T Nation

Another New Guy - Opinions Needed

Hey All,
Glad I started reading this site. Been having the usual symptoms for many years and every year the doctors would tell me that everything looks good. I havent felt good for a long time and had somewhat resigned myself to dealing with feeling beat down. Would appreciate any insight you guys could provide.

Age: 37
Height: 6’4
Waist: 36
Weight: 200
Describe body and facial hair: average body hair, male pattern baldness, average facial hair
Describe where you carry fat: all throughout the trunk, gyno, love handles, gut
Health conditions: have had anxiety issues for 10+ years, kidney stones 1x
Rx / OTC: took celexa and xanax ( as needed )for 3-4 years for anxiety. No hair loss drugs nor any statins, etc
Describe diet: 2,500-3,000 calories per day. Generally healthy although perhaps a bit too many bread based carbs
Describe training: 3-5 days lifting per week, 1-2x cardio per week
Testes ache ever, with fever. Definite ache, not sure about fever. Confirmed varicocele, I believe on both sides.
How have morning wood and nocturnal erections changed: Occur less frequently although they still happen
Symptoms: significant brain fog, anxiety problems, low lidibo, seem to have difficulty dealing with certain stressors, motivation is low, confidence lower than it should be, difficulty shedding fat and gaining muscle.

Some History: Had T levels ( total t only ) checked about 5 years ago and they came back at 350. Doctor offered me androgel but I chose not to take it. Had a recent test about 6 weeks ago that showed total T levels of 300 and my urologist immediately gave me clomid. Took clomid for about a week and felt much worse while taking it. I quit taking the clomid once I had done enough recon here to realize that I needed to understand what the issue is before starting treatment.

Labs 6/20/12:
LH: 1.8 ( 1.7-8.6 )
FSH: 1.7 ( 1.5-12.4 )
Testosterone: 350 ( 348-1197 )
Free Testosterone: 9.2 ( 8.7-25.1 )
DHEA: 146 ( 31-701 )
TSH: 1.45 ( .450 - 4.500 )
Estradiol: 24.2 ( 7.6-42.6 )
Vitamin D: 48.7 ( range unknown )
Cholesterol Total : 131 ( 100-199 )
HDL: 39 ( >39 )
LDL: 77 ( 0-99 )
T. Chol / HDL Ratio: 3.4 ( 0.0 - 5.0 )

I am trying to understand these results but could use some help from the wealth of knowledge here. It seems like at a minimum I probably need to get the doc to prescribe an MRI to rule out anything bad with the pituitary. Is this correct?

Test levels need definite help. Since I saw a 50 point gain six weeks after taking a weeks worth of clomid does that indicate I might respond to a SERM or is that a pretty normal fluctuation?

HDL levels need some help. They have always been borderline low.

Any insight would be greatly appreciated.

What dose of Clomid were you on? It is unlikely that after taking it for a week and discontinuing for about a month that it was still affecting your system. You were probably just seeing normal fluctuation in T levels.

For HDL, consider taking Niacin. It has been shown to improve HDL.

Thanks for your response VTBalla. The Uro had me on 50mg of Clomid every day.

Based on my results above it seems like I fall into the classic secondary case, although I understand that just because i’m secondary that doesn’t preclude primary from being an issue as well. Am I correct in thinking that a SERM restart and varicocele repair is probably the right place to start given the results above? If that doesn’t work then an MRI is probably in order?

I don’t really have a good understanding of DHEA other than the very basics. Is this something that I should supplement separately or will it fall in line once i get the proper treatment for T levels?

Yes from your labs it would appear that you are secondary, but since you have already tried a SERM and didn’t react well to it it may not be the best bet for you. I have no idea if 50 mg is a high dose or not, but I want to say I’ve seen a couple guys recommend somewhere in the 25 mg/day range, so you may want to look into a lower dose?

If not, HCG challenge would also be an option.

Variocles seem to be tricky and I really dont know a lot about that. Some guys have sworn that is the cause of their Low T, but I cant see how that would create secondary hypogonadism.

Im not a big fan of DHEA–I havent seen anyone that started taking ita nd suddenly felt great.

As already mentioned try clomid at 25mg daily and take it for longer. 1 week is probably not long enough if you are wanting to restart your pituitary up. Think about taking it for a month or 2. I had crazy results on 25mg daily and was on for about 2 months. I would have gotten by with 12.5mg daily as E2 climbed very high.

Your LH is low so getting that pegged high is a good test to see what testosterone does.

Or going with HCG is another option.

My Uro said that if my varicocele is not causing me too much grief she would not rush into an operation. She even said that she doubts it is causing my low test, which was the correct call in my situation.

