T Nation

31 Y/O - Case Notes


#1

Age: 31
Height: 5'8"
Waist: ~35" and ~37" at belly button
Weight: ~180lbs

Body/facial Hair: Body hair is very light in texture, but I have it. I would look silly if I didn't shave because it's pretty sparse/patchy.

Where I carry fat: Mostly in my stomach/midsection

Health Conditions/Symptoms/History: Diagnosed with varicocele in late teens. Dr. told me it was only an issue if it bothered me cosmetically. My primary complaints are: low energy/motivation, frequent depression/anxiety, difficulty concentrating, low sex drive, weak/infrequent erections. Most of this has been an issue since my early-mid twenties. I may have morning/nocturnal erections once a week. I'm pretty much sedentary (IT) and currently work the night shift.

I recently went to a GP with these complaints and a list containing almost all of the tests from the lab work sticky post. She said we'd need to start with a subset and work incrementally to keep insurance from getting upset. I called to schedule a followup appointment after getting the results shown below, but she was no longer with the clinic (gone at least long enough for maternity leave), so I'll be starting over with a new doctor. She referred me to a urologist to examine the varicocele and discuss if/how it would impact fertility (wife and I are thinking of kids in the next year or so). I was waiting for lab results to come back and will schedule that soon.

Drugs: Ambien to sleep (prescribed) and small doses (50 - 100mg) Modafinil (self-treatment) as needed to function on night shift. I spent a couple of months taking prozac a few years ago and didn't refill because it didn't seem effective. No hair/loss or prostate drugs.

Lab results:

== 3/2013 7:30 AM - Quest (fasting) ==

-- Lipids --
Cholesterol, Total: 186 (125-200 mg/dL)
HDL: 49 (>= 40 mg/dL)
Triglycerides: 121 (<150 mg/dL)
LDL: 113 (calc) (<130 mg/dL)
HDLC Ratio: 3.8 (calc) (< 5.0)
Non-HDL: 137 (calc) (>30 mg/dL over LDL)

-- CMP --
Glucose: 98 (65-99 mg/dL)
Urea Nitrogen: 16 (7-25 mg/dL)
Creatinine: .95 (0.6-1.35 mg/dL)
eGFR Non-Afr. American: 123 (>= 60 mL/min/1.73m2)
Sodium: 140 (135-146 mmol/L)
Potassium: 4.2 (3.5-5.3 mmol/L)
Chloride: 104 (98-110 mmol/L)
Carbon Dioxide: 26 (19-30 mmol/L)
Calcium: 9.9 (8.6-10.3 mg/dL)
Protein, Total: 7.1 (6.1-8.1 mg/dL)
Albumin: 5.0 (calc) (2.6-5.1 mg/dL)
Bilirubin, Total: 0.7 (0.2-1.2 mg/dL)
**Alkaline Phosphatase: 37 (40-115 U/L)
AST: 16 (10-40 U/L)
ALT: 18 (9-60 U/L)

Hemoglobin A1c: 5.3 (<5.7 % of total Hgb)

**Vitamin D, 25-OH, Total: 22 (30-100ng/mL)
Vitmain D, 25-OH, D3: 22 ng/mL
Vitmain D, 2-OH, D2: <4 ng/mL

Magnesium: 2.1 (1.5-2.5 mg/dL)

TSH w/ reflex to FT4: 1.08 (0.4-4.5 mIU/L)

-- CBC --
White cell count: 5.0 (3.8 - 10.8 k/uL)
Red cell count: 5.26 (4.2-5.8 M/uL)
Hemoglobin: 14.9 (13.2-17.1 g/dL)
Hematocrit: 44.8 (38.5-50.0%)
MCV: 85.1 (80-100 fL)
MCH: 28.4 (27.0-33.0 pg)
MCHC: 33.3 (32.0-36.0 g/dL)
RDW: 14.1 (11.0-15.0 %)
Platelet count: 224 (140-400 k/uL)
Abs. Neutrophils: 2935 (1500-7800 cells/uL)
Abs. Lymphocytes: 1525 (850-3900 cells/uL)
Abs. Monocytes: 400 (200-950 cells/uL)
Abs. Eosinophils: 110 (15-500 cells/uL)
Abs. Basophils: 30 (0-200 cells/uL)
Neutrophils: 58.7%
Lymphocytes: 30.5%
Monocytes: 8.0%
Eosinophils: 2.2%
Basophils: 0.6%

