[Johnny]

Dr Mariano,

In addition to my prior question, do you know if it’s possible to inject Nebido subcutaneously and split up the entire vial? For example on an EOD basis?

Many thanks.

Johnny

[Johnny]

I’m learning from another post of yours that you prefer more frequent injections or application of testosterone in men with low SHBG.

I suppose that excludes Nebido?

[Johnny]

Thank you for your detailed response, Dr Mariano.

In fact, I was opposed to Nebido from the opinions of many seemingly well-educated people who claimed that serum levels would drop too low during the last weeks prior to the next injection.

However, this seems to be false and I later discovered a forum that had many very satisfied patients using Nebido. Several of these were on weekly injections with cypionate and enanthate prior to Nebido and actually preferred how they felt on Nebido, not just the significantly lower injection frequency.

I know some doctors allow for more frequent injections if blood work warrants it, i.e., every 9th week as opposed to every 12th week.

I am not having wild success with my TRT treatment, but I suppose I can rule out Nebido then. I do probably have access to the most popular esters, although they are no longer part of any official protocol here in Norway and needs to be issued as a special order.

Regards,

Johnny

[Johnny]

@hardasnails1973 4928 wrote:

Your vitamin D and A are very low. This may indicate possible bile acid problem which goes back to potential sluggish liver. Even though the liver parameters look good it does not show true functionality. If levels are still elevated I would get evaluated for CAH. I would also recommend 5HIAA 24 hour urine test to rule these out. You may also want a 24 hour catecholamine test urine to see if other parts of the adrenal glands may be effected. I would serious dig into the immune system issues to rule out any chronic viral, pathogenic load as elevated cortisol levels are a response of an immune system reactions. Upping vitamin D is fine, but vitamin A, E, K also have to be balanced as well. Eating yams, sweet potatoes will help to get the proper vitamin A. One may want to explore options of heavy metals which can cause elevated cortisol. Prolong elevation of cortisol can lead to memory loss and other neurological imbalances. Why you need to look at all parts of adrenal function: Aldosterone, DHEA, catecholamines, cortisol.

Optimal for vitamin D – 120-130 provided other fat soluable vitamins are in check.

I don`t see vitamin A on my list?

I will keep supplementing with vitamin D. Should I supplement directly with vitamin K also?

I have started probiotics now. Udo`s Choice Super 8. 30 billions per capsule. From what I read, probiotics can aid in the production of vitamin K.

I tested for heavy metals, but it came back normal, I think.

Liver values have at least been consistently normal, but was elevated on the test before this one, but then came back normal on the latest one.

I don`t think we have the 5HIAA test here in Norway, but we have catecholamines in urine.

After I quit coffee, I feel more relaxed in my body and more tired, so I think maybe my cortisol has come down. My flaccid penis seems to be fuller and hanging better, but I have not improvements in libido, erectile quality or the other issues.

Still waiting for the phosphatidyl serine.

I`m considering looking into trying 5-HTP and see if that can help, if there is something with my dopamine and serotonin levels that are out of whack with my low libido.

Thanks for writing, HAN. Appreciate it a lot!

[Johnny]

@hardasnails1973 4902 wrote:

Means further evaluation is needed with urine or saliva test to confirm
Your body is in a major inflammatory response state with cortisol high /DHEA low
Indication of possible pathogen, or allergen,
Whole blood histamine may be good indicator
CD 57 stricker panel, with possible further evaluation into immune markers. What about lyme, or other viral infection?

I already took a new test with urine and saliva, but unfortunately, it was on one of my rare good days, so I hope it does not come back “inaccurate” of my condition. I will get the new results in two weeks.

So, can I just start on probiotics like VSL then? And drop coffee and start with phosphatidyl serine to lower cortisol?

FWIW, my DHEA have been higher earlier and was actually above range when supplementing with it. Still felt the same.

[Johnny]

Thank you, but I`m not sure if I follow you 100%, possibly since english is not my native language.

Do you not make a distinction between mental and physical illness?

Diabetes and hypertension are physical illness, yes? Which may affect mental function and daily life function?

Are all illnesses mental illness then?

[Johnny]

@DrMariano 4737 wrote:

The only problem then remaining in his treatment is his use of high dose T3 without taking into account the risks, particularly since his diagnosis or established pathophysiology was too nonspecific and consideration of alternative treatment wasn’t done as a result.

What exactly are the risks?

And what about all the reports from people who actually benefit from this type of treatment, both from the Wilson`s Snydrome site and other message boards?

False claims or placebo?

@DrMariano 4737 wrote:

A commonly used treatment in psychiatry for depression is to add T3 to treatment even if the patient is euthyroid.

So I`ve heard. Is this adding T3 to anti-depressants or instead of anti-depressants?

[Johnny]

Thank you, Dr Mariano.

I am humbled by your response and will need to study it further. At the same time, it is discouraging since it further cements how difficult it may be for me to get well since there can be so many complex causes. Complex for me at least.

