T Nation

33 y/o Guy TRT Candidate 01/16


#1

Hey guys. This is a great forum and I feel like it will be a solid source of support as I power through all of this stuff. I just received a referral to an endocrinologist at a mens health institute so I figure I will start my case now and update as it progresses.

I just want to preface this by saying I’ve been reading the board for months (including all stickies) so if I miss something or violate the rules in any way it is purely accidental.

My story isnt unusual. I’m 33 years old, I work as a nurse, I’m in relatively good shape, eat healthy, no family history of anything on either side. Living and working downtown in a big Canadian city. I first sought treatment for ED when I was 27 (6 years ago) and finishing university. Got a 5PDE inhibitor prescription, and used it on and off for the next three years. In retrospect this was coupled with a waxing and waning libido, but I didn’t really notice then.

Long story short, over the course of the next 5 years there was a generalized decline in my sexual functioning, ending finally with zero libido and avoidant behavior when it came to sex. I also went from 165lbs and 14%BF to 183lbs and 20% BF with no clear change in diet or training. I attributed this to a lot of things; stress, night shifts, work, school, etc. But when I was having other symptoms like high emotions, irritability, fatigue (I couldn’t do anything without a cup of coffee first) patchy body hair loss, and a dull ache in my testicles, I figured it was time to go ask for a blood test. I did this on Dec 17 and the results are below.

My free Testosterone came back at 116 pmol/L (or 33 ng/dL) which is low. For every reference range I could find, it was consistently low. My FSH is also low (1), though not my LH (7). My GP referred me to an endo who specializes in this stuff, and I will see him in the next 2 weeks, at which time I am expecting he will order more bloods before deciding what we’re going to do.

My main question for you guys is what questions should I go prepared to ask him on that first appointment, and what to expect. I typically work on the other side in the health care system and I really don’t know what to do now that I’m a patient. I feel like I should know this stuff but I just don’t know where to start. On one hand I’m happy there is a reason for all these symptoms so that they can be fixed, but on the other hand the journey seems pretty daunting at this point.

Thanks. Looking forward to seeing how this turns out.

Age: 33y 5m
Height: 5ft 9in
Waist: 32
Weight: 180lbs

Describe body and facial hair: Reasonable beard, but not particularly thick; moustache is thicker. Hairy legs, moderately hairy arms, hairy stomach. Chest hair is patchy, wiry, and uneven. Full head of hair (dad and brother have been bald since their early 20s). No back/neck hair.

Describe where you carry fat and how changed: Stomach and flank/lower back, increasingly difficult to lose. Lean mass difficult to gain or maintain.

Health conditions, symptoms: Epididymitis at age 10, treated with antibiotics. ED since 2010, taking a 5PDE inhibitor off and on since then, but regularly since 2014. No history of head trauma.

Rx and OTC drugs, any hair loss drugs or prostate drugs ever: No current OTC drugs. Taken acyclovir in the past, and hydromorphone following shoulder surgery in 2014. Supplement only with fish oil 900mg BID and VitD 2000IU OD. No hx of anabolic steroids or hair loss drugs.

Thyroid: Temperatures are nothing exciting. 97.5avg x 3d on waking, and 97.8avg approaching midday. TSH is close to 1, fT3/fT4 are both mid-range. Use iodized salt. No specific hypothyroid symptoms.

Lab results with ranges:
Vitamin B12 402 pmol/L
Ferritin 118 (24-453 ug/L)
Sodium 140 (136-146 mmol/L)
Potassium 4.4 (3.7-5.4 mmol/L)
CK 354 (<225 U/L) HIGH
ALP 52 (40-129 U/L)
AST 30 (<37 U/L)
ALT 22 (<46 U/L)
TSH 1.15 (0.35-5.0 mIU/L)
Free T4 17 (12-22 pmol/L)
Free T3 5.0 (2.6-5.7 pmol/L)
HgbA1c 5.3 (<6.0%)
Free Testosterone 116 (196-636 pmol/L) LOW
*This translates into 3.3 ng/dL
LH 7 (2-9 IU/L)
FSH 1 (2-12 IU/L) LOW
Hemoglobin 147 (135-170 g/l)
Hematocrit 0.46 normal
Creatinine 103 (60-110 umol/L)
Cholesterol 5.03 (<5.2 mmol/L)
Triglycerides 0.7 (<1.7 mmol/L)

Describe diet: Three solid meals + 2-3 snacks a day. Whole foods, do all my own cooking., well balanced. Keep refined sugar, soy, grains, and any processed foods to a minimum. 2 cups of coffee a day but recently switched to green tea. Alcohol intake is minimal (roughly 4-6 beer per month) and I don’t smoke.

