Low T and Missed Reps

[Will Morris]

I don't wish to hijack this thread, but I did wish to say a thing or two before this thread gets lost to the abyss of the rest of the Q&A forum:

First things first, I cannot overstate how important it is to find a provider who has actually studied hormone replacement therapy, its optimization, and indications for treatment more than the "UP TO DATE RECOMMENDATIONS". When you fail to do this, you will have a much greater threat of finding yourself on the dark side of TRT treatment. At the age of 34, I finally made my first complaint to my PCM about feeling less energetic, somnolent, and basically just feeling like hell even though I was doing all the right things to take care of myself. I train frequently, I watch virtually everything I eat, and I have no vices. I figured, at that time, that it had to be something hormonal since I have had abnormal endocrinology panels since I was a young child (delayed onset puberty, constitutional growth delay, etc). At first, my PCM wanted to force a SSRI (selective serotonin reuptake inhibitor) on me, to which I pled my case that I was not depressed. Instead, I was sent for a sleep study. The sleep study confirmed mild to moderate Central Sleep Apnea with some obstructive sleep apnea, as well. I was treated with an auto-titrating PAP machine. That led to some marked improvement in daytime somnolence, but it did not shake the constant feeling of just feeling old and crappy. After that year, I was finally sent for a comprehensive blood panel, which included all the typical labs for testosterone. I ended up testing with something to the tune of 180 for total testosterone. After some wrangling with trying patches and gels, I was finally placed on TRT at a dose of 50mg / week. That was increased to 100/week after about six months. I felt much better. I can't say for certain that it was absolutely life-changing, but I did feel much better. My mood, my affect, my energy levels, etc all improved enough for me to notice. I felt much better. Fast forward two more years and I had a new PCM assigned. He retook my labs and my total testosterone was in the mid 400s. In our system, most providers will only treat enough to get you into the lower bounds of normal. He looked me up and down and said, "I don't really feel comfortable with you being on TRT because you don't look like you need it." His clinical decision making was relegated to looking at my appearance, and instead of chalking my physique up to over twenty years of training and eating well, his pudgy ass decided I needed to be taken off because I was "too muscular" to be on it. To top that off, everyone from the PCM to the pharmacists always treated me like a criminal when I would pick up my refills. I had numerous pharmacists ask me point blank, "Why do you need testosterone?"

Now the dark side part: I did not realize how much better I felt until I was taken off "cold turkey" like this. What transpired next was the worst 9 months, or so, of my entire life. Starting about 4 weeks after that appointment, I had a pretty precipitous decline in my overall mood, energy, and general feelings of well-being. I felt worse than I ever had before, but, with my line of work, I had no recourse to seek treatment elsewhere. Further, a superior officer several levels up authored a policy memorandum that prohibited anyone from being able to travel overseas for their job while being on TRT.

It took about 9 months to get back to some semblance of feeling better. I'm now about 2.5 years out from being taken off, and I feel okay, but I do admit that it is probably because I have now forgotten how much better I felt when I was on it. Interestingly enough, and it shouldn't come as any surprise to Dr. Nichols, but the TRT I was on had absolutely zero effect on me in the gym. I set zero PRs, and I did not have any appreciable improvement in my physique.

My most recent labs I had my total testosterone at 165. Luckily, I think I will be in a position where I can now seek the care of a physician who will consider more than just the fact that I have a relatively low bodyfat percentage for my age. I know spending money on something that you think should be covered by insurance sucks, but, I cannot overstate that "free medical care" oftentimes comes at a great cost. Certainly, insurance may pay for treatment, but, I've known my fair share of providers who will find any excuse to end treatment for someone because they don't want to be held liable if a patient abuses their prescription for TRT. Find a clinic that specializes in this field, and just be okay with paying the fee to have treatment. It is worth the fee to not be perpetually under the threat of having treatment stopped, and you don't have to worry about being treated like you are Greg Valentino when you go to the pharmacy to pick up your refill. Also, the time to diagnosis was measured in tens of months, with quite a bit of additional time wasted trying other forms of the medication that are far less effective. It leaves me curious as to how much of my 30s and into my 40s I have wasted feeling like shit.

[Mark Rippetoe]

Further, a superior officer several levels up authored a policy memorandum that prohibited anyone from being able to travel overseas for their job while being on TRT.

His reasoning?