[Johnny]

@DrMariano 4729 wrote:

Even people with hemochromatosis need appropriate levels of iron to function well.

Old fashion traditional diets would be expected to keep iron levels at the higher end of a reference scale.

Thyroid treatment so long as it is under the care of a physician is frequently done in various forms including T3.

Well, I just got home from my doctor and he said my iron levels were very well, but I know that he does not know what he`s talking about at all so I don`t trust him. Maybe I should supplement for a while.

Is thyroid treatment done with high levels of T3/T4 similar to mine if the patient still have symptoms of hypothyroid?

[Johnny]

Dr Mariano,

Are you able to comment on my current iron levels? Could they be higher?

Both because of my own symptoms, high ferritin and what I read about hemachromatosis, I never even considered that I could have low iron until just recently. Mind you, these levels are after donating blood four times and multiple blood draws for blood work over the last years. But they were not that much higher three years ago.

That`s interesting about the brain and body having two disparate levels. No easy answers here, I`m afraid?

Would a T3 trial be stupid?

Thanks in advance,

Johnny

@DrMariano 4717 wrote:

Hemochromatosis: one problem is overzealous reduction of iron until one is suboptimal. With an iron deficiency, multiple problems occur which can lead to anxiety and depression, lack of energy, etc. Often, I have to restore optimal iron levels for that person in order to restore function.

Thyroid hormone: for a variety of issues, the brain and body can have two disparate levels – with either the brain or the body having too little causing a problem in that area.

Diet: unless a person is eating a traditional diet – like what people use to eat in the 1800s and early 1900s – which were up to 10 times more nutritious that what we have now, then a person is often nutritionally deficient in some or more nutrients. The fact that a person supplements is a realization that some nutrients are insufficient in the diet. The problem is identifying the others that are also insufficient. That is difficult to achieve since the foods these days may not have as much nutrition as in the old days, given massive farming and nutrient defects occurring in the soil itself. If the diet itself was good enough, then no supplements would be needed.

[Johnny]

Hypothalamic-pituitary-adrenal axis dysregulation it is then. Got it.

Three years back I had high ferritin (700+) and was tested for hemachromatosis, but it came back negative and my ferritin eventually dropped down to normal after phlebotomy. I wonder if this indicates that I had an inflammation in the body. At this point I was at rock bottom and virtually impotent. I slept all day long and fell asleep on parties. I have improved since then, but only relatively speaking. Same symptoms, just not that severe.

Another clue for this puzzle, is that my state is not consistently depressed. In fact, I have hours and even stretch of days, where I feel NORMAL and well. Even great! It`s just that my miserable state is the default state for 80-90% of the time. I also tend to believe that all my issues come from the same source, but I have experienced improved sexual function without improvement of other symptoms and I have also experienced feeling great in my body and mind, but with no increase in sexual function.

Another thing is that I often (not always) feel better the day after drinking considerable amounts of alcohol. It puzzles me.

1. Regarding nutrition, I will not say that it could not be better, I simply refuse to believe that my current diet could explain my symptoms, unless there is an allergy of some kind. Thank you for the book recommendation, I will check it out.

2. Interesting, but further confusing for me I`m afraid.

3. Understand. Do you recommend testing rested cortisol? I am taking new blood work this week, so that would be nice to know. I believe the blood work I`ve taken earlier often have been with working out the prior day.

4. That is interesting. With both high T4/T3, my conversion would be good, yes? I know that you can not make any specific comments, but there are few individuals who have said that I should consider a trial of T3 and see if it improves my symptoms. Is that generally a good or bad idea? From what I can tell, the risk is not severe and the body`s own production of thyroid usually picks up after quitting.

5. Understand. I will get the IGF-1 test done.

[Johnny]

A relevant piece of information to this puzzle is that I had a physical breakdown 7 years ago because I had severly exhausted my body with work, training, etc and undersleeping for a long time. It was initiated by a nervous breakdown so severe that I was out of business (the gym and work) for a whole year and struggled with a moderate depression and anxiety issues. Those were all cured naturally, but I believe I have had the physical issues all the way back since then, but they were masked and overlooked because of my personal situation up until three years ago.

Does that make a case for adrenal fatigue or some kind of imbalance created by that incident?

[Johnny]

Thank you for writing, DrMariano.

1. I think my nutrition is very good. At least so good that it can not be causing any problems of this magnitude. I have tried cutting all grains for long periods of time, but I never cut milk, so that remains to see.

2. Gut issues – This is an angle that I`ve been made aware of by others only very recently, but if I have good digestion and no apparent symptoms in that area, could I still be having a gut issue?

3. Because I tested high for cortisol in morning blood prior to starting TRT, I did not think that low cortisol could be the problem, but I will get saliva and urine tests done. My symptoms does indicate low cortisol output.

4. My thyroid is excellent, is it not? Top range T3/T4? The only issue is the mildly elevated TSH and anti-tpo. Could low cortisol be preventing T3 to get into the cells? Or is there such a thing as T3 resistance or problems with uptake?

