T Nation

Diagnosed, But Unsure of Treatment


#1

Age: 33
height: 5'9
weight: 194

body: fairly muscular but no beard(LIGHT mustache/chin hair), not much hair on arms/legs.

lifestyle: very active, sometimes train twice a day(not weights) but strenuous cardio

diet: lots of fresh vegetables / meats / pastas / fruits, no refined sugar/sea food

symptoms: fatigue, stress, low patience, low libido(no problems with ED), mood swings, irritable, lack of focus(fog), slow recovery(soreness). Keep in mind I have had these symptoms for quite a while, just never really thought they were symptoms(silly, but true).

Given the volume of physical activity and level of attention I have for my diet, I should look pretty lean and feel great, yet I am not. Thus the following:

1/6/16 - appt with my PCP regarding symptoms above, had no idea it was related to low T. He mentions potential thyroid issue along with pituitary/hypothalamus etc etc and gives me some paperwork to take to the blood lab(posted below). I go to the lab, get the bloodwork done head home to research this compulsively. Not happy, this seems like a very deep and dark rabbit hole.

Bloodwork comes back:

General Chemistry


Sodium Level 141
Potassium Level 4.1
Chloride Level 106
C02 26
AGAP 9
Glucose Level 93
BUN 24
Creatine Level 1.610
eGFR African American 64
eGFR NON-African American 55
Calcium Level 8.8
Bilirubin total 2.7
Alkaline Phosphate 90
AST 44
ALT 33
Protein total 7.2
Albumin Level 4.3

Thyroid Study


TSH 3rd generation 0.506

Other Study


Sex Hormone binding globulin (SHBG) 30
Testosterone Total 230
Testosterone Free 43
Testosterone % Free 1.9

CBC Study


WBC 7.2
RBC 4.66
Hgb 13.8
Hct 40.6
MCV 87
MCH 30
MCHC 34
RDW 12.2
Platelet 158
MPV 11.9

Differential


Lymphocytes Auto 25
Neutrophils 65
Monocytes Auto 9
Eosinophils Auto 1
Basophils Auto 0
Abs Neutrophils 4,690
Immature Granulocytes 0

1-13-16 follow-up

doc tells me I am secondary hypo and gives me a few treatment options. He reccomends the gel but my research showed the injections to the preferred treatment(that and I really didn't want to rub that crap on my body every day). I insist on home injections and he approves. Writes and rx for 1 x 1ml/200mg shot every 4 weeks.

My research at this point turns up quite a bit of conflicting information. I decide to go with my gut and inject .5ml IM instead of the prescribed 1ml/200mg(this was last monday). Tue-Thurs I felt great, or I should say normal. Almost all of the irritability went away, I felt an increase in patience, mood and energy. Also felt great cardiovascular performance(no increase in libido at this point). By thursday night I started to feel the effect wearing off, and by friday I was fully crashed(or at least my mind was). Monitoring my body temp the entire week(both oral/armpit) I noticed on average I am between 95.1-97.0, never really reaching 98 degrees. This along with the crash feelings(depression, irritibility, patience decrease and energy) and some other questions about dosage frequency, injection types I decide to make another appointment to see doc.

1-20-16 follow-up

Trying my best to not come off as the know it all patient with a degree from google, I let doc know how I'm feeling and about the body temps, mood swings etc. Says its all normal but to contact him if I feel it gets out of hand. Asked about breaking up dosage(1ml/200mg/month) to .25ml per week instead. He didn't seem against the idea but also wasn't jumping on the bandwagon. The same for subq injections vs IM. He strikes me as a fairly open minded guy, just maybe not up to date on HRT. When I asked him about potential issues with estrogen and fertility he seemed confident in saying they would not be an issue(again, not out of arrogance but maybe ignorance?). By the end of the appointment he says he wants to increase my dosage from 1ml/200mg/monthly to 1ml/200mg bi-weekly(14 days). He tells me this is the maximum allowed dose and that we will be able to make any adjustments we need when we get the next blood work back in 6 weeks.

