T Nation

Endocrinologist May be Half-Assing This


#1

I'm glad that I was referred to this forum (from a user on reddit) - unfortunately, I didn't find out about it before yesterday. I had my first TRT shot (200mg, plan is to do it every other week) yesterday, and now I'm wondering if I am even close to the point that I ought to be starting.

I've read most of the stickies and responses to them, but I apologize in advance if I ask a question that's already been answered - my short-term memory is... ridiculously bad, to put it lightly.

Background:

I'm a 23 year old male, about 5'10 315 lbs. I have been morbidly obese since I was ~15-16, and was at 350 lbs. from (at least) age 18 to 22 (lost 35 lbs. over the course of 2010 - not nearly what I wanted to, but depression's a bitch).

Notable medical history:
- Tonsils and adenoids removed at age 3 due to difficulty eating to the point of me refusing to.
- Orchiopexy at age 19 for cryptorchid right testicle; should have been dealt with at age 2, my mother - a nurse - believed that it was not an issue . Right testicle is extremely small as a result (approx. 1/3rd normal size).
- Multiple traumatic brain injuries: one injury that put me at a 9-10 on the Glasgow coma scale for about two hours @ age 4-5, one severe concussion @ age 9-10, a number of other hard hits that were near-traumatic.
- History of chronic migraines: 1-2 per week from age 13 to age 18, tapered off to about 3-4 per year now.
- 3 bone fractures: simple fracture, right femur, age 3; hairline fracture, right ring finger (metacarpal), age 11; simple fracture, right clavicle, age 15. All were trauma related.

Current meds: Cymbalta (30mg @ night), Welbutrin XR (450mg @ morning), daily multivitamin (Centrum, I think), 2000 I.U. Vitamin D3 (programmer plus living in Minnesnowta = very little exposure to direct sunlight), and 2400mg Fish Oil (1200mg @ morning, 1200mg @ night).

I wasn't even aware of hypogonadism until about four months ago, when my SO looked into possible effects or causes of cryptorchidism. After looking into some of the reported symptoms of hypogonadism, it seemed pretty obvious to me that it was likely - I have all of the major ones like brain fog, low motivation, low-grade depression (Dysthymia), social anxiety, manboobs, feminine fat distribution, etc.

I saw my PCP for some bloodwork (all he ordered was the TT test - 141 ng/dL at 10 AM), who then referred me to an endocrinologist.

My endo seemed to know what he was doing, so I trusted him to get the tests necessary. It seems that my trust may have been poorly put, at least according to the stickies here (which seem well-researched).

Many of the tests that are recommended here weren't mentioned, much less performed, and the cause of my low T hasn't been found yet - and my endo stopped ordering tests and said that it was okay to start treatment!

Actually, he wanted to delay treatment for four weeks of me being on the autopap because he is of the opinion that my low T is largely caused by sleep apnea... which seems absurd, since I have no symptoms (no headaches, I wake up feeling well-rested, I don't wake up at night except when I need to go to the restroom 1-2 times nightly, etc.) and since my apnea is relatively mild.

I advocated for starting treatment immediately unless he wanted to run more tests, and he said that he was done running tests and was okay with me starting. This guy did his residency and fellowship at the Mayo Clinic...

I also mentioned that I had heard that using an estrogen blocker was generally a good idea, and his response was to state that it wasn't and that no professional organization recommends it.

Test results:

MRI -- normal, no mass, pituitary is good.
Sleep study -- mild asymptomatic sleep apnea (almost purely hypopnea). Will be getting an auto-pap this week or next.

Here are the results of the endo-ordered 8 AM blood test:

TEST = RESULT (LAB NORMAL)

