the equation. So don`t let your doctor tell you that you`re normal and healthy, when you don`t feel that way.

However, as have been mentioned here earlier, people function at different levels and people are different, so if you can improve by only a small bump in your output in some way, that may be enough for you. :)

Good luck and keep us posted!

Hello sta-kool,

I dropped by my doctor yesterday to get results from bloodwork that I took early February and it was roughly the same as it has been, with testosterone actually slightly lower at 375 ng/dl, free testosterone 10,5 ng/dl (I used an online calculator for this, but I assume it is correct) and LH/FSH bottom range at 2 ie/L. According to him, everything looks fine and healthy, but suddenly I had a prescription of Andriol in my hands without even asking for it. He thought I should give it a try and see what happens, but he did not tell me about any side effects or anything. When I asked him if this was a treatment for life, he said, “Not necessarily, it may start some processes in the body.”

That`s horseshit, right? This liberal GP of mine who is supposed to be enlightened on these matters, is obviously not so at all, but he is liberal and that is more than can be told of most doctors in this country, so I think I`m actually lucky in that I will probably get treatment instead of laughter.

It`s been three years now that I`ve struggled with this and I`ve tried a lot of natural remedies, but nothing seems to help. I`ve had a lot of resistance against TRT and thought of it as a last resort, but now I think it actually may be the last resort. If libido were my only issue, I would keep looking, but since I feel insanely fatigued and lack drive and motivation as well, it looks like low testosterone. The bloodwork seems to confirm it.

However, my worst fear is that there may be some other condition causing it and that as such, I end up treating the symptoms and not the real cause. Adrenal fatigue has been mentioned as one possibility, but my cortisol output seems normal. I can`t say for sure if I`m secondary, although I`ve had bottom range LH levels on 90% of my bloodwork. Going through my bloodwork today, I saw that my LH levels actually had risen to 8 from 2 before I started the clomiphene trial. Maybe that`s a random fluke or maybe I had been using some other natural remedy (I know I used Tongkat Ali, just not sure if it was before or after) that could have caused those levels to be elevated.

If it is secondary, I believe it is recommended to get an MRI to rule out a pituitary tumor, but I`m pretty sure my doctor will laugh at that proposal. By the end of the month, I`m scheduled for a full body ultrasound check, so if he does not find anything wrong with my testicles or other parts of the body, I guess I`m otherwise healthy.

I have almost made up my mind that I simply have to take a plunge and try TRT. I can`t continue like this and hope things will work out on their own. Life is passing by and I`m certainly not getting younger.

Do you know for sure that my body will not shut down further if I start with TRT and HCG?

If I have the option to try to get my system going again at a later time, I don`t think I would hesistate with TRT, but I`m a little anxious if starting it means doing it for life. There are some SERMs on trial now that I may be interested in trying in the future to get my own production going.

Do you know if testosterone injections interfere with the HCG monotherapy protocol? Would I be able to taper off testosterone injections and see if the HCG alone would keep me at acceptable levels?

I guess I could try the HCG monotherapy first, but I have to admit that I`m very impatient now after all this time and I want to get started with the real deal right away.

Do you know any reliable sites where your protocol is listed? My doctor did prescribe Andriol, but I`m not interested in using that. I could possibly accept gel, but I would prefer injections. I think I can convince my doctor to put me on injections, but I may have to find a good online reference to convince him, especially since weekly injections is no longer protocol here in Norway.

Thanks again for all your help and guidance!

Regards,

Renholder

Just wanted to wish you luck on your journey Renholder.

I have an appointment next week with Dr.Purvis as I’m fed up with always lacking energy, mental focus, depressions/anxiety and going around feeling tired all damn day. ( I must drink coffee to even bother doing anything at all it seems, which only contributes to more anxiety) Had testicular cancer about 6- 7 years ago and always felt like I lost that drive and passion in life after the left one got removed, no ‘omph’ so to speak. I do have a well built physique though but really have to work for it and eat right and do also get morning wood, but almost never ever spontaneous erections during the day and rarely jerk off. My free testosterone have been borderline for years ( 8- 12nmol/L) but they always just say, that’s normal, well guess what I do not feel normal anymore. Just had to get it off my chest, sorry for ‘hijacking’ your thread, and good luck once more, hope it all works out for you.

Hey Renholder,

I’ve been dealing with similar issues for quite a while now and have learned a ton. If your LH is low, it’s a very strong likelihood that you’re secondary. You should get your FSH (follicle stimulating hormone) tested also. If these are both low, then you are most definitely secondary, and I would recommend getting a pituitary MRI to rule out any microadenomas that could be causing the suppression.

If there are no pituitary masses causing the issues, then I’d recommend you talk to your doc about trying Clomiphene Citrate (Clomid) or HCG injections. Clomid is pill form and less expensive, so that might be the right place to start. Both drugs cause the same reaction, but work by a little different mechanism. Clomid works by blocking estrogen detection in the hypothalamus, which causes the pituitary to think it needs to create more LH and FSH, which in turn tells the testicles to create more testosterone. HCG works by mimicking LH directly, which tells the testicles to create more testosterone.

