Advice for Conversation with GP

I don’t have too much specific information regarding labs yet, but I’m hoping to get some advice around discussions with my GP.

As a little background, reference point, I had my TT tested over 20 years ago, when I was 20, and it came back in the mid-400s ng/dL. While just a bit on the low/normal range, I didn’t have any symptoms, so all was good. My TSH was also a bit high, but I don’t remember what the number was at all.

About a year or so ago, I started noticed increasing symptoms and they got bad enough, I figured I should probably get some blood work done. I was hesitant to go to a TRT clinic, because they’re selling a product and I want to make sure its actually the issue before jumping into TRT.

My GP was good enough to entertain the possibility of low T and ordered a TT test, along with the usual standard check up blood work. He also referred me in to a sleep study and I have that scheduled for April 27th.

When I got my labs back, my TT was 11.8 nmol/L or 340 ng/dL, reference range 8 - 35 nmol/L (approx. 250 - 1200 ng/dL) and my TSH was 6.67 mU/L, reference range .2 - 4.00 mU/L.

I have a follow up appointment on May 3 to go over my bloodwork and I’m not quite sure how I should approach it. My TT is on the low end, but still within the reference range. Given my symptoms, I’m wondering if I should ask for a referral to a urologist or endocrinologist for a more complete panel. I’m also wondering, though if I should see what the sleep study says and maybe try to tackle that angle first, see if my symptoms improve and then do a follow up TT test and go from there.

My diet and BF% are all in check, so the only lifestyle factor that I could see contributing to the TT number is sleep. I work a 4 on, 3 off work schedule, getting 5.5-6 hrs of sleep when I’m working at 8-9 hours when I’m off. Next week, I’ll be moving to a 4 on 4 off schedule, so I’ll have an equal number of short vs long sleeps. The biggest thing for me about sleep, is that I worked shift work for over 20 years, and I actually work straight days now, so I’m not sure why it would be causing issues now, but I’m willing to accept that’s what it is.

So, I’m not sure if I actually asked any questions here, but if anyone has any advice, that would be much appreciated.

Yeah, welcome to hormone hell.

A couple of things that I’m pretty sure of - TT is not the be all, end all, and you should have a look at your Free T, and SHBG, and the aforementioned TSH. I am blissully ignorant of most of those complications.

I would see what your sleep study has to say. I was diagnosed with apnea many years ago and resolving that alleviated a lot of my fatigue issues.

Final thing, is consider the time of the blood draw. If it was in the morning, that would be your peak and you are most likely low by afternoon. If it was afternoon, you were probably low normal.

So, Free T is the key, along with TSH and SHBG in conert with the sleep study.

You will shortly have several other guys with way more knowledge than myself contribute shortly.

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The Free T is where the rubber meets the road. Not all doctors up to date on current medical literature, especially when it comes to male hormones.

There is data that shows symptoms of low-T can start <432 ng/dL and in some cases <577 ng/dL if you’re unlucky enough to have long gene CAG repeats or activity level at the receptor level.

TRT can’t work well if there are thyroid problems.

Poor sleep can lead to low-T.

With your our total testosterone this low, your free testosterone won’t be great.

Still, you should get free T, SHBG checked, as well as free T3 and free T4, antibodies. I suspect you will have a hard time getting testosterone from an endo. They’re all about the “range”. Nothing wrong with ruling out other possibilities, you did not go into detail regarding symptoms. I don’t see guys who had sleep apnea treated doing great, but they are in my office and would not be if they were. It’ll come down to the severity of your symptoms and the extent they impact your life. Good luck.

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It was before 9 am. I’m not sure how much it drops during the day, but I know it does.

I agree. I’m hoping to get the other labs requested and see how they all look together.

I didn’t expect my GP to request a Free T test at the first appointment. I knew he would just go with TT, but I’m hoping now with the result I got, he’ll be open to looking deeper.

I also recently read something about this. It didn’t reference quite that high, but I’m not surprised at all that there could be symptoms up in those ranges.

I didn’t know this, but I did read that thyroid function can affect testosterone levels, I think mainly Free T.

