T Nation

20, Severe ED but High Total/Free T? Related to T?


#1

20 year old with high total/free testosterone, but symptoms of ED and fatigue. Case details below. Thank you for taking the time to look into my case.

-age: 20
-height: 6’0’’
-waist: To be measured
-weight: 170lbs.

-describe body and facial hair: Thick, very dense body hair hair everywhere from the hips down. Sparse chest hair, but there is more dense hair around stomach and nipples. Facial hair is dense around neck, jawline, and chin, but sparser and slowly filling in on cheeks.

-describe where you carry fat and how changed: Relatively low BF for a long time and carrying fat around midsection. Has not changed in the past.

-health conditions, symptoms [history]: Erectile dysfunction - decreasing erectile strength, difficulty maintaining erection, difficulty reaching ejaculation, little if any orgasm. No morning wood or spontaneous erections. Issues are definitely not psychological. Fatigue, lethargy, fogginess although these symptoms are not as recent as the ED. Little libido. Wake up frequently at night. Muscle twitching.

No serious medical history aside from the occasional cold and frequent sinus infections.

-Rx and OTC drugs, any hair loss drugs or prostate drugs ever: Vyvanse 50mg, frequent ibuprofen, multivitamin, vitamin D. The extension of Rx and OTC history into my past only includes other vitamin supplements, like a B complex.

-lab results with ranges: Posted below.

-describe diet [some create substantial damage with starvation diets]: Have been bulking for the past 3 months at around 200-500 calorie surplus not meticulously counting calories or macros. Diet is strict with eggs, oatmeal, bananas, dark berries, chicken, rice, potatoes, broccoli, other vegetables, whey protein, nuts.

-describe training [some ruin their hormones by over training]: SL5x5 for the past 4 months. Spread the workout out somewhat so I am at the gym 3-5 days a week.

-testes ache, ever, with a fever: Never experienced this.

-how have morning wood and nocturnal erections changed: Cannot remember how frequent morning wood used to be, but I can at least say I never experience morning wood anymore. Can sometimes wake up in the middle of the night with semi-hard erections depending on dream.

INTRO

I have been experiencing symptoms of lethargy, fatigue, and unrestful sleep for a number of years, but the ED is much more recent. Over the past half a year, I have been experiencing the above posted ED symptoms. The only thing I see having occurred around this same time period is that I may have been under more stress and I also started bulking as well. Anyway, I finally saw an endocrinologist who ran a ton of bloodwork and an MRI. He was confused by my normal testosterone levels, my low FSH, high prolactin, high SHBG, and other levels combined with my ED symptoms. I went through a testicular exam and a MRI of the brain to rule out a prolactinoma. Both of these exams yielded no results and - with the prolactinoma ruled out - my endo did not know what to do moving forward. All he did was suggest it might be familial.

Bloodwork, 6 weeks ago

Testosterone, Total: 1440 ng/dL (250 - 1100)
Testosterone, Free: 185.8 pg/ml (25.0 - 155.0)

TSH: 1.14 mIU/L (0.40 - 4.50)

Bloodwork, 4 weeks ago

Testosterone, Total: 1016 ng/dL (250 - 1100)
Testosterone, Free: 170.7 pg/mL (35.0 - 155.0)
FSH: 1.0 mIU/mL (1.5 - 9.7)
LH: 3.7 mIU/mL (1.5 - 9.3)
Prolactin: 27.8 ng/mL (3.7 - 17.9)

Bloodwork, 2 weeks ago

Testosterone, Total: 1003 ng/dL (250 - 1100)
Albumin, Serum: 4.5 g/dL (3.6 - 5.1)
Testosterone, Free, Bioavailable: 97.6 pg/mL (46.0 - 224.0)
Testosterone, Total, Bioavailable: 200.8, (110.0 - 575.0)
FSH: 1.2 mIU/mL (1.5 - 9.7) **
SHBG: 55 nmol/L (10 - 50) **
Prolactin: 20.3 ng/mL (3.7 - 17.9) **

Cortisol, Total: 17.7 mcg/dL (4.0 - 22.0)
IGF: 249 ng/mL (83 - 456)

Thyroid
TSH: 1.86 uiu/ml (0.49 - 4.70)
Free T4: 0.88 ng/dl (0.71 - 1.85)