**Testosterone, total: 338 (241-827 ng/dL)

Diet: On-and-off low carb (carbs/sugar/wheat makes me really tired and feel even worse than normal). It's been pretty crappy overall w/ fast food several times a week. Since going to the doctor, beginning to educate myself, and realizing that fixing my diet might make a big difference in how I feel, I've been avoiding wheat and carbs and have been taking a multi-vitamin, B complex, 5,000 IU sublingual B12, 5,000 IU vitamin D, fish oil, and 500mg magnesium oxide. I ordered the following supplements which should be here tomorrow: zinc picolinate, vitamin E, Lugol's iodine solution, magnesium citrate (to replace oxide), and some lithium orotate (to have on hand in case I want to try it). I've been using non-iodized salt for the last couple of years.

Training: Nothing significant

Testes ache, ever, with a fever?: Periodic aching I believe, but this is the sort of thing I would not have previously given much thought to :(.

===========

So, as mentioned above I'll be making an appointment with a urologist soon. Hopefully he'll be willing to order whatever (at least the next phase) of tests I request. I appreciate any input on which tests my previous results indicate are most important, any thoughts on my current results, what I should bring up with future doctors, and commentary on supplements. Is it possible that the low D and poor diet explain the low (based on what I've read should be normal for 31YO) total testosterone? Might things improve significantly after fixing these?

I'm thinking along the lines of asking (again) for: FT, DHEA-S, Estradiol, Cortisol, LH/FSH, and SHBG. I'm thinking we're not in the clear on thyroid-related issues (see temps below), so should try for the fT3, fT4, rT3 labs. ... still so much to learn.

Thanks for taking the time to read/comment on this. Let me know if I can clarify/add anything. Also, I have Lipid/CBC/CMP results from about a year ago that I can type up if they would be insightful.

Edit: I left out temperatures I took a few days ago. (6:45AM: 96.9 F), (9:04AM: 97.6 F), (12:43PM: 97.9 F), (3:08PM 97.9F), (7:09PM 97.5).


#2

I'm 30 w/similar scores/symptoms and also was on an ambien/stimulant combo for working weird hours. I'm new to this but have been reading a lot. Just my opinion: It's not low D, everyone has that. It's not poor diet, everyone has that. It might be the lack of sleep from working the night shift though.

I think you'll want to read up on Adrenal Fatigue. I'd start with Wilson's book "Adrenal Fatigue." As KSMan says, it's too much to put on the internet. There are some specific supplements/strategies you can put into place to help support the strain you put on your body.

I think the follow-up tests you describe are necessary.

As far as treatment, I would not take Test from anyone unless they explain how you'll stay fertile when you want to have kids. Most TRT docs use HCG to achieve this, not sure what a urologist will say.


#3

I ordered Wilson's book - thanks for the recommendation. I went ahead and started with "small" doses of the Lugol's, since it seems to be indicated by the low body temps. The highest afternoon temp I've been able to get has been 98.1F, even following the no eating/talking/drinking protocol.

The earliest urologist appointment I could get was 3 weeks out. In the meantime I'm going to keep reading through the sticky posts as I add another little piece to the puzzle each time through.

To be honest, TRT scares the crap out of me based on what I've read here. Obviously I don't have nearly enough data or knowledge yet to make any sound decisions, but I see myself keeping TRT as a last resort. My 338 TT doesn't seem as low as many on this board, so maybe TRT isn't really needed in my case.


