25 Y/O with Abnormal Blood Work

Pharma / TRT Testosterone Replacement
1

Stats:
-25 y/o
-5’ 7"
-34 inch waste
-185 lbs
-Light, patchy facial hair. Body hair is only around nipples and a strip above/ below belly button. Sparse.
-Fat is carried in love handles, on chest, and on lower belly. Feminine distributions. Hasn’t really changed, although there seems to be more of it lately.
-Symptoms are listed below. No notable health history, although I’ve been repeatedly diagnosed with depression and/or anxiety by Drs when seeking tests/ explanations for my symptoms.
-No current Rx drugs. Only antibiotics and occasional pain meds in the past. Infrequent OTC drug use.
-Lab results are listed below
-Average daily intake of around 3000 calories. 210 P/ 350 C/ 80 F. Ovo-lacto vegetarian for 7 years. Mostly eat whole foods, and rely on whey, eggs, and cheese for the majority of my protein intake.
-4 days/ week lifting, 1-2 days per week cardio/ conditioning
-Have not ever noticed my testes aching
-I haven’t noticed much change in nocturnal and morning erections. However, they do not occur every day. If I had to guess I’d say about 5-6 days per week only.

Symptoms:
-Extreme fatigue/ exhaustion. Sleep for 9-10 hours per night, wake up tired, take an afternoon nap (sometimes 1-2 hours) and am tired an hour or two later.
-No motivation/ depression/ generally feeling beat down
-Brain fog and trouble concentrating
-Terrible memory
-Very, very slow response to proper training and diet. Muscle and strength gains are poor despite doing “everything right” and body fat is higher than I would expect for someone with my training and diet. Difficult time losing fat without losing a lot of muscle and strength, or gaining muscle without getting fat. I can gain/ lose WEIGHT, but even with careful planning it tends to come from the wrong sources.
-Muscles often feel weak and joints often ache
-Puffy nipples that are sometimes even MORE puffy, sometimes accompanied with aching and swelling (that usually goes away after a couple days)
-Frequent urination (15-20 times some days)
-Weird swings in appearance and gym performance despite nothing changing with diet/ training/ recovery. I’ll look puffy, and skinny-fat for a few weeks and have shit training sessions, then look pretty good and be stronger in the gym for a week despite nothing changing in my life. My appearance changes noticeably and seemingly randomly throughout the day – I assume because of water retention
-Sexual function is not problematic. I may have less “drive” than before and erections are sometimes not as strong as they could be (normal?). Sex or masturbation 4-6 times per week, no issues achieving erections or orgasm.

Potentially relevant: I suffered from eating disorders in early high school and exercised approximately 10-15 hours a week for at least a year. At 23 I also moved overseas to an impoverished part of Asia, losing about 25 lbs in 6 months and returning home at a malnourished 120 lbs.

Labs (HealthOne female hormone panel w/ CBC tested at 10:50 AM after 13 hour fast)

Total T: 777 ng/dL (348- 1197)
Free T: 7.7 pg/mL (9.3- 26.5) <<< FLAGGED AS LOW
LH: 7.8 mIU/mL (1.7- 8.6)
FSH: 6.1 mIU/mL (1.5- 12.4)
Estradiol: 30.8 pg/mL (7.6- 42.6)

The only result from my CBC that I think is worth mentioning is my serum glucose of 98 mg/ dl (lab range 65-99). As a young, weight-training adult, isn’t that somewhat high after a 13 hour fast?

Can anyone help me interpret these results? Based on my reading, it seems like I have a problem with my body aromatizing at an elevated rate. Is my E2 level THAT high? Is my Free T low enough to be causing my symptoms? Should I follow up with a thyroid test just to cover my bases? Any input from you more knowledgable and experienced guys would be really appreciated.

2

Based on your symptoms seems like hypothyroid. Read the thyroid sticky.

Possible adrenal burnout with excessive diet and training. Evaluate your cumulative stress.

Small dose of Arimidex might do you good.

Ping KSman in his thread. You need a heavy hitter here.

