Dr. Scally Scenario Question -- HRT @ Age 19 to 24, no AAS

[James23]

Dr. Scally,

Since you're "new" around here, I figured I'd introduce myself and see what you think of my story!

I suffered from low T my whole life. I never had a "20s" or even teenage experience. I'm 20 and when older guys around here claim that TRT makes them feel like they are in their 20s again, I don't know what the hell they are raving about. I did grow height wise, of course, and my genitalia matured normally (although one doctor checked "abnormal" on his physical sheet.)

Now, I'm 24, with zero sex drive, and my facial hair won't grow in properly -- it sparsely covered my entire neck, and never progressed to my face, except for the area between my upper lip and nose (it did not come down around my mouth.) I have not seen any progress with the hair spreading since age 16. My muslce growth and size matches that of an athletic female.

I saw a GP at age 19, thinking I had thyroid problems. His tests revealed low testosterone. Two endocrinologists and one urologist all said elevated T wouldn't help me. I finally found one that would -- with Androgel, around age 21. I had an MRI pituitary scan that came up normal.

Androgel drove up T, but symptoms didn't subsite, and my hair kept falling out in the shower like I've never seen it.

I switched to injections via Dr. Crisler, and have been doing that for about a year now. 100mg, 80mg, and now 60mg of T-Cyp EW because my E2 shoots up too high. I had Arimidex in the mix, but since discontinued after lowering the T dose so low.

Throught the past couple of years my T fluctuated between 700 and 1100ng/dl, between my lowest and highest doses of T-Cyp, respectively. All other tests came up normal, except E2 (elevated about 2x top of range) and FSH and LH (both zero when I was at 1100ng/dl)

So, I still feel like shit all the time, I have zero sex drive, my facial hair pattern won't spread or become dense (rest of body is very hairy), and I literally CAN'T gain muscle -- I have no chest whatsoever! Benching about 95lbs at age 24 after 4 years of weightlifting.

Any thoughts?

[Sonny]

If your E2 is off the chart, of course you're gonna feel like sh!t. Why isn't E2 being kept under control while T levels are high?

Sonny

[pmgamer18]

Originally Posted by Sonny

If your E2 is off the chart, of course you're gonna feel like sh!t. Why isn't E2 being kept under control while T levels are high?

Sonny

Yep he needs to go back on Arimidex .25 mgs. every 3 days would be not enough. You need to talk to your Dr. about what dose and when to check it again. I was at 90 range <20 to 50 it took .5mgs. everday for 4 weeks to get it down but after I got it down I needed to cut way back to keep from going to low.

[1cc]

Originally Posted by James23

So, I still feel like shit all the time, I have zero sex drive, my facial hair pattern won't spread or become dense (rest of body is very hairy)

DHT is what will cause virilization and DHT is what you are trying to suppress by not using gels and by taking propecia. Since swale is your doctor, what did he have to say about this?

[James23]

1cc -- I started the Propecia three weeks ago, and it made me feel better than normal. 100%, I opt for hair over libido/muscle.

Sonny -- E2 *was* being kept under control when I was on the higher dosage of T -- about 150mg + HCG. It did not help how I felt, at all. I have not been blood tested yet at my newer low dose of 60mg of t-cyp without HCG, so I don't yet know if I need estrogen control. Though, I did use it for about two weeks as an experiment -- and there was no change in feeling.

I guess I should also mention that my last tests showed DHEA about 600% of the normal highest range, and uncontrollable estrogens (the ones besides E2) were all high. I was on Arimidex when this test was done.

[marianco]

SUMMARY OF PAST POSTS:

Originally Posted by James23 10-5-2005

My blood test results show nothing that matches the traditional "primary" or "secondary" patterns. I'm the last person to tout AD's for ED, because I've been on 14 of them since the time I was 16... The only time my libido absolutely surged was when I began taking Wellbutrin XL at 300mg per day.

Originally Posted by James23 10-7-2005

Shots were just as useless as the gels. Even with T at optimal ranges -- and even with free T any where from the optimal range to 400% the higest normal (my body keeps SBGH low.)

Originally Posted by James23 12-4-2005

I used AndroGel to get myself into the upper 1100's.