#4

TSH looks perfect. High or low TSH indicates problems. But TSH=1.0 does not indicate absence of a problem.

Low T and high albumin is rare. Would expect mid or lower albumin with lower T.

Your suggested labs are good!
Cortisol, get up a a normal time, do lab work at 8AM. Problems with guys to get up a 5AM, go to the gym, then do labs.

Yes, do your suggested thyroid labs. If doc asks why, tell him because your body temperatures are low.


#5

Just a quick update on the urologist appointment today. He thinks I should be in the 500ng/dL range. He said that if fertility wasn't an issue we would be having gel/injection discussions. He prescribed 50mg clomid EOD for 3 months and then a follow up appointment. If that doesn't work he mentioned possibly referring me to a colleague that knows about AI.

He didn't feel any of the tests I requested were necessary at this time. He felt that we already know I'm low test per TT on the last lab, and FT and SHBG weren't important unless/until we were doing TRT. He said to wait on the E2 test until after the 3 months of clomid. He implied the thyroid/adrenal tests were out of his area of expertise and that it wasn't relevant to what he was trying to do. I asked about possible causes for the low test and he just said it was idiopathic, that we just wear out.

Please share any thoughts ... I went ahead and took my first clomid dose, but should I stop/wait and go get FT/E2 or any other baseline before continuing? If I'll be regretting not having a baseline in 3 months from now then I can get these out of pocket. I see clomid has potential here, but didn't have enough advance knowledge to bring up nolvadex. Are there any reasons not to go down the path he laid out?

Overall I think I can work with this guy ... at least he didn't say my TT was in range and send me home.


#6

Idiopathic means "we don't know the cause". He's right that he doesn't know the cause, but you still have the ability to try. Something is wrong, whether it is a nutritional defect, a thyroid problem, some kind of stress/adrenal issue, or something else. I'm 30 and for me the low T cause seems to be a combination of sleep problem (was also on ambien), thyroid and diet. Also going to be trying clomid, but I'm doing a cycle of HCG first. Looking forward to your results.

It's up to you to decide if you want to find the root cause. It may or may not be possible. It will probably be expensive because insurance is not very supportive. For example, your MD probably didn't want to run those extra tests because he doesn't want to get dinged by insurance.

I've read that when you're on Clomid the E2/SHBG test is worthless.

You might think about adjusting the dose though. Some docs use 12.5mg-25mg a day, EOD, or even 3x week. Very interested to hear what others here think about that.


#7

Clomid:
- that dose may push LH too high, then testicular T-->E2 can be very high [and immune to AI]
- you will need to check LH/FSH, TT, FT and E2 to see where things are going
- never dead stop a SERM. Must taper off of slowly, HPTA recovery is possible, land on 0.5mg anastrozole/week
- if you feel emotional or fubar on clomid, switch to nolvadex. Clomid does have estrogenic effects for a few guys [not rare]
- all SERM's will increase E2 levels, only AI lowers E2.


#8

I had my 3 month followup with the urologist last week. I told him that I haven't seen much improvement after 50mg clomid EOD for the last 3 months. He ordered CBC and TT tests, and had no hesitation to add LH/FSH, FT, and E2 when I explained why I though they were relevant.

He called today with the results and said TT = 892 and E2 = 74. I don't have the other numbers or ranges until I can make it into their office to get a copy of the lab results (probably Monday). I'll edit this post with the detailed data/ranges as soon as I get it. When he called, he went down the path of telling me I was in good shape due to TT being where it should be, and it didn't seem like he was going to mention E2 until I asked him about it.

After he told me it was 74, I mentioned that I thought that might be high enough to negate the TT improvement, and that we should discuss AI treatment. He agreed and said more-or-less that prescribing clomid is about the extent of his knowledge about this, but that they would set up an appointment with one of his male fertility colleagues that specializes in AI treatment. Problem was that he had no appointments until September :(. They're working on finding something sooner for me, but no guarantees.

