T Nation

53 Y/O, Metabolic Syndrome, Diabetic, Considering TRT


#1

Two years ago, I went to see a doctor because of low energy and libido. At my request, my hormones were tested along with thyroid, blood glucose and other things. The results showed TT = 496ng/dL, Estradiol = 46pg/mL, fasting glucose = 160mg/dL. The doctor immediately declared me diabetic and I got put on 1500mg metformin/day and a lecture about seeing a dietician. I was already well aware of what I should be doing with diet and exercise, and managed to be good for some months which got me close to a normal fasting glucose.

My hormones went unaddressed. About a year later again I was feeling crappy. I couldn’t stick with diet and exercise because I still lacked energy and motivation. I went to an endocrinologist to see if I could get TRT to help ‘kick start’ me back into feeling better so that I could take care of my diabetes. I was told that I didn’t need it and just needed to eat right and exercise. In fact, she told me my hormone levels were “robust”.

I’ve read that there’s an interaction between metabolic syndrome and male hormones, and that a large percentage of diabetic men have low T. I’ve also read that TRT can help improve glucose control. Primarily, I just need to feel better. I can’t get my ass off the couch, don’t even want to socialize, and never feel horny. If it weren’t for Cialis, my wife and I wouldn’t ever have sex.

I went out on my own and ordered blood work. I’ve just gotten the test results:

Testosterone, Serum = 504 ng/dL (348-1197)
Free Testosterone (direct) = 12.1 pg/mL (7.2-24.0)
LH = 7.0 mUI/mL (1.7-8.6)
FSH = 8.6 mIU/ml (1.5-12.4)
DHEA-S = 181.7 ug/dL (71.6-375.4)
Prolactin = 21.5 ng/mL (HIGH) (4.0-15.2)
Estradiol = 41.5 pg/mL (7.6-42.6)
PSA = 0.8 ng/mL (0.0-4.0)

If I understand this right, my free T is low and both my Estradiol and Prolactin are high. I’d like to start the TRT described on this forum (test and hcg injections + arimidex) ASAP. Any advice or feedback would really be appreciated!

Kevin


Non-hormonal lab work from my last physical August 2016:

Cholesterol = 162 mg/dL
Triglycerides = 123
Glucose = 122
Urea Nitrogen (BUN) = 14 mg/dL (7-25)
Creatinine = 1.05 mg/dL (0.70-1.33)
eGFR = 81 mL/min/1.73m2 (>= 60)
Sodium = 141 mmol/L (135-146)
Potassium = 3.6 mmol/L (3.5-5.3)
Chloride = 101 mmol/L (98-110)
CO2 = 30 mmol/L (20-31)
Calcium = 10.0 mg/dL (8.6-10.3)
Protein Total = 7.4 g/dL (6.1-8.1)
Albumin = 4.8 g/dL (3.6-5.1)
Globulin = 2.6 g/dL (1.9-3.7)
Bilirubin Total = 0.5 mg/dL (0.2-1.2)
Alkaline Phosphate = 106 U/L (40-115)
AST = 38 U/L (HIGH) (10-35)
ALT = 49 U/L (HIGH) (9-46)
A1c = 6.9
TSH = 0.97 mIU/L (0.40-4.50)

CBC also available if needed


Medications/supplements

valsartan HTCZ (blood pressure)
amlodipine besylate (blood pressure)
atenolol (blood pressure)
pravastatin (high cholesterol)
gemfibrozil (high triglycerides)
tadalafil (ED)
metformin (glucose control)
alpha lipoic acid (glucose control)
omega-3 fish oil
vitamin D
multivitamin
bupropion (antidepressant) - stopped 2 months ago
medical marijuana (anxiety) - stopped 9 months ago


Drug and/or Hormone-Related Hair Loss
#2

Diet: You need to start avoiding simple carbs and processed foods. Rice is not good for your condition.

Diabetes best evaluated with A1C lab results.

