T Nation

Help With Lab Work - How to Direct Doc


#1

Hello All,

I have been reading these forums for some time but this is my first post. My stats:

Age 43
Male
5'11"
~200
Lift 3 - 4 times a week for approximately 4 years
Diet is low carb-high protein and fat.

Okay, so I have been struggling with ever lower energy levels, mental acuity, attention span, libido etc for the last 10 years or so. Along the way I have been diagnosed with the following:

Sleep Apnea â?? Treated with CPAP
Insomnia â?? Treated with Lunesta 2mg per night
ADHD â?? Treated with Concerta 54mg per day plus 20mg Ritalin in the evenings as needed
Depression â?? Treated with Lexapro 20mg per day
Osteoarthritis in the neck/shoulder â?? treated with NSAID and Tramadol 25mg as needed
High Cholesteral â??Treated with Lovastatin 20mg, Lovasa 4 gr per day and Slo Niacin 1500 mg per day.

With all of this, I still am exhausted, depressed, anxious and generally feel crappy. This led me to these forums and the pursuit of effective TRT in the hope that this is the core issue.
In September 2010, I met with my primary care Doc to discuss this. He agreed to have me tested for Low-T. The test results showed total T of ~400 which was at the very low end of the range. Nevertheless, he deemed me normal and said I was getting older and the best thing would be just to accept it. Not liking this answer and having read these forums, I understood that A, total T on its own is relatively worthless and B being in range does not mean things are well. So with the help of a local compounding pharmacy, I found a Dr. who is a little more open minded and knowledgeable about HRT.

In October 2010, he sent me for the a series of tests te results of which are here:

CARDIO CRP(R) 0.5 mg/L KS
HOMOCYSTEINE,CARDIOVASCULAR 8.5 <11.4 umoLL
GLUCOSE 123 H 65-99 mg/dL
UREA NITROGEN (BUN) 17 7-25 mg'dL
CREATININE 1.02 0.78-1.34 mg/dL
eGFR NON-AFR. AMERICAN >60 > OR = 60 mL/min/1.73m2
eGFR AFRICAN AMERICAN >60 > OR = 60 mL/min/1.73m2
BUN/CREATININE RATIO NOT APPLICABLE 6-22 (calc)
SODIUM 133 L 135-146 mmol/L
POTASSIUM 4.9 3.5-5.3 mmoL/L
CHLORIDE 99 98-110 mmol/L
CARBON DIOXIDE 26 21-33 mmol/L
CALCIUM 9.8 8.6-10.2 mg/dL
PROTEIN, TOTAL 7.6 6.2-8.3 g/dL
ALBUMIN 4.7 3.6-5.1 g/dL
GLOBULIN 2.9 2.1-3.7 g/dL (calc)
ALBUMIN/GLOBULIN RATIO 1.6 1.0-2.1 (calc)
BILIRUBIN, TOTAL 0.5 0.2-1.2 mg/dL
ALKALINE PHOSPHATASE 82 40-115 U/L
AST 25 10-40 U/L
ALT 47 9-60 U/L
VITAMIN D, 25-HYDROXY, LC/MS/MS
VITAMIN D, 25 OH TOTAL 38 30-100 ng/mL
VITAMIN D, 25 OH, D2 <4 ng/mL
VITAMIN D, 25 OH, D3 38 ng/mL
TSH, 3RD GENERATION 1.36 0.40-4.50 mIU/L KS
T4, FREE 1.3 0.8-1.8 nq/dL KS
T3, FREE 2.9 2.3-4.2 pg/mL KS
* DIHYDROTESTOSTERONE 16 L 25-75 ng/dL AMD
SEX HORMONE BINDING GLOBULIN SHBG 15 9-45 nmol/L
ESTRADIOL,ULTRASENSITIVE ELC/MS/MS 5 pg/mL Reference Range: < OR = 29
IGF I, ECL 247 ng/mL Reference Range: 50-303
ESTRONE, LC/MS/MS 15pg/mL Reference Range: < OR = 68
DHEA SULFATE 186 45-345 mcg/dL KS
FSH 4.3 1.6-8.0 mIU/mL KS
INSULIN 7 <17 uIU/mL KS
LH 4.0 1.5-9.3 mI11/mL KS
PROLACTIN 2.9 2.0-18.0 ng/mL KS
PSA, TOTAL 0.8 < OR = 4.0 ng/mL KS
IGF BINDING PROTEIN 3 (IGFBP 3) 4.6 3.3-6.7 mg/L