I’m currently on Clomid therapy and my total testosterone went from well below the bottom of the reference range to smack dab in the middle of the range. I’m scheduled to have a recheck with free testosterone checked as well in a couple of weeks. I didn’t feel a big difference until the doc upped my dosage a couple weeks ago, but I’m starting to notice a difference now.

Another thing that you’ll want to make sure is checked and monitored is your Estradiol (estrogen) level. If you’re too high there, you’ll have the same effect as having low testosterone. Testosterone and Estrogen need to be in balance to feel good and to have a manly physique. Too much of one or too little of the other and your going to feel like crud and start growing man boobs.

If you do a Google search on Clomid for Testosterone, you’ll find some good info on protocols. You’ll also notice that a lot of the info is coming from bodybuilding sources. This is because the Clomid works to help reset the HPT axis that is keeping your testosterone low now. Bodybuilders that are using testosterone are basically causing secondary hypogonadism because they are shutting down perfectly functional testicles by circumventing the HPT axis. When they want to cycle off the external testosterone, they need a way to kickstart the HTPA again. Clomid and HCG are common ways to do this.

Best of luck!

Hey man,

Thanks.

It`s not “my” thread, so feel free to contribute. :)

Sounds like you`re in dire need yourself.

Would that be Dr. Ken Purvis in Norway?

I don`t want to disappoint you, but I had a phone appointment with him 3 years ago and he basically laughed at me when I told him about my issues and my blood work, which is pretty much the same as it is today. I had expected that from a GP, but not him. He then proceeded to tell me out of the blue that I should stop comparing myself to the bodybuilders at my local gym and that I needed to move to the city and see more girls in my daily life. That was it. Thank you and goodbye, 150 bucks please.

Considering that you had testicular cancer and removed one testicle, I hope he takes you more seriously than he did me. Maybe you should print out the reference range sta-kool linked to and use that as reference. 8-12 nmol/L is definitely low and if you have the symptoms like you say, that would most likely be causing it.

Good luck and let us know what happens! :)

Renholder

Hey man,

Thanks for reaching out.

Actually, I already tried clomiphene citrate 25 mg per day for several months of time. I felt that I improved immensely in the energy and fatigue area, but libido did not improve much. Total testosterone increased nicely from 400 ng/dl to roughly 510 ng/dl or so after a month. Nothing dramatic, but I did respond to the treatment. The trouble was that SHBG also increased quite a bit, such that free testosterone never really increased much at all. Perhaps my well-being was placebo, I don`t know.

Eventually my doctor cut me off, because she feared that I might get cancer in the long-term. As it felt like the effects had started to wear off some, I did not argue with her.

Fast forward, my current GP put me on DHEA, but I don`t think I got any effect from it. He then prescribed clomiphene, but after two weeks using that and DHEA together, I felt even worse, so I quit.

Right now, I assume it is an option to try clomiphene alone one more time, but I`m not too optimistic. HCG monotherapy may be one option, but I`m a little impatient now and would really prefer to get some testosterone injected and see what happens.

With regards to my condition being secondary, everything indicates that, since both FSH and LH have been bottom range on virtually all my bloodwork, but two samples. The one prior to starting clomiphene and the one after one month of clomiphene. I wonder if it could be a fluke or if I may have been using some herbs (tongkat ali, etc) that could have elevated LH. I know that I used them, just not sure if it was after the clomiphene trial or before. Think I may have records some place. I do agree with regards to the MRI, just not sure if I can get it done. The level of discussion we guys have here is already way, way above most GP`s reasoning so I`m not even sure he would follow.

Please keep us posted on how things turn out for you. *fingers crossed*

Regards,

Renholder

Thanks. And yes, it’s him.

That did not sound good at all, thought he had a reputation as a professional in his field and hence would take this stuff more seriously. Guess I will see when the time comes though, and bring some ammo with me in form of the reference range( good tip, thanks) and hopefully some old blood test results as well as I got my test levels measured for 5 years straight. Just hope they will send me them though. It’s hard getting treatment for these types of problems in NO(r)way it seems.

Will definitely update when I know more.

Thanks again Renholder for thoughtful remarks. I will follow up on the Google search you suggested. I did find a good study on differential response of different age groups to clomiphene. Although the response to clomiphene is somewhat depressed in older guys, it looked to me (non-statistician) like it was fairly effective in boosting T levels for older subjects.

Once I get my test results (hopefully soon), I’ll check back in. Although anything is possible, I am generally in good health, and other medical causes seem unlikely to me. Definitely no hemachromatosis, diabetes, excessive body fat. I had pretty extensive medical workups before becoming an organ donor a couple of years ago, but they didn’t involve the endocrine system (at least as far as I know), so the doctor may want to look deeper before proceeding with SERM therapy or TRT (assuming he decides I’m a potential candidate). No alcohol or substance issues, so the only lifestyle issues I can see might be exercise volume (fairly high) and some pretty mild sleep deprivation - neither of which is likely to change soon.

