Cloniphene Citrate

It has been two years and eight months since I finished my two years of Androgen Deprivation Therapy (ADT) and my testosterone recovery has been disappointing. Before my first Lupron shot, nearly five years ago, I insisted that my T level be tested and noted. I knew that my normal T level was well above the standard low-normal level used by most labs. I wanted to establish a baseline for me specifically, worried that my doctors would try to do the old gypsy-switch on me -- that I would recover to only a fraction of my pre-ADT T levels, only to be told that my new level was "normal".

Here are my numbers: (Total T in ng/dL)
Prior to ADT: T=699
2 months after end of ADT: T=14
5 months after end of ADT: T=22
8 months after end of ADT: T=106
11 months after end of ADT: T=198
14 months after end of ADT: T=239
17 months after end of ADT: T=271
21 months after end of ADT: T=273
23 months after end of ADT: T=206
26 months after end of ADT: T=188
31 months after end of ADT: T=199

So, in the year and nine months following the end of my ADT my total serum T level recovered slowly to 39 percent of my personal baseline. Then it started to drop off, currently standing at 28 percent of baseline after two and a half years. This is within the stated "normal" range as reported by the lab my doctor uses. It seems like every time I look they have dropped the threshold for low normal. I am pretty sure, for instance, that when my T stood at 206 the lab reported the lower end of the normal range at 200 ng/dL. Now that my T has dropped below 200 the lab is reporting 175 ng/dL as the lower bound.

I expect that the reason the lower end of the normal range keeps dropping is that T supplementation has engendered a bit more controversy just lately and they don't want to encourage men who do OK at low T levels to seek treatments they don't need. There are guys who get by just fine with 175 ng/dL of T. They play sports, annoy their wives, father children. And they feel OK. I'm not one of them. I have all of the usual symptoms of hypogonadiam -- I am fat, listless, moody, I tire easily, and I often feel overmatched by life.

My PSA has been behaving itself -- undetectable for going on five years now -- and since 200 ng/dL already represents an all-you-can-eat buffet for my cancer should it decide to recur, there is no reason not to nudge my T level up a bit. I could have gotten a scrip for a testosterone supplement. That's kind of expensive but my insurance would probably have paid for it. But once you start with T supplements you can't stop without being worse off than you were before. T supplementation causes the testes to shrink and one tends to become dependent on it. I'll cross that bridge if I need to but first there is something else to try.

So my Medical Oncologist and I have decided to try adding some clomiphene citrate to my daily fist-full-o-pills to see if it will increase my natural production of testosterone. Clomiphene citrate (aka Clomid) is not FDA approved for treating low testosterone in men. Its primary use (approved by the FDA in 1967) is to stimulate ovulation in women trying to become pregnant. It has been used by the ladies for 50 years now and its safety in that area is well established. Although it is off label for treating hypogionadism in men there have been a number of studies and most have been very positive. Given to men with low-normal serum T levels, Clomid roughly doubles testosterone, achieving levels actually slightly higher than those generally achieved with testosterone gels.

I did see one slightly disappointing study where they were hoping to show that Clomid was a cure for hypogonadism in young men -- that they could give the drug for a limited period and the higher level of testosterone production would continue after the drug was stopped. It didn't seem to work that way. Giving the men Clomid made their T levels rise but not long after the Clomid was stopped T production would drop back to roughtly the same level as before the intervention. Note that this is still better than supplementing T levels directly. Nothing shrivels when you take clomid. When you stop the drug you go back to how you were before but, as far as I can see, you are no worse off for having tried it.

Weren't you going to try HCG as well? Clomid and HCG is what all the bodybuilders take in order to recover from a cycle of T super-supplementation. HCG is a subcutaneous injection (insulin needle) that they take once a week for 2-3 weeks as they start on clomid. Here's a fun fact - it's made from the pee of pregnant women. Here's another fun fact - HCG features in my blockbuster bestseller, "Thaw's Hammer", as a biomarker for the choriocarcinoma variant ("The Blue Cancer") that is the problem to be solved by the hero.

Are you tracking Free T and SHBG too? The T isn't free to do much for you if your SHBG level goes up in tandem with your T level. It's one of those annoying homeostasis things our bodies do with steroidal hormones.

