T Nation

25 Y/O, Low T Symptoms, Low DHEA/High SHBG


#1

Hi everyone,

Background
• Normal timely pubertal development in terms of physical features: normal height, normal voice depth, strong jawline, good athlete, lean/muscular, normal development of testicles and pubic hair
• Could not ejaculate until age 20, which is WAY past normal range for males
• Was not interested in sex in high school and college; turned it down many times and did not have a good reason why other than lack of interest
• I’ve always been fairly low self-confidence, low energy/apathetic, low sense of urgency, passive, and have had trouble focusing
Jan 2015: Had first intercourse with gf at age 24 but only after trying unsuccessfully for a month due to inability to maintain erection upon penetration (i.e. no problem getting erection, but went limp when it was time for intercourse); this was right around the time I started on finasteride 1.25mg/day for mpb hairloss
Most of 2015: Had good sex with gf every couple days for 8 months, but generally lost interest in sex and after a year was lucky to have sex once/week even though we basically lived together
Nov 2015: Trouble focusing was causing problems in grad school so I went to psychiatrist because I thought I had ADHD. She said I didn’t but actually had low-grade anxiety/depression; started on lexapro (anti-anxiety/depression) and have been on 20mg/day for 6 months; had trouble sleeping on this med so I also take trazodone 75mg nightly to get good sleep
Currently: No longer with gf…have had same ED problem with 2 different girls in last few months…trouble getting hard and staying hard, although it’s improved recently and is now only problematic ~25% of the time.

Body and lifestyle info
Age: 25
Height: 6’
Waist: 30”
Weight: 170 lbs (body fat: 12% on DEXA)
Body and facial hair: Body: moderate levels of arm, leg, chest hair; Facial: Can grow full beard in a couple weeks; shave every other day
Where you carry fat and how changed: Carry slightly more in butt and thighs relative to trunk; distribution has not changed over time
Health conditions, symptoms [history]: Have been diagnosed with psoriasis for the last 10 years; had bad flare-up January-May 2015 that was relieved with methotrexate
Rx and OTC drugs, any hair loss drugs or prostate drugs ever: Currently on finasteride (since Nov 2014), minoxidil, escitalopram (Nov 2015), and trazodone (Dec 2015); took methotrexate for 3 months (summer 2015) for psoriasis
Diet: Have been in a 15% daily caloric deficit for last 6 months or so…generally fluctuate between cut and bulk phases. High protein, low fat, high carb on lifting days (3/week), and high protein, high fat, low carb on non-lifting days. Diet staples are milk, greek yogurt, oatmeal, sweet potatoes, turkey, ground beef, eggs, spinach, strawberries, blackberries, blueberries. Most is organic/grass fed. Eat all meals between 8 a.m. and 6 p.m.
Training: Resistance training on a 3 day/week split of chest/tri, back/bi, legs/shoulders, usually 6 exercises of 3-4 sets per session (18-24 total sets). Jog 2-3 miles on days I don’t lift (3-4 days/week).
Testes ache, ever, with a fever? No
How have morning wood and nocturnal erections changed? Rarely if ever get morning wood or nocturnal erections…suppose I used to get them as a teenager but cannot say for sure how often to compare.
Stress and Sleep: Generally low stress in my life; sleep 7-8 hours per night, usually good quality
Iodine: I do not use iodized salt, but do drink 3 cups of milk and eat 3 eggs daily, in addition to taking a daily multivitamin with 150 mcg iodine.
Oral temperature: Morning 97.7, afternoon 98.2, evening 98.6

Labs - June 17, 2016 [some tests were also done late April/early May 2016 and values are noted in brackets; LH and FSH done May 2 only]