ALKALINE PHOSPHATASE = 71 U/L (40-115 U/L)
BILIRUBIN, TOTAL = 0.7 mg/dL (0.2-1.2 mg/dL)
AST = 21 U/L (10-40 U/L)
ALT = 25 U/L (9-60 U/L)
TESTOSTERONE, TOTAL = 153 ng/dL (250-1100 ng/dL; low)
TESTOSTERONE, FREE = 36.9 pg/mL (46.0-224.0 pg/mL; low)
TESTOSTERONE,BIOAVAILABLE = 67.9 ng/dL (110.0-575.0 ng/dL; low)
SHBG = 13 nmol/L (7-49 nmol/L)
ALBUMIN,SERUM = 4.0 g/dL (3.6-5.1 g/dL)
CORTISOL, TOTAL = 12.9 mcg/dL (4.0-22.0 mcg/dL @ 8 AM)
FSH = 1.5 mIU/mL (1.6-8.0 mIU/mL; low)
LH = 3.1 mIU/mL (1.5-9.3 mIU/mL; low)
PROLACTIN = 9.0 ng/mL (2.0-18.0 ng/mL)
FREE T4 = 1.22 ng/dL (0.71-1.85 ng/dL)
TSH = 2.99 uIU/mL (0.30-5.00 uIU/mL)

After reading through the stickies, there seem to be some HUGE red flags. He didn't order an E2 test, free T3 test, digital rectal exam (fortunately, my PCP did do one when I mentioned low T issues - though my endo never asked about this), no vitamin labs, etc.

So here are my concerns so far - note: I'm looking for advice and information, not answers - I'm not here to ask people to tell me what to do :slightly_smiling:

- Is an E2 test still reasonable despite having started TRT (I am one day out from my first injection of 200mg)?

- How do I advocate for an estrogen blocker with an endo that has a stick up his ass?

	- I have a fairly reasonable PCP.  He's shown a willingness in the past to prescribe medication that I felt would be useful (e.g. Xanax, Celexa).  Would going through my PCP - for both the additional tests and a possible prescription for an estrogen blocker if needed - be a good idea?
  • Edit: should I talk to my PCP about hCG as well? I would like to avoid testicular failure as there's a chance that I may want to have biological children in the future (though I will need to have a fertility test soon to figure out if that's even a possibility).
  • Edit 2: I live close to the Mayo clinic. Would it make sense to get a referral to an endocrinologist there, or would advocating for and picking my own treatment with my PCP be a better option in the long run?

    • Should I STOP treatment right away, or continue through with it?

    • My endo didn't mention any of the side effects of TRT (literally none). I'm now aware that it could likely render me permanently infertile (my understanding was that it was temporary). I am considering having a fertility test ASAP, and possibly freezing sperm if I'm even fertile to begin with. Any objections/suggestions on this subject?

  • Any other comments, information, or advice would be greatly appreciated!

Thanks a ton in advance! I'm going crazy trying to figure out what is the right thing to do at this point, and the posts in this forum have already been a great resource for helping me figure out what's best. I can't believe I didn't find this forum before when I was searching for resources, but I'm glad I was pointed to it today.


#2

welcome onboard - it is hard to give advice that doesn't come across as answers, but I'll do my best.

1 - yes testing E2 is critical during treatment. Please get it tested when you run your next scheduled panel.

2 - you can't unless you can first convince him to run the blood test, then when it shows high AND you have high estrogen symptoms you can push for a trial dose to see if it will help.

3 - you can work with you PCP but will have to take the lead and realize that he is not an expert and you might get into trouble down the road. Finding a good HRT doctor is almost impossible, but it might be worth calling around to a few compounding pharmacies and asking for referrals.

4 - not sure with your previous testicular issues (never heard of those words before). HCG normally helps men produce Pregnenolone which is a critical building block in addition to stimulating Testosterone production.

5 - continue treatment, but please consider more freq shots. biweekly shots have wrecked a number of people here.

6 - infertility can be temporary OR permanent for some. a fertility test may not be a bad idea.

issues you didn't raise:

you have a Thyroid problem that needs to be addressed
you have a potentional cortisol issue (that if it is an issue and is addressed may preclude any need for Arimidex)
you need more blood tests - can you talk your PCP into running them (per the blood test sticky)?
I think that 6,000iu D3 is considered pretty standard. You may want to consider increasing your dosage.


#3

Thanks for the response, PureChance.

