T Nation

*7-22-2013 UPDATE: B WS6 Case*


#1

Hey guys, I jus' wanted some feedback, comments concerning my condition.

In February 2010, I noticed a drop in libido. I attributed this to the winter season and thought things would pick up by spring/summer. I decided to make an appointment during the summer of 2010 because things did not pick up. My blood results came back low in testosterone. She wanted to put me on Androgel on the spot but I said I wanted a referral to an endocrinologist.

Collected 8/12/2010

Total Testosterone: 170 250-1100
Free Tesosterone: 24 46-224
BioAvail Testosterone: 50 110-575
Prolactin: 7.5 2.0 - 18.0
SHBG: 27 7-49
FSH: 3.1 1.6-8.0
TSH: 2.99 0.40-4.50

AST: 28 10-40
ALT: 45 9-60

-age: 25
-height: 5'8
-waist: 40
-weight: 260

-describe body and facial hair: Thick beard, hairy chest, abdomen, legs, arms and slightly hairy back

-describe where you carry fat and how changed: Fat accumulation has not changed. It's always been centered around my torso and top of thighs

-health conditions, symptoms [history]: anxiety

-Rx and OTC drugs, any hair loss drugs or prostate drugs ever: Jus' Lexapro and Xanax when needed (haven't taken Xanax for over 2 years)

-describe diet [some create substantial damage with starvation diets]: Regular diet. I know most of you are health-conscious and compared to your diets, my diet is not normal. I would describe it as the typical American diet. Some junk food, some fast food but mostly whatever we can scrap together. I don't eat any one particular thing in bulk.

-describe training [some ruin there hormones by over training]: No training or exercising

-testes ache, ever, with a fever?: No

-how have morning wood and nocturnal erections changed: Even though I have no libido, I am still able to achieve erections. It is a little bit more difficult to get aroused and erections aren't quite as firm.

-I had an MRI performed last month and it came back normal

I would like to add the following blood results:

Collected 4/3/2009

AST: 41 0-40
ALT: 65 0-55
TSH: 1.9 0.4-4.5

I had a regular routine physical and my liver functions were slightly elevated. I had an ultrasound of the liver and everything was fine. According to her, I had a somewhat elevated liver functions for a year and she didn't tell me. She scheduled an ultrasound because it was still elevated. They are thinking I had a fatty liver from being overweight but as you can see, in the August 2010 blood test, my liver function came back in normal range with no reduction in weight. (Ate less meat though).

Also, I see my TSH level went from 1.93 - 2.99. I asked her if I was developing a case of subclinical hypothyroidism since my mom suffers from hypothyroidism and she said no and that I was within range. I wanted to have some more blood tests to follow up on that and see if it is still increasing but she refused and said to check with my endocrinologist. I'm not going to see her again.

Where should I go from here? I am really anxious to get on TRT therapy but would like to rule out any factors. Should I get tested for sleep apnea? Tested for adrenal fatigue? Lose weight? I jus' don't think sleep apnea (if I have it) or being overweight would supress my levels that low. Also, very little testosterone is produced in the adrenal gland so I doubt that it would also supress my levels below range.


#2

Adrenal fatigue is disabling and one can't cope with stress.

Check your waking body temp when you first wake, up, record and report here after 3-4 days.

Are you using iodized salt or have iodine in your vitamins? [Sea salt does not contain iodine.]

Do you feel cold easily?
Dry skin?
Did doc palpate your thyroid gland?

Note that endo's can be terrible at TRT.

Your body hair suggests that you had high T levels once, making the current levels all the worse.

AST and ALT can be up from sort or bruised muscles, not liver specific.

Supplements?

Post your CBC, fasting cholesterol and fasting glucose.

Blood pressure?
Pulse rate?


#3

I would be suspecting some form of secondary hypothyroidism probably resulting from adrenal insufficency. There needs to be further testing to rule out several other factors. For a guy 25 he should not be condemn to TRT as many have needlessy. Some Drs are just to lazy to look for the root cause and do not ask the right questions to get the answers they need. Endos you are in there for 15 minutes and out the door with one or 2 test which were not were the amount of blood drawn. I personal spend over 1 hour with a client/patient looking for the triggers and eventually putting the pieces of the puzzle together in a logical and clincal scenrio so the person has a better idea of how this occured. Once this is done then we start looking for imbalance with in hormone, thyroid, adrenals, nutrition, lifestyles, sleep hygiene, gut and liver imbalance, environment toxins, emotional or psychological trama, ect to get to the root cause. Once the root problem is identiifed then steps are taking to resolve well at the same time support symptoms till it is dealt with.