So here I am, still feeling like crap trying my best to monitor the situation and stay positive. I have a spreadsheet that I am updating hourly with everything from what I'm eating, to daily mood, sleep and energy feelings. Also keeping track of my weight(both morning and night), body temp and water intake.

Is this my body adapting to the recent influx of T? I mean as I sit and type this, I literally feel like sh!t, perhaps the only thing that lifts my mood is training. What gives?


#2

Wait for some of the more knowledgeable posters to weigh in, KSMan in particular, and follow their advice.

In my experience, your doc isn't up to speed on protocol, like most of them. Injections should be at most two weeks apart, most argue twice weekly is best. I'm on 140 mg weekly after starting on 100 mg and working up to 140 mg based on blood tests. The crash you described coincides with shots being too far apart.

Also, you won't feel the best effect until six weeks of treatment. I assume you are on Test Cypionate, which has a half life of about seven days. If you shoot every seven days, you will be building up a residual, hitting maximum benefit in six half lives, or six weeks. Your first shot will be at 50% after one week, 25% after two weeks, 12.5% after three weeks, 6.25% after four weeks, 3.125 after five weeks, and so on. Be patient.

You should absolutely be concerned about fertility if you are not done having kids. If you are done having kids, you may still want to protect your boys with Hcg - let those smarter than I explain. I'm done having kids and have little concern about the size of my boys so I am not on Hcg. It was offered, and I tried it, and it did have the intended effect, but it wasn't worth refrigerating and getting the script filled - it comes as a powder and has to be mixed gently with water.

I'd be concerned about your body temps but it's beyond my experience, so wait for the smart guys.

For what it's worth, I've been on TRT for fifteen months and it has been a game changer. I had issues with lethargy and concentration and couldn't lose the weight I wanted to despite being in the gym 3-5 times a week and doing cardio 3-5 times a week. That all changed with TRT. But, if you can fix things without going on TRT, why not try it?

Good luck!


#3

UPDATE:

Something I didn't mention was that on my first apt with pcp he initially mentioned that I might have a low thyroid and that we should check it. On my second appointment however he seemed pretty confident that it was a pituitary / hypothalamus issue and we continued on from there.

Having researched ksmann's previous posts I think that maybe I should have had a few more labs done. Curious how some of you approach your doctors about this. I realize that the doctor is there FOR the patient but I imagine there is a fine line between being a condescending know it all and genuinely concerned about tests/treatments that the Doc may or may not be aware of.

For example, lets say your doc is a fairly open minded guy that genuinely cares about the well being of his patients(as I believe mine does). In specialty fields such as this where he unknowingly may not be up to speed on the most current protocol, how do we as patients educate them without sounding like an idiot.

I mean we are essentially entering into a discussion with very little knowledge about a topic that one man has made his professional living for the last 25 years, with only the advice of a few smart individuals on forums and anti-aging clinics. Kind of hard to go to bat with that, no?

To answer some of ksmans usual questions:

Are you on any medications? Rx or OTC
Nothing except for 10,000IU of Vit D3

Do you use iodized salt?
No, but over the last week I have made some changes to diet that should now fix that

Feel cold easily?
Sometimes, but I wouldn't say its often.

Outer eyebrows sparse?
Yes as a matter of fact they are

Last night while trying to fall asleep(11pm'ish) I noticed my heart beat was elevated. Not crazy high but enough that it was noticeable which then becomes uncomfortable due to the fact that I'm just laying in bed. That compounded with a restless mind and some light sweating. It didn't last very long(maybe 20-30 minutes) until I eventually fell asleep. I have never really had any problems with sleep, when I was younger I could sleep up to 15 hours if not disturbed. Over the last couple of years that has changed due to our child being born, but I still usually get ample sleep(5-9 hours).


KSman is Here
#4

Change in sleep. Perhaps body is reacting to newly increased iodine. That should be transient.