I forgot to include some labs that were performed by my PCP at the same time as my original TT check:

TEST = RESULT (LAB NORMAL)

Testosterone (total) = 141 ng/dL (225-825 ng/dL)
Bedside blood glucose testing = 92 mg/dL ('normal'? seems high to me)
Cholesterol = 111 mg/dL (0-200 mg/dL)
Triglycerides = 70 mg/dL (0-149 mg/dL)
High Density Lipoprotein = 29 mg/dL (>39 mg/dL; low)
Cholesterol/HDL ratio = 3.8
LDL Cholesterol = 68 mg/dL (19-130 mg/dL)
25OH Vitamin D = 46 ng/mL (30-80 ng/mL)

I've been writing up a document to track what I have done, what I want to do, and what other considerations are to be made. One thing in the "want to do" column is to have the following tests run (gathered from reading some of the stickies and other posts here):


Free T3
Total T3
Reverse T3
Iodine
Ferritin
B-12/folate serum
antibody TPO
TgAb
E2 (estradiol; 'sensitive' test - NOT 'free E2', NOT 'E2 ultra sensitive'.... "LabCorp serum E2 test or Quest Sensitive 4021x")
DHEA-S
Progesterone
Pregnenolone
Glucose
Complete blood count (CBC)
Chemistry panel (metabolic panel with lipids)


Fertility test

Karyotype (check for Klinefelter's; may not be doable due to lab restrictions or insurance reasons)
KAL1, KAL2, KAL3 genetic testing (check for Kallmann's; may not be doable due to lab restrictions or insurance reasons) -- I have had partial anosmia all of my life


It's a bit difficult to figure out exactly which tests are 'necessary' from the stickies - do you think that I missed any, or have any listed that I shouldn't?

Re: 4 -- cryptorchidism is the medical term for undescended testicle (sorry, should have been more clear), and an orchiopexy is the procedure performed to pull it down into the scrotum and attach it there.

Re: 5 -- yes, I've been getting this message from the people here, and I have to agree that I think bi-weekly is silly. The shot was almost painless and certainly not anything that I wouldn't mind doing more frequently (I've seen the terms EOD and E3D thrown around - I certainly wouldn't mind E3D, and I could do EOD if that's what works best). I am a bit frustrated that my endo didn't discuss treatment options with me at all, other than to say "so you can have the patch, a gel, or a shot, which do you want?"

Re: Thyroid problem -- I'm a bit confused on this. What indicates a Thyroid issue to you? Free T4 and TSH are normal, aren't they? I know that I need to have fT3 and rT3 taken to be sure that there isn't a Thyroid issue, but unless I'm mistaken it's still an unknown...

Re: cortisol -- what is the 'good' range for an 8 AM cortisol test? What can be done to improve cortisol?

Re: D3 -- I think I will pump it up to 4k I.U. at least, and maybe give 6k a try. Mine is in the low-range of the lab normal, but what would you (and others) recommend as a 'good' range?


#4

TSH > 1 = a possible problem
TSH > 2 = a problem
TSH > 3 = a serious problem

please read everything on this site (plus all of the links on the left) --> http://www.stopthethyroidmadness.com/things-we-have-learned/

Cortisol at 8am should be 15+ ideally.

D25oh should be 60-80 I believe. I have to take 17,000 to get to that range. Other can get there with 6,000.

what is your waking body temp? what about at noon? I would guess at waking it is under 97.2 and under 98.6 at noon.

Iodine is not critical (nice to have, but if you can't get 'em all then drop this one)

You also need
DHT
PSA

your CHOL is very low (ideal 150-200) which means your body is starved of basic building blocks. I am trying to eat 4 eggs a day to boost my CHOL levels.

more later - heading home now.


#5

Thanks again, PureChance. This is yet another case of me trusting my Endo blindly - he stated, as fact, that I had no thyroid issues. STTM seems to be well-researched enough to state, at the absolute least, that my Endo should not have been as confident as he was; realistically speaking, it sounds like there's a fairly high chance that I do have a thyroid issue, if that website is accurate.

How accurate are saliva-based cortisol tests? Where/how would I get a kit, and how much should I expect to pay for one? If they're crap, what should I do about testing cortisol?

What can I do to increase my cortisol levels?

I'll definitely boost up to 6k I.U. D3 and see what my labs look like in 5-6 weeks.

I have not checked my body temp at all. I am going to buy a thermometer and start testing waking temperature and temperature every 3 hours afterward and recording those readings, as you mentioned in another thread. Odd question, but do you have any particular recommendations for thermometers? I was thinking of just grabbing a cheap digital thermometer from Walgreens or something (under the tongue, presumably), but I'm not sure how important accuracy is here.