Absolutely. I’m definitely open to this and perhaps this might be the best case scenario. Maybe with my new shift schedule giving me an extra night of 8-9 hours, plus whatever the sleep study finds (if anything), that might be enough to bring my levels up. Do you know anything about the effect sizes. I’ve generally heard poor sleep leads to about a 10-15% decrease. Improving that would get my up closer to 400. A bit better.

I’m keeping my fingers crossed about this. I’m 100% not looking for someone to just give me TRT and if I can fix things another way, like sleep or fixing my thyroid function, I’ll go that route first.

I know I’d have no trouble at a TRT clinic if I wanted to go that route. A guy at work went to the main one here. His TT was also 340 ng/dL and was told that was too low for someone who trains, so they’re “optimizing” him up to 700 ng/dL. I’m trying to take a different approach first, through doctor’s who aren’t also trying to sell a product. If we can’t figure things out this way, I’ll look into the clinic.

My worry is just what you said - I’m technically in range, though with numbers that would be seen in the average 85 year old.

This is a tough one. Sometimes you don’t realize you were feeling bad until you feel good. My main symptoms right now are low libido, increased irritability, poor concentration, low motivation, fatigue. There hasn’t been many real world negative repercussions yet, because I know what I need to do at work, home, and gym and get that done. But, it’s become more difficult and I don’t really want to do anything extra. What I don’t want, is to wait until things get bad enough that it does start to negatively affect my life and then start looking into things.

I know my symptoms can also point to other causes, so everything’s on the table to be ruled in or out right now.

Thanks!

The most widely accepted parameter to establish the presence of hypogonadism is the measurement of TT. Unfortunately, no consensus has been reached regarding the lower TT threshold defining TD, and there are no generally accepted lower limits of normal TT. This lack of consensus follows from the fact that no studies have shown a clear threshold for TT or free T that distinguishes men who will respond to treatment from those who will not.

Meanwhile the number of CAG (cytosine–adenine–guanine triplet) repeats in androgen receptor differs in men and influences the androgen receptor activity. Hence testosterone sensitivity may vary in different individuals.

The same applies to androgen receptor gene CAG repeat lengths >24 in the presence of symptoms and normal testosterone levels may be considered as a state of preclinical hypogonadism.

Though there is still a controversy in defining normal TSH levels in the elderly, thyroid gland function impairment should be excluded in all patients with hypogonadism, as symptoms of hypothyroidism may overlap those of hypogonadism.

Testosterone is metabolized mainly in the liver, thyroid hormones drives that process. You could even have a hard time metabolizing prescription medications if thyroid hormones are low enough.

There was once a member that was checking his levels out of pure curiosity, was very fit and not a symptoms at all. He came in with a Total T at 158 ng/dL.

So imagine another man at the other end of the spectrum with normal testosterone levels and symptoms of low testosterone being blown off by his doctor.

The fact that our reference ranges are so broad tells you that everyone is difference and yet we’re all treated the same.

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This^

Exactly!

Another thing I find really confusing, is it seems that when someone is diagnosed with low T requiring treatment, the treatment goal is around 600 - 700 ng/dL. If the thought is that someone who’s at 250 ng/dL should be brought up to 600 - 700 ng/dL, then why is there such resistance to someone who’s 340 ng/dL, with symptoms, being brought up to that level as well? It seems the acknowledgment is that 600-700 ng/dL is “ideal,” but only if you are clinically low. Otherwise, they’d just bump the person with 200 ng/dL up to 340 ng/dL and call it good, because they’re now in range.

Admittedly, medicine is way out of my wheelhouse, so this is merely curiosity rather than a critique. I know I don’t know even close to enough to actually offer an opinion on it.

Definitely. I’m also not a fan of the reference ranges being relevant across the population and not age specific. I saw a chart on average levels by age and the average didn’t drop to sub 400 ng/dL until you got into the 85-100 year age bracket. I don’t think it’s crazy not to want to be ok because my levels are average for someone who’s already lived past the general life expectancy. :slight_smile:

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We have a sick care system instead of a health care system, it’s all about disease management.

Doctors don’t get paid to keep you healthy, they get paid when something goes wrong. It’s real simply, you can get TRT anywhere (T-mill, cash only clinic) if you’re paying for it, but when insurance companies are footing majority of the bill, they get to make the call.

Insurance companies collect premiums and in order to make a profit, they have to bring in more money than they put out.

