T Nation

27 Y.O. Suspected Low Test


#1

Age = 27
Height = 6' 0"
Waist @ navel = 36.5"
Weight = 181.2 lbs
Body and facial hair: below the waist on legs somewhat hairy, darker hair. Above waist relatively hairless with thin blonde hair on forearms and minimal hair on chest and nipples. Facial hair is thin and grows slowly.

Carry significant fat in thighs, ass, hips and abdominal. Started to get fat at 19-20 maxing out at 230 - 240 lbs. Last 2-3 years I have been very diligent with diet and exercise.
Health conditions: Depression - Had been on antidepressants (celexa/citralopram) for approx. 6 years. Got off them recently as I did not feel they were doing much and feared they were doing more harm than good.

Other symptoms - fatigue (lack of enerygy and drive), lifts in gym gain slowly and often regress. Body fat remains in "feminine areas" even when dieting my ass off and lifting 6 days/wk. Social withdrawal, easily agitated, virtually no libido (erections are somewhat soft, not full on hard, infrequent morning erections at half mast), brain fog (difficulty concentrating and memory problems), just generally not a lot of motivation and ambition.
Rx and OTC drugs: No Rx (had been on ssri for approx. 6 years).
OTC = Multivitamin (Animal Pak), Melatonin and 5-HTP before bed, cod liver oil, vit-d3, supps (whey protein).

Lab Results:

First set of labs: June 14, 2014 (11:00 a.m.)

"Sex binding panel"
Test (total): 11.70 nmol/L (Ref. range = 5.80 - 28.00)
SHBG: 28 nmol/L (13 - 71)
Free Androgen Index: 41.5 (14.8 - 94.8)

"CBC & Auto Differential"
WBC Leukocytes: 7.0x10e9/L (4.0 - 10.0)
RBC Erythocytes: 4.87x10e12/L (4.30 - 5.40)
Hemoglobin: 148 g/L (140-180)
Hematocrit: 0.443 L/L (.400-.500)
MCV: 90.9 fL (82.0-97.0)
MCH: 30.3 pg (27.0-32.0)
MCHC: 334 g/L (320-360)
RDW - Erythrocyte Dist. Width: 13.6 (11.5-14.5)
Platelets: 225x10e9/L (150-400)
MPV: 9.2 fL (7.4-10.4)
Neutrophils: 2.8x10e9/L (1.5-6.5)
Lymphocytes: 2.9x10e9/L (1.2-3.4)
Monocytes: 0.6x10e9/L (0.2-0.8)
Eosinophils: "H" 0.6x10e9/L (0.0-0.4)
Basophils: 0.1x10e9/L (0.0-0.2)

"Liver Panel"
Bilirubin, Total: 14 umol/L (2-20)
ALP - Alkaline Phosphate: 100 U/L (40-135)
ALT - Alanine Aminotransferase: 19 U/L (4-55)

"eGFR - Glomerular filtration rate/1.73 sq M Predicted (MDRD)"
eGFR: >60 (>= 60 normal or slightly decreased)

"Thyroid"
TSH: 1.13 mIU/L (0.49-4.67)

"Glucose Random"
Glucose: 4.8 mmol/L (3.6-11.0)

"Renal Panel - Community - Renal function panel"
Sodium: 139 mmol/L (135-145)
Potassium: 4.3 mmol/L (3.5-5.0)
Chloride: 106 mmol/L (98-110)
Urea: "H" 8.8 mmol/L (3.0-7.1)
Creatinine: 98 umol/L (60-130)

Second set of labs: July 26, 2014 (8:03 a.m.)