At this point I'm not sure if I should keep on taking 50mg EOD or start tapering off. What are your thoughts on long term SERM+AI treatment? I have a feeling that my life would be much improved by keeping TT where it is and knocking E2 down in the 20s. This doctor doesn't seem to grok the whole picture, but then again he probably doesn't read tnation. So, what are your thoughts and recommendations? At this point I don't know whether he intended to just keep my on my current clomid regimen or not. I could probably either convince him that we could work together to get a good E2 result from AI, or find somewhere to self-prescribe an AI .... just not sure yet.

What should I be shooting for here? 892 TT and 20 E2? Any other tests that would pull us in the right direction?


#9

I dropped my clomid dose to 25mg EOD (half of what it has been for the last 3 months) after uro told me E2 was 74 on the phone. I have an appointment with the new doc next week, so we'll see what he says. Please share any thoughts/suggestions.

Here's the labs (7/12/2013 11:30AM):

=== CBC ===

WBC 6.4 x10E3/uL (4.0 - 10.5)
RBC 5.61 x10E6/uL (4.14 - 5.80)
Hemoglobin 16.0 g/dL (12.6 - 17.7)
Hematocrit 49.7 % (37.5 - 51.0)
MCV 89 fL (79 - 97)
MCH 28.5 pg (26.6 - 33.0)
MCHC 32.2 g/dL (31.5 - 35.7)
RDW 14.0 % (12.3 - 15.4)
Platelets 218 x10E3/uL (140 - 415)

=== FSH & LH ===

LH 21.2 mIU/mL (1.7 - 8.6)
FSH 19.9 mIU/mL (1.5 - 12.4)

=== Testosterone ===

Testosterone, Serum 892 ng/dL (348 - 1197)
Testosterone, Free 21.0 pg/mL (8.7 - 25.1)

=== Estradiol ===

Estradiol (Roche ECLIA) 74.6 pg/mL (7.6 - 42.6)


#10

In my opinion which is just my own. I think you have done the right thing :slight_smile:

Dose was to much


#11

Thanks for your feedback. I couldn't think of any reason to stick with 50mg EOD with LH, FSH, and E2 that high. What do you think about my LH/FSH being so high? I've run across labs of other guys on the clomid path and their LH/FSH weren't nearly as high as what I ended up with.

I don't really know what to ask for from the new doc when I see him. I feel conflicted between the following options:

  1. Taper off the clomid and see where my numbers are in 6 weeks. This would give me a baseline, which I'm missing now. I really wish I knew what my LH, FSH, FT, and E2 looked like before starting the clomid. Unfortunately I only know what TT was. The only thing I have been able to conclude is that my testicles are capable of producing more testosterone when flooded with LH.

  2. Continue with the clomid at a reduced dosage and add an AI. I haven't found any definitive information about the long-term safety implications of this. Does anyone know of risks of LH receptor down-regulation?

I'm planning on getting a 4x cortisol test soon (I found it online for $109 or so). I strongly suspect my adrenals are out of whack due to working 3rd shift. Unfortunately, getting off 3rd shift isn't an option for me for at least another 12 months, so I'm not really sure what steps I could take to improve my adrenal situation in the meantime.

I'd love to hear anyone's thoughts on the two options I mentioned above, any suggestions on where to steer the new doc, my labs results, or anything else. Thanks in advance.


#12

If I were you I would taper off clomid and land on the AI and start from scratch. Dose was to high and you need to know these answers in order to move forward with an educated choice of treatment. It is possible to desensitize lh receptors. Back off and see where you land

Wait a month to 6 weeks and test everything again


#13

I have not done this myself, but from everything I have read, I would add an AI like anastrozole, taper off the clomid slowly, and continue with anastrozole for awhile after being completely off clomid to prevent estrogen rebound, which will put you back at square one.

Do some research on estrogen rebound after SERM use.

If you're feeling tired, I would suggest to anyone to get a 4-point cortisol test. At the very least it will rule out adrenal function as being the culprit for fatigue.