T Nation

39 YO Considering T-Replacement


#1

I have some of the symptoms of low-T, low sex drive, low energy, very little interest in sex (wrecked my last relationship), depressed mood. Saw my primary care physician this week and asked for some hormone tests. He was only willing to initially test for what I believe to be total testosterone. My doctor's nurse called with total testosterone results today and said I was normal. I said come on, I want more than that. She said total testosterone was 376 which I believe is just a little above the cutoff for low T (300 or 350?).

I am 11% body fat, am 185 & 5'11", I workout every day (two days lifting, 1 day cardio), I eat a high protein, low carb diet with plenty of vegetables, have no fat around my waist, and am very active. From what I have read a TT of 376 at age 39 is quite low and could warrant T replacement therapy. I obviously won't be seeing my primary care physician for this. I know I need more tests including some of these: total testosterone, free testosterone, estrogen (E2), prolactin, thyroid, thyrotropin, cortisol, sex hormone binding globulin (SHBG) levels, follicle stimulating hormone (FSH), Luteinizing hormone (FH). SHBG and free T are the most important from what I've read. Can anyone tell me which specific tests I should request on my next blood draw? I know I need a few more tests before starting anything like T replacement.

I am looking into finding an endocrinologist who will listen and take me seriously. I am quite muscular and have no problem building muscle. By looking at me no one would ever suspect I have low T. I don't want to waste my time going to doctors who have no intention of Rx'ing T. I hope to find a doctor who does prescribe T for his/her patients and has an open-mind. I live in SE Wisconsin and hope to find one nearby. If anyone here knows of a good endo. or GP who does this kind of work please let me know.

Just found out my insurance will cover none of this. So figures.. How common is this; being not covered? After reading a lot of stories on here this appears to be a formidable process to put it lightly especially when I will have to be paying out of pocket (tests being very expensive). I already find myself concluding that living with low T is probably easier and way less frustrating than trying to get help for it. Kinda sad.

Back to reading stickies.


#2

My basic concern at this point is the dollar cost of doing the doctor visits, the labs (this really scares me), and the pharmaceuticals. I don't see this addressed anywhere in the forums. I am in the U.S. Perhaps the forum users are all insured and do not know the cost of doing this without insurance. I really appreciate all the technical info here.

I have a good idea of what I need for next lab test or at least an educated guess. I would like to only test for the minimum factors as I know each factor of testing can be very expensive. When I see guys testing for the entire laundry list I have to believe insurance must be paying for it or perhaps money is no object for them. I want to be safe at the same time and not neglect something important.

I just read the post and replies for a guy who posted on 11/16 and that whole drama. I don't really want to go down that path so I will just assume I am on my own here.

Thanks everyone for your contributions to the forum and the stickies.


#3

Most people here have insurance. SO do you. What insurance do you have and why do you think they will not address a health issue? Can you switch insurance at the first of the year? Yours doesnt sound very helpful.

Its possible to do this without insurance, but it is painful and wont be cheap.


#4

Why not? A knowledgeable and open minded PCP is without a doubt more helpful than your run of the mill endo or urologist as far as TRT is concerned. They mostly care about your health and understand your other health issues. If I had a knowledgeable PCP, I wouldn't hesitate to use him.

Since cost is an issue, you will probably only want to concentrate on the sex hormones. This is not ideal and is shooting in the dark, hoping to hit something, but you have to play the hand you are dealt.

Look at www.privatemdlabs.com or www.lef.org They both offer cheap blood tests where you select the ones you want, pay them, and they send you a lab req that you take to Quest or Labcorp (cant remember which) for the labs. This is discussed in the stickeys.

At your age, you shouldn't have much trouble convincing a switched on PCP to consider TRT for you.

As far as cost of your meds, look around for cheaper options. A vial of T from Costco runs about $60 without insurance. You can get needles on Amazon for pennies. Arimidex/Aromasin and HCG can be sourced from Indian pharmacies at a fraction of the price as the US prices. There are also generics available for Adex that are much cheaper even here in the US.

You've got some work to do and decisions to make.


#5

First off, thanks for the response. I get what you are saying about PCP, but my PCP considers my TT level to be normal, end of story. At least that's what I got from the nurse who called with results. He is willing (and did) Rx Viagra for me but has told me he isn't plugged in enough to prescribe hormones. He's a GP in a mostly small town/rural area who does the basic drill of what a GP does. He doesn't really specialize in anything but GP. He's an old-school doc. I wish he was more experienced in this or open-minded because I have seen him since I was a kid, but I think the reality is I need to look around suburban Milwaukee or Madison to find a doctor who is actively doing TRT for patients. It isn't that far for me, maybe 45 minutes to either location. I just have to ask around to find out who is good in my area. I don't yet know the rules on that on this forum, if it's ok to name docs, but I will research it.