"Magnesium"
Magnesium:0.98 mmol/L (0.66-1.07)

"Sex binding Panel" - free t was requested but not done don't know why, haven't had a chance to talk to doc again yet
Test - Total: 14.10 nmol/L (5.80-28.00)
SHBG - 25 nmol/L (13-71)
Free Androgen Index: 57.6 (14.8-94.8) - free androgen index was designed for women and does not correlate well in men so I don't put much value in this
Prolactin: "H" 20.28 ug/L (2.60-18.10) - no orgasm within 48 hours of test
Estradiol: 68 pmol/L (<205)
FSH: 0.92 IU/L (Male 13-70 yrs: 1.4-18.1)
LH: 1.80 IU/L (Male 20-70 yrs: 1.5-9.3)

"Thyroid"
TSH: 3.24 mIU/L (0.35-5.0)
-"additional thyroid function tests requested were not assayed. A free t4 and or free t3 will be done if TSH is abnormal"

"Liver Panel"
Billirubin: 11 umol/L (2-20)
ALP: 107 U/L (40-135)
ALT: 29 U/L (4-55)

"Other"
PSA: 0.3 ug/L (0.0-4.0)
Vit-B12: 654 pmol/L (175-880)
Phosphorus: 1.49 mmol/L (0.75-1.55)
CRP - C reactive protein; high sensitivity: 0.4mg/L (0.0-8.0)
CK - Creatine Kinase: "H" 862 U/L (55-170)
Calcium: 2.40 mmol/L (2.14-2.66)
Albumin: 41 g/L (35-50)
Corrected calcium: 2.38 mmol/L (2.14-2.66)
Iron: 11.3 umol/L (7.0-32.0)
TIBC: 70.3 umol/L (45.0-80.0)

Describe diet: diet I would say is quite healthy. Lately I have been doing a cyclical ketogenic diet.

Describe training: 6 days/wk with 2 heavy compound lifts (5x5) and supplemental high rep lifts as needed. Take a day off if i'm gassed or no motivation.

Testes ache ever: Yes, notice a dull ache. Not 24x7 but often enough.

How have morning wood and nocturnal erections changed: Infrequent morning wood at half mast.

I have read the stickies and am ready to print out the protocol for injections and take it to my doc and hope for the best. Sick of feeling like this. Any thoughts and advice are much appreciated.


#2

Kona, firstly, congratulations on your weight loss over the past two years. That is a great accomplishment that you should be extremely proud of! Also, congrats off of trying to ween out of your anti-depression meds. After six years of SSRI's, that must also be an extremely difficult process. It's clear you are a mentally strong guy to do both and you shouldn't short change yourself on both of those great accomplishments.

I only wanted to note that after such a prolonged cut, you should note that it's not reasonable to expect your gym gains to come at the pace you experienced them in the past. It is extremely, extremely rare that an experienced lifter gains strength while on a cut. The expectation is to maintain as much strength as possible during the cut, not gain. The one time this is not necessarily the case is for very overweight folks and new lifters that either have the extra fat to burn while still building strength and/or have the benefit of experiencing the "newbie" exponential gains of a beginner. Once these two factors end (either you are no longer over weight or you extinguish your newbie gains), you are back with the rest of us: few if no gains during a cut. The point of bringing that up is that your slow gains (or even regression) is not an abnormal element if you are continuing to cut, especially after such a prolonged period. That type of prolonged weight loss can also have a detrimental effect on your libido. I think it is a mistake to point to that as being caused my "low test" (which you don't seem to have, based on the above).

Have you considered taking a two or three month "diet break", where you say give yourself the goal of straying at 179, say, and just continue to recomposition, or at a minimum gain some strength? Just a simple plan to 1) give your body a break from your very long diet and 2) on a maintenance calorie, you will likely see your strength increase a bit and your progress increase a bit, which is a psychological boost you seem need. Y

ou may likely also your libido change for the better. It's important you explore all options before jumping on something that may permanently mess with your hormones and cause additional problems, especially at such a young age.


#3

Cut wasn't prolonged. I did slow carb and cut down to 175 inside of 4 months. The diet I am on now is anabolic and is well above maintenance cals. I linked to the details of the diet but mods don't like links I guess. It is Jamie Lewis's Apex Predator diet.