[J. Keith Nichols MD]

I don't wish to hijack this thread, but I did wish to say a thing or two before this thread gets lost to the abyss of the rest of the Q&A forum:

First things first, I cannot overstate how important it is to find a provider who has actually studied hormone replacement therapy, its optimization, and indications for treatment more than the "UP TO DATE RECOMMENDATIONS". When you fail to do this, you will have a much greater threat of finding yourself on the dark side of TRT treatment. At the age of 34, I finally made my first complaint to my PCM about feeling less energetic, somnolent, and basically just feeling like hell even though I was doing all the right things to take care of myself. I train frequently, I watch virtually everything I eat, and I have no vices. I figured, at that time, that it had to be something hormonal since I have had abnormal endocrinology panels since I was a young child (delayed onset puberty, constitutional growth delay, etc). At first, my PCM wanted to force a SSRI (selective serotonin reuptake inhibitor) on me, to which I pled my case that I was not depressed. Instead, I was sent for a sleep study. The sleep study confirmed mild to moderate Central Sleep Apnea with some obstructive sleep apnea, as well. I was treated with an auto-titrating PAP machine. That led to some marked improvement in daytime somnolence, but it did not shake the constant feeling of just feeling old and crappy. After that year, I was finally sent for a comprehensive blood panel, which included all the typical labs for testosterone. I ended up testing with something to the tune of 180 for total testosterone. After some wrangling with trying patches and gels, I was finally placed on TRT at a dose of 50mg / week. That was increased to 100/week after about six months. I felt much better. I can't say for certain that it was absolutely life-changing, but I did feel much better. My mood, my affect, my energy levels, etc all improved enough for me to notice. I felt much better. Fast forward two more years and I had a new PCM assigned. He retook my labs and my total testosterone was in the mid 400s. In our system, most providers will only treat enough to get you into the lower bounds of normal. He looked me up and down and said, "I don't really feel comfortable with you being on TRT because you don't look like you need it." His clinical decision making was relegated to looking at my appearance, and instead of chalking my physique up to over twenty years of training and eating well, his pudgy ass decided I needed to be taken off because I was "too muscular" to be on it. To top that off, everyone from the PCM to the pharmacists always treated me like a criminal when I would pick up my refills. I had numerous pharmacists ask me point blank, "Why do you need testosterone?"

Now the dark side part: I did not realize how much better I felt until I was taken off "cold turkey" like this. What transpired next was the worst 9 months, or so, of my entire life. Starting about 4 weeks after that appointment, I had a pretty precipitous decline in my overall mood, energy, and general feelings of well-being. I felt worse than I ever had before, but, with my line of work, I had no recourse to seek treatment elsewhere. Further, a superior officer several levels up authored a policy memorandum that prohibited anyone from being able to travel overseas for their job while being on TRT.

It took about 9 months to get back to some semblance of feeling better. I'm now about 2.5 years out from being taken off, and I feel okay, but I do admit that it is probably because I have now forgotten how much better I felt when I was on it. Interestingly enough, and it shouldn't come as any surprise to Dr. Nichols, but the TRT I was on had absolutely zero effect on me in the gym. I set zero PRs, and I did not have any appreciable improvement in my physique.

My most recent labs I had my total testosterone at 165. Luckily, I think I will be in a position where I can now seek the care of a physician who will consider more than just the fact that I have a relatively low bodyfat percentage for my age. I know spending money on something that you think should be covered by insurance sucks, but, I cannot overstate that "free medical care" oftentimes comes at a great cost. Certainly, insurance may pay for treatment, but, I've known my fair share of providers who will find any excuse to end treatment for someone because they don't want to be held liable if a patient abuses their prescription for TRT. Find a clinic that specializes in this field, and just be okay with paying the fee to have treatment. It is worth the fee to not be perpetually under the threat of having treatment stopped, and you don't have to worry about being treated like you are Greg Valentino when you go to the pharmacy to pick up your refill. Also, the time to diagnosis was measured in tens of months, with quite a bit of additional time wasted trying other forms of the medication that are far less effective. It leaves me curious as to how much of my 30s and into my 40s I have wasted feeling like shit.

Your experience is extremely common and I hear it all the time. It's absolutely a travesty. Your levels of 165 ng/dL are a recipe for disaster. Everything bad that can occur will occur with those levels. The only danger for someone with your levels is not utilizing testosterone. Let me say this again and that is that most physicians do not understand hormone replacement therapy or better yet hormone optimization. Let me say this out loud again and that is that your levels need to be supraphysiologic in order for you to obtain the maximum health benefits from testosterone. There is no danger in being supraphysiologic but this term has been hijacked to equate to harm or abuse and it is anything but that. The best way for someone like you to utilize testosterones would be to utilize a compounding pharmacy from a experienced provider. The Compounding pharmacy understands why you're using it I understand why the position is prescribing it. You could consider using the trans scrotal cream instead of injections for only one reason. You could simply not apply it for a day and your levels will be low like they are now and nobody would know that you're on it and since your levels will remain low they will be happy. They won't be happy if you have optimal levels but they'll be quite pleased and happy if you have low levels. I don't promote lying of course but when your health is concerned then that may be a different story. So when we are treating men and women with thyroid for instance the family physician gets very upset. In order for them to not be upset the patient can simply not take their thyroid for a couple of days before they see their family physician and their levels will be in the normal unhealthy range and everybody is happy. The same can be done for testosterone and it's just easier to do it with the cream versus injections but it can be done with both. So because of the half-life of the cream if you don't apply it for a day or two your levels will be low like they are now.