The big problem is no one can agree with what’s normal. Dr. Eugene Shippen who has been prescribing TRT for over 50 years says these normal ranges aren’t normal at all.

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I’m surprised that will everyone embracing “spectrums” lately that the testosterone range still continues to be so black and white. If you’re in range, docs say you’re fine, 1 point below and you get TRT. Would it make more sense to have the range look like:

<300ng treatment required
300-450ng lifestyle/possible intervention
450-550ng lifestyle/diet/SHBG
Greater than 550ng no treatment required/retest in 3 months

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I always found this to be insane, either the doctor has a bias, a massive character flaw or is an underachiever incapable of critical thought and analytical thinking.

You don’t go from being able to build muscle easily at 300, rock hard erections and a libido to boot, then at 299 full blown low-T.

A new member recently made a great point, the guidelines instruct doctors to shoot for around Totral T at 600 as this seems to be the optimal level for most men. So a guy walks into the doctors a office and complains of low-T symptoms, 600 is optimal and ideal for health and longevity, but the poor guys is told 340 is normal.

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I’m about halfway through right now. It’s been really interesting.

I agree. I did find one source, The British Society for Sexual Medicine, that recommends a 6 month trial for men with levels between 8-12 nmol/L to see if symptoms improve, so at least there’s a bit of a spectrum somewhere.

Exactly!

I have an update and I think things may have gone better than expected, but not perfect.

I had the follow up with my GP and he was in agreement that things are in a bit of a grey area. As mentioned, my TSH was a bit high and outside the range. Not high enough to definitely require immediate treatment, but it should be monitored. He suggested retesting in 6 months, but also said he would be willing to start me on low dose synthroid, if I wanted.

As for TT, he admitted it was definitely on the low-normal range and brought up the topic of TRT himself. The part that had me a little weary was when I asked about testing FT or any other labs, he said no and that TT was the standard. I suggested that we could also retest that in 6 months, as I still don’t even have my sleep study results back and he said that was reasonable.

For both, he stated it would come down to how aggressive I wanted to be. I said I wasn’t opposed to either synthroid or TRT, but felt it prudent to at least wait for the sleep study results first. I definitely don’t take going on a life-time medication lightly, so if waiting a couple months means I’m confident I’ve done everything I can and it’s the best course, then I think it’s not a bad idea.

One thing I have been considering, though, is going on synthroid sooner. I have a family history of hypothyroidism and my TSH was also a bit high 20 years ago, so I don’t see it improving. I’ve read there’s a lot of similar symptoms between hypothyroidism and low testosterone and the former can actually lead to the latter, so I’m wondering if addressing the thyroid might improve the test. If that’s the case, then waiting the 6 months before starting synthroid might push back any potential TRT treatment another 6 months to give it a chance to have an effect.

I might have to book another follow up with my GP to discuss these thoughts.

That’s what you call a red flag. It may have been standard to test for Total T 5-10 years ago, but since then things have evolved and your doctor hasn’t kept up with advances in male hormones.

I think it’s a waste of time to seek TRT from this doctor, the Free T is where the rubber meets the road.

You do want to optimize the thyroid if indeed there is inadequate levels of fT3 first before going on to TRT, because you can’t metabolize testosterone efficiently in the liver without enough thyroid hormone.

That was my first reaction and one of the main reasons I decided to retest in 6 months vs pushing ahead with him. At least he was open to the idea, which was more than I expected.

I’m not sure what my fT3 levels are. We only tested for T4 and it was in range.

I also read that hypothyroidism can also be related to a subnormal response of LH to GnRH, leading to lower testosterone production.

I only know what I read, so it’s all speculation on my part, but there at least seems to be reason to get my thyroid straight, then retesting TT. An unknown for me is the expected effect size. My TSH level (6.67 mU/L) technically is considered subclinical hypothyroidism and it isn’t clinical until over 10 mU/L, so I’m not sure how much of an effect just bringing it down below 4 mU/L would have.

Normal reference ranges for TSH is 0.5 to 5.0 mIU/L.

You can’t diagnose hypothyroidism was just TSH, you need to test the fT3. There are some people who don’t convert T4 to fT3 well enough, so the TSH and T4 alone can be deceiving.

There was a member a couple years ago with a TSH at 2.7 and low fT3. Thyroid treatment quickly turned things around.

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