Dr. Visit - What Should I Request?

Pharma / TRT Testosterone Replacement
1

I have met with my doctor who was willing to prescribe some trt. I have to go back and am wondering what I should request? He seems to take my recommendations and everything is up for discussion. I have all the symptoms of low t…no energy, brain fog, low libido, etc, etc. Blood test from several months ago (34 years old):

testosterone 407 (range 250-1100)
free 1.67% (1.5-2.2)

From Saliva Adrenal Stress Test

morning testosterone 47.7 (40-130)

Been working on adrenal protocol, but no real success.

What should I request from the Dr? As far as prescription and dosage and further testing?

My wife and I are trying to have kids, what are the issues with this?

Thanks.

2

those are all good questions.

  1. welcome on board

  2. read through all of the sticky posts at the top of this forum to get a good understanding of the complexity of HRT

  3. ask for as many blood tests as you can (per the blood test sticky) BEFORE you start on HRT

  4. Try to uncover and treat other underlying problems/issues BEFORE you start on HRT

  5. if you find other issues and treat other issues, get blood tests later on to see if they have had any impact on your Testosterone levels BEFORE you start on HRT

  6. what adrenal problems do you have? what are your test results? what treatment plans have you tried?

  7. what are your symptoms?

3
  1. Thanks
  2. In the process of doing this
  3. Will do. Then how long do you wait for the next blood test? 1 month? Longer?
  4. Have been working on this for around 9 months.
  5. No real changes in the limited blood work I had recently.
  6. I have elevated (outside the normal range)cortisol for the morning and noon readings, and depressed for the afternoon and night readings.
    Other:
    Cortisol sum 38 (23-42)
    DHEA 2.81 (2-10)
    Totatl Cortisol - DHEA S 13.6 (5-6)
    Estradiol 2.4
    Estriol 1.9
    Progesterone 113 (5-100)
    Test am 47.7 (40-130)
    Melatonin 17.6 (12-23)
    Treatment: Change of diet, trying to repair gut health (have Crohn’s), Adrenal protocols (Supplemental adrenal support, glandulars, phosphitdlyserine, licorice, DHEA), repairing insulin sensitivity, etc.
  7. Symptoms - Extreme lack of energy, especially afternoons and evenings. Brain fog/bad memory, moodiness/mild bouts of depression, low libido.

Thanks for the help.

4

not a problem.

what are the ranges and units for those results you posted?

have you ever tested your Thyroid, Pregnenolone, Ferritin, B12, Vitamin D25OH, etc?

5

Estriadiol range was (1-3) and estriol (.5-3)
Estradiol and estriol were in pg/ml and cortisol in nM and DHEA in ng/ml.

TSH was 1.93 mIU/L range (.4-4.5)

Vit D25OH was 37 ng/ml range (20-100) - I was on 10,000 iu last spring and 5000 iu this summer after the test.

Thats all i see on the results. thanks.

6

hmmmm…

those units and ranges don’t make any sense. What type of test was it? blood, saliva?

blood Estradiol range in pg/mL is something like 10-50 (with the ideal being around 22).

Also was it DHEA or DHEA-S? DHEA is useless because it is too variable. DHEA-S gives more reliable readings - but again the ranges and unit don’t match up to anything I have seen before.

Never heard of Cortisol Sum before. Sum what? Cortisol minus DHEA-S??

your TSH is high.

I would recommend checking:
Total T4
Total T3
Free T4
Free T3
Reverse T3
ferritin
AM Cortisol

7

Sorry for the confusion.

Blood Work (11 months ago):

Vit D 37 ng/mL (20-100)
TSH 1.93 mIU/L (.4 - 4.5)
Testosterone 68 pg/mL (35-155)
Testosterone Total 407 ng/dL (250-1100)
Test Free 1.67% (1.5-2.2)

Saliva Cortisol Test (4 times - morning/noon/afternoon/night) (Tested 10 months ago):

Morning 26 nM(13-24)
Noon 8.4(5-8)
Afternoon 5.5(4-7)
Nighttime 2 (1-3)
SUM 38.2(23.0-42.0)
DHEA-S Avg 2.81 (2-10)
Cortisol to DHEA-S Ratio 13.6 (5-6)
Testosterone A.M. 47.7 pg/ml (40-130)
Salivary Progesterone 113 pg/ml (5-100)
Salivary Estradiol 2.4 pg/ml (1-3)
Salivary Estriol 1.9 pg/ml (.5-3)

Any ideas what I should ask for? I’ll request more blood work. What trt? what dosage to start? What are the issues with trying to conceive at the time? What can I do about it? Thanks.

8

If you have tried for awhile without getting pregnent (no idea how long is too long - 6 months? a year?) then go in for a semen analysis. No need to borrow trouble.

On the plus side - it sounds like you have a decent doctor who is willing to think outside of the normal box (i.e. - saliva tests). That is very rare.

that being said - you need a much stronger baseline of tests before you jump into HRT.

did you check out the blood test sticky? Ask for as much as you can get.

