T Nation

Fatigue/LowT, Endo Workup

After years of fatigue and having recently found that my testosterone is low, I am looking for a complete endocrinology workup.

My plan classifies all endocrinologists into Reproductive Endocrinology or Endocrinology & Metabolism. I’m not trying to impregnate anyone right now, and I’m not diabetic. Is there a consensus on which branch to start with?

The blood testing sticky is a good read and is a great place to start testing. If fatigue is your primary concern, you need to IMMEDIATELY shift your attention AWAY from testosterone. Too often people focus on the T because it’s common knowledge, but the fatigue is a result of dysfunction elsewhere. Low testosterone is a result of dysfunction, not dysfunction itself. Your adrenals may be overtaxed from years of stress. Your thyroid may be malfunctioning due to poor diet. You might have a latent viral infection that your body never dealt with properly. Your hypothalamus may be sluggish.

By all means, get as much testing as you can, but don’t focus on testosterone. Think of it like this. Right now you have a smoldering fire. Testosterone is lighter fluid (not gasoline). Lighter fluid isn’t going to restart a fire. You need fire and oxygen to get it going again. Testosterone will increase the size of the flame once it’s burning again.

Honestly assess your diet. If you have a lot of processed foods, sodas, coffee, etc, clean it up and eat more greens. You can buy some D-Ribose on amazon and do a three week trial of 5 grams 3 times a day to improve mitochondrial function and increase ATP production. Your body has to work to make ATP, and if your body is overly taxed, it won’t make ATP very well. Also, you need ATP for EVERY SINGLE muscle contraction in your body, including your heart which pumps oxygen and nutrients where you need them.

Thanks; I appreciate the reply. My diet and rest are good. I agree with you that working on fatigue first is important.

I also gave up on the endocrinologist (for now) after reading the comments here. I looked at some thyroid support groups for recommended doctors in my area: my problem is probably NOT thyroid, but I am using that as a proxy for their overall philosophy. I found a wellness-oriented practice that is on my insurance plan and am trying to get an appointment.

BASICS
-age 36
-height 6 ft 3 in 1.9 m
-waist 38.5 in / 978 mm
-weight 178 lb / 80 kg
-describe body and facial hair: Medium to light body hair (seems mostly around nipples and belly); normal facial hair.
-describe where you carry fat and how changed
stomach, chin, and chest: I think it’s not really gynecomastia, just proportional
-health conditions, symptoms: childhood asthma & allergies, former hypoglycemia (not an issue now); mostly fatigue
-Rx and OTC drugs
Occasional Loratadine antihistamine
any hair loss drugs or prostate drugs ever: used TOPICAL spironolactone a few times about 10 years ago. Shampooed with Nizoral occasionally until I realized it was bad, but topical use should not be very significant.
Used Clotrimazole (Lotrimin) late 2012-early 2013 for a groin skin infection (misdiagnosed: it was bacterial, but I can’t find the name of it again)
-describe diet [some create substantial damage with starvation diets]
Generally low-carb. Very clean this spring: switched to frozen vegetables; lots of broccoli and Brussels sprouts. I’ve never been much of a drinker.
-describe training [some ruin there hormones by over training]
Basically on hold for right now due to the fatigue and not wanting to affect test results. It’s definitely not overtraining in my case: part of getting my energy up is to be able to train.
-testes ache, ever, with a fever?
Not that I recall. My scrotum has felt really tight / like someone has been pulling on my balls fairly often over the last few years: I mentioned this to an IDIOT doctor in December 2013 who dismissed it.

NARRATIVE:
As above, I seemed to have much lower energy than my peers all my life (sometimes I masked it with stimulants like caffeine, but that kept me awake but didn’t help my mental performance).

Between 2011 and 2013, I had a lot of stress at work and long hours, though late 2012-early 2013 was better. I saw a doctor (idiot) in mid-2012 who misdiagnosed a groin rash. I saw another doctor (idiot) in December 2013 who dismissed all my concerns (including scrotum tightness, which I thought was kind of a strange question to ask, but apparently it’s relevant).