How is your weight and describe how it has increased over the years. My concern is prolactin. We normally expect that to decrease LH/FSH but the opposite is happening. Elevated prolactin often leads to a MRI to detect possible pituitary adinoma after a repeat prolactin lab confirms an issue. If adinoma grows and presses on optic nerves, one of the first symptoms is reduction of width of peripheral vision that should be near 180 degrees.

Labs indicate that your testes are the problem.
Do you have high blood pressure?
Did doc examine your testes? any aching?

Prolactin can be inflated by hugging babies, puppies/kittens and orgasms. Was your 21.5 clean?

High E2 might be from poor liver clearance. Test AST/ALT. Can also be from drugs, Rx and OTC that compete for enzyme pathways that clear E2.

Post non-hormone lab results as well.

Insulin resistance can also be driven by low thyroid function, see last paragraph in this post.
What is your history of using iodized salt?
Feel cold easily?
Outer eyebrows sparse?

You could lower your E2 with anastrozole now, but that will increase LH/FSH even higher and the testes are still the problem.

Please read the stickies found here: About the T Replacement Category

  • advice for new guys - need more info about you
  • things that damage your hormones
  • protocol for injections
  • finding a TRT doc

Evaluate your overall thyroid function by checking oral body temperatures as per the thyroid basics sticky. Thyroid hormone fT3 is what gets the job done and it regulates mitochondrial activity, the source of ATP which is the universal currency of cellular energy. This is part of the body’s temperature control loop. This can get messed up if you are iodine deficient. In many countries, you need to be using iodized salt. Other countries add iodine to dairy or bread.


#3

Thanks for the reply. I’ve added test results from my last physical to my original post, as well as my medications. There are values in there for A1c, AST and ALT. If we took it now, my A1c would be much higher as I’ve been eating poorly and not exercising since a car accident last October.

It’s typical for my liver enzymes to be elevated. This has been a recurring issue since my mid-30s. I had a liver biopsy back then and was diagnosed with fatty liver. This is probably related to my tendency to carry my fat around my midsection, and of course organ fat has been linked to insulin resistance.

I currently weigh about 250lb. I’ve been in the 240-260 range for at least five years. I started gaining weight in my late 20s and it has slowly ratcheted up over the years. I have lost significant amounts of weight (30 lbs or more) on a few occasions, but this has never lasted.

I have high blood pressure and am on medication for it.

I have no aching in my testes.

My prolactin test was ‘clean’. No orgasm or babies of any species for 48 hours prior.

When cooking, we use either iodized salt or sea salt. I do not feel cold easily and my eyebrows are normal. I will take the body temperature history you suggest.

Please explain what you mean by “your testes are the problem”.


One additional observation re: high prolactin. I’ve been doing some reading (e.g. here) and it sounds as if my prolactin would be several times higher if I had a prolactinoma. In addition, it sounds as if low dopamine can cause high prolactin levels. Two months ago, I weaned myself off of bupropion which is a dopamine reuptake inhibitor. During that time, my energy and libido problems have gotten noticeably worse. I’m wondering if the declining dopamine levels in my body have led to the high prolactin, which in turn has killed what libido I had.


#4

I’d focus on diet with those labs, hormones aren’t the root of your problem. Most doctors still tell people to do the wrong things.

Limit net carbs to 28g/1oz per day, switch to iodized lite salt, eat lots of broccoli, meat, cheese, eggs, green vegetables, butter and coconut oil. Make sure you get enough sodium, potassium, and magnesium the first couple weeks, you’ll feel bad at first and crave sugar/carbs when your body is running out of glucose but then you’ll feel much better.

Once you’re feeling good start lifting heavy things.

I don’t think hormone therapy will help if you don’t fix the underlying problems of insulin resistance, bodyfat and fitness and fixing those things will fix your hormones.