T (total): 954 ng/dl Normal: 300-1080 [929 on May 2, 2016] [1042 on April 22]
SHBG: 72 nmol/l Normal: 16.5-55.9 [58 on May 2]
T (free): 13.1 ng/dl Normal: 4.8-25.7 [15.1 on May 2]
E2: 31 pg/ml Normal: <=63 [35 on April 22]
FSH: 2.7 miu/ml Normal: 1.3-11.4 [May 2]
LH: 3.3 miu/ml Normal: 1.2-7.8 [May 2]
DHT: 207 pg/ml Normal: 112-955
Pregnenolone: 156 ng/dl Normal: 27-203
DHEA-S: 246 ug/dl Normal: 240-549
Cortisol A.M.: 15 ug/dl Normal: 7-25
TSH: 1.3 uiu/ml Normal: 0.5-4.7 [1.6 on April 22]
fT4: 1.21 ng/dl Normal: 0.73-1.95
fT3: 2.9 pg/ml Normal: 2.3-4.2
T3 (total): 77 ng/dl Normal: 60-181
rT3: 17.2 ng/dl Normal: 9-27
Cholesterol: 179 mg/dl Normal: <200
HDL: 60 mg/dl Normal: >39
LDL: 111 mg/dl Normal: <100
PSA: 0.3 ng/ml Normal: <4
Prolactin: 14.1 ng/ml Normal: 3-30
Vit B12: 920 pg/ml Normal: 250-1100
Vit D, 25OH: 63 ng/dl Normal: 30-100 [48 on May 2]
Folate (rbc): 723 ng/ml Normal: 280-800
Homocysteine: 6.4 umol/l Normal: 5-12
Glucose: 74 mg/dl Normal: 70-99
A1C: 5.3% Normal: 4.0-5.6
Insulin: <2 uiu/ml Normal: <4
Creatinine: 1.07 mg/dl Normal: 0.80-1.4
Sodium: 140 meq/l Normal: 133-146
Potassium: 4.4 meq/l Normal: 3.5-5.3
Chloride: 98 meq/l Normal: 97-110
Calcium: 9.6 mg/dl Normal: 8.5-10.5
Protein (total): 7.3 g/dl Normal: 6.4-8.3
Albumin: 4.6 g/dl Normal: 3.5-5.2 [4.4 on April 22]
Globulin (calc): 2.7 g/dl Normal: 2-3.8 [3.2 on April 22]
A/G ratio (calc): 1.7 Normal: 0.9-2.5
Bilirubin: 0.7 mg/dl Normal: <=1.2
Alkaline Phosphatase: 38 u/l Normal: 40-130 [42 on April 22]
AST: 17 u/l Normal: <40
ALT: 15 u/l Normal: <41
WBC: 3.6 k/ul Normal: 4.0-11.0 [4.81 on April 22]
RBC: 4.79 m/ul Normal: 4.1-5.7 [5.17 on April 22]
Hemoglobin: 15.9 g/dl Normal: 13-17 [16.8 on April 22]
Hematocrit: 45% Normal: 37-49 [47.9 on April 22]
MCV: 93.9 fL Normal: 80-100
MCH: 33.2 pg Normal: 27-34
MCHC: 35.3 g/dl Normal: 32-35.5
RDW: 12.7% Normal: 11-15
Neutrophils: 36% Normal: 40-74 [46.6 on April 22]
Lymphocytes: 49% Normal: 19-48 [37.2 on April 22]
Monocytes: 11% Normal: 4-13 [13.3 on April 22]
Eosinophils: 3% Normal: 0-7
Basophils: 1% Normal: 0-2
Platelet count: 243 k/ul Normal: 130-400

A couple insights:

  1. SHBG is high, and fT/E2 ratio is suboptimal. I’m thinking the ssri antidepressant med (Lexapro) is increasing SHBG since it’s jumped considerably from early May to mid-June, which are months 4-6 I’ve been on it. This certainly isn’t helping me, but my symptoms (other than ED which is impossible to tell since I started having sex when I started finasteride) pre-date my prescription drug use so I doubt Lexapro is the main culprit. SHBG could very well have been high before lexapro, so lowering this is a priority.
  2. DHEA-S is low. May be cause of most of my symptoms including low libido, depressive symptoms, energy, etc. since they have been chronic and are generally associated with low DHEA levels.
  3. WBC and neutrophils were low, and lymphocytes high suggesting I was fighting off something at time of testing, though I don’t remember being sick at all during that time. Don’t think this would significantly affect the steroid levels save maybe cortisol, so I feel comfortable interpreting them as normal.

Questions:
Would like feedback on labs (other numbers that appear interesting? way off on my insights?) and potential course of action given these results. I’m thinking start taking DHEA and wean off the Lexapro, since it has helped my mood slightly but not substantially, and DHEA has anti-depressive effects. Have been to one hormone replacement doc who provided no help. There is a good endocrinologist I trust who I will see shortly; she doesn’t specialize in steroids, though, so I may ask her for a referral to one that does. This group is as knowledgeable as I’ve seen on this topic, so I’d greatly appreciate any comments. Much thanks in advance!




KSman is Here
#2

Great intro post!

I’d supplement DHEA. You might consider taking low doses of an AI to get your e2 down about 22 instead of the 30s. Your T level is great.


#3

Agree, that’s the best intro post of all time!

DHEA supp is a no brainer. I also like the suggestion of dropping your E2.


#4

You have very good T numbers for such a high SHBG. I would get off the Finestride asap. I am convinced that is the source of all my problems as I took it for 10 years. There are a number of law suits right now and studys showing permanent ED problems due to Finestride as well as it causing hypogonadism. You don’t have hypogonadism with your levels, not even close but the Finestride could be causing other issues. Its also known to cause depression.