Describe training: Weight train 3x week, usually one body part. Cycle 2x week, yoga 2x week.

Testes ache, ever, with a fever? Ache yes, usually at night. Not severe, more like dull ache sort of like blue balls. No fever.

How have morning wood and nocturnal erections changed: Inconsistent. When it’s hard it’s never really hard and doesn’t stay hard for long.

I will note though that I do work in a hospital (intensive care unit), and spent a year administering chemotherapy in a clinic (though no known direct exposure to any cytotoxic agent.)


#2

fT3 regulates mitochondrial metabolic rate and thus body temperature. fT3 level is more than enough to deliver decent body temperatures. In this case, we suspect that rT3 may be blocking fT3. Please see the thyroid basics sticky and note references to rT3, stress, adrenal fatigue and Wilson’s Book.

I have a suspicion that of the stressors that can lead to elevated rT3, that low thyroid function [body temperatures] may be a significant factor itself. It makes things a struggle by having to compensate with more willpower[stress] to overcome.

Patchy hair thinning may be from low thyroid function.
Are your outer eyebrows sparse?
Fat gain and inability to loose weight is probably from low T and low thyroid function.

Body temperatures reflect the balance of the effect of thyroid hormone levels, mostly fT3 and rT3.

2,000iu Vit-D3 may not be enough in your climate!
All the more of a concern with night shifts!
Please find 5-6,000iu Vit-D3 tiny oil based caps. Take ~25,000 for first 5 days.
Take fish oil and vit-D3 with a meal that has more fats/oils and less fiber.

Labs:
rT3
prolactin
total testosterone [or SHBG]
AM cortisol [at 8AM please] (adrenal function)
DHEA-S [not DHEA] (adrenal function)
CRP
homocysteine
CBC to look for anything odd in antibodies

When considering rT3, we need to look for signs if inflammation or chronic infection.

fT3 has a short half life and is pulsatile. Lab results are influenced by lab timing. TT levels are steadier and are often a better indicator. In any case, you need TRT unless we can identify and correct a cause.

Was there a blow to the head prior to problems starting years ago?

Testes softer now?
Hanging normally?
[indicator of LH]

TRT care in Canada is typically rather poor. Not good in Ontario. Indications that better in Alberta and BC.
Transdermal T delivery my not work for you because of low thyroid function.
See the protocol for injections sticky.

Suggest:

  • a multi-vit that contains trace elements including iodine and selenium that does not contain iron
  • natural source Vit-E

Blood pressure and resting BP? + time-line for changes

Note that FT lab ranges vary a lot from one lab to another. Really cannot eval FT without lab range references. We have one lab in USA that has FT levels 4x5 times higher than some others.


#3

Thanks for your reply, this is great information.

Before I go any further though I want to point out an error: My midday body temperature is 98.6, not 97.8. We use different units of measurement in Canada and I didn’t convert properly. My point was that my body T is normal, which is what I meant by it’s not very exciting. To answer the other questions though, my outer eyebrows are fine and my tolerance to cold is normal. The patchy body hair is only on my chest - I haven’t experienced any hair loss anywhere else.

I’m expecting the endo will order most of the tests you suggested as I’m anticipating that he will work me up for a prolactinoma if my prolactin is high. Though I feel like if that was the case, both my LH and FSH would be suppressed whereas it’s only my FSH that’s decreased (and this doesn’t explain the low T). It would almost be more satisfying if my LH was low. Causes for this are largely lifestyle related (e.g. obesity, diet, etc.), a pituitary adenoma, or idiopathic. Fingers crossed for idiopathic.

No blow to head in my history at all. Testes were always a bit larger than normal. Lately they are definitely smaller in volume though hang and consistency seems to be relatively unchanged. BP is 120/70 consistently, and resting HR is 60. In terms of timeline for changes (if I interpret your Q correctly), I first sought help for ED in 2010 and noticed a sharp increase in my need for the 5PDE in Jan 2014. Specific low T symptoms (low libido, irritability, etc) began early 2015. No precipitating events that I can recall.

Ranges for FT are next to the value; my level is 116 with lab ranges of 196-636 pmol/L. I have also since stopped working night shifts as of September 2015.

I will try the VitD although 25,000IU seems a bit excessive.

Any comment on the low FSH/normal LH as they relate to my low FT?


#4

Vit-D3 is made in the summer [you hope] and stored for darker times. Vit-D3 300,000iu has been used in studies and 50,000iu is available and also offered in some doctor’s office. My recommendation was to build up your reserved. Vit-D3 is slowly converted to Vit-D25 which is a true steroid hormone that is mission critical. RDA is not optimal, but prevents bent bones in children.