TESTOSTERONE, FREE AND TOTAL, LC/MS/MS
TESTOSTERONE,
TOTAL TESTOSTERONE, 374 250-1100 ng/dL
FREE PERCENT 2.50 H 1.50-2.20
FREE TESTOSTERONE 93.5 35.0-155.0 pgâ?¢mL
HDL-2 (LARGE,BUOYANT) 8 L >10 mg/dL
HDL-3 (SMALL, DENSE) 39 >30 mq/dL
VLDL-3 (REMNANT LIPO) 16 H <10 mg/dL

At this point my doc put me on 25mg of Chlomid every day, 4 gr of Lovasa per day and the cholesterol lowering meds. Lovastatin 20 and Slo Niacin 1500.
Six weeks later he re-ran some tests with the following results:

Test Name In Range Out Of Range Reference Range Lab
* DIHYDROTESTOSTERONE 21 L 25-75 ng/dL
SEX HORMONE BINDING
GLOBULIN
SHBG 20 9-45 nmol/L
IGF I, ECL 141 ng/mL ref range 50-303
ESTRONE, LC/MS/MS 42 pg/mL Ref < OR = 68
DHEA SULFATE 335 ref 45-345 mcg/dL
ESTRADIOL 51 13-54 pg/mL
CORTISOL, P.M. 2.5 L mcg/dL Reference Range 4 p.m. (3-5 p.m.) Specimen: 3.0-17.0
CORTISOL, A.M. 14.2 Reference Range 8 a.m. (7-9 a.m.) Specimen: 4.0-22.0
PSA, TOTAL 0.8 < OR = 4.0 ng/mL
TESTOSTERONE, FREE AND
TOTAC/MSmL,
TESTOSTERONE TOTAL 696 250-1100 ng/dL
FREE TESTOSTERONE 166.3 H 35.0-155.0 pg/mL

Based on this, he says all is well except for PM Cortisol which he is ordering a Cortrosyn Stimulation Test to rule out adrenal insufficiency.

So my questions other than a general sanity check about my Drâ??s approach are as follows.
What other test might I request?
Is Clomid a long term answer?
What about Thyroid, Pituitary or sub-clinical adrenal problems? Dr. says due to TSH that Thyroid is okay but since that is low and free T3 are low, isnâ??t that problematic?
Other data:
AM body temps usually between 95 and 96
Body hair is generally on the light side
Male pattern baldness since late 20â??s
Putting on abdominal fat but not elsewhere.
Not losing fat on ketogenic diet as in the past.
Have had head impacts.
Mood swings and low frustration threshold.
Lack of general motivation etc.
Anyhow, any general, or specific suggestions or comments welcome. I want to direct my Doc to look more closely at the Thyroid, Adrenals, Pituitary as from I understand, if these are out of whack, TRT will be ineffective. So if anyone can assist, it would be greatly appreciated.
Regards,


#2

first welcome

second you are on way too many medications trying to treat your issues. It's what doctors do nowadays, just rip out a prescription and kick the person out of the office - why find the cause of the problem when the drug reps have convinced me that it is so much easier just to write a simple script.

HOMOCYSTEINE,CARDIOVASCULAR 8.5 <11.4 umoLL ideal range is under 6.7
High glucose (was this fasting?)
low vitamin D3 (need to start on at least 6,000iu D3 daily)
Low sodium - I wonder what your aldosterone levels look like.
TSH is only slightly high, but Free T3 doesn't look good (3.3 - 3.9 ideal)
that plus terrible body temps indicate a thyroid issue.
ultrasensitive estradiol test is useless.
2nd estradiol test is valid and shows your E2 being way too high
low/moderate LH/FSH ith very low Total T indicate primary testicular failure, but response to clomid seems to say otherwise.

clomid is not a long term solution.

