T Nation

Covering My Bases Before Giving TRT a Shot After Thyroidectomy


#1

Background

  • Total thyroidectomy and 1-131 radioactive iodine treatment in 2014. TSH levels have been consistently in the .01 - 1.0 range over the last year which is the target range for me.

  • Currently being treated for a Microprolactinoma with cabergoline. Prolactin levels have since been lowered to normal range.

  • Healthy aging clinic suggested I go on T.R.T. and HcG in 2015. I did Hcg only for 2 months, then stopped in hopes of picking up treatment through my insurance, but I haven’t been able to find a doctor yet.

  • 0 libido except when I was on Hcg for 2 months and recently when i started taking cabergoline, however even with libdio back I could not maintain an erection. Morning wood 1 once, maybe twice a week if that.

  • The last year or so I’ve been getting progressively more run down and brain fog is at an all time high. My job has always come very easy and stress free for me, but lately normal routine is exhausting to the point I need my entire weekend to rest and recharge. Mentally I’m useless if I get less than 8 hours of sleep. I frequently forget what day it is. I go out, maybe once a month as opposed to multiple times a week. I’m currently dating someone which again requires about 4 or 5 days of recovery after hanging out (which is extremely hard to explain).

  • I first started noticing minor libido issues at the end of 2012, but didn’t really think anything of it. A routine physical in early 2013 detected that I had papillary thyroid cancer and the next two years were spent dealing with that (2 surgeries and radiation). Libido issues increased but it wasn’t really a priority at the time. I wasn’t sexually active and I just figured everything would go back to normal once I got my TSH under control, but it never did. For about 6 months after having my thyroid removed my TSH was really high (30), but my energy and strength levels were still great then through medication I got my TSH under control and things kind of went downhill from there.

Sticky Questions:
Are your outer eyebrows sparse? No
Have you used iodized salt for years? no
Do you get cold easily? no
Any blows to your head before? No
Were things better earlier? Definitely.
More hair before? Same amount.

Current Medications
Levothyroxine 150 mcg daily
Cabergoline 0.25 mg once a week
Vitamin D 35,000 iu/ a week
Unisom - over the counter sleep aid

Past Medications
HCG 1800iu 3x a week
Cabergoline .5 mgs a week
DHEA

Body and lifestyle info
Age: 32
Height: 6’0
Weight: 160lbs (down 15 lbs in the last two years)
Body and facial hair: Full head of hair. Thick beard. Lots of body hair.

Training
Weight training 4 to 5x a week for the last 15 years. My strength has fallen off a little bit, but nothing drastic. More so my desire to workout is what has changed. I commute 20 minutes to my gym. I used to look forward to the drive to get me mentally and physically pumped up for the gym, but lately the drive has become too exhausting i’ve had to switch to a closer gym. I condensed my hour long workout into 20 minute workouts consisting of all supersets to trick my body into being too busy to be tired.

Diet
I eat pretty clean. Minimal fake sugar. Nothing processed. Gluten free except for the occasional beer. Lots of eggs, fish, fruit, nuts, and veggies. I just doubled up carb intake to 350-400 grams a day through white potatoes and fruits high in boron. Strength has gone up probably from the increased calories, but fatigue and erectile dysfunction remain unchanged. Protein is around 1 to 1.5 grams per lb of body weight. I eat a lot of healthy fats. In hindsight I should’ve been eating more carbs this last year, but I don’t know if it would’ve made much of a difference.

Questions
I’ve had my finger on the trigger to go with T.R.T. and HcG. for some time now. I already have to take Levothyroxine the rest of my life so I’m reluctant to add more medications to that list, however my quality of life is trending downwards so I’m at a point where I think it will be worth it and just want to make sure that I am not over-looking any other options? Decreasing my chances (even a little bit) of having children is somewhat of a concern, however having ED and always being tired is probably decreasing my chances more than T.R.T. would since now I’m terribly unpleasant to be around.

Dr History (full lab work with ranges at the end)

  • End of 2014: Complained to my primary endocrinologist (who I’m very happy with in terms of treating my thyroid cancer) that I have 0 libido and asked to have lab work done to check my testosterone. She admitted that’s not her speciality and advised I seek out a general practitioner.

  • Beginning of 2015: General Practitioner #1: Took lab work 1/22/15: Total Testosterone was 308. She said that was the normal range and prescribed me cialis.

  • Healthy Aging Clinic Doctor: Took lab work 10/15/15: Total Test: 467. Free T: 6.9. He recommended Trt and Hcg. I started HCG only @ 1800ius 3x a week (i know this is a lot). For 2 months. Test went up: TT 610. Free T: 10. I stopped seeing the healthy aging clinic doctor so that I can find someone my insurance covered.