#5

Thanks for the reply. This is exactly the advice I got from the GP and the endocrinologist. I’ve done what you’re suggesting before. It works but never sticks. Diet and exercise are always the best solution, I understand that, but for me (and I’m sure a lot of other guys) it isn’t that simple.

I’m not looking for TRT to fix my problems. I’m hoping it will make me feel good for a change so I’ll have the energy and motivation to do the other things and stick with them. Right now I’m just stuck in a negative feedback cycle that’s driving me to worse and worse health and need a kick to start moving things in the right direction. Ideally, fixing my hormones would lead to diet and exercise which would lead to weight loss and then I would wean off the TRT as my body’s natural hormone balance is improved.


#6

That is a lot of medication.

Big factors for metabolic health:

  • testosterone and optimal E2
  • cortisol, get AM cortisol, test at 8AM or 1 hour after waking up
  • thyroid function and iodine
  • IGF-1 as a measure of growth hormone status, do not test GH directly

5000iu Vit-D3?

Blood pressure has too major influences.

One is arterial muscle tone.

There are three factors for that. Low magnesium can limit ability of arterial muscles to relax to receive and dilate for the next pulse of blood, the muscles then contract behind it. Get a good magnesium product. There is ZMA sold on this site’s store. If you get leg or muscle cramps or you muscles can lock up when tightened, you gave a magnesium deficiency. Most people are deficient.

Another factor that can mess up muscle tone is a CoQ10 deficiency and that can be caused by a Statin drug. When this happens there can be muscle pain or a persistent cough as left ventricle weakness causes pressure build up in the lungs and fluid leaks int the airways.

And low T can affect muscle tone and TRT sometimes lowers blood pressure.

Other source of high BP from accumulated damage and scaring from endothelial dysfunction. If labs for homocysteine are high the one cell layer thick endothelium that separates blood from arterial wall is inflamed and disease process is there.

Get homocysteine tested. Try 50mg Ubiquinol form of CoQ10 and see if you feel better. Do not get the Ubiquinone form!

CRP is a generalize inflammory marker and not cardio specific, although that was wrongly once though to be the case.

Suggest high potency B-complex multi-vit with trace elements including 150mcg iodine and 150-200mcg selenium. Most guys do not need iron and should not have iron in their vitamins. If wife still cycling, she need iron. Your CBC: hematocrit, RBC, ferritin, hemoglobin would be useful to settle your iron issue. When men need iron, something is typically wrong. Should also contain chromium picolinate [insulin sensitivity].

TRT can/may improve insulin sensitivity.

Test prolactin and see if lowering.


#7

Feeling a bit overwhelmed. I do appreciate all your input.

My D3 dosage is currently 2000IU. I can easily up it if you think I need more.

I have magnesium citrate on hand from when I was having muscle twitching/tremors. Stopped after I figured out the bupropion was the cause. I can go back on it, or should I test first?

I’m back on a low dose of bupropion (half what I was taking before) and already feeling better. Wonder if it’s lowered prolactin - how long before I retest that?

Will look into getting an updated CBC. Not sure if I can just walk into my MD’s office and give them your list, but if that fails I’ll just get it done on my own.

Thanks.


#8

How do you think I feel trying to stay on top of all of this traffic. No one has bought me a beer in the last year! [sob]

More Vit-D may be helpful.

Everyone needs supplemental magnesium unless they drink large amounts of milk. So never any signs of muscle cramps or tightening? But with high BP, a good idea.

It takes more than one read to get through my posts and links! You will get there, absorb and enjoy!


#9

I will up my vit D and go back on the mag citrate. I haven’t had any muscle cramps/tightening but it couldn’t hurt to try it.

As a point of information, my BP has dropped 10 points since stopping medical MJ last September. I’m hoping to reduce my BP meds at my next physical.

Now that I’m back on the bupropion, when do you think I can retest prolactin to see if it’s coming down?


#10

When to test? If you are feeling great there is no urgency.


