T Nation

38 y/o Male with Low T


#1

Hey everyone, I'm a 38 year old guy, and I've been diagnosed with low T. I've got an appointment with my doc tomorrow to discuss treatment options, and I'd like to have plenty of good information going in there.

Age: 38 (39 in July)
Height: 6'2"
Weight: 414
Waist: ~60"
Body Hair: pretty thin on the arms and legs, shaggy on the chest & back, facial hair is "normal" I guess
Where I carry my fat: From my chin to my groin, and not much anywhere else. It's been growing steadily, but it's not until the past year or two I have been trying to get rid of it.

Health Conditions: Obstructive Sleep Apnea (treated with CPAP), borderline hypertension (high enough to keep an eye on, but not to medicate yet), can't get it up in the evenings (mornings OK though)
Current drugs: Cialis (recent scrip), occasional Naproxen for DOMS, OTC Allerclear (generic Allegra)

Diet: I try for 3000-3500kCals/day, including plenty of meat, fish, and dairy. Some days I'm admittedly over that.
Training: I'm doing a hybrid 5/3/1 and Westside 4-day split, including a deload every 4 weeks.

Lab Results (morning blood test, fasted):
Glucose 97MG/DL (65-100)
Lipid Panel
Cholesterol 113MG/DL (<200)
Triglicerides 107MG/DL (<150)
HDL Cholesterol 34MG/DL (>39) - LOW
Calculated LDL 58MG/DL (<100)
Risk Ratio 1.69 RATIO (<3.55)

Hemoglobin A1C 4.9% (4.0-5.6)
Estimated Average Glucose 94MG/DL
PSA, Total 0.2NG/ML (<4.0)
FSH 3.7MIU/ML (1.3-11.4)
LH 4.5 MIU/ML (1.2-7.8)

Testosterone, Total 206NG/DL (241-827) (The doc called this "somewhat low" btw)

Morning wood is there some of the times - it's definitely there after a heavy lower body day at the gym, but on other days it's sometimes iffy. Non-enhanced ability (and desire) to perform in the evenings is hit or miss, with miss being more often of late. This is especially bad since the wife & I are trying to get pregnant and not wanting or being able to do the deed is a pretty hefty roadblock.

Any (useful) advice would be helpful. I'm already reading the "threads that should be stickied" trying to get up to snuff on this. Thanks in advance, everyone!


#2

your CHOL is dangerously low. Ideal is 150-200. Under 150 and people can start to experience all sorts of problems.

You need more tests including at the very least Cortisol, Estradiol and TSH. Please do not jump into HRT or Testosterone treatments without additional tests - the more the better to get your initial baseline per the blood test sticky.

with your weight I would assume high estradiol. FSH and LH are low, but that could be due to excess estradiol suppressing your hypothalamus/pituitary.

sleep problems can also cause cortisol problems which would also increase your estradiol and impact your Thyroid.


#3

Well, I talked to my doc today, discussed my concerns. He wanted to originally prescribe me a gel or cream. I then showed him the stickies I had printed out, and his first reaction was "I generally don't prescribe injections". Well, he leaves the room, reads the information a bit, and then comes back in with a syringe and prescription for 200mg every 2 weeks of T-cyp (I think). I then asked him about the AI and the HCG, since my wife and I are currently trying to get pregnant, and shouldn't I be concerned about my E2 levels. After all, since the way I'm carrying all my weight suggests high E2 levels, shouldn't that be something we check? His answer, "Well, I generally look to see how you feel after a certain dosage and adjust as needed." But... if I'm already converting test to E2, doesn't that imply that more test = more E2 which will just make the problems go around in circles?

Well, he then said, "You know, you are probably more informed than 99% of my patients who come in here on this. I'm going to refer you to someone who can answer your questions better".

Well, so now I have an appointment with a urologist next Tuesday. I'll definitely be going in there better informed than I was the first time. What additional tests should I get based on what I've got?

So far I've got:

Cortisol
Estradiol
TSH

What other information do I need to get on this?


#4

Most urologists are useless for hormone issues. Why would a run of the mill dick doctor be able to treat hormones that affect all areas of the body? Unless he also is up to speed on andrology, I wouldn't expect much from him.

I would ask your current doc to work with you. He seems to be willing to do that, maybe just not try to push him so fast.

I agree with him that you should not get on an AI or HCG until you're sure you need it. That means running a test for E2 (which I see you have). Make sure you run the right one (sensitive NOT ultra-sensitive). From Quest the code is 4021x (ranges 13-54). Labcorp's range is 3-70 or something like that (don't know the code).