Originally Posted by James23 12-13-2005

After being on shots for a while (60mg t-cyp) I find that I am sort of mentally eager to experience sexual pleasure, but I can't seem to rember how it feels. I can get an erection just fine. I don't experience them autonomously throughout the day, but I can manually create one with physical stimulation. I can orgasm, and I have always been able to do that no matter how extrodinarily high or low my T or T supplementation may be. The problem is, I don't get any pleasure from it! That is to say -- my brain does not produce the reward hormones/transmitters that would be produced in a normal person -- even though I can orgasm! What do I feel then? Muscle contractions. Here's the part that makes it even stranger -- I CAN experience the reward hormones every now and then. Usually, it's whenever I quit a TRT treatment regimen and my T levels start to plummet. Sometimes it's completely random -- usually for three days every month and a half. So, the fact that I can "feel" something means that it isn't nervous damage. The fact that I can orgasm means it isn't a mental blockade, depression, or a problem with a partner. The fact that I can get hard means it isn't a vascular problem. What do you guys think it could be? I'm convinced that my brain just, literally, "runs out" of reward hormones. I get about three days worth, and it takes about a month to regenerate that amount. If that's the case -- then what are these transmitters for which I need to build up greater stores? Anti-depressants don't help -- not Wellbutrin, Effexor, Paxil, Celexa, or Luvox, anyways. I think I need soemthing to restore oxytocin. Is there anything known to do that?

Originally Posted by James23 1-2-2006

See, I'm losing relationships left and right because I can't peform and I feel like shit all the time. Diet, excercise, and whatnot are all in check, and I'm on an appropriate TRT protocol (SWALE designed/monitored) so I don't need to fix any of that. I'm just seriously f-ed up and in need of some INSTANT improvement.

Originally Posted by James23 1-2-2006

Low T, high DHEA, and midrange E2 (because I used Arimidex) BUT: That left me with superhigh total estrogens! Have you had that checked yet? STATS:Age: 24; Height: 6'1", Wt.: 182lbs., BF%: 15%

Originally Posted by James23 1-13-2006

I mean, I am able to get erections (while alone) that are fine -- they're just rare. The biggest problem is that even with an erection, I don't feel the sexual pleasure. That is, I truly have no drive. Even when I'm in one of my sexual low periods, I can even have a half-assed orgasm. It's so mild that if given the option between a orgasm and a Dr. Pepper, I'd go with the Dr. Pepper.

Originally Posted by James23 1-14-2006

About the insulin resistance, what glucose levels should I be looking for? I do have a monitor, but the lowest I've ever seen is 90. However, at 90, I feel like absolute shit -- meaning, I need to get to the nearest place to lie down -- I then pass out or fall asleep for an hour -- and wake up in a hot sweat, shaking from hunger, but feeling absolutely too week to get up for food -- the only thing I want to do is sleep again.

Originally Posted by James23 1-12-2006

Re: Test Enth. @ 250mg/week. I did 400 a week and felt nothing at all.

Originally Posted by James23 3-25-2006

In my case, my erectile response is fine, but I cannot experience the usual sexual rush. NOTE: I CAN ejaculate and so forth. The plumbing is fine. It just does not register as sexually pleasant in my brain. It all just happens with a slight tickle. You might suggest it's related to nerves, but it isn't -- every now and then, when I actually feel horny, everything works FINE. Sensation is not a problem, and I can experience pleasure. It doesn't even matter what the source of stimulation is -- if I'm "ready to go", absolutely everything is arousing. So, it's not a "find something that really turns you on" issue, either. It's literally that my brain is producing something so slowly that it takes weeks upon weeks for it to build up to a level that supports sexuality. Testosterone doesn't help, either. This problem has been with me since age 13.

Originally Posted by James23 4-5-2006

This is no joke. -- for me, with a staggeringly low libido since I hit puberty -- it (Propecia) actually RAISED by libido. Not only that, but my stress level and mild OCD have made a definite decrease, which has increased my sense of well being. Believe me, I'm not one to fall for a placebo effect, not after 14 anti-depressants, and HRT regimens that have failed miserably. I don't have a SINGLE positive thing to say about ANY of these drugs. Not HCG, and not even T. Selegiline, cabergoline, DIM, Viagra, etc.. all bullshit. I know when things have changed, and things have definately changed -- for the better -- while on Propecia. I can't imagine why it has all of these positive benefits for me. Perhaps, since it blocks 5-AR, it caused more of my T to convert to something more beneficial for me? Or maybe my body sensed the DHT reduction and kicked up something else?

Originally Posted by James23 4-5-2006

TylerR:
I had DHT tested with nearly every lab that I've had since 2002. I don't have the exact values handy, but I do know that they were always midrange. I have an extreme anti-social personality disorder and looks are my only doorway into the world.