This year, I’ve have had an opportunity to get a lot of rest, and was trying to do Starting Strength. I decided to order a testosterone test from requestatest.com in February just to make sure I wasn’t wasting my time training. Since getting the results, I eliminated canned foods and switched to grass-fed cheese and stuff like that, and also switched to a standing desk.

I posted this when I decided that I should be feeling better after this much rest, and also that my dietary changes had had some time to take effect.

My new doctor seems pretty good because he is wellness-oriented and takes me seriously. I would have liked to get a lot of other stuff tested (vitamins & minerals, E2, etc.), but he promised me that this was no the end, just an initial screening. I have a followup visit Monday to discuss these results.

LABS (date / time / test / result / units / reference range*):

  • If reference range is not given, it’s because it was not given to me.
    2013-11-12T08:30_EST BPS 118 mmHg
    2013-11-12T08:30_EST BPD 70 mmHg
    2013-11-12T08:30_EST CHOL 162 mg/dL <200
    2013-11-12T08:30_EST HDL 40 mg/dL >40
    2013-11-12T08:30_EST LDL 101 mg/dL <100
    2013-11-12T08:30_EST TRIGLYC 100 mg/dL <150

2014-02-18T11:22_EST TotTestosterone 303.6 ng/dL 348.0-1197.0 LabCorp
2014-02-18T11:22_EST FTestosterone 9.4 pg/mL 8.7-25.1 LabCorp

2014-03-29T12:00_EDT HbA1c 5.5 % ReliOn

2014-05-29T13:30_EDT OT 97.8 degF 98.6 DoctorOffice
2014-05-29T13:30_EDT BPS 124 mmHg DoctorOffice
2014-05-29T13:30_EDT BPD 70 mmHg DoctorOffice
2014-05-29T13:30_EDT BPP 75 bpm DoctorOffice
2014-05-29T13:30_EDT LYME AB < or = 0.90 index MidAmerica
2014-05-29T13:30_EDT Ferritin 145.9 ng/mL 21.8-274.7 MidAmerica
2014-05-29T13:30_EDT IRON 80 mcg/dL 65-175 MidAmerica
2014-05-29T13:30_EDT TSH 4.20 uIU/mL 0.35-4.94 MidAmerica
2014-05-29T13:30_EDT FT3 2.9 pg/mL 1.7-3.7 MidAmerica
2014-05-29T13:30_EDT RT3 15 ng/dL 8-25 MidAmerica
2014-05-29T13:30_EDT FT4 1.0 ng/dL 0.7-1.5 MidAmerica
2014-05-29T13:30_EDT TPOAb <10.0 IU/mL 0.0-34.9 MidAmerica
2014-05-29T13:30_EDT TGAb <20.0 IU/mL 0.0-39.9 MidAmerica
2014-05-29T13:30_EDT Cortisol(blood) 13.1 ug/dL MidAmerica
2014-05-29T13:30_EDT TotTestosterone 237 ng/mL 250-1100 MidAmerica
2014-05-29T13:30_EDT FTestosterone 44.9 pg/mL 35.0-155.0 MidAmerica
2014-05-29T13:30_EDT LH 3.2 mIU/mL MidAmerica
2014-05-29T13:30_EDT WBC 7.4 K/CUMM 3.3-10.5 MidAmerica
2014-05-29T13:30_EDT RBC 4.76 K/CUMM 4.15-5.75 MidAmerica
2014-05-29T13:30_EDT HEMOGLOBIN 15.1 G/DL 12.8-16.9 MidAmerica
2014-05-29T13:30_EDT HEMATOCRIT 44.6 % 38.8-50.2 MidAmerica
2014-05-29T13:30_EDT MCV 93.6 FL 78.0-100.0 MidAmerica
2014-05-29T13:30_EDT MCH 31.7 PG 27.0-34.0 MidAmerica
2014-05-29T13:30_EDT MCHC 33.9 G/DL 32.0-36.0 MidAmerica
2014-05-29T13:30_EDT RDW 13.0 % 11.5-15.0 MidAmerica
2014-05-29T13:30_EDT PLATELET_COUNT 177 K/CUMM 150-450 MidAmerica
2014-05-29T13:30_EDT MPV 9.3 FL 7.7-11.2 MidAmerica
2014-05-29T13:30_EDT NEUTROPHIL 58 % MidAmerica
2014-05-29T13:30_EDT LYMPHOCYTES 35 % MidAmerica
2014-05-29T13:30_EDT MONOCYTES 4 % MidAmerica
2014-05-29T13:30_EDT EOSINOPHILS 3 % MidAmerica
2014-05-29T13:30_EDT BASOPHILS 1 % MidAmerica
2014-05-29T13:30_EDT ABS_NEUTROPHILS 4.3 K/CUMM 1.3-6.0 MidAmerica
2014-05-29T13:30_EDT ABS_LYMPHOCYTES 2.6 K/CUMM 1.5-3.5 MidAmerica
2014-05-29T13:30_EDT ABS_MONOCYTES 0.3 K/CUMM 0.0-1.0 MidAmerica
2014-05-29T13:30_EDT ABS_EOSINOPHILS 0.2 K/CUMM 0.0-0.7 MidAmerica
2014-05-29T13:30_EDT ABS_BASOPHILS 0.1 K/CUMM 0.0-0.1 MidAmerica