#11

@KSman As you suggested, here are my temperature readings over the past week or so:

AM	PM
97.6	98.5
---	98.5
98.1	98.9
97.8	---
97.4	98.4
98.1	99.1

Also, the doctor did a thyroid panel on me about two years ago and ruled that out. I know these are old results, but the labs showed T4 free = 1.2 ng/dL (0.8-1.8), T3 free = 3.0 pg/mL (2.3-4.2).


#12

@KSMan

Have retested prolactin, with the following results:

Prolactin = 18.9 ng/mL (HIGH) (4.0-15.2)

Previous results from 5/17/17:

Prolactin = 21.5 ng/mL (HIGH) (4.0-15.2)

For about a month, I’ve been back on bupropion but at a lower dose (75mg/day) than before I quit. Had hoped the additional dopamine would push my prolactin down further.

Am now debating trying cabergoline

Have also read that taking estrogen can raise prolactin (see here). Wondering if it might be fixed simply by lowering my high estrogen with an arimidex?


#13

@KSMan Update with new lab results:

As a first attempt to balance hormones, I started anastrozole 0.3mg E3D on 7/2/17. Retested my hormone levels on 7/11/17 with these results. (Most recent previous values shown to the right.)

Testosterone, Serum        = 566 ng/dL (348-1197)         was 504
Free Testosterone (direct) = 13.6 pg/mL (7.2-24.0)        was 12.1
DHEA-S                     = 143.4 ug/dL (71.6-375.4)     was 181.7
Prolactin                  = 16.1 ng/mL (HIGH) (4.0-15.2) was 18.9
Estradiol                  = 27.0 pg/mL (7.6-42.6)        was 41.5
PSA                        = 0.9 ng/mL (0.0-4.0)          was 0.8

Note that I didn’t do a full panel since I’m just measuring progress of the anastrozole as I increase my dosage.

In the week since that test was done, I have increased my dosage to 0.5mg E3D. I am now starting to feel improvement, such as increased energy and some return of libido. I am also sleeping better now, not sure if that’s related.

Since I was at E=27 before my dosage increase, my plan is not to increase again until I’ve done more blood work.

Any input is appreciated.


#14

Update with new lab results:

These show the results of my latest blood tests taken 8/4/17. This is after increasing my dosage of anastrozole to 0.25mg E2D from 0.3mg E3D (25% increase).

                          8/4/17                     7/11/17    5/17/17
    Testosterone, Serum = 496 ng/dL (264-916)        566*       504* (348-1197)
    Free Test (direct)  = 11.5 pg/mL (7.2-24.0)      13.6       12.1
    DHEA-S              = 175.5 ug/dL (71.6-375.4)   143.4      181.7
    Prolactin           = 10.9 ng/mL (4.0-15.2)      16.1       18.9
    Estradiol           = 17.0 pg/mL (7.6-42.6)      27.0       41.5
    PSA                 = 1.0 ng/mL (0.0-4.0)        0.9        0.8
    LH                  = 8.2 mIU/mL (1.7-8.6)         -        7.0
    FSH                 = 10.0 mIU/mL (1.5-12.4)       -        8.6

*Note that the previous T values were against a different, higher reference range. Not sure if that means the 496 in the new test should be interpreted to be higher than it seems?

Other than that, it seems like I’m narrowing in on the correct dosage. I’ve been feeling dramatically better - energy level and motivation returned, erections more easily, sex drive increased. Perhaps a tiny bit unfocused, but thinking a slight decrease of my dosage could help that.