Mental health is always open to question I guess. : ) Still, I don’t see myself as clinically depressed. Experiencing many of the symptoms on Shippen’s list for a long time definitely takes a toll on self- image and sense of well-being, but I generally had (and still try to maintain) a pretty sunny outlook.

I have tried a couple of simple things (ZMA and tribulus supplements) in an effort to see if I could induce small improvements in endogenous T levels. Sometimes I think I can feel mild positive effects - but nothing even close to eliminating overall symptoms

Renholder - don’t get so hung up on your balls. They can be turned back on with hCG or clomid. (Confirm this with your doctor though.)

You need to get your T-levels up so you can get some relief. Take your doc up on TRT.

In the US the standard treatment for primary and secondary is exactly the same: Testosterone Replacement Therapy.

The TRT + hCG protocol is being done by some doctors. It isn’t common. Most docs doing it are on the west and east coast. I was able to convince my doctor to try it based on a scholarly article and he called around and asked his colleagues about it. I posted the link around here somewhere to the article. Will dig it out again.

But I want you just to forget about it for right now. Get your T-levels up. Then deal with the rest later.

I would say just start with the gel. He will be unlikely to move you to injections if the gel is effective. It does work for many many guys.

You will need to do follow up bloodwork to see if it is working. If your levels do not improve, then ask for the injections.

As far as the HCG + TRT protocol, I would say get your levels where they ought to be and then talk to your doc about adding hCG later.

It definitely is and I think it is entirely due to a lack of knowledge in this field, even with endocrinologists.

Even in the US, where the subject of TRT seems to be far more mainstream, a lot of doctors still got their head up their ass. Hopefully, the medical field will catch up eventually.

Let us know what happens and good luck!

Renholder

I agree that I probably do not need HCG immediately, but my balls are fairly small already and I`m very paranoid about anything happening here. At least I want to know that I have the option to start using it further down the road. I read a question online from a younger guy here in Norway who were on testosterone gel, who expressed concern because his entire scrotum had pulled up into his body and he pretty much did not have any testicles left. He had not been using it for that long either.

Are you saying that I should go with the gel because that is what my doctor most likely will comply with?

Personally I would prefer injections both because it seems more practical and because I know that it works. Sure, there are many guys who use gel successfully and Crisler even says it is his preferred administration of TRT if it works. I would prefer to just get started with injections already instead of risking more time waiting and disovering that the gel does not work, is a pain in the ass to use, etc.

But I do agree that it may be harder, if not impossible, to get my doctor to agree with shots. Either way, I would want gel and not tabs, which seems like the most inferior method.

Regards,

Renholder

Renholder - I’m still waiting for my latest test results to see if my doctor will agree to give me anything to boost my low free T (about 1/3 of you level last time I was tested). I’d love to be in your shoes and have the chance to try ANY course of action that might bring improvement.

If given a choice, I too would prefer injection as a delivery method, since I believe it may be less costly and eliminates risk of transfer to partners. Plus, as a regular “gym rat,” I have some question about how well the gel stands up to significant sweating and/or multiple daily showers.

That said, my sense is that a lot of doctors - at least ones not associated with TRT clinics - probably have a bias toward starting with gels or patches to see whether and how well you respond to exogenous testosterone. For one thing, its easy for them. They don’t have to administer frequent injections or trust you to properly/safely self-inject.

I don’t see the harm in giving the gel a reasonable period of time to work. (I’m not sure how long that is, but evidently longer than the instantaneous “silver bullet” I was hoping for). If it fails to produce a sufficient boost in T levels to relieve symptoms, the doctor may be more willing to consider the injection route. If the gel DOES work for you, I’d enjoy the benefits for a while. Once you’re outside the “trial period” and it seems clear endogenous T is going to be part of a longer term therapy, maybe the doctor will be open to considering injection as a delivery method - especially if it really does have a substantially lower cost per unit of T delivered.

Yes, you can start the hCG later and it will wake your balls up. My have gotten larger since starting the hCG.

I’m going to echo pretty much what meatbuilder said.

Basically the docs want to solve the problem in the least invasive way possible. So they start with the gel. Also the gel delivers testosterone to your body every day, so that your levels are steady. Like they were when your testicles worked.

For me, it did not take that long a time to determine whether or not the gel worked. I can’t remember how long. I want to say several weeks. Basically the doc will do follow up blood work and look at your numbers to tell whether it is working or not.

A good friend of my was recently diagnosed with low test, and the gel is working really well for him.

Gym rat here too. And a big secreter when it comes to sweating!

Apparently there is going to be a generic gel in the US soon.

Until then, when I was on androgel, Solvay had a program were you could register and receive basically an Androgel gift card that knocked off cash on every prescription.

Injecting test enanthate is definitely a cheaper option for me, as my insurance covers 100% of generics.