3

Thanks for the reply, Igs! I have suspected hypothyroidism and have some physical characteristics that seem to be indicative of thyroid issues (namely very dark circles under my eyes and pale, almost yellowish skin). However, since I am paying for these test out of pocket I am getting them incrementally. I will order a thyroid test tomorrow and receive the results in a few days. Additionally, I have reread the thyroid sticky and will begin taking my temperature 2x per day as instructed.

Iodine: I use a considerable amount of “steak seasoning” on my sweet potatoes and vegetables to replace the savory flavors that tend to be missing from a vegetarian diet. The first ingredient listed on this seasoning is “salt,” but it does not specify the kind of salt. If this is iodized salt, I get a lot of it in my diet. If it isn’t, then I get very little.

Cumulative stress: I live a very low stress life. No kids, no real money problems, job I enjoy and that requires relatively few hours, etc. However I still often find myself feeling anxious and/ or “burned out.” Social interaction leaves me feeling physically tired.

Could thyroid issues lead to low levels of free t and/or elevated E2, or is this a separate issue entirely? Would a SERM or AI raise free t? Does it make sense to try fixing the issues highlighted by this blood test (Low free T, High E2, High Serum Glucose) before getting the results of my thyroid labs?

4

Thyroid can mess up every cell in your body.

Urination: Did you know that having to go a lot can be a symptom of diabetes? The alternative is an enlarged prostate. At your age, that would be prostatitis, some kind of inflammatory process. The the question is whether your are able to fully empty your bladder.

A1C test gives you a picture of your average blood glucose (blood sugar) control for the past 2 to 3 months.

TSH, fT3, fT4

FT levels change a lot, so its hard to make a call on that been low if the labs picked up a low spot.

You have more than enough LH/FSH.

Estradiol can be high from increased aromatization or from reduced clearance in the liver. AST/ALT can detect liver problems but you must lay off the training as sore and over-worked muscles can create elevated readings.

It would be good to have:
CBC
CRP
fasting cholesterol [in case its too low]
DHEA-S

There does not seem to be any iodine in your salt product.

*** Post temperatures and ping me again before ordering labs. ***

Note that starvation [diets] can make permanent epigenetic changes to your systems and increase rT3 that blocks fT3, lowering energy in every cell in your body.

Do you get essential fatty acids [EFA’s] in your diet? Fish oil, nuts, flax seed oil/meal.

How are you getting B vitamins and specifically B12

5

Here are my body temperatures thus far, taken with a new, under-the-tongue digital thermometer. I will update with more results as I gather them:

9/13: Afternoon (4:00 PM) – 97.6
9/14: Morning (6:45 AM) – 96.6
9/14: Noon (11:45 AM) – 96.4 [I fell back asleep at 10:00 and took my temp upon rising again]
9/14: Afternoon (2:00 PM) – 97.9
9/15: Morning (9:00 AM) – 96.0
9/15: Afternoon (3:00 PM) – 98.2
9/16: Morning (8:00 AM) – 96.4

KSMan: to answer your other questions, I get EFAs from nuts and flax seeds in my diet, although I have gotten lazy with my flax consumption. I do not currently take a fish oil supplement. I eat at least 6 whole eggs and 6 whites every day, a lot of whey protein, and consume cottage cheese a few times a week usually. These are the only sources of B12 that I can name.

6

Update: I’m not sure why I forgot to mention this before, but for the last few weeks I’ve noticed that my heartbeat occasionally feels strange and bouncy. This typically happens when I wake up in the morning and is sometimes accompanied by a feeling of anxiety.

It happened when I was laying down with my girlfriend last night, so I had her feel my chest. She said it did feel somewhat odd, but then took my pulse and noted that that was normal (not my heart rate, just the rhythm). I had the same sensation when I woke up this morning and decided to take my heart rate by feeling my carotid artery and counting on a stopwatch. It came to 52 beats per minute – so not elevated. I’m not sure if any of this is related to my problems, especially because this is a relatively new occurrence while I’ve dealt with most of my other symptoms for nearly 10 years (although they do seem to be getting worse).

7

Your body temperatures are indicating that your metabolic rate is poor. Not enough fT3 getting into your cells.

With your “steak seasoning”, I suspect that iodine deficiency is the root cause. You can do the labs now. If they indicate a problem, you can then do iodine replenishment then, or skip the labs and do replenishment now.