Originally Posted by James23 4-6-2006

I suffered from low T my whole life. ... Now, I'm 24, with zero sex drive, and my facial hair won't grow in properly -- ... My muslce growth and size matches that of an athletic female. I saw a GP at age 19, thinking I had thyroid problems. His tests revealed low testosterone. Two endocrinologists and one urologist all said elevated T wouldn't help me. I finally found one that would -- with Androgel, around age 21. I had an MRI pituitary scan that came up normal. Androgel drove up T, but symptoms didn't subsite, and my hair kept falling out in the shower like I've never seen it. I switched to injections via Dr. Crisler, and have been doing that for about a year now. 100mg, 80mg, and now 60mg of T-Cyp EW because my E2 shoots up too high. I had Arimidex in the mix, but since discontinued after lowering the T dose so low. Throught the past couple of years my T fluctuated between 700 and 1100ng/dl, between my lowest and highest doses of T-Cyp, respectively. All other tests came up normal, except E2 (elevated about 2x top of range) and FSH and LH (both zero when I was at 1100ng/dl) So, I still feel like shit all the time, I have zero sex drive, my facial hair pattern won't spread or become dense (rest of body is very hairy), and I literally CAN'T gain muscle -- I have no chest whatsoever! Benching about 95lbs at age 24 after 4 years of weightlifting. STATS:Age: 24; Height: 6'1", Wt.: 182lbs., BF%: 15%

Originally Posted by James23 4-6-2005

I started the Propecia three weeks ago, and it made me feel better than normal. 100%, I opt for hair over libido/muscle. E2 *was* being kept under control when I was on the higher dosage of T -- about 150mg + HCG. It did not help how I felt, at all. I have not been blood tested yet at my newer low dose of 60mg of t-cyp without HCG, so I don't yet know if I need estrogen control. Though, I did use it for about two weeks as an experiment -- and there was no change in feeling. I guess I should also mention that my last tests showed DHEA about 600% of the normal highest range, and uncontrollable estrogens (the ones besides E2) were all high. I was on Arimidex when this test was done.

POINTS OF INTEREST:
1. 24 y.o. male, no anabolic substance abuse, hypogonadal, impaired developmental masculinization.
2. Symptoms: depressed mood/“feels like shit”, at times severe fatigue, sleepiness, at time shaking from hunger, can’t gain muscle/strength, “extreme anti-social personality disorder”, low self-esteem, “mild OCD”, stress
3. Wellbutrin XL at 300 mg a day caused libido to “absolutely surge”
4. Testosterone replacement results in total testosterone of 700-1100 ng/dl but libido is still impaired.
5. At one time had low T, high DHEA, midrange E2 (using Arimidex)
6. Able to get erections while alone, occasionally. No pleasure from erection. No sex drive. Little pleasure from an orgasm.
7. Sometimes glucose dips to 90, where he feels “like absolute shit”, feels need to lie down to pass out, wakes up to hot sweat, shaking from hunger, very weak.
8. Episodically feels “horny, everything works FINE”. Feels like something takes “weeks for it to build up to a level that supports sexuality”
9. Propecia raised libido, reduced stress level, reduced “mild OCD”, increased sense of well being to “better than normal”
10. DHT level midrange
11. E2 increases to 2x of maximum range on testosterone replacement, while FSH and LH are suppressed.
12. Arimidex lowers E2 but results in lower testosterone.
13. “All other tests came up normal”
14. MRI pituitary scan normal.

THOUGHTS OF INTEREST (outside of genetic problems which can be difficult to fully solve):
1. MISSING LABS: It would be of interest for most people on this forum to see what are the full lab test results were even if they are “normal”. The pattern of the results, even if normal (i.e. within the reference range), would help reveal what problems are present. The results would also help determine what more needs to be done. For example, one can do saliva tests for cortisol and DHEA-s several times a day to see if adrenal fatigue is present. One can also do urine tests for neurotransmitters including serotonin, norepinephrine, epinephrine, dopamine, GABA, glutamate, phenethylamine. These are all involved in the sexual response. One can measure blood oxytocin levels as well.

2. ADRENAL FATIGUE AND OTHER CAUSES OF SEXUAL DYSFUNCTION: when testosterone levels are optimized (and if needed, estrodiol levels controlled), yet sexual dysfunction remains, it is highly important to look for other causes - with the most common cause I’ve found being adrenal fatigue. Adrenal fatigue can result in loss of libido, loss of pleasure, depressed mood, anxiety, an episodic buildup until sex drive is present, low frustration tolerance, irritability, perception of increased stress levels, etc. Blood tests when adrenal fatigue is present will offen look normal to the untrained clinician. It does show up easily on a saliva test for cortisol and DHEA-s done at least 4 times in a day. Low DHEA-s or High DHEA-s levels, low blood sugars are clues to adrenal dysfunction.

3. WELLBUTRIN: Wellbutrin increases norepinephrine levels. This may improve libido by its effect on the brain. However, it may also improve libido by forcing the adrenals to work harder. Eventually, if the adrenals burn out with fatigue as a result of treatment with Wellbutrin, the libido will drop.

