T Nation

Help with TRT


About a year ago I started having fatigue issues then about 6 months ago my Libido started going in the tank (not gone just realy low). I had blood work done and the doc said my my SHBG was to high he put me on 5G of Androgel per day. At first I was happy someone actually found something but after 10 days on the Gel my Libido is completely gone and nothing has improved. I am not convinced this is the correct treatment or dosage. I would think my test would be on the high side to begin with because I lift 4 days a week and do mostly heavy compound lifts. I am 43 in good shape, low BF (10-12%), and eat good. I am not over weight (5'7" 145) or out of shape two things I have found that contribute to elevated SHBG. I have no clue about TRT and am woried the Doc may be screwing me up rather then helping. It seems to me if the problem is high SHBG then tell me what to do to make it lower rather then increasing test but again no clue. any advice would be great.

Total Test 589 (ng/dL) (250-1100)
LH 9.7 mIU/mL (1.7-8.6)
FSH 11.7 mIU/mL (1.5-12.4)
Estradiol 22.4 pg/mL (7.6-48.4) â??Roche ECLIA methodologyâ??
SHBG Serum 65.6 nmol/L (14.5-48.4)

Thanks in advance

KSman is Here

Read the advice for new guys sticky, then the protocol for injections for general background, then read the other stickies. That is best advice.

Nothing lowers SHBG directly. Estrogen and age increases it. Lowering E2 can lower SHBG, but your estradiol is not elevated.

TT is rather decent for your age. LH and FSH are high. The combo does not make sense. What were the circumstances surrounding this lab work?

Would also like to see FT, fasting glucose, cholesterol, prolactin, TSH, fT4, fT3

Do you use iodized salt?
Iodine in vitamins?
Feel cold easily?
Changes to skin/hair/nails?
How do you sleep, how changed?
Salt/sugar cravings?
Changes to urination?
Brain fog, moody, depressed, intolerant, cranky?
Gum disease?
Changes to guts?
Loss of energy -seems not

What supplements, Rx and OTC drugs?

At this point, your labs and symptoms present a situation that we have not seen before and does not seem to be a case of hypothyroidism as we normally would define it. I suspect that your FT is low. So we will be looking for comorbidities and more info that you can provide will be important. I guess that comorbidities is out of place, we are looking for other problems. You may not have hypothyroidism.

What other health issues?
How are you managing with stress these days?


Thanks for the detailed response and with the information I found I tend to agree with you my Doc may not have me on the correct path.

Would also like to see FT, fasting glucose, cholesterol, prolactin, TSH, fT4, fT3

The Lab work I gave you is all I have at the moment. I probably need to find a good Endo but I have not been good luck with doctors lately and don't know of a good way to find one other then asking friends.

If FT is free test then in reading several post on the web it sounds as if a lot of people prefer to use a free testorone calculator rather then the lab test.
Using one of the recomended calculators with my latest blood work:
My Free test: 7.85 ng/dL = 1.34 %
My Bioavailable Testosterone: 184 ng/dL = 31.4 %
The Calculator i used is:http://www.issam.ch/freetesto.htm

Do you use iodized salt? Yes
Iodine in vitamins? No
Feel cold easily? Not to bad but the short answer is yes
Changes to skin/hair/nails? No, Hair is a little thinner then it used to be but still a full head of hair
How do you sleep, how changed? Good 6-7 Hrs per night, no changes been the same my entire life
Salt/sugar cravings? Nothing I can think of
Headaches? None other than Sinus related if I get a cold, I cant remember the last time I had one

Thirst? I drink a lot of fluids, this is not new

Changes to urination? This is one syptom that is hard to explain but when I lay down at night I have to have a completely empty bladder or I feel like I have to pee. I sleep lying on my stomach and it literally feels like someone is pressing on my bladder, I have no problem with stream or during the day only when I am lying down and it is almost the instant I lye down and always within 5-10 Min of lying down.

Brain fog, moody, depressed, intolerant, cranky? Nope usually in a good state of mind other then feeling frustrated with the current situation
Gum disease? None
Changes to guts? None
Apathy? No I am anything but apathetic

Loss of energy -seems not
Actually yes but that has been ongoing for over a year. I get rather tired around 2-3 in the afternoon push through my workout and usaly 2-3 times a week I will fall asleep on the couch for an hour or so before dinner. Funny thing is other nights I will be fine (This may not have anything to do with it just trying to give as much information as possible)

What supplements, Rx and OTC drugs? None other than Protein shakes a few times a week

At this point, your labs and symptoms present a situation that we have not seen before and does not seem to be a case of hypothyroidism as we normally would define it. I suspect that your FT is low. So we will be looking for comorbidities and more info that you can provide will be important. I guess that comorbidities is out of place, we are looking for other problems. You may not have hypothyroidism.

What other health issues?
!. Had an umbilical Hernia two years ago they surgically fixed with a mesh patch.
2. Probably not related but I have been fighting problems in my forearms over the past year or so, Had golfers elbow in my right arm then after that healed got Tennis elbow in my left arm, and now I have what feels like tendonitis on the top of my left forearm just below the elbow. As I said probably has nothing to do with it but it is frustrating since these tend to take 2-6 Months to heal.