If I don't have to do TRT that's fine too, maybe even preferable. One more fold to my situation is that I am bipolar and take five meds, one of which definitely lowers my T level (Cymbalta). The reality is that I need at least three of these meds probably for the rest of my life because I can & will become suicidal without them. I had an abusive upbringing which probably triggered whatever needs triggering to become bipolar. It cannot be undone either as I have tried most everything.

It would be great to discuss with another forum member who happens to have bipolar disorder how TRT effects/interacts with their meds and how it may have helped them. I suspect that if I got my T level to a higher number that I might not need the Cymbalta and Wellbutrin. The possibilities are intriguing. Really glad I found this place.

Thanks


#6

Since this all came up yesterday and I didn't check my coverage until after the customer service closed, I just read the policy. I intend and will call for specifics tomorrow/Monday whenever they open again. It is not totally clear because it says nothing about testosterone. It is the HIRSP Federal Plan. Anyway, here is what it says:

"Section X. General Exclusions
The following are not covered under this policy.

B. Medical-Surgical Services Not Covered by HIRSP Federal Plan

  1. Health care services, including, but not limited to, surgical services, devices and drugs for, or used in connection with, sexual dysfunction, including, but not limited to, impotence, or for the purpose of enhancing or affecting sexual performance, regardless of whether the origin of the sexual dysfunction is organic or psychological in nature, including, but not limited to, Viagra, Caverject, MUSE, Yohimbine, Femprox or their generic equivalent, penile implants and sex therapy."

It's really all academic until I talk to them but it doesn't sound good from the above reading. Maybe it only refers to pro-erection therapies, not testosterone. T definitely covers a broader set of symptoms than outlined above, but the terms "in connection with" makes me think that that covers TRT too.


#7

This has been true for a couple of our members here. Once they got their T levels and other hormones straightened out, their "preexisting mental health issues" ended up going away.

True story, when I first went down this path my initial doctor scoffed at my symptoms, decided I was depressed, and scripted me Wellbutrin. I took the bait and tried it out for a while, but didn't feel any better (slightly better, but still something wrong).

Luckily I didn't quit and 9 months later, I got my REAL diagnosis: Testicular Cancer. Once I went through surgery for that and started TRT, I suddenly am no longer depressed and feel great!

I think that docs nowadays are lazy and/or uneducated and no longer bother to get to the root of the issue and just throw SSRIs and anti-depressants and hope it sticks. This is bullshit.

Not to say your issues will magically disappear when you get your hormones straightened, but keep that in the back of your mind.


#8

T issues are far far far more involved than just sexual dysfunction. I read that statement and think you will probably be ok. But obviously you need to follow up with them.


#9

You seem to have a responsible attitude toward finding the cause of the problem. This will probably be more useful to you than most "professional" therapy you pay for.

If you can have an informed talk with your PCP, using the stickies found here and copies of studies from PubMed, maybe he will take you seriously. You will certainly know more about the subject then he does, or anyone else he would refer you to. Make him an ally, to monitor the general things that he knows about you. My Doc won't prescribe any of this stuff for me, but he will order tests and listen to reason, and tell me what he thinks. I then buy my T and other meds from questionable sources, and pay pennies on the dollar.


#10

Thanks for the input dooright. I am learning a lot here so far. Still, it will take me a while longer to learn enough to be able to properly advocate for myself in detail either to my PCP or another doc. It seems like there is quite a bit of variance here as to how many different items should be blood tested for initially. Some labs seem to be over the top in the number of items tested for. I feel like I should know how each item affects the others which is quite complex (to put it lightly). I already know about the basic HPTA relationships.

Dooright, does your doc know about what you are doing "on the side?" I think my PCP would not be party to me medicating on the side in a harm reduction sense by doing labs for me. I will ask him if he does treat low T clients but from what he has said before I am fairly certain he does not. I have been searching for other docs to help with this. Maybe it would be worth it to make the trip to Lansing, MI? I really don't want to waste my time going doc to doc. Problem is that my insurance only covers doctors within & just outside of WI (Certified WI Medicaid Providers). I am not a Medicaid client, but that is all my insurance will allow me to see. There must be competent docs in and around either Madison or Milwaukee. Been doing searches on here but so far they are fruitless.


#11

The fact is that "men's issues" have not been very high on the medical/drug/insurance industry's list of things to cure. You can count the number of approved therapies for the whole range of maladies using just your fingers, and don't expect any doctor to stray from this list, that would be un-professional!

Where the medicos can be useful for is finding the cause of your complaints, maybe. In my case, the diagnosis was pretty easy, and the doc told me what I needed. But he also said in so many words that he would be sending me off to a specialist because he didn't want to get in trouble for prescribing this stuff. So, I got the Synthroid and Testosterone for myself (at bargain, offshore prices), and was retested. He was happy with the numbers, and I doubt I could have gotten a better result by spending thousands at a specialty clinic in Miami.