First test gives me a total test below the average 85-100 year old man. Second test (done @ 8:00 a.m.) gives a total test well below the average levels for men aged 55-59, in the 5th percentile for men my age. Who wants to be a bottom of the barrel man? I don't want to be on TRT if it is unnecessary for me but my quality of life is not good and has been this way for a while. My LH and FSH numbers being so low are a concern with FSH well below range and LH barely in range. If anyone has any insight on these numbers as well as the elevated prolactin it would be much appreciated.

Sources: Vermeulen, A. (1996). Declining Androgens with Age: An Overview. In Vermeulen, A. & Oddens, & B. J. (Eds.), Androgens and the Aging Male (pp. 3-14). New York: Parthenon Publishing.

Simon, D., Nahoul, K., & Charles M.A. (1996). Sex Hormones, Aging, Ethnicity and Insulin Sensivity in Men: An Overview of the TELECOM Study. In Vermeulen, A. & Oddens, and B. J. (Eds.), Androgens and the Aging Male (pp. 85-102). New York: Parthenon Publishing.


#4

"Thyroid"
TSH: 3.24 mIU/L (0.35-5.0)
-"additional thyroid function tests requested were not assayed. A free t4 and or free t3 will be done if TSH is abnormal"

This is a problem and the ranges are useless. TSH should be nearer to 1.0

Please read the 'thyroid basics sticky", check your waking and mid afternoon body temperatures. Evaluate your long term iodine inputs from iodized salt and any vitamins that list iodine. If using sea salt, kosher salt or Himalayan sea salt you are iodine deficient.

Thyroid problems can make you fat, make weight loss unobtainable and can also kill hormones in some cases.

Read the advice for new guys sticky to start to understand the issues and lingo.

Prolactin can also suppress LH/FSH. With low LH/FSH and elevated prolactin, you need to have an MRI to see if there is a prolactin secreting pituitary adinoma. You meet the diagnostic criteria for the MRI.

Prolactin can the be reduced with 0.5 mg/week [oral] cabergoline/Dostinex. If that increases LH/FSH, that would be a good result.

Do not shrug off the thyroid issue. Functional thyroid problems can cause the same spectrum of symptoms of low testosterone, you can be getting doubled up symptoms.

Also read this third sticky: the one about things that can damage your hormones.

Action items:
- read three stickies
- check body temperatures
- eval long term iodine intake, get iodized salt if not in use
- get pituitary MRI
- then get Rx for cabergoline and retest TT, LH/ FSH after 6-8 weeks [you may simply feel better]
- if any hint of gyno, get E2/estradiol tested and manage with anastrozole if possible


#5

KSman thank you for your input in my thread here. I have read through the recommended stickies again, it is a lot of information to soak up. As for iodine intake I use table salt pretty liberally but not sure if it is iodized or not and my multi-vitamin has 150 mcg, as you point out this would lead to going nowhere fast anyway if iodine deficient. Will go to check out gnc/health stores tomorrow for an iodine replacement supp.

Will also pick up a thermometer and report back with body temps. I do have chronically cold extremities a lot of the time, and do have a family history of thyroid problems, my mom takes thyroid meds. Will also book appointment with doc and request pituitary mri. I played jr. hockey competitively for several years and did get a few concussions, one bad enough to induce vomiting and stayed in a dark room for a couple days after.

I am wondering if this could be more to do with the damaged HPTA as a prolactin secreting pituitary adenoma would have prolactin levels in the 150-200 range rather than slightly elevated? - http://pituitary.org/knowledge-base/disorders/prolactinomas

Article about hormones and TBI's: http://www.lef.org/magazine/mag2012/jan2012_Using-Hormones-Heal-Traumatic-Brain-Injuries_02.htm

Question:

1) What kind of LH and FSH levels would one expect in an HPTA intact 27 y.o. male assuming healthy thyroid, adrenals, etc.?