Thanks for the comments VTBalla and Irocz. I’m going to start with low dose clomid and see how well I can tolerate it. Thinking either 25mg EOD or 12.5mg ED for the next 5 weeks. If I can’t tolerate it i’ll see if the doc will prescribe HCG and if not i’ll begin the search for a switched on doc. With any luck my E2 levels wont deviate too much from where they are right now but we’ll see.

There are a couple studies out there that look at varicoceles and low T and the results seem pretty intriguing. The problem I see is they don’t distinguish between primary or secondary nor do they discuss the size of the varicoceles in the studies. I have zero desire to jump into a surgery, but it’s something i’d consider down the line simply to stave off any further degradation of testicular function.

Just providing a quick update.

Some symptoms have gotten better while on Clomid. Brain fog is gone which is great, energy levels are slightly better, although i’ve noticed very little difference in the gym.

6 week test results after taking 25mg Clomid EOD:

LH: 2.1 ( Range 1.7 - 8.6 )
FSH: 2.0 ( Range 1.5 - 12.4 )
Test: 519 ( Range 348 - 1197 )

E2 didn’t come back with this round of tests. I dont know if the lab missed it or if I missed it on the lab prescription, but will check this next time. Dr has some moronic reasoning why he thinks free test is inaccurate and doesn’t add it to the tests. I might just get the full panel from lef.org going forward since insurance usually bills me some portion of the cost of these labs anyway.

I’m happy to see a 169 point jump in test, but was expecting more. Also a little confused why my LH and FSH didn’t respond more to the clomid. I’m going to up my clomid dosage to 25mg ED for six weeks and see where things land, if those numbers don’t increase I guess it’s time to look at other issues like pituitary or varicocele. Not sure how optimistic I feel that a restart is going to stick, but it’s probably too early to judge that.

Mere FNG here, so no claim to expertise… but FWIW, I did encounter the same stance from my urologist, along with a rationale that made sense to me: He said the typical Free T assays were so inaccurate as to be useless, and he preferred to infer the value from looking at Total T and SHBG together.

[quote]farrago wrote:

Mere FNG here, so no claim to expertise… but FWIW, I did encounter the same stance from my urologist, along with a rationale that made sense to me: He said the typical Free T assays were so inaccurate as to be useless, and he preferred to infer the value from looking at Total T and SHBG together. [/quote]

Agreed…I have seen some truly bizarre Free T calculations (not necessarily assays I don’t think) that didn’t make a bit of sense given Total T levels and patient symptoms…one guy here has a current thread with TT in literally the bottom 5% of the range, with Free T in the top 25%…either an anomaly or jacked up test method IMO


OP you don’t seem to be responding well to the SERM, pituitary wise…but your T increase is good, and symptom alleviation is really what you are after…seems to be good from that standpoint…

[quote]VTBalla34 wrote:

OP you don’t seem to be responding well to the SERM, pituitary wise…but your T increase is good, and symptom alleviation is really what you are after…seems to be good from that standpoint…[/quote]

Agreed. I’m hopeful to see a better response with a higher dose with regards to the restart as I don’t want to take clomid any longer than necessary. I could certainly live at these test levels compared to where I was so it will be interesting to see how I feel at optimal levels.

[quote]farrago wrote:

Mere FNG here, so no claim to expertise… but FWIW, I did encounter the same stance from my urologist, along with a rationale that made sense to me: He said the typical Free T assays were so inaccurate as to be useless, and he preferred to infer the value from looking at Total T and SHBG together. [/quote]

I don’t really understand the free test calc but I could see the logic there. My uro isn’t checking shbg separately so I’m not sure what his reasoning is. Will post it after the next appt

A lot of guys feel like crap with clomid. Nolvadex does not have that problem.

LH has a short half-life and is released on pulses. So you will never get good data. TT levels are your best indicator of LH function.

You really need the E2 lab data!

Varicocele surgery: if the problem is progressive, how much worse does it need to become first?

[quote]KSman wrote:
A lot of guys feel like crap with clomid. Nolvadex does not have that problem.

LH has a short half-life and is released on pulses. So you will never get good data. TT levels are your best indicator of LH function.

You really need the E2 lab data!

Varicocele surgery: if the problem is progressive, how much worse does it need to become first?[/quote]

Agree completely on the E2. I might get that tested in the meanwhile on my own, specifically if I notice symptoms.

Also agree on the varicoceles. Trying not to muddy the waters just yet but I believe that the varicoceles will cause continual degradation of testicular function and it makes no sense to not take action on that, specifically for someone who is secondary. I don’t love the idea of microsurgery on my nuts but that might be the smart play long term. I wish there were more studies showing the relevance between varicocele and test levels - the ones I have read so far are fairly convincing.