I have no insurance, and pay cash. Maybe that changes my doctor-patient relationship a little; he's working for ME, not the insurance company. If your doc won't work with you, find one that will! It's your problem, and your responsibility to find decent care. You still don't have a diagnosis. That is where you start. If you were buying a car or a camera, you'd spend some time researching the features and differences, so read the info referenced above. Yeah, it's complex stuff, that's why the "pros" rent expensive offices, form professional societies, and spend tens of thousands on lawyers and liability insurance--to intimidate you--because they're no damn good at understanding it either!

One advantage the "experts" have is the ability to draw conclusions from seemingly incomplete information. It's the old "heard of horses, not zebras" analogy. It is not necessary to have the results of all of the blood tests, but certain ones are very important, depending on the set of circumstances. But you have to understand them all to know which ones apply.

Hope this helps. Thirty nine is still young, believe me. Get it fixed.


#12

I've been doing a lot of reading (stickies & many other posts) on this forum. I've made an appt. with a TRT doctor who takes my insurance. The receptionist told me he only uses hCG with his weight loss patients, so if I go this route I will need him to be open to suggestion, something I cannot predict. Since that is the case I'm still calling around to other TRT docs and asking questions. Luckily there seem to be quite a few docs who do this near me.

Since I last posted I began taking nightly supplements of DHEA 25mg (for five days). I have noticed a slight but noticable uptick in libido, but not nearly enough to be considered normal. Not sure if this is likely to continue or if it will disappear with time. This sort of makes me think that maybe there's nothing wrong with my gonads and maybe they are just not getting enough LH. From this very limited info am thinking I'm possibly secondary hypo? Not enough info - I know.

Now here comes the real reason for this post. Lets presume (and I know the answer will be largely based upon the numbers in my labs) that my lab numbers come back relatively normal with no abnormalities (primary hypo) or if they come back with low FSH/LH (compromised HPTA - secondary hypo) what would be the sensible and conservative first few steps in treatment?

Now these questions are for either case (primary or secondary) as supposed above; is it prudent to try a four week SERM restart/reset of my HPTA first (probably only for secondary)? If that does not work would one then move onto (or in the case of primary start with) hCG monotherapy for a limited amount of time & how long is reasonable, if so? If either or both of those two fail to work then is the next & final step lifetime TRT? I already know extended (longer than six months) AI monotherapy is contraindicated as the AI tends to become ineffective and is also very unlikely to fix a 376ng/dL TT longterm.

The reason I ask this before labs is because I want this doctor to understand from the outset that I need him to be my partner in treatment, not a dictator. I don't want him jumping straight to TRT even though it's probably in his financial interests to make me a lifetime patient as quickly as possible. I totally understand the logic of having labs done before the first appt. His office did not request this and I am hesitant to ask him to have labs first because I have made up a list of what I would like him to test for (with the assistance of KSman's excellent information here) and would hope he might agree to this so we don't waste my initial baseline lab. I just haven't seen clear cut suggestions of what either a primary or secondary hypogonadal guy (assuming all other factors are normal/not unhealthy) should try first before resorting to lifetime TRT.

I want to be as informed as possible BEFORE I visit a doc so I can head him/her off before they try to play a quick one on me. I also want to be able to fire the doc as quickly as possible if he's not willing to at least try conservative methods first before TRT.

I apologize upfront if I have stupidly missed something in the stickies or elsewhere, but I have been doing many searches looking for this info and haven't found it spelled out clearly as of yet. Thanks for all the great info & hard work put into this forum guys.

EDIT: Just ran across this type of therapy on another site.


#13

You're getting ahead of yourself...I would take it one step at a time...see what your blood results are before mapping out every single treatment pathway


#14

I get what you are saying VTBalla34 and part of me thinks you are right. The following is my reasoning for asking all of what I asked. You can consider the following to be rhetorical or respond if you really want to.

Since the first appt is longer than the rest I want to size up the doc's treatment philosophy. If the only ammo he's got in his bag is TRT then I don't want to waste anymore time with him other than the lab. I am not willing to jump straight into TRT until I know that's all that will work for me because we have already prudently exhausted all the other options. That is why I want to be well-versed upfront in what those options are so I can be well-informed enough to suggest one or more to see his reaction.

There are already red flags as I know he prefers compounded creams (my insurance doesn't pay for those, I swim, and am at the gym everyday) and he doesn't use hCG with TRT (I haven't had any kids yet and won't go on TRT without it). I'm only trying to get to the point where I'm hopefully only just a little bit less of an idiot that he is. I need to be able to make reasonable suggestions to the doc about possible courses of treatment to see if it's going to be his way or the highway. Would it be wise to request labs before the first appt by sending him my list of lab requests so we can save a visit or should I just let it be? I will call the clinic on Monday and ask this.