  • Beginning of 2016 General Practitioner #2 He was the first doctor that my insurance covered that recommended T.R.T. but would not prescribe it himself. He was against hcg. Took labs and recommended a specific endocrinologist. Lab work (off hcg for 7 weeks): Test: 427. Free T: 9.5 prolactin 18.9. LH: 5.1 SHGB: 60.3

  • Endocrinologist #2 saw lab work from GP#2 and suggested i take viagra and see a therapist.

  • An MRI showed i had a Microprolactinoma and i was put on .5 of cabergoline by endocrinologist #2. After 3 months on cabergoline my prolactin went down to 2. TTest went up from 384 to 545. Free T from 8.3 to 9.6. SHGB: 65. LH 3.7 It was again recommended I take viagra and see a therapist.

  • I’ve been tested for celiac’s disease which came back negative. Clean EKG. Cholesterol is usually at the high range of normal.

Asking for certain things to be tested with blood work and getting the actual tests are two different things so pardon my lab work if things are missing.

Detailed Lab Work

1/22/15
Medications: 175 mcg Levothyroxine
Issues: 0 libido

Test serum (349 - 1197): 308
No free t, LH, FSH, DHEA, or SHGB on this test
T4 (.82 - 1.77): 1.37
AST (0-40): 33
ALT (0-44): 25

CBC:
Wbc (3.4-10.8): 4.5
RBC (4.14 - 5.80): 5.12
Hemoglobin (12.6-17.7): 16.0
Hematocrit (37.5 - 51.0): 47.5
MCV (79 - 97): 93
MCH (26.6 - 33.0): 31.3
MCHC (31.5 - 35.7): 33.7
RDW (12.3 - 15.4): 13.1
Platelets (150 - 379): 131 (my platelets went down significantly after radiation)
Neutrophils: 59%
Lymphs: 34 %
Monocyes: 5%
Eos: 2%
Basps: 0%
Neutrophils (absolute) 1.4 - 7.0): 2.7
Lymphs (absolute) (.7 - 3.1): 1.6
Monocytes (absolute) (.1 -.09): .2
Eos (absolute) (.0 - .4): 0
IMmature Granulocyes: 0
Immature Grans (abs): 0

10/6/2015
Medications: 175 mcg Levothyroxine
Issues: 0 libido

Test serum (348 - 1197): 467
Free T (8.7 - 25.1): 6.9
Prolactin (4.0 - 15.2): 17.6
LH (1.7 - 8.6): 7.1
No SHGB tested
T4 (.82 - 1.77): 1.44
PSA: .6
PSA free: .28
FSH (1.5 - 12.4): 6.9
Cpro: .61
Vit D: 31 (range 30 - 100)
Estradiol (7.6 - 42.6): 12.0
AST (0-40): 22
ALT (0-44): 15

CBC:
Wbc (3.4-10.8): 3.8
RBC (4.14 - 5.80): 5.15
Hemoglobin (12.6-17.7): 16.0
Hematocrit (37.5 - 51.0): 47.3
MCV (79 - 97): 92
MCH (26.6 - 33.0): 31.1
MCHC (31.5 - 35.7): 33.8
RDW (12.3 - 15.4): 13.9
Platelets (150 - 379): 162
Neutrophils: 48%
Lymphs: 43 %
Monocyes: 7%
Eos: 2%
Basps: 0%
Neutrophils (absolute) 1.4 - 7.0): 1.8
Lymphs (absolute) (.7 - 3.1): 1.6
Monocytes (absolute) (.1 -.09): .3
Eos (absolute) (.0 - .4): 0.1
IMmature Granulocyes: 0
Immature Grans (abs): 0
IGF-1

12/1/2015
Medications: 175 mcg Levothyroxine, 50,000 iu Vitamin d, DHEA, HcG 1800 iu 3 days a week for the last 2 months
Issues: Libido was revived, but erections were difficult to maintain

TT (348 - 1197): 610
Free T (8.7 - 25.1): 10

Cortisol (8.0 - 19): 17
LH - not tested
SHGB - not tested
Vitamin D (30 - 100): 36.5
T4 (.82 - 1.77): 2.07
Hemoglobin (4.8 - 5.6): 5.1
Estradiol (7.6 - 42.6): 19.7
C Reative Pro (0 - 3): .55
DHEA (138.5 - 475.2) 403.9
reverse t3 (9.2 - 24.1): 24.7
Triiodothyronine (2.0 - 4.4): 3.3
Insulin: 2 (2.6 - 24.9 range)
B12 (211 - 946): 419
Folate: >19.9
Homo plasma (0 - 15): 8.1
IGF-1 (88 - 246): 145
TSH: (.450 - 4.5): .153 (I have to stay as close to 0 as possible)