#5

I didn’t catch that you were still on finasteride. Stop taking that asap!

I’d much rather be bald than low T. You may even find that getting your hormones sorted (yours really aren’t that far off) will grow back hair on its own. Mine certainly has. Still shaving the head though.


#6

Thanks for the quick input everyone, I appreciate it! I really care about trying to get right and have some academic background in hormones hence the detailed first post.

Since DHEA is low and T is high, it appears DHEA production is normal but it is being converted too quickly to T. This seems like an enzyme issue, either overactive 17-B HSD or 3-B HSD. I’ve read a couple old papers that implicate low DHEA in psoriasis, so it may be that my DHEA production is ok but it is not sticking around long enough to inhibit the pentose phosphate cycle which is overactive in psoriatic cells. The question now is will DHEA supplementation be effective if the enzymes remain overactive, or will it just push T and E higher? Only one way to find out I suppose, so starting on DHEA immediately is step 1. Starting with 25mg orally then adjusting based on symptoms and labs seems like the standard procedure. Any thoughts on dosage or oral vs transdermal delivery?

As for finasteride, I agree it’s not helping things hormonally, but I’m very hesitant to stop for 2 reasons: 1) nearly all of my symptoms pre-date my finasteride use, and I did not notice any negative sides after starting it other than ED. Even the ED is hard to blame on finasteride because I never had sex before starting on it so the ED could have been there all along especially given my other symptoms that usually cluster with ED. 2) part of my income comes from modeling so it’s financially advantageous to keep my hair. Once a safer treatment comes along or I have $ for a transplant, I will get off finsasteride but short-term it’s helping me with money so I’m ok with it.

Will start supping DHEA and see how that goes, but the high SHBG levels and poor fT/E2 ratio given my fitness and body composition are also problematic. Dropping the depression med will help, but DHEA can also increase E2 in some cases. Any recommendations on lowering SHBG and increasing fT/E2 ratio? fT is 1.37% of total T which seems low but other opinions are welcome.


#7

An aromatase inhibitor (AI) will help with reducing the conversion of T to E2.

Do your research on finasteride, the boards are littered with men who had their HPTA fucked by finasteride. I may be included in that number as I took it some years ago. Don’t ever get a strip transplant. It leaves a horrible happy face scar on the back of your head and looks pretty bad if/when you give up and shave your head. I have personally seen far too many bad plug jobs to ever consider it.

Sucks that your finances depend on your having hair.


#8

I’ve been bald since early 30’s. So glad I never tried any meds.


#9

Propecia seems to be a one way ticket to hormonal health. No coming back it seems.


#10

The only inconvenience to being bald is the need to wear a hat at the beach or when we spend a long time on our boat. Otherwise it has never bothered me at all.


#11

Well atleast from learning about all these problems, i will know better than to just take whatever doc gives me. I’ll get transplant if i ever need it (touches wood) before ever considering propecia. Seen so many men on the cusp of suicide from that stuff.


#12

I appreciate all the concerns about finasteride, but like I said, nearly all my symptoms pre-date my finasteride use so that is not my primary concern here. I’m more interested in best course of action to increase DHEA (oral vs. transdermal, dosage, benefits of sustained-release oral, etc.) and to improve the free T:E2 ratio. Does anyone have experience supplementing with DHEA? I’ve read plenty of cases here and it seems hit or miss on improving a wide variety of symptoms.


#13

I supplement dhea with 25mg daily orally. Does it do anything? No clue, because I started taking a bunch of stuff with it at the time. If you have low DHEA, it’s generally suggested to supplement.


#14

Started on 25mg yesterday. Will update on how it goes.


#15

Greetings,

After careful review of your post - a few things came to mind. I also wondered if there was anything else that was maybe relevant to your post. You did a great job presenting your background, and, just to remain cohesive, I’ll address each question in order made:

  1. Feedback/labs/insights:
    I personally feel Psoriasis MAY be the primary cause. It’s an autoimmune disease and there may be disease activity in the absence of skin-related symptoms. There are certain tests/blood panels for autoimmune diseases that can measure activity. They look for things that (in excess) indicate inflammation. This can impact blood circulation, mood and ED. Supporting evidence: You were fine when you were taking Methotrexate in all departments.

It’s often recommended for people with autoimmune disease to be checked for Hashiomoto Thyroiditis. This is common and should be considered.

  1. Comments:
    If my hypothesis is valid and treatment is administered? Symptoms should resolve in time.

If not? Then, GOOD. Just keep monitoring that stuff. Then start increasing your calories and see if you start feeling better. Your level of activity and caloric restriction (combined) may be culprit. A cheat day would answer that question!