4. PROPECIA: Propecia inhibits the 5-alpha-reductase enzyme. 5-alpha-reductase transforms testosterone to dihydrotestosterone (DHT). Additionally (not often known), 5-alpha-reductase also metabolizes progesterone to allopregnenolone. Allopregnenolone is important for neuron axonal myelination. It has neuroprotective properties. (In women, allopregnenolone has a strong anxiolytic effect. Using Propecia in women may cause panic attacks. ) By blocking the metabolism of progesterone, progesterone availability may improve. Progesterone has antidepressant, anxiolytic, mood stabilizing effects. Progesterone receptors are present in several brain areas, where Progesterone may help improve output of serotonin, dopamine, norepinephrine, and GABA. Progesterone is also a precursor to Cortisol. It is one way to treat adrenal fatigue - which can then improve one’s sense of well-being and improve libido.

5. ARIMIDEX: Arimidex may reduce the conversion of testosterone to estradiol or estrone, but may increase total estrogens. Since these estrogens play a much smaller role in libido, the estradiol level itself is most important to consider. Fractionated estrogens are useful to obtain to tease out the actual estradiol level. A single estradiol lab test often is influenced by the presence of other estrogens, resulting in a false high level.

6. SEROTONIN: Except for Wellbutrin, the other antidepressants raise serotonin level. Raising serotonin level can reduce dopamine production. Raising serotonin level may reduce perceived stress but it also often blocks libido or sexual pleasure.

[marianco]

7. UNDEFINED TERMS: It would be useful to know what is fully meant by: “extreme anti-social personality disorder”, “mild OCD”, libido to ‘absolutely surge’ while on Wellbutrin, feeling “like absolute shit”. These are vague or overly broad terms. Clearly defining them can help determine a person’s condition.

[1cc]

Excellent post Marianco. Your handle should have been Sherlock Holmes.

[DavidN]

I agree with Dr. Scally's comment regarding transmitters. Having the optimum levels of Epi, Norepi, Dopamine, Serotonin, and Gaba, can lay down a good foundation for any hormone protocol. This is a big subject. Testing is available.

This is my first post on Meso-RX. I'm a health care professional, and personally use many of the medicines being talked about in this forum. I'm looking forward to learning more.

[asih.net]

James,

This must be a particularly vexing problem. I wane to reply when I saw the other posts you have had. It appears as if you have vented this problem fairly well. Have you had genetic testing performed? If so, for what?

The reason I am asking is Kleinfelter syndrome is fairly common in males, 1:600, and has a very variable presentation. It is the most frequent form of male hypogonadism. However, despite its relatively high frequency, the syndrome is often overlooked.

Clinically, the syndrome is characterized in adolescents and adults by the constellation of small, firm testes and symptoms of androgen deficiency. Other often-associated clinical features are azoospermia, tall stature, and bilateral painless gynecomastia. The symptoms of the Klinefelter syndrome are not exclusive and the syndrome may be overlooked during clinical diagnosis.

General features (eg, reason for admission, age, age of the parents, body weight, and frequency of maldescended testes) as well as testosterone, estradiol, sex hormone–binding globulin (SHBG), and prostate-specific antigen (PSA) serum levels and prostate volume are not significantly different from normal.

Klinefelter syndrome are taller; have smaller testis volumes, higher follicle-stimulating hormone (FSH) and luteinizing hormone (LH) values; and carry a tendency for less androgenic phenotype and secondary hair distribution.

In patients who provided an ejaculate, azoospermia was found in 54% of the patients in group II and in 93% of the patients with Klinefelter syndrome. Although not exclusively characteristic for Klinefelter syndrome, the combination of low testicular volume and azoospermia, together with elevated gonadotropins, is highly indicative for a Klinefelter syndrome and should stimulate further clinical investigations.

In clinical routine, the occurrence of Barr bodies in a buccal smear has been used as a rapid and simple diagnostic method in suspected Klinefelter syndrome. However, the diagnostic accuracy of screening for Barr bodies has never been evaluated systematically, and this simple test has been neglected in recent years.

From your posts there are no values for your initial workup. Lab values are needed with no medications on board. NONE. Since you do have a tall atature, over 6', lack of body hair, and other attributes it should have been strongly considered. Please tell me that this has already been checked.

Mike

[James23]

Dr. Scally,

Thank you for the interest and taking the time to lend your expertise to my problem.

I do not know that I have recieved any genetic testing.

In early treatment, I believe I was tested for Cushing's Disease and possibly Klinefelter syndrome. The tests involved testicular size measurement, and arm measurement.

Is this the type of testing to which you are referring? If not, what could I specifically ask for at the office?

I will dig up my old labs and post specific values. I can describe my very first set of labs from memory -- however they were of limited scope, and everything came back normal except testosterone. Total testosterone values were 185, 293, and 320 ng/dl. Those last two numbers were what prevented me from getting treatment. The second two were done at a different lab. They were all repeats of the same test, because they needed to "confirm" the results. Free T was in the middle of reference range for each test, while SBGH was lower in the range. Everything else was within range.

Thanks!

-- James