CBC:
Wbc (3.4-10.8): 3.9
RBC (4.14 - 5.80): 5.42
Hemoglobin (12.6-17.7): 16.8
Hematocrit (37.5 - 51.0): 49.7
MCV (79 - 97): 92
MCH (26.6 - 33.0): 31.0
MCHC (31.5 - 35.7): 33.8
RDW (12.3 - 15.4): 12.8
Platelets (150 - 379): 155
Neutrophils: 59%
Lymphs: 32 %
Monocyes: 7%
Eos: 7%
Bas0s: 0%
Neutrophils (absolute) 1.4 - 7.0): 2.3
Lymphs (absolute) (.7 - 3.1): 1.2
Monocytes (absolute) (.1 -.09): .3
Eos (absolute) (.0 - .4): 0.1
IMmature Granulocyes: 0
Immature Grans (abs): 0
AST (0-40): 25
ALT (0-44): 24

1/14/16
Medications: 150 mcg Levothyroxine, no longer on HCG for 7 weeks
Issues: Libido disappearing again, noticing i needed recovery time from things that used to come easy to me.
TT (348 - 1197): 427
Free T (8.7 - 25.1): 9.5
Prolactin (4.0 - 15.2): 11.6
Cortisol (6.2 - 19.4): 21.5
LH and SHGB not tested
T4 (.82 - 1.77): 1.88
TSH (.450 - 4.50): .301

CBC:
Wbc (3.4-10.8): 3.5
RBC (4.14 - 5.80): 5.34
Hemoglobin (12.6-17.7): 16.3
Hematocrit (37.5 - 51.0): 47.3
MCV (79 - 97): 89
MCH (26.6 - 33.0): 30.5
MCHC (31.5 - 35.7): 34.5
RDW (12.3 - 15.4): 12.9
Platelets (150 - 379): 134
Neutrophils: 46%
Lymphs: 45 %
Monocyes: 7%
Eos: 2%
Bas0s: 0%
Neutrophils (absolute) 1.4 - 7.0): 1.6
Lymphs (absolute) (.7 - 3.1): 1.6
Monocytes (absolute) (.1 -.09): .3
Eos (absolute) (.0 - .4): 0.1
IMmature Granulocyes: 0
Immature Grans (abs): 0
AST (0-40): 22
ALT (0-44): 14

3/10
Medications: 150 mcg Levothyroxine
Issues: Loss of libido. Always tired. At this point I pretty much had stopped drinking for a couple months, but now not only did i not drink when I’d go out, but i stopped going out all together to recharge.

TT (348 - 1197): 384
Free T (8.7 - 25.1): 8.3
Prolactin (4.0 - 15.2): 18.9
LH (1.7 - 8.6): 5.1
SHGB (15.5 - 55.9): 60.3
T4 (.82 - 1.77): 1.87

6/15/16
Medications: 150 mcg Levothyroxine, .50 mg cabergoline
Issues: Starting cabergoline 3 months ago and it kick started my libido and i jumped right back in and started seeing someone, but it was somewhat of a cruel joke. I could get erections, but I couldn’t keep them long enough to do anything with them. Fatigue and memory fog at an all time high.

TT (348 - 1197): 545
Free T (8.7 - 25.1): 9.6
Prolactin (4.0 - 15.2): 2.3
LH (1.7 - 8.6): 3.7
SHGB (15.5 - 55.9): 65
T4 (.82 - 1.77): 1.87


#2

rT3 is probably blocking fT3 and making you symptomatic.
When you take more T4 meds, you increase T4–>rT3
rT3 can be elevated from:
stress
illnesses
crisis
starvation diets
over training - anything beyond your current metabolic capacity
inflammation
infections

hCG: You have primary hypogonadism, so hCG will have limited effects. 250iu hCG SC EOD is a replacement dose for otherwise healthy males. High dose hCG can make things worse in a number of ways. BB guys often have this wrong and many doctors are ignorant of the downsides of high dosing.

Sleep: This as a generic is cheaper: https://en.wikipedia.org/wiki/Diphenhydramine . The problem with this medication is that it wears off in about 4 hours and you wake up early. Works well at first. Suggest 50-75mg Rx trazodone 150mg which breaks to 50 or 75mg. $40 for a years worth at Walmart/SAMs. Also, time release melatonin 5-6mg can be very useful. Must be time-release as the dropping levels are the mechanism of waking up and fast acting will wear off during the night and wake you up. Locate this on drug store shelves, can be hard to find amongst the fast acting melatonin products. Magnesium supplements at bed time can also help with sleep - also can eliminate foot-leg cramps.