#4

Check your waking body temp when you first wake, up, record and report here after 3-4 days: I have before, it was on the low side.

Are you using iodized salt or have iodine in your vitamins?: I take no vitamins or supplements and the salt I do use, is iodized.

Do you feel cold easily?: Pretty normal temperature regulation.
Dry skin?: Only in the winter,
Did doc palpate your thyroid gland?: No enlargement of thyroid. Doctors have palpated my neck but I don't know if they were checking my lymph nodes or thyroid.

Supplements?: No supplements.

Post your CBC, fasting cholesterol and fasting glucose.:

Collected 8/12/2010

WB Cell Count: 7.0, 3.8-10.8
RB Cell Count: 4.41, 4.20-5.80
Hemoglobin: 14.4, 13.2-17.1
Hematocrit: 41.6, 38.5-50
MCV: 94.3, 80-100
MCH: 32.7, 27-33
MCHC: 34.7, 32-36
RDW: 12.8, 11-15
Platelet Count: 224, 140-400

Collected 4/3/2009

Cholesterol: 277, 100-199
HDL: 62, >39
LDL: 190, 0-99
Glucose: 88, 65-99

Blood pressure?: Pretty good on average; 130/82, 134/72

Pulse rate?: Usually high 80's


#5

If I did have adrenal fatigue, how would go about treating it? I can see how adrenal fatigue may dip testosterone levels, but is it possible for it to suppress it this low? (25 year-old with a 170, Ref 250-1100)?

This all happened 2 years after my dad's heart attack in 2008 where I had a relapse of anxiety.


#6

First you need to identify the root cause then you need to treat it properly by giving it the proper support both nutritional, and also making major lifestyle changes, the way you think, eat, ect. Once I start digging on a case I will not stop untill all stones are turned as in 90% of cases I will find something that out of balance. How you go about treating depends on several factors. Each case is individualized. This was not an over night thing, but more so a building process. If I was to look back at your child hood, and start digging I am sure I would to be able to connect the dots and basically give you a start to finish scenerio and its affect on the body.


#7

That is the same approach I decided to take since it sounds logical to rule out causes first. I went down the list of causes of hypogonadism such as: Klinefelter's, Kallman's syndrome, mumps, HIV/AIDs, medications, pituitary disorders, sleep apnea, testicular failure. I don't believe I have any of these issues; maybe sleep apnea.

I'm jus' growing tired of feeling this way. I've been very patient and I feel like digging into adrenal fatigue and other conditions might be a waste of time.

Having said that, I'll make one last effort to find the culprit. What should I ask for in a blood test in addition to the basic parameters?


#8

If your adrenals are underperforming then your sodium will be low and your potassium will be high (not necessarily out of the ref ranges, but toward those ends of the ranges) as a result of low aldosterone output. Kidney measures are generally a little off as well. Post electrolyte levels, BUN, and creatinine if you have them (if you don't have them, ask for a basic metabolic panel). Had any salt cravings recently?

Even full-blown Addison's (adrenal failure, which you don't have at present or you'd be writing to us from a hospital bed) is unlikely to drop T that low in someone your age all by itself, but it can be a contributing factor in a couple of different ways.

If your aldosterone is fine but your cortisol is low then you are likely to have a pituitary problem, not an adrenal one.


#9

In order to find the cause there has to be specific testing that needs to be done. Alot of drs are not open to going the extra distance to dig for the root cause. When dr's are stuck on cases they may contact me to help them look deeper into other avenues. If dr's will not do it then patients will seek me out because they are tired of dealing with dr's irrationality.


#10

Hardasnails, what specifically should I be testing for?

I don't have any current lab reports with those tests but this one:

Collected 4/3/2009

Serum Glucose: 88, 65-99
BUN: 13, 5-26
Creatinine: 0.84, 0.76-1.27
BUN/CREAT Ratio: 15, 8-27
Sodium: 141, 135-145
Potassium: 4.2, 3.5-5.2

I do not crave any salty snacks. In fact, I avoid them because I have this negative connotation that any salty snack is unhealthy. If picking out a snack, I'll usually pick out something chocolate-y or sweet.


#11

All looks good from here, but of course those numbers are almost 2 yrs old.

Salt craving (low sodium due to low aldosterone) is a classic symptom of primary adrenal insufficiency. If you're not sneaking shots of olive brine or eating potato chips for breakfast, your sodium probably isn't particularly low.


#12

Read this: http://www.amazon.com/Adrenal-Fatigue-Century-Stress-Syndrome/dp/1890572152/ref=sr_1_1?ie=UTF8&s=books

Topic is too complex to cover in a post.