You need to get blood tests for the main indicators - a number of sources say that saliva tests are only really realiable for Cortisol and maybe DHEA-S. There is not much confidence in other hormone saliva tests.

Don’t worry about what protocol or treatment plan you may need until you get all of your blood tests back. Most people jump into treatment way too soon. I wish I had known all of this stuff before a doc slapped a Androderm patch on me 3 years ago. It would have saved me years of fluctuations and struggles.

Given you earlier tests results, this is what I would ask for to start with (assuming you have a good insurance plan that covers blood tests):
1 Metabolic Panel (14), Comprehensive
2 CBC w/ diff/PLT
3 VAP TM Cholesterol Test
7 Magnesium, serum or Magnesium, RBC
10 C-Reactive Protein (CRP)
14 Iron and Iron Binding Capacity
15 Iron, Total
16 Ferritin
19 Hemoglobin A1c
22 Vitamin D, 25Hydroxy
23 T3, Total
24 T4, Total
25 T3, Free
26 T4, Free
27 T3, Reverse
28 Ultrasensitive TSH
29 Thyroid Peroxidase and Thyroglobulin Antibodies
30 Thyroglobulin
36 IGF-1
37 DHEA Sulfate
43 Prolactin
44 Progesterone
45 Pregnenolone
47 Estradiol, sensitive
49 Total Testosterone
50 SHBG
52 Dihydrotestosterone
Vitamin B12

Good luck.

9

PureChance…thanks for the help.

I did another Saliva Adrenal Stress test this week (this is out of my pocket…not through Dr). I sent a message to my Dr requesting those blood tests prior to starting. I’m not sure if that will happen or not. I think through my insurance that I only get one set of labs per year covered (not 100% sure though). NOt sure if my Dr thinks “outside the box” per se, he is just open to trying anything.

When I discussed this with him he really had no knowledge on the subject. He basically asked me what I wanted to try and what dosage I was thinking. Told him need to wait and look into it further. The initial visit was basically to see if he do it. So this is were we are at currently.

On the pregnancy note, we haven’t been necessarily “trying” just letting nature take its course. She is off any birth control for a few months, we are basically not trying not to have kids, if that makes sense. But, it is a priority, so I don’t want to do anything to screw it up.

10

well if you have problems make sure that you have your wife check out all of her hormones, thyroid, ferritin, D3, B12, etc. etc. etc.

birthcontrol pills can really mess up a woman’s system. Does she have regular periods?

also as for the blood tests - you have symptoms and you have a high TSH reading… that should be sufficient for the doctor to order more tests. Also check out the Finding a doctor thread for additional points or to be ready to find a new doctor if needed.

11

Why is it important to get all the thyroid panels prior to trt? Do you have link that I could read up on that?

Also, my wife spoke with her pharmacist and he said that if I started on trt, that would make me more fertile. This is not accurate is it? Goes against most of the research that I’ve done.

I’m doing another Saliva Test and put in a request for the extensive blood work. I’ll wait to meet with him again until I get those numbers back.

thanks.

12

When TRT increases metabolism, weak/improper thyroid function can be next weak link and thyroid function may not be able to support the new demands.

13

you are correct - trt does not make you more fertile.

14

[quote]PureChance wrote:
you are correct - trt does not make you more fertile.[/quote]

But if you are having sex every day, the odds are different from ED.

15

So what needs to be done? Say, I start Androgel? What do I need to do to ensure I have the ability to conceive?

Just went in for all the blood labs and did another saliva test. Should have the results end of the week. Thanks for the help.

16

Have you read the stickies yet?
Prevent testicular atrophy with hCG.

17

[quote]j-man1 wrote:
Why is it important to get all the thyroid panels prior to trt? Do you have link that I could read up on that?

Also, my wife spoke with her pharmacist and he said that if I started on trt, that would make me more fertile. This is not accurate is it? Goes against most of the research that I’ve done.

I’m doing another Saliva Test and put in a request for the extensive blood work. I’ll wait to meet with him again until I get those numbers back.

thanks.[/quote]

You can be on TRT but if testicles or pituitary are dysfunctional, you’ll likely be infertile.

18

He is making some T now, so testes are working to some extent. If fertile now, hCG should maintain that sufficiently. But we really need LH/FSH numbers to know what the story is.

19

KSman, I’ve read the stickies, but probably need to several more times to grasp everything. So, do most people (in my situation) start with hCG right away…or test after say a month to see if they need it (hypothetically…i realize this is putting the cart before the horse). Are 100% of people that are on trt and want to conceive on hCG (or should be anyway)? Thanks for the help and I’ll have some numbers end of the week.

20

The only test for needing hCG is shrinking testes that start to pull up close to your body. No lab work is of any use in that regard. If no shrinkage, you could have sperm counts done from time to time to see how that is changing.

If you allow your testes to shrink, there is a reasonable expectation of permanent damage to the testes.

The major issue remains that one typically has a difficult time finding a doc who will script hCG.