#6

Ok I did some more googling and it appears with larger pituitary adenomas "can slightly elevate blood prolactin levels. Doctors think this occurs because of compression of the pituitary stalk, the connection between the pituitary gland and the brain. It is called the "stalk effect." Prolactin levels are only slightly elevated, as opposed to prolactinomas in which the prolactin level is usually very high." - http://pituitary.ucla.edu/body.cfm?id=47


#7

Interesting link re injuries.

LH/FSH levels vary from guy to guys as well as T levels. Your levels are very low. We do not get to see labs here from young virile normal guys so I don't have that context.

We do see a couple of guys each year here with prolactin levels in the elevated range like yours and some have abnormalities in their MRI's

It might not take much prolactin to suppress LH/FSH levels, but as you point out, there seems to be a cause of both issues so perhaps the link is not as it once seemed.

You are doing some very interesting research!


#8

Body Temps:

Sunday Aug. 24, 2014
2:44 p.m. - 96.7 (Took my 3 year olds temp. for comparison = 99.0)
3:20 p.m. - 96.4 (3 year old = 98.5)

Monday Aug. 25, 2014
6:00 a.m. - 95.6 (lay in bed half asleep until 7:00 a.m.)
7:00 a.m. - 96.8
12:15 p.m. - 97.3
5:15 p.m. - 97.0

All temps taken 3 times and averaged except for my 3 year old because she would not put up with that nonsense. "I am not sick Dad!" I am working a manual labor job right now so i'm not sitting in an a/c office during the day. I have a feeling my doc is gonna give me the "ok pseudo intellectual, looking things up on the internet" look.. when I ask for a pituitary mri.. Oh well hopefully he'll work with me to get to the bottom of things. He gave the expected "within range" spiel in regards to the T levels.


#9

Just got done a heavy workout and sweating buckets checked the body temp and I was expecting for sure to be higher. 9:15 p.m. - 97.1.


#10

Update: Went back to my GP to inquire about elevated prolactin and ask about pituitary MRI. He indicated a second test would be necessary in order to justify an MRI. Second result came back just within range, I am not at home right now and do not have the results in front of me.

I asked about an Rx for cabergoline and asked about my LH/FSH levels being so low if there could be a pituitary problem. The vibe he was giving me was that he thinks I am just being a hypochondriac. He said the questions I had were beyond the scope of his knowledge and asked if I wanted a referral to an endo. He said I could expect to here from the endo’s office within a month or so.

After 6 weeks or so I contacted the endo’s office and the receptionist indicated I could expect to wait at least 12-14 months for an appointment.

I did iodine replenishment with 50mg/eay for 2 weeks with lugols and didn’t notice much of anything other than my finger nails seem thicker. I contacted a compounding pharmacy in my city that advertises on their website that they do consultations for HRT for men and asked if they could recommend a local GP that is knowledgeable in men’s hormonal health and they gave me the number of a doctor that I am going to try and get an appointment with when his office opens on Monday.

I would appreciate any input from KSman or other knowledgeable members about questions or a treatment plan I could communicate to him. My thinking is that 350 ng/dl TT seems to be the “cut-off” diagnostic criteria among compassionate/progressive physicians treating age related androgen deficiency. My TT results coming back at 337 ng/dl and 406 ng/dl coupled with very low LH/FSH numbers for a young man point to a shut down or repressed HPTA/secondary hypogonadism. In terms of what to ask/suggest, this is what I am thinking:

  1. Prolactin elevated - can I have the MRI just to rule it out? Is cabergoline appropriate to teat the elevated prolactin, is the elevated prolactin suppressing my LH/FSH?

  2. Low dose (10mg/d) nolvadex for a period of time to attempt HPTA restart and re-test LH/FSH, TT,


#11
  1. If HPTA restart doesn’t work then start TRT