CBC (missing hematology)
Sodium: 140 mmol/L (135 - 145)
Potassium: 4.6 mmol/L (3.5 - 5.5)
Chloride: 101 mmol/L (95 - 108)
CO2: 29 mmol/L (22 - 32)
Glucose (morning): 89 mg/dL (60 - 99)
Calcium: 9.4 mg/dL (8.5 - 10.5)
Urea Nitrogen: 21 mg/dL (8 - 22)
Creatinine, Serum: 0.9 mg/dL (0.5 - 1.5)
eGFR: 121.7 (60 - 120)
Total Protein: 7.0 (6.0 - 8.5)
Albumin: 4.4 g/dL (3.5 - 5.0)
Globulin: 2.6 g/dL (1.5 - 4.5)
Total Bilirubin: 0.4 mg/dL (0.2 - 1.3)
SGOT (AST): 47 U/L (5 - 50)
SGPT (ALT): 104 U/L (5 - 65)
Alkaline Phosphatase: 91 U/L (35 - 125)

Cholesterol: 188 mg/dL (< 200)
Triglyceride: 60 mg/dL (< 150)
HDL Cholesterol: 70 mg/dL (> 40)
LDL Cholesterol, Calculated: 103 mg/dL (< 100)

Iron: 156 mcg/dL (50 - 195)
Ferritin: 78 ng/mL (20 - 345)

I greatly appreciate anyone looking into my case because I have no idea how to move forward with this and neither does my current doctor. The high prolactin seems like it would cause some of my symptoms but I have no idea what’s the root cause.

EDIT: I am still working on getting the remainder of my thyroid tests, hematology, and estradiol. Also, I have never used any kind of testosterone boosting supplement. I have only ever used fish oil and various vitamin supplements in my life.


#2

To answer your question we need to know if you are on trt or not


#3

Yeah I’d be real interested in your estradiol levels. Get that and post them. You have high testosterone which is great, but you may be converting a lot of it into E2.

Ever have nipple sensitivity or soreness?


#4

I am not on TRT and never have been. Just to be clear, I have never taken any kind of testosterone boosting supplement. All I have ever taken in my life is fish oil and various vitamin supplements.


#5

I’ll get the estradiol test done along with the remaining thyroid tests. No, I have never experienced nipple sensitivity or soreness.


#6

Have you looked into vyvnase causing Ed?
Also one of your liver functions ALT came back elevated. That’s something to follow up on.


#7

Welcome to Vyvanse, it’s a vasoconstrictor, it can constrict the blood vessels in your body including your penis. T is high because SHBG is out of control for only 20, those are levels seen in older men. You should stay the hell away from plant based diets, if SHBG is naturally high your FT could shrink to nothing as you age unless you get it under control.

TRT is in your future because TRT lowers SHBG more than anything else. Once SHBG gets in the 40’s it starts to take control of your FT inflating your TT. That’s why your TT is above ranges, FT shrinks TT increase as it’s a balancing act.

Your labs look inconsistent, was your first two test using TT, SHBG and albumin to calculate your FT? Direct measured FT is inaccurate, you must calculate FT by calculating TT, SHBG and albumin on a SHBG calculator. You third test shows much lower FT than the other two and no SHBG on first two labs.


#8

Yes, the first free testosterone test is using the direct method, and the second one is using calculation. Actually, looking back at the Quest info pages on the direct free testosterone test that was ordered initially it describes how it is not to be used for healthy, young males. Are my bioavaliable and accurate (second) free testosterone measurements low then?

Would consistent use make the effects of Vyvanse a long-term issue in terms of vasoconstriction? Could I not wait a series of days, weeks, or months before it is fully flushed out of system if this is a contributor to my ED? My usage was only about 1-3 times a week in the past. Regardless, I have been off it for a month now to experiment with just that and will continue in order to see if it makes any difference.

I don’t know how my levels could be naturally high. In the time period I started experiencing ED, I started working out again, bulking, and drinking a little bit more, but really only a couple beers every 1-2 weeks. Nothing even to the point of getting drunk. In terms of medications, I take ibuprofen frequently and experimented with ashwagandha and bacopa somewhat, but these herbs were a while before the ED. No significant diseases either. Just some colds, frequent sinus infections, and repeated lyme disease infections years ago.

I noticed my ALT levels are high - could liver issues be a cause here? Would you recommend a liver ultrasound or some other tests in this regard?

So, it seems the SHBG will gradually rise with age, binding more and more of the free testosterone while simultaneously keeping the total testosterone around the same value since it includes bound testosterone. Seems like this would make it extra difficult for me in terms of getting TRT because my total testosterone levels are high and I am young.

Are there no other causes for high SHBG I should be considering or ways to bring it down? I saw anecdotal evidence for p5p, but it seems my high SHBG cause is still unknown.


#9

Could the vyvanse cause permanent ED? Could I stay off it for a few months in order to relieve the ED if that is the issue?