depression may equal possible thyroid, cortisol, estrogen, or testosterone issues
insomnia may equal possible thyroid, cortisol, estrogen, or testosterone issues
high CHOL may equal possible cortisol, estrogen, or testosterone issues (your body is simply trying to feed more raw material into your production chain because of shortages with T and maybe others like Cortisol)

suggestions:
retest for thyroid and include RT3.
discuss thyroid treatment - go off symptoms (body temp, etc) + below ideal blood work results
maybe test for pregnenolone(+ wait for results of more detailed cortisol test)
is the new cortisol test like an ACTH stim test or what?
after getting results - maybe discuss boosting cortisol (maybe try Isocort which works for some or maybe low dose Cortef)
discuss controlling your estrogen levels (boosting cortisol can help downregulate estrogen production or you can discuss taking generic Arimidex)

you should try the sea salt test - check out this thread http://velocity.T-Nation.com/free_online_forum/sports_training_performance_bodybuilding_trt/labs_help_and_advice?id=4030954&pageNo=1


#3

Thanks PureChance.

I completely agree about the meds. Realizing how much crap I am on and the fact that I am still feeling poorly was the primary reason for seeking an alternative and these forums have helped me to begin to understand the relationship of various hormones to one's overall health and well being.

The High Glucose reading was fasting but that is the only time it has ever been high. We retested with A PreDx test which included Numerous things as follows:

Glucose - 98 ref range 70-99
HbA1c 5.7 ref range ,6.0
Insulin 4 range 2-22
hsCRP 6.7 range <3.1
Ferritin 115 range 20-250
IL2Ra 286 range 223-970
Adiponectin 11.2 range 5.2-13.1

Overall this gave me a predicted .8% chance of developing type 2 diabetes over the next 5 years. Not sure why it was high on the earlier test.

So what happens with Clomid? Do Docs generally have you on it for a while then remove and see if levels stay up? If that does not work then am I looking at Test in all likelihood?

I appreciate the feedback and suggestions. I am going to meet with my doc and I want to gather as much information as possible so I can make requests based on knowledge as opposed to ignorance.

Thanks again


#4

not a problem. glad to help. please note that I am not a doctor and these are just my opinions. Please discuss everything with your doctor, but be informed, be armed, and have a serious discussion about what is best for you.

my research says that HbA1c needs to 5.7 or less. You are the exact edge of the ideal cut off plus fasting glucose at 98 is still very high. so it seems like your diabetes chance should be higher. I'd keep an eye on it - and try to watch your carb intake.

Clomid mimics estrogen or something like that (hence it's interference with your hypothalamus detected your actual estrogen levels) and docs have no idea what the long term impact could be. The best docs advise against long term Clomid use.

if your system doesn't stay up once you've tried the restart protocol, then you would need to look at gels, patches, injections, or pellets. but with your high estrogen, once you come off the clomid then your hypothalamus will detect the too high estrogen and could simply shut down again and tell your pituitary to stop sending out LH/FSH to the testicles.

for your thyroid - you could try supplementing Iodine. I am on 12.5mg EOD (but I also have a blood test showing low iodine levels). Some also take Selenium 100mcg daily to help support the thyroid.


#5

Thanks again for the suggestions PureChance. Met with my doc today. Put me on 1/2 mg Anastrozole twice a week for the high estrogen and 60 mg a day of Armour for thyroid. He is further testing RT3, Thyroid anti-glubulins..or something to rule out autoimune problem then we are doing the cortrosyn stim test next week to see if I need Cortef. Sounds like he has e the bases covered but would appreciate any feedback.

Thanks all.


#6

Take high potency B-complex multivits, that will increase HDL and lower homocysteine.
fish oil, 4000-6000iu VitD3.

When taking any statin drug, you should be taking 50iu CoQ10, as the drug can induce a CoQ10 deficiency. If CoQ10 is deficient, every cell in your body will slow down and act like they are much older.

Have you been using iodized salt? Iodine in vitamins? You do not want to taking a drug to treat an iodine deficiency.

fT3 and fT4 seem to be best at midrange. If rT3 is blocking fT3, your fT3-fT4 could be ideal and you could have hypo symptoms, including low waking body temp. Note that the leading cause of elevated rT3 is low cortisol levels.

If your sex hormones were perfect, you might feel like shit from the prescription drugs.

You need to get off of: http://en.wikipedia.org/wiki/Lexapro#Side_effects_and_drug_interactions
Wellbutrin does not have sexual side effects and does not blunt emotions.