Please read the thyroid basics sticky.

You also need selenium in your diet. Please find a high potency B-complex multivit with trace elements that also includes iodine and selenium.

If you resolve your thyroid and body temperatures your heart rate may normalized. I assume that you are getting vit K2 in your vege diet.

Please see my prior post again and make sure that you did not miss any points there.

8

Thanks for the help and guidance KSman.

To be clear, these are the tests I should order:

  • A1C (rule out diabetes/ abnormalities in blood sugar control)
  • TSH, fT3, fT4, rT3 (overview of thyroid function – test for hypothyroidism)
  • DHEA-S (snapshot of adrenal function)
  • Cholesterol (Too low = reason for low FT???)
  • Total and free testosterone (Double check levels/ verify low FT result of original test)
  • E2 (verify borderline high results of first test)

I will likely be going to an endo to receive these tests so that my insurance will pick up the cost. Anything that he refuses to order, I will order myself and pay for out of pocket. Is there anything that I missed (other than liver function test which would not give an accurate result due to current resistance training)?

Lastly, should I ask my doctor about a prescription for Arimidex to regulate E2 and possibly raise my low FT? Or would it be better to simply order the tests and then tackle any major problems that they show (hypothyroidism)?

9

I talked to an endo over the phone – apparently he likes to screen his prospective new patients before scheduling an appointment. I explained to him my situation and he said the following things:

  1. Why would you ever order a test from a private lab?
  2. My total test is high so I’m fine.
  3. Free testosterone is irrelevant and no doctor would ever order that test.
  4. “Why would you test for estrogen? Estrogen is for ladies.” < DIRECT QUOTE
  5. He won’t order a thyroid test for me because he’s a specialist. I should get my GP to order a test for TSH ONLY because if anything is wrong with my thyroid, the TSH test will show it. No other test matters. (Note that I don’t have a GP).
  6. Waking temperature and body temperature don’t matter. Not relevant at all.

So? now what?

10

You need to find another doctor ASAP.

11

Your situation is very odd and unique.

The high TT and low FT might is very rare and one should always be looking out for a lab error sending you down the wrong path.

Repeating some labs is advisable.

What is not ambiguous is your low body temperatures. You can confirm that another health person can get 98.6 in the afternoon to ensure that there is not an equipment problem.

I would focus on iodine and thyroid issues and get them resolved before acting on the current steroid hormone lab work.

With the current steroid lab results, we are forced to assume that SHBG is very high and then one needs to try to find a reason for this.

12

[quote]KSman wrote:
Your situation is very odd and unique.

The high TT and low FT might is very rare and one should always be looking out for a lab error sending you down the wrong path.

Repeating some labs is advisable.

What is not ambiguous is your low body temperatures. You can confirm that another health person can get 98.6 in the afternoon to ensure that there is not an equipment problem.

I would focus on iodine and thyroid issues and get them resolved before acting on the current steroid hormone lab work.

With the current steroid lab results, we are forced to assume that SHBG is very high and then one needs to try to find a reason for this.

[/quote]

Thank you for your help KSman; your input thus far has proved invaluable. I will get the necessary tests (thyroid, FT, SHBG, cholesterol, A1C) and report back. I will schedule an appointment with a GP who will hopefully order these, as I have insurance and it seems silly to pay out of pocket for legitimately necessary bloodwork. If anyone has advice for finding a decent GP or convincing one to do the labs I want, I’m all ears.

As for SHBG, I found this interesting article for anyone curious about the relation of SHBG to sex hormones: Search Results.

Of note to me is this quote: “Patients with anorexia nervosa have high SHBG levels.” While I am far from anorexic now and have been for years, my history of eating disorders and malnutrition may have left SHBG levels elevated despite a return to adequate nutrition. Interestingly, another risk factor for high SHBG seems to be HYPERthyroidism, as HYPOthyroidism reduces SHBG levels. This seems contrary to the conclusion alluded to by my symptoms and temperatures, but I suppose I won’t know until thyroid labs are taken.

