T Nation

In Trouble with my TRT, Need Help/New Labs

So I got my labs back 3 days ago and haven’t posted them yet because I’ve been severely bummed out. My NP doesn’t know anything about balancing hormones and it’s been suggested that I go another route…now I have no choice. My NP took my labs BETWEEN 30-40HRS AFTER MY LAST TESTOSTERONE CYPIONATE IM INJECTION and ended treatment because my Testosterone levels were out of therapeutic range. If anyone can help me understand what’s going on where :arrow_left:’s are at, it would be appreciated. Here are my current labs from 02-05-2019:

-Testosterone Serum
Testosterone, Serum 1102 (264-916 ng/dL)

-Testosterone Free with SHBG
Testosterone, Serum (Total) 1161ng/dL
% Free Testosterone 1.8%
Free Testosterone, S 209pg/mL
Sex Hormone Binding Globulin 57.6nmol/L⬅️

-Estradiol (L-004515) NON SENSITIVE TEST!:arrow_left:
Estradiol 16.1 (7.6-42.6 pg/mL):arrow_left:

-PSA Total (Reflex To Free)
Prostate Specific Ag, Serum 0.8 (0.0-4.0 ng/mL)

-CBC with Differential/Platelet
WBC 6.5 (3.4-10.8 x10E3/uL)
RBC 5.76 (4.14-5.80 x10E6/uL)
Hemoglobin 12.0 (13.0-17.7) g/dL
Hematocrit 38.4 (37.5-51.0 %)
MCV 67 (79-97 fL)
MCH 20.8 (26.6-33.0 pg)
MCHC 31.3 (31.5-35.7 g/dL)
RDW 17.9 (12.3-15.4 %)
Platelets 289 (150-379 x10E3/uL)

-Iron and TIBC
Iron Bind.Cap.(TIBC) 293 (250-450 ug/dL)
UIBC 223 (111-343 ug/dL)
Iron 70 (38-169 ug/dL)
Iron Saturation 24 (15-55 %)

Please don’t be concerned by the tests related to Hemocrit, Hemoglobin, MCV, MCH, and RDW. I have a genetic blood disease called Thalassemia Minor. I am not anemic as far as Iron is concerned. I know the other values don’t make sense in reference to the other blood levels. I don’t need to be medically treated for Thalassemia Minor.

I checked in with a guy from Defy Medical and all the initial costs are to high for me right now. I did see a flat rate of $195 monthly for Royal Medical Center. Does anyone know anything about Royal?

Labs one or two days post injection? Of course they are out of range. I would have thought they would be higher that close to the injection. How much were you taking?
E2 is lower than expected too, are you using an AI?

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Thank you for responding highpull. I’ve read a lot of your comments in threads and feel like you’re knowledgeable, discerning, and fair.

I was on 100mgs weekly…my NP, being my NP and not knowing or caring to learn about TRT, doesn’t care about when my injection was taken or when peak Testosterone values peak. She tested my Total and Free when I requested a SHBG and E2 panel. I told her my T levels weren’t worth testing because I just injected…she did it anyway.

I’m not on an AI which is why I’m baffled by my E2 levels and symptoms (high BP, weight gain, etc). I have been taking Zinc for a long time but I dunno if that explains things. Plus the E2 test was not a “Sensitive” test, it’s the one they give women…again, my NP.
@highpull

The ECLIA test (aka immunoassay or IA) for E2 management is commonly used for those on TRT. It is not an incorrect test or a test for women, but simply one way to check estradiol levels. The other commonly utilized test is the LC/MS/MS method (aka liquid chromatography dual mass spectrometry, sensitive or ultrasensitive). It is the more expensive of the two. There are inherent advantages and disadvantages to each of these two methods. I have been fortunate to be able to speak with professionals who work with both methods. One is a PhD researcher for Pfizer and the other is a medical doctor at Quest. I’ll summarize their comments.

The ECLIA method is the more reliable of the two in terms of consistent results. The equipment is easier to operate thus accuracy is less reliant on the skill of the operator. If the same sample were to be tested twenty times, there would be very little, if any, difference in the results.

The ECLIA method is not as “sensitive” in that it will not pick up E2 levels below 15pg/mL. If your E2 level with this test is 1-14pg/mL, the reported result will be “<15”. Because of this, it is not recommended for menopausal women, men in whom very low levels of E2 are suspected, or children. In other words, if your levels are below 15pg/mL, and it is important to know if the level is 1 or 14pg/mL, you do not want this test. For us, this is likely moot, since if you are experiencing low E2 symptoms and your test comes back at <15, you have your answer. For a woman being treated with anti-estrogen therapy for breast cancer, it may be necessary to know if the E2 level is zero or fourteen because therapeutically, they want zero estrogen.

A disadvantage to IA testing is that it may pick up other steroid metabolites, which in men would be very low levels, but still could alter the result. Another potential disadvantage is that elevated levels of C-reactive protein (CRP) may elevate the result. CRP is elevated in serious infections, cancer, auto-immune diseases, like rheumatoid arthritis and other rheumatoid diseases, cardiovascular disease and morbid obesity. Even birth control pills could increase CRP. A normal CRP level is 0-5 to 10mg/L. In the referenced illnesses, CRP can go over 100, or even over 200mg/L. Unless battling one of these serious conditions, CRP interference is unlikely.

The LC/MS/MS method will pick up lower E2 levels and would be indicated in menopausal women and some men if very low E2 levels are suspected and it is desired to know exactly how low, children and the previously mentioned women on anti-estrogen therapy. It will not be influenced by elevated CRP levels or other steroid metabolites.