Monitor your balls and sperm count--if changes, then push for hcg.

Key is always to use the least amount of meds possible to optimize your health. Don't add things until you need them.

You should split your injections up to EOD or E3D to maintain more stable levels (you will find this info in the stickeys which you are reading).

TSH is mostly useless. At the very least, test Free T-3 and Free T-4 (FREE not TOTAL).


#5

odds are the urologist will say you are fine, or will insist on patches or injections, but won't be interested in anything else.

best is to read the Finding an HRT Doc sticky and call around to compounding pharmacies asking for referrals.

the blood test sticky has some great recommendations on tests to request.

Cortisol test needs to be from an 8am Blood Draw.


#6

Is there a sticky anywhere with "optimal" levels of the various blood tests? I'm especially looking for the levels for LH and FSH...


#7

I posted what I found out on Ideal Levels from various doctors and put that in the blood test sticky, but don't believe it shows levels for FSH or LH.


#8

In most circumstances, your LH/FSH need to be in the top part of the range (say 25-33%) to elicit the desired effect in the testes (higher testosterone)..


#9

You need an endocrinologist...not a urologist.

Also, if you have a 60" waist and weigh 400+lbs, you NEED to get that under control. You might find that your other problems disappear once you get to a healthier body composition (which requires a healthy diet + exercise). Don't bullshit yourself about this - it's your biggest problem. Sorry if this is blunt, but that's the reality.

Sleep apnea will definitely cure itself with weight loss. Hypertension should take care of itself as well with a good diet. And MAYBE your T-levels will elevate as well.

Good job on lifting and getting on this site - these have you on your way...take care of the diet and good things will come your way. May there be many cruciferous vegetables in your future!


#10

talldude - have you read of any success stories from this site or others where an Endocronologist thought outside of the box and was able to actual help someone? If so, could you please show me those links because I have never seen one.

yes weight control is necessary, but if your hormone, thyroid, cortisol levels are off then your attempts at weight loss may fail. Best to try and tackle both at the same time. Get your levels where they need to be while trying to lose weight.

weight may be able to help or cure aleep apnea or hypertension, but not in every single case.


#11

Guys,

I know I need to get the weight under control -- I've been eating at what should be a calorie deficit and I've increased my activity level significantly, but the weight is VERY slow to come off (about a pound every couple weeks). I know that that even with my hormones in check, I've got a lot of work to do, but getting the hormones back in balance will definitely help me get farther along with my goals.

FYI, my last body fat analysis was "only" 29%. Which means of that 400+ lbs, about 290 is lean body mass. If I can lose 50-60lbs of fat, I should be back down towards a relatively healthy 15% body fat. ALL of my extra fat is in my midsection -- my arms and legs are lean enough that I've got some "mild" muscular definition there.


#12

So I had my appointment with the urologist today, and it was actually a fairly pleasant surprise. I initially started out talking with him about my symptoms, my low sex drive, my ED, and handed him the last blood tests that had been done. I asked him about the low cholesterol and low LH numbers. He did agree that they were low, but he had not yet seen anyone whose cholesterol was so low that it significantly affected their hormone production. I then told him my wife & I are trying to get pregnant, and the ED and sex drive is definitely hurting things. He said "Well, that pretty much changes everything."

At that point I knew he was much more informed than I expected him to be. I told him the reason I was there was I had serious disagreements with my GP about treatment in my case, and I'd much prefer to start at somewhere that wasn't going to make things worse (like kill my sperm count).

I told him that my GP had recommended starting straight T therapy and if my wife isn't pregnant in a few months, then we'll consider other things. The urologist said, "definitely a good thing that you didn't do that." We discussed a number of other things, including possible treatments. He is going to run some more blood tests: FSH/LH, prolactin, estradiol, free/total T, and I get to see him again in 2 weeks to discuss. His initial recommendation is to treat with Arimidex. I asked him about hCG, and he said that was also certainly an option in conjunction with the Arimidex. He said though that I'd definitely want to check with my insurance to see if they covered it.

Otherwise there would be a whole bunch of extra paperwork. I also showed him the sticky on the injection therapy, and he said, "Yes, hCG can support your sperm count to a degree, but I still wouldn't recommend any exogenous testosterone while you're trying to get your wife pregnant. However, hCG will prevent your sperm count from going to zero, and while 80% of the population can recover from that ..." and he left it at that.