13

[quote]TrevorLPT wrote:
Of note to me is this quote: “Patients with anorexia nervosa have high SHBG levels.” While I am far from anorexic now and have been for years, my history of eating disorders and malnutrition may have left SHBG levels elevated despite a return to adequate nutrition. Interestingly, another risk factor for high SHBG seems to be HYPERthyroidism, as HYPOthyroidism reduces SHBG levels. This seems contrary to the conclusion alluded to by my symptoms and temperatures, but I suppose I won’t know until thyroid labs are taken. [/quote]

Starvation increases SHBG and is also known to cause some epigenetic changes and have also been shown to be transgenerational. So persistence of SHBG does not seem all that impossible after you fixed your diet.

14

[quote]KSman wrote:

[quote]TrevorLPT wrote:
Of note to me is this quote: “Patients with anorexia nervosa have high SHBG levels.” While I am far from anorexic now and have been for years, my history of eating disorders and malnutrition may have left SHBG levels elevated despite a return to adequate nutrition. Interestingly, another risk factor for high SHBG seems to be HYPERthyroidism, as HYPOthyroidism reduces SHBG levels. This seems contrary to the conclusion alluded to by my symptoms and temperatures, but I suppose I won’t know until thyroid labs are taken. [/quote]

Starvation increases SHBG and is also known to cause some epigenetic changes and have also been shown to be transgenerational. So persistence of SHBG does not seem all that impossible after you fixed your diet.
[/quote]

While I’m not going to make any conclusions without bloodwork (I have an appointment with a doctor who will hopefully schedule tests on tuesday), this seems like a likely explanation. Do you have any knowledge of how to reduce SHBG in this sort of case? So far I’ve come up with a supplement regiment of 10 mg Boron, 3000 IU Vitamin D3, 1 g Magnesium, and a large serving of fish oil daily, based on this article: anabolicmen.com/10-ways-lower-shbg-boost-free-testosterone/. This will/ would be in addition to Iodine for hypothyroidism and possibly a few herbs like stinging nettles and tongkat ali, per this article: peaktestosterone.com/Free_Testosterone_SHBG.aspx. Note that I am currently taking none of these things, so once labs come in, I will self-medicate with these supplements unless a more “serious” problem is found and retest in a few months.

15

I just spent 30 minutes transcribing the results of a full blood panel on here, which was inexplicably deleted immediately after I posted it. I will update later with full labs, but here is the relevant info:

Cholesterol, Total: 153 (125-200 mg/dL)
HDL Cholesterol: 41 (> or = 40 mg/dL)
Triglycerides: 57 (150 mg/dL)
LDL- Cholesterol: 101 (<130 mg/ dL)

Hemoglobin A1C: 5.2 (<5.7 %)

TSH 2.98 (0.4-4.50)
fT4: 1.3 (0.8-1.8)
fT3: 3.9 (2.3-4.2)

Ferritin: 106 (20-345 ng/mL)
DHEA-S: 233 (85-690 mcg/dL)
FSH: 6.5 (1.6-8.0 mIU/mL
LH: 7.7 (1.5-9.3 mIU/mL)
Progesterone: 0.7 (<1.4 ng/mL)
Prolactin: 11.1 (2.0-18.0 ng/mL)

Total Testosterone: 830 (241-827 ng/dL)
E2: 36 (< or = 39 pg/ml)
SHBG: 68 (10-50 nmol/ L) <<< Flagged as High
(Free Testosterone not tested due to lab error)

Vitamin D, 25-OH, Total: 33 (30-100 ng/ml)

16

Ask if FT can be done from stored blood samples [often done so docs can order up followup labs].

  • the intent was to verify the first low FT result

TSH 2.98 (0.4-4.50)
fT4: 1.3 (0.8-1.8)
fT3: 3.9 (2.3-4.2)

  • low body temperatures

Your fT4 is mid range [good] and fT3 is getting high.
You are not getting enough fT3 inside your cells to maintain metabolic rate and body temperature. This then suggests that rT3 might be blocking fT3 at the fT3 receptors in the cell walls. See the thyroid sticky again and note:

  • rt3
  • Wilson’s book
  • stress
  • adrenal fatigue

Vit-D3=33 is not considered adequate, take 5,000iu per day.

You could get total cholesterol higher.
Triglycerides: 57
– are you on an extreme low fat diet?