Peter - I may be one of very few men here with direct experience taking clomid. I've struggled with hypogonadism virtually all of my adult life, but was not diagnosed until my early 50's. They always said "You're just above the lower limit of 'normal', so. . . you're fine." Not so. . .

When we had been married some years, we wanted to start a family. Tried and tried, but no success. My wife's gynecologist, who must have been really on top of the research of the day, prescribed clomid for me. I took it for a couple of months, then stopped. A month later. . . we were expecting. Although my T levels were not measured at the time, the results speak for themselves. I hope your results are as good as mine.

On the T levels, though, I continued to struggle with the symptoms of low T until my early 60's, at which time I was formally diagnosed, and began TRT. To this day, I continue the therapy -- before, during and after SBRT treatment for my PCa. A man's got to do what a man's got to do.

Celebrate: Thanks.

Tall: Yes, I was thinking about the combo but when it came time to pull the trigger I could find quite a bit of research about treating hypogonadism with Clomid but much less about the combination treatment of Clomid plus hCG. It's all a bit out of my MO's usual modus operandi and I wanted some fairly specific research (with method and results clearly spelled out) to share with him. The discussions I could find for the combo were generally rather vague about dose, duration, and expectations. I am sure your bodybuilder friends are excellent people but they don't leave a particularly clear paper trail on PubMed. At the same time as I was failing to find the hCG data, the research I found about Clomid seemed quite positive, reducing my incentive to continue researching hCG. Clomid is actually quite inexpensive and seems safe and convenient. I couldn't think of a good reason not to try that first.

Currently we are just tracking total serum testosterone and dihydrotesosterone -- the two markers he looks at for ADT monitoring. If the Clomid fails to improve my T score or if I am unable to convince myself that I feel better, then we'll try other, more complicated things.

Trailguy: No particular advice. You probably want to see where your T level winds up and what your PSA does once your T levels out. Then what you want to do will depend on how bad your low-T symptoms are, and how much faith you have in the new "saturation" theory that says that once you get above castrate levels extra T doesn't make much difference.

Paxton: You were lucky your wife's gyno hooked you up. T supplementation helps low-T men feel better but it actually tends to make them less fertile.

Sailor: You are right that one shouldn't obsess over T levels. They are only part of the picture. Hypogonadism is mostly diagnosed by a questionnaire that asks about its symptoms. Since you've been on ADT you are probably familiar with them. The symptoms of hypogonadism are more or less the same as the side-effects of ADT, except that low-T guys don't usually get hot flashes.

Paxton,

During my time on ADT my hot flushes were infrequent and mild. I think we are both unusual, you and I. I wasn't bothered much by hot flushes and most guys on ADT are bothered more. You were troubled by hot flushes which most low-T guys are not.

Back with an update: So, I've been on Clomiphene for a while now and I guess it's not too soon to observe that it isn't working. My total T dropped from 199ng/dL three months ago to 124 on Monday.

I see my MO tomorrow. I'll see where he stands on hCG (human Chorionic Gonadotrophin) which is the other drug that sometimes restarts natural production.

Here's a link to a document that shows a couple of graphs of my T history. The first page is about Vitamin D so you will need to scroll down.

/docs.google.com/document/d/10wpIvXEXXYC5gnRPmrdAi0xGr0i00WxRJBQuyzRexf8/edit?usp=sharing

Yuck. If he doesn't go for hCG, will he support TRT?

I agree that they're probably all interrelated. Are the spikes in Vitamin D causing shut down of T production? Maybe you have had a proliferation of VitD receptors? All this steroidal stuff is incredibly complex. Your body can find ways to turn one into another and there are negative feedback loops. I'm sure there are wide individual differences. And SHBG levels matter a lot too.

Here's what epocrates says:
hypogonadotropic hypogonadism, male
[individualize dose IM 2-3x/wk]
Start: 500-4000 units IM 3x/wk; Info: dose, frequency, duration vary widely based on response.

As you may know, it's collected from the urine of pregnant women. The only serious risk is for thromboembolism, presumably because it may result in estrogen increases too.

There is definitely an association between hypogonadism and metabolic syndrome.
/www.ncbi.nlm.nih.gov/pmc/articles/PMC4650473/

/www.ncbi.nlm.nih.gov/pmc/articles/PMC3354945/

It's probably bidirectional -- they each make the other worse.