LH has a short half life and lab may have caught the peak of a pulse. FSH has a longer half life and ‘normally’ is a better indicator of LH status than LH itself. A LH secreting pituitary tumor is rare, but if that happens, a constant level of LH, instead of pulsatile can make LH receptors insensitive. But that is a long shot…

Thyroid is good! No need for rT3 labwork.


#5

OK got it about vit-D3. I’ll check out my pharmacy for the gelcaps and failing that I’ll enquire with my GP when i go for follow up.

Yeah my big question mark was the LH/FSH/FT relation. When I was first treated for ED back in 2010, my GP drew a FSH which came back low at 1.2, though my FT at that time was 474. These numbers have no relevance now, but maybe I’ve always had some level of FSH hyposecretion and only now it’s becoming clinically apparent.

Other labs drawn at that time (2010, 27 years old):
Prolactin 11.5 (2.7-16.9 ug/L)
Estradiol 150 (55-165 pmol/L)
*this translates to 41 pg/ml
Cortisol (random) 292 (83-690 nmol/L)
Total Testosterone 22.80 (8.6-23.9 nmol/L)
Free Testosterone 474 (196-636 pmol/L)
SHBG 35.7 (8.7-44.5 nmol/L)
DHT >8600.0 (860-3406 pmol/L) - Never did figure out what this was all about.

I’m not too hopeful about TRT being offered very quickly - it’s been reported in the media as being overprescribed in Canada and lately I would imagine the decision to prescribe it is not taken lightly. In any case, for someone like me who is highly symptomatic and with a documented low FT, I would hope that it’s at least discussed as a treatment option because I’m really struggling here.

Any other Canadians on here who can share their experience with TRT docs in Canada?


#6

My earlier comments re TRT in Canada are based on dealing with many CDN guys. Every Province is different. What does the media know when many hypo guys are not getting proper medical care?

E2=150pmol was bad. Ideal would be around 80.
SHBG was high because of E2.

TT was good but FT may have been low because of T+SHBG dominance.

You were put on TRT based on those labs? I would have suggested an AI only and looked for reasons that E2 was elevated. Many on TRT with E2=41pg/ml would be moody/depressed with reduced libido.


#7

That’s fair. I’m in Ontario so I guess I’ll find out soon enough what the docs are like here. To my advantage though I’m a nurse and I speak their language so hopefully that will get me somewhere with them.

Those labs in my previous post were done in 2010. I moved from the city I was living in shortly after and the results were never followed up on, so no I wasn’t put on any treatment. Looking at them again now though I agree a AI would have been indicated. I imagine when I go for my initial visit with the uro/endo they’ll draw another E2 so I’m interested to see what it is at now.


#8

In USA, we can find 5,000iu Vit-D3 in Walmart vitamins section. It should not be a specialty item.


#9

Update (January 26, 2016)

I had my initial appointment with a urologist specializing in sexual medicine and andrology at Mt. Sinai in Toronto this morning. Honestly I had no idea what to expect and was pretty nervous but here’s how it went.

I basically sat at a computer and filled out a 6 page questionnaire - normally I’d be a bit weary about these things but it covered pretty much everything. I was seen pretty quickly after that. The doc just asked me a few questions about my history, and said that my T is definitely low, but it was somewhat concerning given my age. In any case, he said that I would need androgen replacement therapy. I had baseline labs drawn after my appointment and I’ll see him again the three weeks to discuss next steps.

In addition to all the regular labs, he also ordered TSH, prolactin, E2, FT/TT, and LH/FSH. I have to say I was not hopeful at all given others experiences with TRT in Canada, but I was super relieved and happy with how that went this morning.

It’s nothing short of relieving to know that there might be a solid solution to this.


#10

Nice progress! Looking forward to details.


#11

New bloods (Jan 26, 2016)

First follow-up with uro (the one I was so optimistic about last time) today. Didn’t go exactly as I’d thought it would.

Most recent labs:

TSH 1.54 (0.35-5.00 U/L)
LH 4 (2-9 IU/L)
FSH 2 (2-12 IU/L)
TT 19.4 (7.6-31.4 nmol/L)
FT 286 (196-636 pmol/L)
Prolactin 13 (<18 ug/L)
E2 136 (<224 pmol/L)

He said everything is normal, don’t need TRT. Despite my reasoning with him about my persistent symptoms, and him acknowledging that I may have just “had a good day”, he was adamant about me not needing it and insisting my symptoms were likely related to a mood disorder. I didn’t really know what to say after that.

I asked specifically, does he think that I may see an improvement in my symptoms with a therapeutic trial, especially given my significantly low FT (116) two months ago. He said yes, it is a possibility, but no he would not try. I asked to have my labs repeated, which he did agree to, and now I’ll see him again in two weeks to see what they say.