Can anyone set me straight on the validity of E2 testing while taking Clomid? I’ve read that the results of E2 testing are irrelevant while on a SERM but i’m not quite clear why that is.

I’m noticing over the past week or two some joint pain, fatigue, and more soreness than i’d usually expect from the gym. I’d have to believe this is either E2 climbing or T falling. Currently taking 12.5mg of Clomid ED and not scheduled to see the doc for another 3-4 weeks.

Update as of 10/12

Still taking .25 mg clomid EOD

I’ve come to the conclusion that my urologist is not competent to handle my care. Nice guy but he’s clearly behind the times when it comes to trt. Time to start playing musical doctors. If anyone has any suggestions in the central Florida area it’d be appreciated.

Labcorp messed up and didn’t provide T numbers so I have to go back in for that.

LH. 5.2. ( 1.7 - 8.6 )
FSH. 2.5 ( 1.5 - 12.4. )
E2 43.2 ( 7.6 - 42.6 )
PSA. 0.6 ( 0.0 - 4.0 )

Looks like LH and FSH are starting to respond so hopefully the restart attempt will stick.

Have felt ok but not as good as before for the past 6 weeks or so. Have also noticed increased fat gain in chest and gut despite a pretty clean diet and gym routine. I was expecting high E2 and that appears to be the culprit. Urologist said he didn’t know how to get E2 down and felt that the usual AI meds were only useful for those on exogenous T. That was the statement that made me decide it was time to find a higher standard of care.

Am I going to have issues finding a doctor to prescribe an AI? Any natural things I can do in the meanwhile?

Update as of 11/6

Stopped taking Clomid as of 10/25. Met with an endo who seemed somewhat promising and he ran a whole battery of tests. Relevant labs are below:

TSH: .669 ( .400 - 4.00 )
T3: 98.9 ( 76 - 164 )
FT4: .93 ( .89 - 1.76 )
FSH: 1.9 ( .7 - 11.1 )
LH: 1.8 ( .8 - 7.6 )
Test: 396 ( 160 - 726 )
Prolactin: 10.4 ( 1.90 - 25 )
E2: 28 ( nd - 56 )
IGF-1: 202 ( 109 - 284 )
SHBG: 25.3 ( 10 - 57 )
Free T: .327 ( no ref range - median result for 17-65 year old is .361 and the 95th percentile is .637 )

Based on these results the endo quickly decided that I was at a good range and that my baseline was somewhere just below average. He even went so far as to say that even if we got my levels up near the top of the range that i’d likely see no benefit and that the risks outweigh any small benefit.

At this point I’m going to wait a month and see what happens to my T levels after being off of Clomid for a while. Since stopping Clomid my e2 has come down a bit and symptom wise i’m doing ok.

So i guess the next step is to find yet another doctor who might be able to pinpoint why my levels are off. Is it worth visiting an out of town doctor who specializes in this stuff and just doing follow ups via phone / skype / etc?

Anyone have any advice?

Did you taper out of clomid?

Many feel badly with clomid, nolvadex does not have that problem.

Yes, you can SERM+AI. SERM only hides SELECTED tissues from E2, others see the high E2.

Small dose anastrozole, 0.5mg/week in EOD divided doses may be helpful.

TSH is low, T3 is low, should be fT3
T4 is low.

Something is wrong.

[quote]KSman wrote:
Did you taper out of clomid?

Many feel badly with clomid, nolvadex does not have that problem.

Yes, you can SERM+AI. SERM only hides SELECTED tissues from E2, others see the high E2.

Small dose anastrozole, 0.5mg/week in EOD divided doses may be helpful.

TSH is low, T3 is low, should be fT3
T4 is low.

Something is wrong.[/quote]

Thanks for the response KSMan

I didn’t realize I was supposed to taper off of Clomid until at least a week after I stopped taking it. I was only taking .25 mg eod so hopefully i haven’t caused myself any setbacks by not tapering. The endo of course made no mention about the need to taper.

I need to do some reading on thyroid to understand what the levels mean, but sounds like it’s time for me to find yet another doctor. If you were in my shoes would you try another endo or an internal medicine dr, or someone completely different?

I don’t know a whole lot about thyroid results so i guess i’m off to read the stickeys and some other resources.

First: report body temperatures, iodized salt or sea salt, iodine in vitamins “Advice for New Guys” sticky.

Usual body temps are 97.2 - 97.9 and Ive pretty much never added salt to anything in my life. I’m certain to be pretty deficient. Will start tracking temperature and start supplementing salt and iodine based on your sticky. Thanks again for your help