7. Growth hormone deficiency. This is a new one to me. I suppose it is a specific test. How is this treated?

I have no reason to suspect any mental issues. If I feel down or anything, it is because my body feels so miserable.

Thank you very much for writing and sharing your thoughts, Mariano. It means more than you can imagine.

@DrMariano 4650 wrote:

Once Testosterone is in a good range, then any problems that are left have other causes.

A lack of testosterone is often not sufficient to explain all symptoms a person with mental issues has. Generally, when a person develops mental problems, one is dealing with a multisystem problem.

Adding testosterone does not often improve a person’s ability to function if there are more important problems going on.

Since psychosocial issues can influence gene expression, metabolism and nutrition, and nervous system neuroplastic changes, psychosocial interventions involving areas such as exercise, therapy, education, relationships, etc. need also to be considered.

General areas to examine and address physiologically are:
1. Nutrition – optimizing nutrition so that is has high nutrient density – more vitamins and other nutrients per calorie.
2. Immune system issues – including gut issues: big ticket, high reward area to examine and optimize, though finding tools to accomplish this effectively can be difficult.
3. Nervous system issues – what some call “adrenal fatigue” is generally a nervous system phenomenon, a response to excessive stress signaling. Psychiatric treatment consideration is important. Adjusting nutrition and doing hormone treatments alone generally are not enough to help most seriously ill people.
4. Thyroid hormone optimization.
5. Diabetes and prediabetes – complex conditions in and of themselves
6. After everything else is considered, optimizing Testosterone and Estradiol signaling.
7. Last, consider addressing growth hormone deficiency – which usually does not work well if the foundation for its treatment is not established.

Note that I prefer fasting insulin to be less than 69.45 pmol/L (10 uIU/mL). A value greater than this is a sensitive indicator for insulin resistance (prediabetes to diabetes). Insulin promotes fat storage and pro-inflammatory signaling, and may reduce testosterone production, among many effects.

Gut issues often mean immune system problems.

[Johnny]

Latest bloodwork. This was on Nebido and HCG. I have now been on hormone therapy for 4 months, so I don`t think it is a matter of being impatient.

My own comments:

– Elevated insulin?

– Could iron be better? Due to a streak of elevated ferritin (700-800) a few years back, I never looked into my iron levels. I have also donated a lot of blood without supplementing iron. It looks like they could be higher.

– Cortisol elevated over the range. Not sure what one can infer from the cortisol in blood.

– Low SHBG?

– Excellent T3/T4? Looking more like hyperthyroid, in spite of symptoms of hypothyroid? TSH elevated and also anti-TPO.

Insulin 85 (18-173)
Alat 50 (<70)
Albumin 44 (36-48)
ASAT 62 (<45)
CRP 1 (<5)
Ferritin 58 (20-300)
Folat serum 26,6 (>5,7)
Free T4 17,3 (11,0-23,0)
Free T3 6,5 (3,5-6,5)
TSH 2,9 (0,20-4,0)
Anti-TPO 51 (<100)
FSH <1 (<12)
Free testosterone index 17,7 (2,3-9,9)
Hb 15,8 (13,4-17,0)
HDL-cholesterol 1,6 (0,8-2,1)
Hematocrit 0,48 (0,40-0,50)
Iron saturation 19 (15-57)
Iron 14,2 (9,0-34,0)
Iron binding capacity 74 (49-83)
Copper serum 14,4 (12,0-25,0)
Cholesterol 4,1 (2,9-5,1)
Cortisol morning (blood) 841 (250-750)
Creatinine serum 80 (60-105)
LDL-cholesterol 2,3 (1,2-4,3)
LH <1 (<12)
Magnezium serum 0,85 (0,71-0,94)
Prolactin 203 (<700)
PSA 0,5 (<2,6)
Vitamin K 0,2 (0,1-2,2)
Selenium 1,7 (0,6-1,8)
SHBG 13 (8-60)
Zinc serum 15,1 (9,0-17,0) (up from 9,9 on last test, have been supplementing since then)
Total testosterone 24 (8-35)
Vitamin D3 79
Vitamin A 2,8 (>0,7)
Vitamin B12 689 (170-650)
Vitamin D 79 (50-150) (up from last test, but maybe I could supplement some more)
Vitamin E 30 (14-50)
Estradiol 0,10 (<0,18)

[Johnny]

I`m curious if my low estradiol could explain my symptoms?

Is there any safe way to raise estradiol levels as a practical experiment?

Further, would my high cortisol levels be lowered if my testosterone levels increased from Clomiphene treatment?

I just visited my new family doc and she told me that my testosterone was completely fine (no surprise since she just see that it`s within the range), but I was a little more surprised that she said my cortisol was normal, even though it is beyond the ranges that I have seen.

I am pretty confident that I will start Clomiphene treatment with or without my family doc. She has ordered more bloodwork looking for infections and such, but I`m quite sure she won`t find anything.

[Author]

Posts