#7

Hey KSman,

Thanks for the advice. To start, one of the big drivers for my seeking this kind of help is to get off the ever lengthening list of drugs they keep putting me on. The SSRI sucks but I felt like I had to give it a try to stop feeling depressed. Effects were nominal but Doc says if there are some positives to stay with it for a year. I will be having him wean me off once I get cortisol/thryoid/test/estro all balanced and in line. I also hope to dump the stims for ADHD and insomnia. Reads like a who's who of problems associated with thyroid and adrenal problems to me.

TO you questions:

I take a B complex a multi, coQ10 100mg, a D3/Vit K each every day.

Not sure about the salt. I did just start on a kelp supplement and my doc recommended iodoral as a better option. Will look into that.Also please my doc put me on a dessicated thyroid treatment and not a synthetic T4 only.

I just got blood drawn for an rt3 level and


#8

Hey KSman,

Thanks for the advice. To start, one of the big drivers for my seeking this kind of help is to get off the ever lengthening list of drugs they keep putting me on. The SSRI sucks but I felt like I had to give it a try to stop feeling depressed. Effects were nominal but Doc says if there are some positives to stay with it for a year. I will be having him wean me off once I get cortisol/thryoid/test/estro all balanced and in line. I also hope to dump the stims for ADHD and insomnia. Reads like a who's who of problems associated with thyroid and adrenal problems to me.

TO you questions:

I take a B complex a multi, coQ10 100mg, a D3/Vit K each every day.

Not sure about the salt. I did just start on a kelp supplement and my doc recommended iodoral as a better option. Will look into that.Also please my doc put me on a dessicated thyroid treatment and not a synthetic T4 only.

I just got blood drawn for an rt3 level and thyroid anti-globulins ?? The are doing the adrenl stim next week. I am encouraged at least that the doc listens to me. His previous not said my labs were fine with estradiol at 51. Also had said thyroid was fine due to TSH. So I expected a bigger fight but he listened to what I said an is treating accordingly.

The only thing I am not sure about is that he seems to think long term clomid use and 25 mg a day is safe and effective as opposed to TRT. I don't have a problem if he is right. Would much rather stimulate my bodies natural production that be stuck doing EOD injections forever. But PurChance seems against this and I am not sure how hard to push. Think I will wait until thyroid etc are worked out to cross that bridge.

Lastly, I will ask my psych about Wellbutrin as an alternative to Lexapro. Perhaps a good choice until the underlying causes are treated.

Thanks again for all the information. This site is a lifesaver and those of you who contribute help change lives. With so much bullshit out there, it's good to find a place where knowledgeable folks engage in a civil discourse.

Looking forward to rejoining the living when this all clears up.


#9

Oh also forgot to mention, I take 4grams of Lovasa which is a prescription fish oil. With my insurance, it's cheaper than the Walgreen stuff.


#10

just as a side note, I know extremely little about Clomid and have never taken it myself. The advice about not using it long term is from what I have picked up from doctors, sites I trust, and various forum members I trust.

how much D3 are you taking?

have you found or read http://www.stopthethyroidmadness.com/things-we-have-learned/
it is a great site with tons of good information. read through all of the links on the left. Top Notch Site.

if you get your cortisol up, you may find that you no longer need the Arimidex as cortisol helps regulate testosterone metabolism and aromatase.

as lastly as a side note - you do know that you are paying for that prescription for fish oil through higher and higher premiums every year because your insurance is covering a majority of the costs (multiplied by everyone whos taking a prescription which costs x3-x10 more then just regular OTC fish oil)?


#11

PurerChance, no worries. I understand it is an informed opinion. My question with Clomid is more about understanding my docs perspective that he feels it is safe and potentially less problematic than TRT due to not having to manage shutdown issues.

I am trying to understand if this is valid and of course safe. I haven't found anything saying it is not safe but it seems like there is not alot of information as this is typicaly used long term. Anyhow, it is cool for now. Once we get everything else in line, I'll revisit the T issue.

Taking 9K ius D3 per day usually. Minimum is 5K but usually take 4 more later in day.

Yeah, I think the Cortisol results will be interesting. Having a cortrosyn stim test which my doc says is similar to ACTH stim. He is thinkig Cortef if that proves to be an issue.

Thanks again.