I’m trying to compare these numbers with the stickies and stuff from other sites, but any feedback here is appreciated.

PS: I’ve taken some temperature measurements and will get back to it. I seemed to get OK readings IF I left the thermometer in for 7 minutes (even though it beeps after 60 seconds or so). I compare it to a Geratherm.

I do plan to get some Iodoral next week: I’ve never really used iodized salt much. It’s interesting that my T3 & T4 numbers are close to the midpoint of the reference range despite such a high TSH.

My iron is pretty low (only 14% from the bottom of the range); the “thyroid madness” people say men should be at 130. And I took an iron-containing vitamin that morning (I think).

I really need to get E2 checked and probably prolactin.

This doctor no longer seems willing to look into the cause of the low testosterone (despite an inappropriately normal LH, which is pretty low), but he did suggest seeing an endocrinologist. I’m mulling my options at this point.

Your T numbers are pretty much where mine were at baseline. I looked into “longevity” “doctors”; spoke with one over the phone that sounded like a total salesman; then went to another, less expensive guy who still was a ripoff. Then I asked my GP to help based on my lab results and bingo I was generally good to go and covered by insurance. When you say “[t]his doctor,” are you referring to your GP? If not, why not address the issue with your GP?

Admittedly, my GP is increasingly skittish. She’s fine prescribing Androgel, but gets nervous about AIs and Hcg. So I’m looking for another option should I need one. But she’s still pretty cool for now. I’d try that if you haven’t. The bottom line is that you have a legitimate T issue. You’re not someone looking to abuse anything. I don’t see why expensive specialists (who often don’t know sh*t) are necessary.

BTW:"Shampooed with Nizoral occasionally until I realized it was bad"
Off subject, but could you unpack this statement a little? I use Nizoral. Why is it bad?

[quote]NeverAlone wrote:
When you say “[t]his doctor,” are you referring to your GP? If not, why not address the issue with your GP? [/quote]
Yes, this doctor is my GP now, but I’ve only seen him for the two visits above.