How are you managing with stress these days? fine, not feeling over stressed


More Info
This is Prior to Androgel, : (Morning wood and nocturnal erections are now gone after 10 days on the Gel)
-age 43
-height 5â??7â??
-waist 32
-weight 145
-describe body and facial hair; some body hair, not a lot, normal facial hair
-describe where you carry fat and how changed: Belly, very little fat until my mid 30â??s and probably between 10-12% BF
-health conditions, symptoms [history] Fatigue over a year, Low Libido last 6 months
-Rx and OTC drugs, any hair loss drugs or prostate drugs ever Took Flowmax for 5 days about two months ago then quit
-lab results with ranges:
Total Test 589 (ng/dL) (250-1100)
LH 9.7 mIU/mL (1.7-8.6)
FSH 11.7 mIU/mL (1.5-12.4)
Estradiol 22.4 pg/mL (7.6-48.4) â??Roche ECLIA methodologyâ??
SHBG Serum 65.6 nmol/L (14.5-48.4)
Calculated Free Test using http://www.issam.ch/freetesto.htm
Free test: 7.85 ng/dL = 1.34 %
Bioavailable Testosterone: 184 ng/dL = 31.4 %

-describe diet [some create substantial damage with starvation diets] Normal Healthy diet
-describe training [some ruin there hormones by over training] 1-1.5 Hrs 4 days a week mostly heavy compound lifts and a little Cardio once a week (20 Min on treadmil)
-testes ache, ever, with a fever? No they are sensitive to press but it has always been that way
-how have morning wood and nocturnal erections changed: Yes fewer maybe 2 a week at the most


You can do labs on your own: http://www.lef.org/Vitamins-Supplements/ItemLC322582/Male-Panel-Blood-Test.html
Cheaper to get a membership. Note that you can't do with your insurance, but you could use a HSA account debit card. Blood work in on sale April-May.

Not sure if California presents barriers to doing labs this way.

Suggest that you focus on thyroid and adrenals. Take more iodine to address any deficiency.

Take 4000-6000iu vit-D3 per day, fish oil, B complex vitamins.


Don't Have a ton of Money So I would prefer to have a Dr. Order them so I can use my insurance. I am reading to help me get a handle of what to ask for. Spent most of today trying to find a new GP to work with but it's a 2 month backlog just to get an Appointment. I did get a call back from Cenegenics Medical Institute and they will see me right away for a $3995 consolt fee and they do not take insurance. If I can get an apointment with a GP I will have them check for thyroid and adreanl problems but untill that happens should I stay on te Androgel untill my Apointment in 2 weeks? Also keep the information comming I am trying to become as educated as possible but i don't find a whole lot of information with people in the same situation normal (mid Range) Test levels and elevated SHGB, LH and FSH


Ok it looks like I have good lead on a GP that is a problem solver and my wife will hopfully get me and apointment in the next day or so.

One of things that is puzzling me is, if the bellow is true then wouldn't just Androgel without an AI be fighting a loosing battle since I have elevated SHBG to begin with? I know the theory is for injections and Gel is supposed to better about E aromatization but how much better. I think I have plenty of T I just need to free some up and idealy find the root cause.

"The reaction rate is [somewhat?] bound by the availability of T. When you start TRT, E will go up, leading to more SHBG which reduces the FT levels from what they can be is E2 is not rise to elevated levels."

Oh One last thing I forgot to mention is I have quite a bit of Varicocele on my left testicle but it does shrink as soon as I lay down and i have had it there as long as I can remember. In reading this seems to be quite commn and I cant imagine that has much to do with my situation but it is more ifo for anyone interested.

And KSman I have read quite a few of your post and have to ask how long have you been a study of TFT? your knowledge is amazing


Been reading for 7, doing for 5. Have read about things medical for decades. I try to explain things in context which allows others to understand instead of see facts they cannot understand. Writing in this fashion for years has lead to improvements. My engineering background does shape my understanding and approach.

I fixed the post where you quoted above. It was horrible. Now reads:

E is created by T-->E aromatization. The reaction rate is [somewhat?] bound by the availability of T. When you start TRT, E will go up, leading to more SHBG which reduces the FT levels from what they could be if E2 did not rise to elevated levels.

A Varicocele can reduce T levels.

Speaking of learning: I am reading "Testosterone" A man's guide - Nelson Verfel" It is the next new book and someone here mentioned it. I am 1/2 way trough it and it is full of errors. Does not know the difference between an aromatase inhibitor and a SERM, so he refers to anastrozole as a SERM. Readers get lots of facts, but many are wrong, as well as concepts. Readers will be misinformed. I give the book a failing grade so far.


What? I was about to pick up that book. I'm a sucker for cool-looking book covers. :slight_smile: Are there any books that you can recommend in regards to hypogonadism and hypothyroidism?


This a good intro but:
-did not understand how to do injections right
-predates anastrozole
-predates hCG


Many some others can suggest.