#12

PurerChance, no worries. I understand it is an informed opinion. My question with Clomid is more about understanding my docs perspective that he feels it is safe and potentially less problematic than TRT due to not having to manage shutdown issues. I am trying to understand if this is valid and of course safe. I haven't found anything saying it is not safe but it seems like there is not alot of information as this is typicaly used long term. Anyhow, it is cool for now. Once we get everything else in line, I'll revisit the T issue.

Taking 9K ius D3 per day usually. Minimum is 5K but usually take 4 more later in day.

Yeah, I think the Cortisol results will be interesting. Having a cortrosyn stim test which my doc says is similar to ACTH stim. He is thinkig Cortef if that proves to be an issue.

Thanks again.


#13

I wanted to update this and seek advice. I have been on 60mg of Armour (taken once a day in the morning) for about 3 weeks. Doc said to expect to feel better in 2 weeks. At this point while I think I am feeling a bit better, my body temps continue to be very low as follows:

  • Avg waking temp = 95.83 with no trend towards increasing.
  • Avg daily temp = 97.21 with no trend towards increasing.

Additionally, I had a Cortrosyn Stim Test which apparently came back normal. I have not received the numbers yet but will post when I do.

So, my question. My doc wants to wait for another week then retest Thyroid levels and anticipates raising Armour dose. Some here have suggested that Cortisol might actually be the culprit here but I haven't gotten any tests to confirm. Does my Docs approach seem valid or should I get a Saliva Cortisol test before increasing Thyroid meds?

I am just a little confused as to the relationship between Cortisol and body temps and how to distinguish whether low Cortisol or Hypothyroid is the key issue.

Thanks for any input.


#14

yes - your doctor's approach is valid (is it perfect? no, but it is better than 90% of docs out there).

yes, you should test your 8am cortisol before raising your Armour dosage. Great time to ask when you get the thyroid tests in another week. + ferritin and D25-OH (to see if your supplements are helping). does he test for free t3, free t4, and Reverse T3?

there is a link at the end of the blood test sticky to a site about body temp

low body temps = low thyroid
fluctuating body temps (95 at noon day one, 97 the next day at noon or 95 to 97 to 94 to 96 all within one day) = low cortisol


#15

Thanks PureChance. I had an AM PM Cortisol test done. PM Cortisol was low.

Doc does test free t3 & t4 plus reverse. Had those done before starting the Armour and am waiting for the results. I would assume that is what he will order next as well.

Following is the data from my actual temps. Not sure if this variability is indicative of Cortisol issue. Input appreciated.

Date Waking 3hour1 3hour2 3hour3 Daily avg
1/24/2011 95.50 97.20 97.70 97.20 97.37
1/25/2011 95.00 97.30 97.30 96.10 96.90
1/26/2011 96.00 96.20 98.40 97.70 97.43
1/27/2011 98.00 98.40 97.00 96.50 97.30
1/28/2011 95.10 96.40 97.30 97.30 97.00
1/29/2011 95.10 97.40 98.00 97.90 97.77
1/30/2011 95.10 96.50 96.80 98.40 97.23
1/31/2011 97.00 95.70 97.70 98.20 97.20

*Edit - Also, I read the blood work sticky and followed link to the body temp information. Very helpful. Thank you for pointing this out.


#16

yes, it seems that your body temps are saying that you have low cortisol and low thyroid.


#17

So if this is the case, what is the logical treatment order? Cortisol->Thyroid then sex hormones? Seems like until cortisol is addressed, thyroid will be ineffective. Do I understand this correctly?

Thanks for all your help.


#18

That's what has been said in my thread for the most part. Seems like cortisol/adrenal function is tied in to a lot of your systems (most notably the HTPA systems) working.

As for how to fix cortisol... that's a bit of a complex issue. I'm still trying to work it out for myself, someone else may be able to give you some advice.


#19

Thanks Akaji. What sorts of things have you tried thus far?


#20

I'm struggling to figure out what I should try at the moment. I have an appointment on Monday with a PA. I'm hoping she's able to give me some more ideas, or at least run some more labs (e.g. Pregnenolone) to figure out why my cortisol is so damn low.

Here's my thread: http://tnation.T-Nation.com/free_online_forum/sports_training_performance_bodybuilding_trt/concerned_that_endocrinologist_may_be_halfassing_this

Everything's going at a glacier's pace as I'm having difficulty getting labs performed. I'll try to keep you updated if I find something that works for me, and feel free to check back in on my thread as I update it.