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

  • advice for new guys
  • things that damage your hormones
  • protocol for injections
  • thyroid basics
  • finding a TRT doc

In ‘thyroid basics’, check your oral body temperatures as suggested. If low, you are under medicated. Cause of under medication can easily be from rT3. You can try to get on T3 only medication and serum T4 will go down and T4–>rT3 will be reduced. In this case, the T3 that you take will be blocked by rT3 to some extent. As rT4 drops, you need to reduce T3 dose. So that is tricky. Watch oral body temperatures. You need time release T3 and that is only available from compounding pharmacies. A partial step would be a desiccated thyroid product that has T3+T4, but rT4 can block that.

In your timeline, do you think that T levels dropped after radioactive iodine treatment?

Low thyroid function has may of the same symptoms as low T and I suspect that you are dealing with both.

By not using iodized salt, your TSH would have been high and that level of stimulation may lay the ground work for cancer as it can lead to thyroid nodules, with can then also progress to hyperthyroidism.

For the first 4 months of thyroid meds, T4–>rT3 may have been progressing and the effects of I-131 on your testes may have been progressing. When you read paper about I-131 on testes, remember that you are a sample of one and clinical averages may be of little comfort.


#3

Thanks for taking the time to respond.

Sleep: This as a generic is cheaper: https://en.wikipedia.org/wiki/Diphenhydramine .

Yup! I live off the generic stuff. I’ve tried melatonin and didn’t love it so I’ll just stick with what works for me.

In ‘thyroid basics’, check your oral body temperatures as suggested. If low, you are under medicated.

My temperature before i went to sleep last night was 98.0 and when i woke up this morning it was 96.3 :confused: I’ll keep monitoring my temp while doing some research to devise a plan of attack.

In your timeline, do you think that T levels dropped after radioactive iodine treatment?

Definitely. Throughout the whole cancer adventure I felt great before my diagnosis, throughout two surgeries, etc. I literally felt the best I had ever felt in my life until about 3 months after radiation when coincidentally I was in remission. I’ve seen similar studies as the one you referenced. Some say test will recover after about a year. I’m creeping up on the two year mark since radiation so I’m losing a little faith.


#4

I had to go on an essentially iodine free diet for 5 weeks twice in the last 16 months for the radioactive iodine treatment. I’m guessing that did not help my body temperature as I was probably already iodine deficient to begin with.


#5

Yes, you need to avoid iodine before I-131 as iodine saturated tissues will not absorb the isotope. Medical people will tell you to avoid bread, but iodine dough conditioner was eliminated decades ago and they did not get the memo. Unfortunately, bromines were used to replace iodine as a dough conditioner.

So not using iodized salt might have been a factor with your thyroid issues? I am noting that you did feel great prior to all of this and that seems unlikely if your thyroid function had been low for years beforehand. We do see a lot of subclinical thyroid issues on this forum, and some thyroid autoimmune problems, rarely hyperthyroidism; thyroid cancer seems to be rare in the population coming here. Low T secondary to I-131 is a new connection for me.

rT3 is a big issue for you and your body temps say that you are still hypo. More T4 medication will not help as T4–>rT3 will then increase. Your fT3 should be supporting good body temps and rT3 is the reason that this is not happening.

Review ‘adrenal fatigue’ in thyroid basics sticky.

Keep watching IGF-1 over time. You are lowish for age now.

TRT: There is a strong expectation that you will not absorb transdermal T products, try for injections. Do not expect doctors to understand this complication. It really seems to be a connection that has shown up with TRT guys here. I do not know how widely this realization is across other TRT forums.

Try to get on time release T3. Only at compounding pharmacies. I get that from:
The Compounding Pharmacy of America, Knoxville TN, 855-277-2488 and they deliver this by USPS. I do not know if widely available elsewhere. Using multiple 5mcg capsules to find what dose feels right for me via body temperatures. Dose per capsule can be increased later as needed. Note that as you depress rT3, your serum T3 will be more effective and dose would need to be reduced. I strongly feel that you are not going to do well with T4 or T4+T3 meds at this point in time.


#6

So not using iodized salt might have been a factor with your thyroid issues? I am noting that you did feel great prior to all of this and that seems unlikely if your thyroid function had been low for years beforehand.

Yea I felt great. All my thyroid levels were good except TPO ab was 408 on a range up to like 30, but I was told that was unrelated. During an annual physical the doctor noticed a nodule and recommended I get it checked out and that’s what eventually lead to a diagnosis.

Low T secondary to I-131 is a new connection for me.

From my experience the majority of patients endocrinologists see with papillary thyroid cancer are women or older males where low T isn’t terribly relevant so there’s not a demand for such research. That’s just my theory from having multiple endocrinologists look at me like I have three heads when I bring up testosterone.

Thanks again for your time and input. I’m excited to read up on adrenal fatigue, rT3, and T3.

lunch time body temp 97.3 -_-