Using the Wrong E2 Test?
#15
  • Many have gone to Anastrozole dosing by the drop once we know E2 number after being on anastrozole for some time

  • Formula for calculating Ana dosage (if not an over-responder) ==> E2 number / 22 = mg of ana/wk

  • Given that your new E2 number is lower than the commonly accepted optimal of 22pg/mL, you need to lower your dosing of Ana

  • Recommended dosage would be 17/22 = .772mg Ana / week ==> new dose = old dose(e2/22)

  • You were taking .25mg EOD/E2D so that equals .875mg Ana/week (old dose)

  • New dose = .875(17/22) .676mg

  • To get .676mg go to dosing by the drop as cutting will not be accurate

  • Dissolve 1mg pill in 1mL of vodka, or 2mg in 2mL, 3mg in 3mL, etc.

  • Using graduated dropper, draw 1mL into dropper and count how many drops it take to dispense

  • Use the # of drops per mL multiplied by .676 to get your weekly dosage and then divide by 3.5 if you are going to do that E2D.

Example:
  • Your dropper measures 33 drops per mL (each dropper is different so you’ll have to determine your actual number)
  • 33 drops x .676 = 22.3 drops of Anastrozole per week
  • 22.3 divided by 3.5 days = 6.37 drops E2D
  • 6 or 7 drops E2D would get you where you want to be (or very close to 22pg/mL)

#16

@cdmac24
Thanks for the great info. As I’ve been adjusting my dosage, I’ve been thinking in terms of mg/day, since I’ve been adjusting the amount and the frequency, but mg/wk gives you bigger numbers so I can see how that would be convenient! What I’ve seen so far is 0.3mg E3D (0.700mg/wk) brought me to E2=27, and 0.25mg E2D (0.875mg/wk) resulted in E2=17. My thinking after the most recent labs was to split the difference, i.e. 0.787mg/wk. I figured I’d skip a couple of days to let my number rise a bit then start the new dosage.

Based on your recommendation, I’m now wondering. It would have me taking less than I was at the start. This would certainly bring my E2 up from 17, but wouldn’t it then continue to rise above the desired 22? Thoughts?


#17

I think either way works (using the math but also just splitting the difference).

  • There may have been some variability in the E2 numbers based on timing of labs
  • I think I would do as you suggest: split the difference and retest in 3-4 weeks (if feasible)
  • Seems like some can dial in right to 22 but others have more variance in their E2

Looking forward to your next labs (as well as my own) to see if you get it dialed in, and if getting it dialed in helps with your symptoms

I’m currently in a state where I think I’m Hypothyroid and/or have adrenal fatigue so I’m not sure getting my E2 dialed in is going to relieve all my symptoms just yet


#18

Just thinking out loud here:

  • you were doing .7mg/week when you were on .3 E3D

  • You increased to .875 mg/ week

  • You obviously understand the change there and I’m just wondering if your older dose (.7mg/wk) may not have had enough time (just 9 days between labs) to balance out your numbers like it would have if you had been on that dose for a longer time period.

  • More simply, would the .3 E3D eventually brought your E2 down past the 27.0 number reported on the 7/11 labs

  • This may account for the yo-yo effect you see in your numbers


#19

You’re reading my mind here! This did occur to me, and I honestly won’t be surprised if I end up back at 0.7mg/wk again when all is said and done.

I feel that my symptoms are drastically better. To the point where I’m feeling energy and motivation I haven’t had in a decade. It’s frustrating when doctors won’t engage on the topic of hormones, because plainly they make a HUGE difference. All this time I thought “I’m overweight and aging, so of course I feel like crap”. Who knew?

I hope you get your situation figured out. Stick with it!


#20

Thanks @keigwin

I’ve just started so all of this is very new to me and I’m trying to digest all the information.

There have been about 5-6 days since March 30th that I’ve thought, “man, this (TRT) is awesome!”

The rest of the days I’ve been impatiently dealing with sides of some sort and wondering if the sides are worth it.

To be honest, the increased libido and sexual performance benefits are why I haven’t scrapped TRT all together. I just need to get thyroid and adrenals figured out then dial in my TRT and I hope I’ll be a success story.

I’m nowhere near as lethargic and apathetic as I was before starting TRT so that’s the good news.