While some may believe the ECLIA test is for women, on the contrary, as it pertains to women on anti-estrogen therapy, such as breast cancer patients, the LC/MS/MS is the test for women as CRP levels are a consideration and it is necessary to know if the treatment has achieved an estrogen level of zero.

On the other side of the coin, LC/MS/MS equipment is “temperamental” (as stated by the PhD who operates both) and results are more likely to be inconsistent. Because of this, researchers will often run the same sample multiple times.

It is not clear if FDA approval is significant, but this appears on Quest’s lab reports: This test was developed, and its analytical performance characteristics have been determined by Quest Diagnostics Nichols Institute San Juan Capistrano. It has not been cleared or approved by FDA. This assay has been validated pursuant to the CLIA regulations and is used for clinical purposes. This statement is on LabCorp’s results: This test was developed and its performance characteristics determined by LabCorp. It has not been cleared by the Food and Drug Administration.

It is unlikely that any difference in the same sample run through both methods will be clinically significant. Estradiol must be evaluated, and it should be checked initially and ongoing after starting TRT. It obviously makes sense to use the same method throughout. Most important are previous history and symptoms related to low or high E2. Those are correlated with before and after lab results. Any estradiol management should not be utilized without symptoms confirmed by lab results.

Some examples of the two tests run concurrently:

IA%20vs%20LCMS%20result IA%20LC%2021%2018 IA%20LC%2023-23 IA%20LC%2028-27

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That makes some sense then. Still, would like to see where you are on day seven.

You need full labs, but you already know that.

Call the Dr and tell them you are causing me to go through hell by ceasing treatment. Insane.

They stopped your own production. Remind them.

Try to find a urologist who does trt.

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Thank you for the clinical data and explanation of the 2 methods of testing. You’ve covered every base that might conflict with my concerns on the quote sensitive/standard E2 test methods. I am still wondering what the jury thinks about E/T ratios and if my balance might be what might have had something to do with my symptoms. At least I don’t ever have to worry about taking a damn AI

I would like to see where I’m at on day seven as well but the NP has pulled out of my treatment. My challenge now is to find a relatively affordable doc to work with me on my hormone optimization. I really fear crashing off of the T I’ve been taking…my Testes are grapes. Who ever I end up with will hopefully do full labs for my Endocrine system this time.

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I’m with you charlie. My NP just doesn’t care how I feel after coming off Testosterone and as I gradually found out, she doesn’t know anything about it…to be fair she probably feels overwhelmed and out of her league in this matter. Her overseeing doctor is the one she ran to with my tests and they told her to stop treatment, no exceptions.

I think the word Testosterone scared the hell out of my NP and her authorities. I get the feeling they are washing their hands of the situation, probably out of fear of another Testosterone treatment lawsuit if I had to guess.

Anyone in Nashville who touches Testosterone treatment, that I know of, charges anywhere from $700-1K for testing, consultation, all initial costs. I can’t afford that, and won’t be able to afford that till I can get my son situated. I’m hoping a year from now I’ll be in the green to go local.

Do you have a gym membership? That may be a good place to start. Ask around, maybe the employees can point you towards someone on TRT who could give you a referral. Or, maybe one of them could. Good luck.

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Do you have medical insurance?

@highpull

This has been a thought of mine as well. I’m not as big as I used to be though and don’t really chum around with these guys as easily as I used to…never the less, it is an avenue to try.

Does you or anybody know anything about Royal Medical? Their pricing is reasonable. They charge $195 flat every month. I’m pretty sure I can swing that in the immediate future.

No charlie, I really wish I still did. After my shoulder surgery and a broken rib 3 weeks after returning to work, they let me go…I live in a “Right to Work” state and I didn’t qualify for FMLA.

I see. I hope it will all work out soon.

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So you have a high shbg and that should mean total serum doesn’t convert to e2 at a high rate. Same with conversion to free t. This means you would take more T per dose to increase. Maybe 2 x a week 75mg or simply more than your current dosage.

Don’t be bummed you have some good info there and I think the guys can help you.

Everything does charlie

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Wow stop treatment. Idiots. Sorry man. That sucks. Low t nation is 300 a month no other coast. 195 sound good. Just tell them your 150 a week doesn’t work so they give you more. You don’t have to take more but it’ll give you more for storage and a rainy day.

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Agreed enackers, SHBG seems to be a culpable suspect. I think an online TRT clinic will be more disposed to be flexible with me on that.
I’m going to hang in there till the option presents itself as a viable one.

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The majority of doctors have no desire to learn how to do TRT, it’s not profitable and has no investor money behind it so doctors are not interested.

Those doctors that are interested are all in private practice, anti-aging and Sports Medicine. You may need supraphysiological levels due to your high SHBG which an ordinary sick care doctor cannot allow.

If in the states Defy Medical is a telemedicine clinic worth considering.

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I’m starting to see that this is the case systemlord.

I’m in the states. I checked Defy and it seems like this is the outlining model of what I should shoot for right now especially given my circumstances. The phone rep said the cost was $250 upfront and a few other expenses like discount lab tests to start. His take was that this would run about $700-$800 to start. The rest of the year was very reasonable. In the long run, this is an ideal path to pursue. The breakdown he estimated was 2K yearly, which I could do, it’s the upfront cost that’s got me in a bind.

I reached out to Royal medical who gave me an upfront cost of $195 and $195 for every month following. Sounds too good to be true…but the rep said that’s the price, no catches. Your thoughts?

Anyone heard of or used Royal Medical? Any idea as to if they’re reputable?