As for cholesterol, my PCP has been telling me "exercise, exercise, exercise" since I was 15. It's tough to do when you barely have enough motivation to get out of bed and go to work so you don't starve to death. As for building blocks, are we talking proteins primarily? I do need to eat more healthy protein sources (e.g. eggs, fish, nuts) and cut back on my beef consumption, so maybe now would be a good time to start for cholesterol's sake.

I'll add DHT and PSA to my list.

Again, thanks!!


#6

Endos are mostly idiots. You found an average idiot. He worked at Mayo and now he thinks he is a god.

We will tell you what to do, it take too long to spoon feed.

Young men never need a DRE, they do not get prostate problems.

Your cholesterol is pathologically low. Low cholesterol is associated with increased all-cause mortality. Cholesterol is the base for all of your steroid hormones. Read this: http://en.wikipedia.org/wiki/Steroid_hormone and follow the many links in the article. Note that cortisol and other non-sex hormones are there as well. There is normally a huge amount of cholesterol in the brain, could be causing problem for you. You cannot expect to be well or as good as you could expect if your cholesterol levels are not corrected.

See "Cholesterol = 111 mg/dL (0-200 mg/dL)" that range is bogus. No one gets near zero, they would be dead a long way before that.

What the hell is this: "As for cholesterol, my PCP has been telling me "exercise, exercise, exercise" since I was 15. It's tough to do when you barely have enough motivation to get out of bed and go to work so you don't starve to death. As for building blocks, are we talking proteins primarily? I do need to eat more healthy protein sources (e.g. eggs, fish, nuts) and cut back on my beef consumption, so maybe now would be a good time to start for cholesterol's sake. "

Did you typo your lab results. Is your doc trying to kill you?

What is wrong here: "I had my first TRT shot (200mg, plan is to do it every other week) yesterday ... I've read most of the stickies " Go back to the protocol for injections sticky.


#7

boosting your CHOL could help boost your Cortisol (I have no idea really how to do it though, I just eat 4 eggs a day and got a slight bump myself 140 to 160).

Niacin and a good B complex vitamin can help with your CHOL balance.

eating more protein and fat over Carbs is always good as well.

taking Pregnenolone (oral, transdermal, or lipid matrix) 'could' help boost your Cortisol

any thermometer should do ok (as long as it is oral).

every doctor I trust believes in the saliva cortisol tests (they don't think that they are accurate for anything else though).

keep reading the STTM site - they know what they are talking about > 90% of doctors out there. I have not found a single issue/problem/contradiction with any of their advice yet.


#8

You do not need a PSA at your age, and if you insist you do, your doctor may not take you as seriously....

I would look at pregnenolone and if this is low (which it probably will be, given your low cholesterol numbers) then I would ask my doc about an Rx for it, or supplement with it on your own....this will help your cortisol if your adrenals are healthy as it is the building block for all hormones, including cortisol...

Personally I don't think one lab showing slightly less than ideal cortisol is anything to worry about, but a 4 sample saliva test wouldn't hurt...

Do you get stressed out easily?
Have hard time controlling your anger?
Become physically exhausted if you think about doing something mentally? (e.g. thinking about climbining a mountain makes you physically exhausted, even if you are sitting in your chair)

These can be signs of adrenal insufficiency (i.e. cortisol issues)...

Your low LH/FSH indicate secondary hypogonadism...something is out of whack up top...


#9

With low cholesterol I would rule out
1) gluten sensitity
2) food sensitity
3) malabsorption of fats
4) Heavy metals or toxic overload
5) hidden inflammation
6) lack of bile production - resulting in fat malabsorption
7) starvation - low fat diet (vegeterian? or low protein? )
9) Dybiosis -
10) Small villi due to intestinal inflammation


#10

Did you typo your lab results. Is your doc trying to kill you?

Heh, no - he wanted me to get my HDL up, and stated that exercise is the way to do it.

What is wrong here: "I had my first TRT shot (200mg, plan is to do it every other week) yesterday ... I've read most of the stickies " Go back to the protocol for injections sticky.

I'm aware that it's an issue. "plan" being the Endo's plan. I'm not planning on following it. I'll probably try E3D and see how that works for me.

boosting your CHOL could help boost your Cortisol (I have no idea really how to do it though, I just eat 4 eggs a day and got a slight bump myself 140 to 160).