Lowish waking body temps... that is not helpful.

Dry skin is from low T and/or hypothyroidism. If border line, will be a winter thing.

So we have potential liver issues, some kind of thyroid problem. Both can mess with your hormones. Your E2 is probably high, making weight loss difficult or impossible. Your body weight and waist size is expected to contribute to a lot of T-->E2. Thyroid problems also cause weight gain and make weight loss difficult or impossible. You have a lot of cards stacked against you. You need proper labs. I suggest that you get aggressive about getting these things managed. If you are paying for labs yourself, you would be better getting them done via LEF.org as you can get any tests you want and for less cost than out-of-pocked by a doc. If you have insurance, that and your doc can prevent you from getting labs done. Many have done labs on their own to establish what is going on, then presenting the data to a doc to get medical help.

http://www.lef.org/Vitamins-Supplements/ItemLC322582/Male-Panel-Blood-Test.html

adding

http://www.lef.org/Vitamins-Supplements/ItemLCTHYROID/Thyroid-Add-On-Panel-Blood-Test.html


#13

Could also be celiac, which should be ruled out whenever adrenal issues or Hashimoto's are serious possibilities.


#14

Drexel good call, I spoke to one on my colleagues today and just found out 1 in 90 people have celiac. Celiac can increase GI cancer, diabetess, and other degenerative disorders. I am right now designing I protocol for pin pointing celiac in patient that is much more accurate through a combination of specific testing alot of dr's are not aware of. I have it for lyme and found out disturbing information why it goes through undiagnosed even though the patient is most likely positive. My goal right now is for patients/clients is to have the ability to identify both lyme and celiac more accurate indirectly then directly.


#15

Thanks for the feedback. I'm going to make an appointment with the doctor to undergo some blood tests. So along with the basic metabolic, hepatic and complete blood count I'll ask for:

Total Testosterone
Free Testosterone
FSH
LH
Estradiol
Prolactin
DHT

TSH
T3
T4
fT3
fT4
rT3
Thyroglobulin Antibodies
Thyroid Peroxidase

DHEA-S
CORTISOL
Pregnenolone

What else is missing? Hardasnails: How do you specifically test for celiac disease?


#16

B WS6, most docs will tell you that the gold-standard test for celiac is a small intestine biopsy, but there's a blood test (tTG IgA) that is pretty accurate. It's inexpensive, too -- have your doc throw that one on the order.

Hardasnails, celiac commonly shows up with a LOT of autoimmune stuff: Hashimoto's, MS, Addison's, Crohn's, etc., and it's way way underdiagnosed. There are clear genetic links, though whether the autoimmune conditions are actually triggered by damage/malabsorption due to undiagnosed celiac is an open question.

But in particular, anyone with hypothyroid issues who is on one of the good natural thyroid meds, whose blood levels look okay, and who still feels like crap should get a celiac screen as a first step.


#17

Ok, I am now starting a protocol and it is:

(2) 50 mg's of Testosterone Cypionate per week
(2) 250 IU's of HcG
1 capsule of 1.1mg's of AI (Anastrazole) per week

The only question I have is the AI. It's in a capsule but I can't break it in halves or else all the powder will disperse. How are you guys going about splitting up capsules?


#18

Hey guys, so what would be the best way in splitting up an Anastrozole capsule?


#19

I've administered 3 HcG shots over the past 10 days and this last Tuesday was my last shot. Since then, I've developed a rash on my stomach. What should I do about this? I haven't read anything about rashes on the boards and can't find any info on the web concerning men.


#20

Update:

The day I started the TRT protocol, I decided to get a comprehensive blood panel done to jus' use as a reference as to where I stood at that moment. One of the things I checked was Estradiol which I haven't before. My lab value came in at 62 with a range of 20-54. I was about 10 days into my TRT protocol when I received these results and I placed my TRT on pause, but I continued to take the Anastrozole at .5mg's EOD.

About 6 weeks later I retested and here are my values JUS ON THE AI(NO TEST or HCG!):

Total Testosterone: 638 (250-1100)
Free Testosterone: 99 (50-150)
Estradiol: 24 (20-47)

I am overweight at 5'8" and 260 pounds and I am thinking my hypogonadism is due to being overweight. Any of the testosterone I produce is quickly converting into estradiol. However, I do not feel any better. My Testosterone increased and my Estradiol is in optimal range but my libido has not picked up. I don't know what to do from here. The only thing that I can think of is that the test was done too early, and picked up high levels of testosterone. I got blood tests from a local doc' jus' down the street, (on the same block actually). So I literally rolled out of bed in the morning and had my blood drawn.

So what do you guys think?