#15

You can try, but the chances of him giving you labs before the appointment are somewhere around 0%...somethingto do with liability and you not showing up for your appointment after the labs, and never technically being "under his care"...


#16

I decided before I try a qualified physician to resolve my T issues to attempt a SERM restart, like PCT. Using Nolvadex first two weeks 40mg/day (split into two doses of 20mg spaced 12 hours apart), and then will drop down to 20mg/day in the evening for the third & fourth week. Started on the evening of Jan 31st. Will post subjective results when done. I thought this might be a good measure to try before committing to a lifetime of T injections.

My hesitancy with going to the doc has been because I am out of work and money is tight. I do have insurance but cannot incur large out-of-pocket costs at this time. I really want to look into this further and get started, but I may have to wait as most docs near me want cash payments up front. One or two do not, but they don't seem to like injections taking place anywhere other than their offices, 40 miles away. I demand home injections, I demand hCG and an AI. I do have a doc in mind who I have a hunch who will go for this, but I have to wait until I've got some disposable income. If local docs fail I can always drive 5-6 hours to Michigan (Crisler ?) and get what I need.

Oh yeah, I'm 40 now so this thread has me looking a bit younger. :slightly_smiling:


#17

Did you get your blood work results yet? Sounds like you have all these plans mapped out but you don't even know what you are treating yet.

You say you are demanding hcg and AI, but for what?

Get your results back, if your LH and FSH levels are low then you are a candidate for HCG therapy. Do that for a month and retest your blood. See if you even need an AI.

But as VTballa said, you are getting ahead of yourself.

I am awaiting my blood work as well. Previously, my blood work showed low T, LH, FSH levels. I have tried HCG in the past and know my body is receptive to it.

I'm still a little concerned about the long term effects of using HCG mono therapy.


#18

I only had TT tested so far. I will get labs done when I finally get to a doc. I had reason to believe I am secondary hypo since several times when I started DHEA I received a substantial, but also very brief boost in sex drive. Its still too early to tell if the SERM is doing anything yet. I figured it was worth a try before embarking on a lifetime of TRT, assuming that is what the labs point to. I would also think it to be doubtful that most T docs would try a restart before Rx'ing T. I've had my thyroid tested several times in the past and its always been normal. Will find out about the rest.

Yeah, I thought long-term hCG mono therapy had to be a pretty low dose to be safe. I haven't really heard from anyone on here who is doing that. All I was saying above is if I am to do test cyp, I want for it to be injectable (for several reasons) and I wouldn't want to be on T without also hCG & very likely an AI to keep E around 20-30.


#19

So I'm three weeks into the Nolvadex therapy and I can feel no difference. Even DHEA has a little more effect than this has. Finally, I have an appt with a DO who does T-replacement, allows home injections and has worked with hCG before. They even take my insurance. Getting that info before the appointment is key. So many docs I called won't allow home injections. I've heard of so many others who have needed to shop around & around to get there. We will see if these promises are correct on May 15. Long wait, but hopefully worth it.


#20

Finally saw the doc today after nearly three months of waiting. She's open-minded and listens but the appt was short for all I wanted to ask. She ordered a variety of lab tests. Should be ready to post them early next week. I recently became hypothyroid on a test in March (5.7 on 1.0-5.0).

She is willing to Rx T injections, but for the moment I will have to drive to get them weekly at some "local" clinic. Probably a 35 mile round-trip for that. I think I can convince her to teach me & let me do them at home, with time. One can only hope. I mean, diabetics are allowed to do it, so what gives? She does not Rx hCG but knows a colleague who does and will work with him. That's a plus, but can imagine only more driving for injections. Not to mention that once a week for either T or hCG is anything but ideal.

Unfortunately she does not Rx anastrozole. She mentioned something about "the load on the body" like it was hard on the body. I hadn't read that before. It sounds like she is just willing to accept E2 wherever it goes and if its too high she'll just drop the T dose. I am ready to order a research chemical (AI), anastrozole. It makes me feel kind of bad because I want an honest open-relationship with her. I figured maybe I can even wait 6 weeks until the next lab test to start the AI, and then ask what she's going to do about the increased E2 on the lab report. Or maybe just go rogue & self treat 1mg/week. I know it takes some time to bring E2 back down so its tempting to start the AI with the T. I am willing to continue to see her at this point. Doctor shopping is no fun at all, but there are maybe six or seven others in my area.

For so many guys it seems like the only, the best, & the most economical course is to self-treat. You just have to find a doc to order your labs then. Today raised more questions than answers.

Will post lab results next week.