I have read quite a few and all books by doctors will be of limited value. I have to do the job some day.


Ok Quick update.
1)Got an apointment with new GP next week will bring notes and curent blood work results, looking for help on if Lab Corp has a blood work up that will cover what i need to look for Ie Male Hormone test, CBC etc...

2) Yesterday was about as bad as it has been for me, in terms of fatigue, since I started the Andro. I was tired all day starting around 10AM but I pushed through the day and managed to get through about an Hour at the Gym, did arms no way I could get through Deadlift yesterday and by 8:30 I fell asloeap on he couch. Now for the good news woke up this morning with wood that was hard as nails, go figure no morning wood in over a week.

3) The more I read the more information I see I have left out. I was experiencing sore knees for a while a few months back (Don't think it is related but it did happen) and I have nevver had joint problems with my knees ever.

4) Since I have ben on androgel I have had kind of an acid reflux problem. I will do the best I can to explain this mabey someone will know what I am talking about. About two weeks before I went on the Androgel, I had an incident that felt to me like having a heart attack, chest felt tight and a burning like sensation, kind of feels like when you breath real cold air when running. I had an EKG and all was well but they sent me to a Gastro Dr and he put me on dexlansoprazole and decided I did not need a scope. They also tested me for H. pylori and it came back negative.
4a)Could the dexlansoprazole afect my other syptoms (libido and fatigue)
4b)could this be related to everything else


This is done via LabCorp


If paying out-of-pocket it would be cheaper to do this via LEF


Just personal experience here, no scientific proof to back me but I notice an increase in heartburn/reflux when I starte TRT, for a week or two. It has since subsided. It has done this both times I've started TRT. Some of those reflux meds are pretty nasty - I'm sure someone here has some info on them.


Ok I have an apointment with my new GP today and want to get a few facts straight in my mind before I go.

In looking at my blood work results posted above I have elevated LH and FSH but my TT is in the normal range (Seems to normaly be between 580-625)and I also have elevated SHBG. I think this all works in some sort of feedback loop that is controled through GnRH. If I have this straight in my head the GnRH will control LH and to a lesser extent FSH levels to tell the testes how much Testosterone to produce.

The GnRh will elevate LH and FSH to tell the testes produce more Test. My question is is this based on total TT, FT, or do I have this compleatly jacked up in my head. It looks to me that my body is not happy even at 598 and is telingmy system to produce more but it cant get there but I don'y have a clue about the eveated SHBG. So please help me get a better understanding of what is going on with me and what should I be asking the Doc to look at?


I don't want to scare you or throw you in to panic, but I experienced the same "heartburn" sensations. I went to a Gastro and had all the tests and scopes (both ends) done, which came up negative. He gave me a script for Prilosec and it seemed to help, but I was eating them like candy. The Gastro asked if I had been to a Cardiologist at all, he suggested I see one.

I made an appointment, the Cardiologist set me up for a Nuclear Stress Test (dye injected for artery tracing). The "heart burn" I was experiencing turned out to be a blockage in my aorta, which they fixed by inserting a medicated stent. Tell tale sign is, if you feel the heartburn through the middle of your back (between the shoulder blades), you may have a problem. Get it checked out, especially if it is consistent, even more so if you are experiencing shortness of breath.


Thanks for the info but no back or between the shoulders pain and I quit taking the dexlansoprazole and feel a lot better.

Met with the new Doc today and I am pretty happy. He knows quite a bit about TRT and Male hormones in general. He is going to check for thyroid or adrenal issues but wants to wait till I get back from the other Dr that put me on TRT to see what my current situation is.


I have been reading a bit more trying to find out what exactly is going on with my elevated SHBG, FSH and LH levels.

If My SHBG is elevated could it also be causing low Free E2? If so i think this needs to be checked as well

If Free T and Free E come back low, what about taking a SHBG suppressing supplement such as Nettle Root Vs. Androgel? Any thoughts on this?

I go tomorrow for a more blood work, including CBC, male sex hormones, thyroid, and adrenals but I wont see that Doc again until the 29th


One Last thing I have not posted before that may matter is I have had low semen volume for as long as I can remember, could this be caused by low FT even with normal TT?


Elevated SHBG can be due to low carbs in diet, malabsorption, excess of alcohol, or gut dysbiosis which can cause byproduts more 10 times more toxic then alcohol, elevated thyroid, low GH, low cortisol.

Danazol can lower if all else fails
PRoviron increased DHT by over 40% not good if you have BPH (DHT 160 to 240)
With high LH I be concerned about testicular cancer which needs to be ruled out by urologist.


Thanks for the help
I eat a fair amount of carbs and I don't think I have malabortion problems or dysbiosis.

My thyroid and GH levels should have been checked with this mornings blood work and the plan is for my new doc to send me to an Endo for the Cortisol check if nothing else looks out of place.

I just had a check up with two urologist and they did not feel any lumps so I am hoping I dont have cancer.I have an appointment with urologist are there any other checks he should do to check for cancer?