Would following up mean a liver ultrasound then or some other test?


#10

I would assume those medications would at some point tax your dopamine receptors too much.

How would that work? Does someone that is prescribed Adderall, or vyanase eventually have the same feeling that someone who abused Meth or Ecstacy would have? Lack of dopamine.

Anyway, Lack of dopamine can cause ED.


#11

I don’t know about the medication causing permanent damage.

My liver enzymes get elevated when I gain weight. I have fatty liver disease. It could be alcohol causing alt elevated. If it’s the first time you took those labs. It’s worth to retake to confirm high number. Am sure if you go to a gastroenterologist they will check for all the hepatitis and more iron test labs. My fatty liver disease was dx while doing cat scan for kidney stones. And then again during ultra sound of my kidney. It is close by.

Edit: medications can also cause higher liver enzymes


#12

When I was on Vyvanse it took longer to get a full erection, it was as if something was trying to prevent it and once I got it I had no problem keeping it. My erections are rock hard so perhaps Vyvanse wasn’t strong enough to overcome them, but once my T levels started falling it started constricting my penis. It only took about 3 weeks for Vyvanse to wear off, it was one of the easiest withdraws I’ve had.

You can absolutely get TRT with high SHBG no matter how high your TT, what most doctors don’t realise is if SHBG is high enough you are basically low T regardless of your TT. That’s because your test is bound up (mostly inactive) when bound to SHBG, when SHBG gets high it reduces FT and you feel as if your T levels are low, because they are.

Having truly low T (low TT and FT) and having high T with high SHBG is the same because FT is what matters and some doctors don’t bother checking TT. TT is mostly inactive, FT is the active hormone and is low.

So yes you are a candidate for TRT do to high SHBG, FT is low, you are low T. Your pituitary gland is trying to increase your TT do to SHBG being so high, the battle can’t be won. As SHBG goes up, TT goes up to compensate in an attempt to maintain optimal FT levels. Your pituitary gland is fighting strongly, it just will never be enough.

https://naturalbiohealth.com/2015/05/06/shbg-critical-to-your-health/


#13

TSH should be closer to 1.0
T4 is well below mid-range
This may be from not using iodize salt. Iodine is essential for thyroid hormone production.
fT3 is the only active thyroid hormone and should be tested. There is no T4 receptor.

Do you get cold easily?
Are outer eyebrows getting sparse?
Low thyroid function has most of the same effects as low T.
Please see ‘oral body temperatures’ below to further assess this.

SHBG is too high, perhaps from elevated E2.
Prolactin opposes dopamine production which can rob one of ability to enjoy or feel reward - result can be depression.

While an adinoma was not detected and imaging method may not have been optimal, you should ask for a trial of 0.25mg Dostinex/cabergoline twice a week for a month or so to access how this has been affecting your HPTA and mental state. If things improve, you have a diagnosis and treatment in one stroke.

Prolactin can be elevated by recent orgasm or cuddling {puppies | kittens | babies} - so avoid for a few days prior to labs.

Low dopamine can cause increased prolactin, they move in opposite directions. Your stimulants may have worn down your dopamine production and that is also the measure of what addictive drugs do via excess dopamine activity.

E2 levels can be increased by more production or reduced liver clearance. AST is high. ALT/AST can be increased by recent training and sore/injured muscles. - avoid

Higher SHBG can inflate TT with non-bioavailable T+SHBG so TT overstates your T status. Your
bio-available are low relative to your TT.

Some liver problems can increase SHBG in the liver.


Please read the stickies found here: About the T Replacement Category

  • advice for new guys - need more info about you
  • things that damage your hormones
  • protocol for injections
  • finding a TRT doc

Evaluate your overall thyroid function by checking oral body temperatures as per the thyroid basics sticky. Thyroid hormone fT3 is what gets the job done and it regulates mitochondrial activity, the source of ATP which is the universal currency of cellular energy. This is part of the body’s temperature control loop. This can get messed up if you are iodine deficient. In many countries, you need to be using iodized salt. Other countries add iodine to dairy or bread.

KSman is simply a regular member on this site. Nothing more other than highly active.

I can be a bit abrupt in my replies and recommendations. I have a lot of ground to cover as this forum has become much more active in the last two years. I can’t follow threads that go deep over time. You need to respond to all of my points and requests as soon as possible before you fall off of my radar. The worse problems are guys who ignore issues re thyroid, body temperatures, history of iodized salt. Please do not piss people off saying that lab results are normal, we need lab number and ranges.

The value that you get out of this process and forum depends on your effort and performance. The bulk of your learning is reading/studying the suggested stickies.