I'm working on increasing my intake of 'good' fats and proteins (e.g. nuts, lean meat, etc.).

keep reading the STTM site - they know what they are talking about > 90% of doctors out there. I have not found a single issue/problem/contradiction with any of their advice yet.

Will do. I'm going to set up an appointment with my PCP today. Hopefully I can convince him to give me most of the tests that I'd like, and I'll be able to post results within a couple of weeks.

Do you get stressed out easily?
Have hard time controlling your anger?
Become physically exhausted if you think about doing something mentally? (e.g. thinking about climbining a mountain makes you physically exhausted, even if you are sitting in your chair)

Yes to one and two. As a teenager, especially, I was constantly stressed (probably part of the cause of my migraines) and I would go off the handle at a moment's notice. I think that I've learned to cope with the stress and anger in that I no longer express them very much, but I am easily stressed and very irritable most of the time.

As for three - I'm not sure. I will say that thinking about doing something that requires physical effort, e.g. cleaning or exercising, does cause me to feel very lethargic. I don't know if this is an adrenal issue or a simple motivation issue.

With low cholesterol I would rule out
1) gluten sensitity
2) food sensitity
3) malabsorption of fats
4) Heavy metals or toxic overload
5) hidden inflammation
6) lack of bile production - resulting in fat malabsorption
7) starvation - low fat diet (vegeterian? or low protein? )
9) Dybiosis -
10) Small villi due to intestinal inflammation

I have no idea what to do about any of these, e.g. how to test for them. I am not on a low-fat diet; my diet is fairly balanced, though I am working to reduce my carb intake. I also eat more calories than I ought to, given my low metabolism.


#11

Well, turns out that my PCP isn't as open-minded as I thought. I will be seeing my SO's PCP, a Nurse Practitioner, sometime soon. My experience with her is that she is a lot more willing to listen to her patients (e.g. my SO), and not believe that she has every answer.

Stupid things my PCP said: "no, you can't pay out of pocket, the tests will run in the thousands" (I looked at the lab form as the nurse was filling it out, the most expensive test was $72, and most were in the $30-40 range), "free T3 is meaningless, TSH is the best test there is", "a TSH of 2.99 is perfectly fine, 'fringe clinics' will tell you it should be under 1.0, but every major reputable clinic does things by the book, which says that under 5 is fine", etc.

He also stated outright that TRT-induced infertility is "extremely rare", and that there's no point in getting a fertility test until I am stable on TRT (~6 months from now).

Of the tests I requested, he was willing to order:

Total T3
antibody TPO
E2 (who knows if he got the right test, though -- the lab at this clinic only had one option for 'Estradiol', despite it being a huge clinic... the nurse who ordered the labs did put 'male' at my request, though she refused to write anything like 'do sensitive, not ultrasensitive, give exact numbers')
Progesterone
Glucose (again)

He also added:

Cortisol (am; again)
TSH (again)

I'll go in to get these labs on Friday, since it doesn't hurt to do it anyway (I already paid the copay for the PCP visit, and my insurance covers the labs fully), but I'm a bit pissed. I'll see my SO's NP as soon as I'm able to. With any luck, my TSH will randomly jump again (turns out he had a TSH of 1.55 on record from about half a year ago) and I'll have a better case for arguing hypothyroidism. You'd think that moderately elevated TSH plus very low FSH/LH, with an MRI to rule out pituitary issues, would be enough...


#12

God I despise doctors.


#13

Me, too. Wouldn't it be great if our governments would stop telling us what we can and cannot put in our bodies? I mean, they're ours, what the fuck do they care what we do so long as we aren't hurting anyone else?

/rant


#14

I dislike all of the endocrine organizations because of their glacier pace in embracing "new" information, but even they know that TSH > 3 is a serious problem that requires treatment since 2003.

American Association of Clinical Endocrinologists
http://www.aace.com/public/awareness/tam/2003/explanation.php

good luck your new doc.


#15

Oh man, thanks PureChance, I'll print that off and bring it with me when I see the NP.


#16

It's a free market after all...

Oh, except for all the oligopolies, and monopolies...