Hope all works out.


#16

Your TT is high and FT is lowish.
E2 is moderately high for your FT level
High SHBG is creating a lot of T+SHBG that is inflating your TT numbers, in this case, TT needs to be ignored in favor of TT or bio-T.

finasteride can have horrible effects on T and libido in a few males, do you see a change with timeline introduction of finasteride?

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

  • advice for new guys
  • things that damage your hormones
  • protocol for injections - some good general info
  • finding a TRT doc

You biggest challenge will be the doctors. You need to lower SHBG. Lower E2 lowers SHBG and higher active testosterone as well. TRT would help, but docs are the problem here. So that leaves lowering E2 and low dose anastrozole would help.

rT3 is a bit below mid-range. Body temperatures are decent. You might try getting more iodine and multi-vits should also contain selenium. Because you have not been using iodized salt, you are probably marginally deficient. See the thyroid basics sticky.

“”“
SHBG levels increase with estrogenic states (oral contraceptives), pregnancy, hyperthyroidism, cirrhosis, anorexia nervosa, and certain drugs. Long-term calorie restriction of more than 50 percent increases SHBG, while lowering free and total testosterone and estradiol.
”""

AST/ALT - liver looks good. SHBG is made in the liver to grab steroid hormones and return them for metabolization. So something about your liver may be abnormal. Are you aware that you metabolize any medications differently or oddly? Is your alcohol tolerance normal?

Your training patterns may be stressing your body when your testosterone status is low. Thyroid can be like that too. Stress can be a problem.

SSRI’s have a bad reputation for interference with sexual function. So getting that out of your system would be a good idea. Taper off slowly, it can be a rough ride.

I do not think that DHEA was low enough to be responsible for any problems. But adding it may complicate things. A few guys will freely DHEA–>E2 with supplemental DHEA.


#17

Hey

I have exactly the same profile as you

I was on propecia for 5 years and had to stop because of terrible sides (ED,Fatigue,Weight Gain, Depression etc)

I also developed severe psoriasis during this period and have been on and off of Methotrexate also

The methotrexate makes me feel terrible, like I have a hangover every single day but it does clear up my psoriasis

How are you progressing with your psoriasis and the rest of your treatments?

Thanks
Daniel


#18

Hey daniel - appreciate the follow up. Agreed, methotrexate is excellent at clearing up symptoms but causes problems in many other areas. The recommended timeframe is 3 months before getting off…I did that once and it cleared me up, but the psoriasis has returned somewhat on my scalp. I am curious on other markers of systemic inflammation (CRP, IL-6) that are likely elevated in those with psoriasis, and may get mine checked soon. This is similar to what jeremy32 recommended earlier in this thread.

Shortly after writing this post, I went to an extremely knowledgeable reproductive andrologist who said that my T levels were so high that there was nothing he could do. Because I have a twin sister, I have been doing some research on epigenetics and transfer of sex hormones across the placenta in utero…there is a chance that sex hormone transfer from my sister in the womb could have altered my brain structure development to be more/less sensitive to certain sex hormones, hence my low T symptoms but high T levels and otherwise normal blood work. The andrologist said there is no way to test any of that, so I just have to accept it.

I have been off my antidepressants for a month and have noticed slightly increased libido and some subsiding of ED, but also slightly decreased motivation. May get back on a half dose soon. The andrologist also suggested to get off the DHEA for fear of it converting to estrogen…I’ve been off and on the DHEA and cannot say I notice any changes one way or the other.

Still on the finasteride, which is working quite well. The observable benefits with my hair outweigh any negative sides, which I still cannot confirm I am experiencing with any confidence. I don’t plan to stop any time soon.

As for next steps? As mentioned earlier, I want to check levels of systemic inflammation that are hypothesized to be elevated with an autoimmune disorder like psoriasis. If numbers are out of whack, that may highlight a need for looking at medications other than methotrexate that lower systemic inflammation, and/or trying a less-inflammatory diet. Here is a paper on psoriasis inflammatory markers and benefits of systemic treamtent (mose used fumaric acid esters which are a common psoriasis treatment in Europe but not sanctioned in the US) http://www.pdf.investintech.com/preview/51807144-7b88-11e6-89aa-002590d31986/index.html.


#19

I have psoriasis all over my body - right now my propecia sides are the priority : little libido, shrunken testes, extreme fatigue, no strength or energy, unable to play football, hypoglycemic attacks

I am about to start TRT gel this week as I have low normal levels
Strangely I also have very low levels of Estrogen

Mehtotrexate also gave me slight scarring on the liver

Good luck on your journey - please share any useful info


#20

please read through this and see if it looks valid: https://www.google.com/search?q=psoriasis+iodine+deficiency