[Will Morris]

His reasoning?

If I were to wager a guess, it was authored, partly, in response to the SSG Robert Bales case, which occurred within a unit aligned with the Pacific Command….but, there is a general disdain for testosterone replacement therapy and strength, in general, among the senior leadership in this organization.

[Mark Rippetoe]

If I were to wager a guess, it was authored, partly, in response to the SSG Robert Bales case, which occurred within a unit aligned with the Pacific Command….but, there is a general disdain for testosterone replacement therapy and strength, in general, among the senior leadership in this organization.

But I'll bet you a lot of money it would be okay to cut off your cock and balls and take estrogen and still travel on such an assignment.

[DanielAcorn]

I've got the same T reading as Will (as of a few weeks ago).

The consultant's response to me saying I don't produce ejaculate: "you don't need to produce ejaculate because you don't want children yet".

I asked him whether I could go on TRT if I lost 50 lb and was still low T. He said yes. So there is some hope...

[dalan]

But I'll bet you a lot of money it would be okay to cut off your cock and balls and take estrogen and still travel on such an assignment.

Right. It would likely be equally as permissable for a female wanting to become a male to administer testosterone for that purpose.

[topcraig]

Being retired from the Marine Corps I could use my medical benefits and try to find someone who would "allow" me to go on TRT since the Tricare formulary covers just about every known Testosterone product. At my age, I'll be 65 in 3 months, I probably would have been denied TRT because my numbers were in the reference range. I chose to go to a TRT clinic and pay out of pocket because I don't want my insurance provider to be involved at all. If I have to go to the VA someday to have myself assessed for disability, I don't want them to point to TRT as a reason to deny me any benefits I might need to take advantage of. My wife and my TRT provider are the only ones that need to know. My TRT Clinic gave me a 25% discount for being a Veteran. My rate won't go up even if my dosage goes up.

[Will Morris]

Your experience is extremely common and I hear it all the time. It's absolutely a travesty. Your levels of 165 ng/dL are a recipe for disaster. Everything bad that can occur will occur with those levels. The only danger for someone with your levels is not utilizing testosterone. Let me say this again and that is that most physicians do not understand hormone replacement therapy or better yet hormone optimization. Let me say this out loud again and that is that your levels need to be supraphysiologic in order for you to obtain the maximum health benefits from testosterone. There is no danger in being supraphysiologic but this term has been hijacked to equate to harm or abuse and it is anything but that. The best way for someone like you to utilize testosterones would be to utilize a compounding pharmacy from a experienced provider. The Compounding pharmacy understands why you're using it I understand why the position is prescribing it. You could consider using the trans scrotal cream instead of injections for only one reason. You could simply not apply it for a day and your levels will be low like they are now and nobody would know that you're on it and since your levels will remain low they will be happy. They won't be happy if you have optimal levels but they'll be quite pleased and happy if you have low levels. I don't promote lying of course but when your health is concerned then that may be a different story. So when we are treating men and women with thyroid for instance the family physician gets very upset. In order for them to not be upset the patient can simply not take their thyroid for a couple of days before they see their family physician and their levels will be in the normal unhealthy range and everybody is happy. The same can be done for testosterone and it's just easier to do it with the cream versus injections but it can be done with both. So because of the half-life of the cream if you don't apply it for a day or two your levels will be low like they are now.

I think you should be expecting a consult request about five minutes after my flight hits the tarmac back in the US, Dr. Nichols.

[Browndog]

Reporting from the Thyroid Front:

I've been started on Synthroid (25mcg), and it's been 30 days so far. I notice some improvement, but not nearly enough.

I contacted my PCP, and asked to have the next round of blood tests moved up so that we can get to a more efficacious dosage.

He grudgingly acceded to my request. He had reservations about moving too fast, he preferred to take a conservative approach to titrating up the dosage. I wanted to scream at him: DUDE, I'm a prostate cancer survivor (for how long, who knows); I've been feeling like shit for two years. I want to feel better NOW, not a year from now. Honestly, let's move the process along.

And a bit off topic, this doc freaked out over a high creatinine assay (which have been running to just outside the high side of "normal" for years now). According to him, my kidneys were failing, and he scheduled a kidney ultrasound to determine the next steps to take. However, to his great surprise the scan came back totally normal. This next round of blood tests will included another creatinine survey. He's had me off creatine and NSAIDS for 30 days, and I'll probably skip my Deadlift session before going into for the blood draw the next day.

Doctors who don't lift, do not understand powerlifters.