#17

I got a call from my PCP this morning (the aforementioned douchebag) with a couple of the results (the rest are in the mail).

Edit: forgot to mention - this was an 8:45 AM blood draw.

TSH - 1.99 (so far it's been 1.55, 2.99, and 1.99 in three separate tests... what's going on here?)
Cortisol - 6.1 mcg/dL (HOLY SHIT, that's LOW, no wonder I've been feeling like shit lately... morning ideal range is ~15-20)
Progesterone was low (didn't get the value, it'll be in the results he mails me)
E2 - 55 (fuck!)
Total T3 (I think it was total) - 3.7 (I don't know what the range is)

So. Protocol for dealing with cortisol is supplementation? Sounds like I need an AI for E2, as well. My PCP said to see an endo (predictably), and I could see a different one than the asshat I saw earlier, but I'm contemplating trying that NP I mentioned earlier - but I don't know if she'd even consider prescribing an AI.

I'm not really sure what to do. Hrm...


#18

Odd, it isn't saving my edits to my post.

Yesterday I injected with 100mg IM in my right thigh. I meant to do 50mg, but forgot that my script is for 200mg/mL. Still, this is preferable to the 200mg/EOW that my endocrinologist prescribed.

Today is the first day that I feel any better from TRT. The last two weeks were hell, culminating in me being suicidal on day 12 after injection #1. I decided to inject on day 13 (yesterday) rather than day 14 (today) as my endocrinologist wanted me to, and I'm very glad I did.

Starting next Tuesday I will be dosing myself with 50mg E3.5D (e.g. Tuesday evening, Saturday morning). Depending on how I feel on that, I may move up to EOD.

As soon as I get my lab results in the mail I'll set up an appointment with that NP (she has very few patients, which is fortunate for me - I'll be able to get in right away) and see what progress I can make with her. If I don't have any luck there I'm going to find a nearby compounding pharmacy and ask them if they know of any doctors prescribing hCG and AI for hypogonadism instead of or in addition to TRT - a doc doing that would probably fit the bill for what I need. If I'm lucky, maybe I'll find one that is willing to put me on Armour Thyroid as a trial to see if I really do have hypothyroidism.


#19

normally -
Total T3 is ng/dL with a total range of 85 - 205 and
Free T3 is pg/mL with an ideal range of 3.3 - 3.9

so I would guess you got results for Free T3 which looks great, but with your fluctuating TSH numbers I would assume that your Reverse T3 is sky high (this theory is also supported by your abysmal cortisol results) and blocking a lot of your T3 receptors (which seems to fit your symptoms - inability to lose weight, hunger issues tie to insulin/blood glucose control which requires cortisol. low cortisol = impaired insulin/glucose control)

have you found or read thyroid-rt3.com?

you really need to test for:
Reverse T3
Ferritin
D25-OH wouldn't hurt

you should look into trying IsoCort (I order through Amazon for my wife. It is recommended by STTM). It is a good first step in treating low cortisol. If that doesn't work, then you can look into a prescription for Hydrocortisone.

cortisol regulates T-E2 conversion. Low cortisol = high E2. All things being equal Good Cortisol = regular E2. You may want to try cortisol treatments first before jumping to AI and see what impact that has.

Boosting T normally places additional demands on cortisol and pushes cortisol levels down. I wonder if the need most people seem to have for AI drives from the fact that their cortisol can't keep up (which leads to the body shunting excess T into E2), and if that is true, then most people could avoid using AI if they treated or boosted their cortisol levels.


#20

IF you have high RT3, then armour will only make the situation worse as it will add even more T4 which your body will convert to even more RT3 UNLESS you have ideal levels of cortisol waiting and ready for the extra T4 AND you have cleared out the excess RT3.

I went down that road for over a year trying different doses of Armour to get my symptoms under control. Then I ran out and couldn't take any for a week, and found out that I didn't feel any different on or off Armour. that's when I researched and found out about RT3 and all of the implications. I am now on T3 only and trying to get my RT3 under control.

get your cortisol under control if critical and needs to happen BEFORE anything else. (You can live with bad T, bad E2, bad thyroid. Your body can not live without cortisol.)
then fix your high RT3 (if that is shown to be true)
then work on your testosterone levels
then see if E2 is still a problem. If so then treat it.