I didn’t really have a GP between moving here in early 2011 and December 2013, when I saw an idiot for one visit who dismissed all my concerns (including tight scrotum: which I thought at the time was too weird to ask about): I believed him and went on with my life. I had to go on Obamacare as of January, and at that time the only in-network doctor within a 20 mile radius was over 70 years old and pretty close to the 20 mile mark. In February, I ordered the tests online in conjunction with buying my weight training equipment. When I got the results, I decided to try to improve through rest and diet (including not eating canned foods).

When I didn’t really feel better after months of copious rest and very clean eating, I decided to look for a doctor. By midyear, a lot more providers are in the network.

[quote]NeverAlone wrote:
The bottom line is that you have a legitimate T issue. You’re not someone looking to abuse anything. I don’t see why expensive specialists (who often don’t know sh*t) are necessary. [/quote]

See Kaynon311’s reply: I think my low T is a symptom of something deeper and a little subtle. While this doctor might prescribe T for me, I’m not prepared to sterilize myself and become dependent on a prescription that I may not always be able to afford when I don’t know the root cause. My thyroid gland is 80% less effective than it was in high school: that may be part of the problem. My LH is pretty low despite low T: do I have a pituitary problem? Do I have really high estrogen (and if so, why? A big tumor pumping it out somewhere?).

I’ve suffered from fatigue for years, and having a low T is my only truly abnormal labwork. The only other time I had my T checked, about 10 years ago, it was in range (high 500’s, IIRC, but I can’t get those records, and maybe it was an unusually high number: I noticed my beard had seemed to be growing faster). Some years are better than others, but I’ve really underachieved and had trouble in life due to overall low energy.

It’s not an emotional issue, and it’s not in my head.

[quote]NeverAlone wrote:
BTW:"Shampooed with Nizoral occasionally until I realized it was bad"
Off subject, but could you unpack this statement a little? I use Nizoral. Why is it bad?[/quote]
Nizoral’s active ingredient is Ketoconazole[1], which is a known antiandrogen[2]. It’s mentioned in the Cleveland Clinic paper[3]. I’d like to know how much systemic effect the shampoo has. Who knows: perhaps the reason it helps prevent hair loss has as much to do with its antiandrogen effect as its antifungal.

[1] https://en.wikipedia.org/wiki/Ketoconazole
[2] https://en.wikipedia.org/wiki/Antiandrogen
[3] http://www.ccjm.org/content/79/10/717.full.pdf+html

I’m putting all medical issues on hold for now. I’m still really far from my deductible, and seeing a specialist would require at least 2 visits (probably at a higher cost than a GP visit), plus whatever testing or procedures the specialist wanted to do.

I did order the E2 and prolactin tests online yesterday: it’s about the price of one primary care visit and will give me a reasonably complete picture of my situation at this point in time, at least regarding sex hormones. I knew they were necessary, but gave up on pressuring my GP for them when he said “just a screening” and bragged about how persistent he was.

I’m not giving up, and I have specific reason to expect my finances to improve in the next couple of months.

[quote]NeverAlone wrote:
I don’t see why expensive specialists (who often don’t know sh*t) are necessary.
[/quote]

And sorry for the multiple posts, but while I initially was seeking a specialist, after hearing how bad most of them are, I was really hoping to avoid specialists and instead work through this issue with this GP, who claimed to be wellness-oriented and bragged of his persistence.

The reason a specialist is necessary is that this doctor is not willing to pursue the issue any further with me, except to provide a referral to a specialist.

He didn’t really object to my desire to not just jump onto TRT without further investigation. And for the record, he suggested an “Endocrinology and Metabolism” type endocrinologist.

The plot thickens. Unlike last time, this blood draw was difficult: the technician was a trainee, maybe I was just dehydrated yesterday, and maybe my condition changed in the 18 days since my last lab work.
2014-06-15 Prolactin 10.1 ng/mL 4.0 - 15.2 (54% of reference range)
2014-06-15 Estradiol 14.1 pg/mL 7.6 - 42.6 (18% of reference range)

As before, I will be seeing an endocrinologist, but any thoughts are appreciated.