You have read these links in the 2nd post of the first topic in this forum?
- advice for new guys
- thinks that damage your hormones
- protocol for injections
- thyroid basics
- finding a TRT doc

Where are you located? - affects your options

You needed to have had LH/FSH tested before TRT. Too late now.

Labs: - you have some now
TT
FT
E2
LH/FSH - cannot do now
prolactin
TSH
fT3
fT4 [ please not T3, T4]
AM cortisol [at 8AM please]
DHEA-S
Fasting cholesterol = 93
AST/AST - are elevated now, could be from training and sore muscles

TSH does not tell us enough about your thyroid function.
Body temperatures indicate that metabolic rate is depressed.
By training intensely with the deficits in T and metabolism, you may have elevated rT3 from adrenal fatigue.
Low metabolism many not be allowing muscle recovery, but you are also simply over-training.

Need lab ranges, please use the edit in you first post to add ranges. FT ranges are vastly different from lab to lab.

Need waking and mid-afternoon body temperatures. Please see the thyroid basics sticky.

I can provide guidance, but you have to do the work. You seem to be doing well so far.

Your doctor does not know what he is doing. He completely blew off the diagnostic window because he things low T is the problem when, at your age, it is the symptom. He has T tunnel vision. You are been too passive with your doctor. You need to manage your own heath care and view doctors as sub-contractors.


#5

I have read those links, but will be sure to give them another pass.

location = eastern MA

I came to a similar conclusion as yourself after browsing the stickies and other resources. As far as the ranges are concerned, I will have get ahold of the doctors nurse to get those results as all I have are the actual lab numbers.

The doctor did say that the TT range was between 350-1100

Temps are as follows:

Morning

Sun: 97.6/oral
Mon: 97.6/oral
Tue: 97.2/oral
Wed: 96.7/oral
Thur: 95.6/oral
Fri: 96.2/oral
Sat: 97.1/oral

Evening

Sun: 97.8/oral
Mon: 96.8/oral
Tue: 97.1/oral
Wed: 97.2/oral
Thur: 97.2/oral
Fri: 96.9/oral
Sat: 97.1/oral


#6

Temperatures drop in the evening. I wanted to know mid-afternoon temperatures to see if you got near 98.6 then.


#7

While I didn't document afternoon temps all of last week, I can say without a doubt I have never been as high as 98.6 @ in the afternoon. The closest I have seen that high was yesterday when I registered a 98.6 @ 5:52pm

Since Friday I have been documenting my temps in morning/afternoon/evening. They are:

Fri: 96.2 (7:15am) / 96.2 (11:13am) / forgot to document evening
Sat: 97.1 (9:38am) / 98.1 (12:54pm) / 97.2 (9:02pm) *IM inecjton .25ml 200mg test cyp
Sun: 97.2 (9:05am) / 97.7 (12:13pm) / 97.9 (6:15pm)
Mon: 96.6 (7:23am) / 97.5 (11:09am) / 98.6 (5:52pm)
Tues: 96.6 (8:18am) / 97.5 (11:10am) / 97.7 (5:50pm)
Wed: 96.6 (7:13am) / 95.9 (9:59am) / 97.9 (6:36pm)
Thu: 96.5 (7:13am) / 97.7 (11:15am) /


#8

That is a good sign. Some are low all day.


#9

Updated temps:

Fri: 96.2 (7:15am) / 96.2 (11:13am) / forgot to document evening
Sat: 97.1 (9:38am) / 98.1 (12:54pm) / 97.2 (9:02pm) *IM inecjton .25ml 200mg test cyp
Sun: 97.2 (9:05am) / 97.7 (12:13pm) / 97.9 (6:15pm)
Mon: 96.6 (7:23am) / 97.5 (11:09am) / 98.6 (5:52pm)
Tues: 96.6 (8:18am) / 97.5 (11:10am) / 97.7 (5:50pm)
Wed: 96.6 (7:13am) / 95.9 (9:59am) / 97.9 (6:36pm)
Thu: 96.5 (7:13am) / 97.7 (11:15am) / *IM inecjton .25ml 200mg test cyp