@KSman can you have a look? I’m wondering how much more I should pursue this or if I’m fighting a losing battle with these numbers.


#12

FSH is quite steady with a longer half life.
LH is the opposite.
So FSH is a better indicator of LH status than LH most of the time.

With a peak of LH, we get a peak of FT and similar to the above, with natural guys, TT is the better indicator of status. Lowering E2 would be helpful, but probably not the root cause.

Prolactin is not the problem.
E2 should be nearer to 80pmol/L. E2 is contributing.
AST/ALT indicate that liver is OK.
Any meds, Rx or OTC that could be reducing E2 clearance?
Exposure to toxins?

IF DHT staying high, that can repress LH/FSH.

Have you read the finding a TRT doc?
2nd post, 1st forum topic.


#13

Reviving this thread with an update.

After I was basically shamed out of the urologist’s office for even suggesting TRT for my low FT almost two years ago, I parked the idea of feeling better or getting on treatment. TRT is hard to come by in Canada and I didn’t have the numbers to support my complaints, so it didn’t look good for me and I didn’t have it in me to try and convince anyone that I needed it.

I saw a psychologist for the next year who was excellent - I mean its always nice to have someone to provide some insight into your life and feelings - though she didn’t do much for my libido, ED, confidence, hardgaining, fatigue, and moodiness. She suggested I start thinking about reopening my pursuit of treatment and after about 6 months of psyching myself up I finally went back to my family doc and asked for a referral to a different clinic an hour away, which he happily provided me with. I got an appointment 3 months later in late September.

First appointment was basically intake. Doc was excellent if not a little rushed. Also saw a nurse practitioner who would be involved in the treating and monitoring. Got a req for first bloods, and an appointment for two weeks time.

First AM bloods (Sept '17)
TT 13.4 (3.5-31.6 nmol/L)
E2 132 (<224 pmol/l)
LH 4 (1-13 IU/L)
Prolactin 11 (2-20 ug/L)
TSH 1.1 (0.5-5 mIU/L)

Everything else (transaminases, CBC, PSA) was within normal limits. Doc said he doesn’t look at FT because the test they use in Canada is inaccurate and often falsely high (which wasn’t particularly encouraging for my initial FT of 116 two years ago), and no SHBG initially because there’s no indication for it as of yet. In any case, he listed off all of the risks of having low testosterone, told me my TT was too low, and wrote me a script for 100mg/wk Test E, injected once per week.

I know better than to inject once a week. I split my dose into 50mg every 3.5 days (Sun AM and Wed PM). I felt better within a few days after my first injection - mood and confidence was a little better though that was probably placebo since I was pretty happy to finally be on treatment. For the first three weeks I felt amazing though - strong morning wood came back and spontaneous erections, libido gradually improved around week 3, just generally felt more like myself.

At the week 3-4 mark I hit a wall. I didn’t feel as bad as pre-treatment, but the honeymoon phase definitely was over. No ED, but delayed orgasm, foggy head, WATER RETENTION, severe heat intolerance and sweating, and headaches. I felt like my E2 was high, but I wasn’t exactly sure either because I figured there were other things like my HPTA shutting down that could be contributing and that things had to just even out. Had second bloods done prior to my next appointment that was 5 weeks post initiation:

Bloods (Nov 10, '17)
TT 27.1 (3.5-31.6 nmol/L)
E2 117 (<224 pmol/l)

I saw the nurse practitioner at this appointment, and she actually put far greater emphasis on how I was feeling rather than the numbers. My E2 was actually the lowest it had been ever, and my T was at the high end of the range. She said that the water retention may or may not be E2 related, but offered me an AI as a 0.5mg/wk dose, just to have if I felt that I needed it. So I took the script but I haven’t filled it yet. She also gave me a lab req to get my E2 checked again three weeks post if I do decide to start it.

I learned a few things from this:

  1. EDUCATE YOURSELF. And this forum is invaluable in your efforts to do so. I spent almost two years reading before I opened this back up and it was much easier with my expectations and knowledge in check.

  2. Be patient. This is a slow process and can take a long time. Don’t rush anything. Don’t try to convince anyone of anything, especially physicians who don’t know anything about you. You need to find someone who is on your side from the beginning and is committed to helping you.

  3. TRT is absolutely not a magic bullet. It’s easy to think everything will be better once you’re pinning your 50mg 2x/week, and for some days it will be - but there are bad days too, and you need to understand that it’s not necessarily E2 that’s causing them.

  4. Nurse Practitioners are the best.

I’m going to cruise on this for the next 8 months or so and see where it takes me. In terms of body composition (which was a factor), I haven’t seen much change yet though maybe I will once the water comes off. Fingers crossed for the three month mark.