So, I think I'm definitely in a better position than I was last week. I'll definitely keep this updated.


#13

sounds like a good start....but make sure that you get your blood tests results in your hands BEFORE the doctor's visit. post the results here, and go in armed with information so that you can truly partner with the doctor on your treatment plan.


#14

Well, I'm already 1000% more confident that this doc is well-informed, but I will definitely post the blood test results here as soon as I have them. After my experience with my GP, I know that being well-informed is DEFINITELY the way to ensure you get the right treatment for YOU.

I really do appreciate the information and advice from the other guys here. I'd be stumbling around blindly without it.


#15

Okay, latest batch of blood work is in. Please advise:

LH: 6.4 mIU/mL (1.7-8.6)
FSH: 3.5 mIU/mL (1.5-12.4)
Testosterone, Total: 278 ng/dL (249-836)
Testosterone, Free: 4.3 pg/mL (8.7-25.1) LOW
Prolactin: 5.2 ng/mL (4.0-15.2)
Estradiol: 56.6 pg/mL (7.6-42.6) HIGH

Well, the E2 levels were high - that didn't surprise me. I'm just surprised by HOW high they are. I'm pretty new about this, but the LH looks OK this time around (in the top 1/3 of the range).

Here's what my initial read on this is that my aromatase levels are WAY high, resulting in lots of T->E2 conversion and high levels of SHBG (hence the low free T), so using a AI should definitely help get both my total and free T levels out of the basement. However, I definitely defer to the experience of everyone else here. Opinions are definitely appreciated!


#16

what happened to the tests for TSH and Cortisol?

low cortisol can also drive excess aromatase.


#17

He didn't test for TSH or Cortisol, and I was so in shock that I had a doc that actually seemed to have a clue that I forgot to ask him for them. I will, however, suggest we check them on the next blood draw.

Based upon the information I have already provided, do you feel it would be a good idea or bad idea to start AI+hCG therapy, or is it possibly a bad idea to do so without the cortisol/TSH levels in hand?

Edit: Actually, my GP did the TSH tests at my initial blood draw. The results are:

TSH: 2.6 uIU/mL (0.3-5.1)


#18

TSH > 1 = a possible problem

2 = a problem
3 = a serious problem

the lab ranges are out of date.

please check out stopthethyroidmadness.com/things-we-have-learned/

I strongly advice getting additional thyroid tests right away before starting on other medications. tests like Free T3, Free T4, Reverse T3, ferritin, and Cortisol (with a blood draw at 8am) + it's always good to test for D25-OH.


#19

Update:

When I went back to my doc he prescribed me with Anastrozole. He initially wanted to prescribe me at 1mg/day, and I said something like "Isn't that a little high?" He told me something like, "Well, it only comes in 1mg tablets..." He then asked if I'd like to try it at .5mg/day. I went with that, thinking that was still high, but I can experiment and figure out the dose that works best for me symptomatically.

After some trial and error, I found that .25mg/day seems to work pretty well. Libido, performance, and sexual enjoyment are MUCH better. Had the appointment with the doc Wednesday and discussed this with him. He didn't have my latest blood tests back yet, but they showed up right after I left:

TT is up in the 470's range (don't remember the exact number), up from 278. The admin assistant called this "good". I think of it as a "good start," because at 38 "normal" should still put me in the 600'ish range.

Free T is up to ~11 (from 4.3). This has me at the low end of the "normal" range at least. Not quite where I want to be long-term. He didn't test for E2, but gave me an additional order for a blood test for E2+TT+Free T. I figure since I'm feeling much better, I'll just save that for the next time I need a blood test. I also asked the assistant to mail me a copy of the results so I can keep them in my file for future reference

He also did a semen analysis and said that there's no reason on my end that the wife & I can't get pregnant. With the AI, libido and ability are no longer a factor.

We also revisited the protocol suggested on here with the injectable T, hCG and AI. The doc says pretty much whenever the wife turns up pregnant we can start on that protocol. He reiterated that it won't sustain a normal level of testicular function, but it will at least preserve the ability to return to normal testicular function.

So energy level is up, libido level is up, "morning wood" is back to normal (at least when I have a normal evening's sleep), and random erections are now happening without conscious thought. I'm definitely liking the way things are going so far.


#20

Awesome to hear things are going well for oyu man...it sounds like you have a good dco who is willing to work with you and learn as he goes...keep us posted