Did you get vitamin K2?
iodine?
selenium?

DHEA-S might be low for your age

Your Ferritin=106 is good and low ferritin is not impeding fT4–>fT3 which happens to be a bit high.

About your thyroid labs:
Your doc will think that things are great if he does not understand the implications of low body temperature indicating that fT3 is not entering your cells and that the typical cause is elevated rT3. So you will have to fight that battle. Wilson’s book has a few recovery game plans. This is not something that you fix with a pill.

17

Thanks for the reply. I will call the lab to see if Free T can be tested from current sample, and if not I will have another drawn. The intent was to verify low free T, but given my very elevated SHBG, I suspect that the first free T lab was accurate and SHBG is the culprit.

Weird FSH number was due to an error I made while transcribing results – actual result is 6.5. I edited the post to reflect this.

rt3 was the one lab that my doctor did not order off of my list. He seems extremely knowledgable about hormone issues and said that every one of the tests I asked for were things the he orders on a regular basis for men with my symptoms (with the exclusion of rt3). The list of labs he ordered for me mimicked almost exactly what you have recommended to me and others. I will ask why he feels rt3 is unnecessary.

I will start supplementing with Vit D3 today.

I am not on extremely low fat diet – get approximately 80 grams a day. 6 whole eggs, a handful of almonds, and several tablespoons of olive oil for cooking daily, plus incidental fat. Any other possible reasons for low cholesterol?

Not supplementing with K2, selenium, or iodine but will start.

Is it wise to supplement with DHEA? I worry that it might already increase my elevated E2.

I will bring up the issue of rt3 again, as I was so happy to have a doctor who was knowledgable and took my concerns seriously that I didn’t press that issue initially. Worst case scenario I can order online for <$150.

I am surprised that you did not mention my very high SHBG and elevated E2, as those were the things that stuck out to me. Do you think these are unlikely to be the causes of my symptoms (excluding low waking body temps)? As an aside, I took my temps for another consecutive 3 days last week – they were still low in the morning but I was hitting 98.2- 98.6 in the afternoons. Is this relevant?

18

Point out to your doc that low body temperatures when ft3 is elevated suggests that elevated rT3 is preventing fT3 from getting into the cells and one then has symptoms of hypothyroidism even though some the other labs state the opposite. Elevated TSH also suggests that rT3 is preventing the hypothalamus from been able to sense the otherwise normal thyroid levels.

Not many docs understand rT3 as is it not the root of any drugs/profits.

I understand the SHBG and E2 implications. I was looking to see if we could close the equation with the expected low FT. [There are other medical issues that can affect SHBG.]

19

Met with my doctor to discuss lab results (posted above). He said that rt3 has not been a useful test to run in his experience and he typically only runs it on very ill, hospitalized patients. However, we discussed “stop the thyroid madness” book and website, the general uselessness of endocrinologists in cases like this, and other subjects which led me to believe that he is progressive with his treatments and knows what he is talking about. If symptoms do not improve under the current course of action, I will push the rt3 issue more.

For now, he prescribed me a low dose of a T3/T4 compound from a compounding pharmacy. He admits that this is a somewhat “radical” prescription based on my levels and age, but says he has had enough success with patients (usually older females) with my symptoms and levels that he wants to try it. We are meeting in 3 weeks to assess it’s effectiveness based on my symptoms, and ordering blood work in 5-6 weeks once levels stabilize. He also advised supplementing with 5000 IU of D3 daily.

As for the FT and SHBG issues, we were unable to order a FT test from the current sample because it was too old. So, we’re going to order another round of sex hormone labs when we check thyroid levels in 5-6 weeks. He says that the free test level would be inconsequential now, as he wouldn’t try to adjust multiple levels (thyroid and FT) at the same time. If symptoms do not improve with the T3/T4 compound OR we settle on an effective dose of T3/T4 but FT and SHBG still test as abnormal we will attempt to correct those issues next.

Does this all sound appropriate and on-the-level from your perspective?

20

I think lot of guys here would kill for a doc like yours. Willing to work with you and all. Perhaps not at the speed you may want but still receptive.

Whether T4/T3 is the right course of action in your case, I am not sure. Hopefully you get someone more knowledgable to chime in.