T Nation

KCLarry - Labs and Protocol


#1

Hi, I’m Larry, and here’s my story.

I’m a 48 y/o male and I’ve been physically active for most of my life. I have never been on a prescription drug, have never had a surgical procedure and have a squeaky clean medical history. Last August I noticed that minor cuts and scratches were taking longer to heal than normal, you know how a scratch will scab up and heal in a week – mine starting taking 3 – 4 weeks. I also started feeling tired, worn down and fatigued, so, like most folks do, I turned to Google. Many of the symptoms I THOUGHT I was experiencing aligned with search results suggesting Diabetes.

My annual check-up was scheduled for early December and I decided to wait and discuss at that time.
I had lab work scheduled for 12/5 and the office visit for 12/13; I called ahead and left a message with my Dr. giving him a heads-up in the event he needed to expand tests to assist in diagnosing my symptoms.

Here are the results of the 12/5 lab (blood drawn @08:00 AM w/fasting @Quest Diagnostics):

CBC:
Component Value Standard Range


WBC 5.4 not provided
RBC 5.60 not provided
Hemoglobin 15.9 not provided
Hematocrit 48.0 not provided
MCV 85.6 not provided
MCH 28.3 not provided
MCHC 33.1 not provided
Platelet Count 207 not provided
MPV 9.0 not provided
RDW 14.0 not provided

Lipid Profile:
Component Value Standard Range


Cholesterol 198 not provided
Triglycerides 74 not provided
HDL 49 not provided
LDL 134 not provided
Non HDL Cholesterol 149 not provided
Cholesterol/HDL Ratio 4.0 not provided

COMPREHENSIVE METABOLIC PANEL:
Component Value Standard Range


Sodium 140 mmol/L 135 - 146 mmol/L
Potassium 4.3 mmol/L 3.5 - 5.3 mmol/L
Chloride 107 mmol/L 98 - 110 mmol/L
CO2 27 mmol/L 20 - 31 mmol/L
Blood Urea Nit 23 mg/dl 7 - 25 mg/dl
Creatinine 1.01 mg/dl 0.60 - 1.35 mg/dl
Glucose 100 65 - 99
Calcium 9.3 mg/dl 8.6 - 10.3 mg/dl
Total Protein 6.7 g/dl 6.1 - 8.1 g/dl
Total Bilirubin 0.5 mg/dl 0.2 - 1.2 mg/dl
Albumin 4.5 g/dl 3.6 - 5.1 g/dl
Alk Phosphatase 70 u/L 40 - 115 u/L
AST (SGOT) 47 u/l 10 - 40 u/l
ALT (SGPT) 45 u/l 9 - 45 u/l

TSH WITH FREE T4 REFLEX:
Component Value Standard Range


Thyroid Screen 2.58 mIU/L 0.40 - 4.50 mIU/L

TESTOSTERONE:
Component Value Standard Range


Testosterone 262 ng/dl 250 - 827 ng/dl

During our 12/13 lab review, my Dr. suggested that the symptoms were likely due to low test levels. I’m 5’ 8”, 215# with <20% BF, I have a lot of muscle mass and I was much leaner before all of this started. He felt I basically had more mass then the test levels could maintain and that the fatigue was probably a symptom of this. At this point, I had started to experience the fatigue, had been at a plateau in the gym since early October and was beginning to be less active than normal. He suggested we pursue TRT and in discussing the various options at our disposal, we agreed on an injection protocol. However, he first wanted to wait about a month and perform another lab looking at Total Test, LH and FSH.

We scheduled the lab for 1/16 and the next 4 weeks began a downward spiral in how I felt. By the time the next lab rolled around my fatigue was nearly unbearable, I had no energy, no motivation and no matter how much rest I got, I still didn’t feel rested. The fatigue was the worst part, I couldn’t handle sitting or lying still for more than a minute, and I started getting 3 – 4 hours of sleep/night because the fatigue was so damned persistent.

Here are the results of the 1/16 lab (blood drawn @09:00 AM no fasting @Quest Diagnostics):
Component Value Standard Range


FSH 10.3 mIU/mL 1.6 - 8.0 mIU/mL
LH 1.4 mIU/mL 1.5 - 9.3 mIU/mL
Prolactin 7.0 ng/ml 2.0 - 18.0 ng/ml
Testosterone, Total 163 ng/dl 250 - 827 ng/dl

When reviewing the results with my Dr. on 1/18 he was concerned about the FSH/LH levels and wanted me to see an Endo to identify the root cause, are we dealing with primary or secondary hypogonadism? I called the Endo’s office to schedule an appointment and they said their first opening was at the end of May – I kind of flipped out, because by this time the fatigue was ruining my life… Thankfully a patient cancelled while we were still on the phone and she said “Can you be here @08:00 in 2 days?” Yes I can!

So, I arrive at the Endo’s (University of Kansas Hospital in downtown KC), the nurse takes my vitals and in strolls the Endo. He has me strip down, gives me a complete physical, has me stand in front of him nude, and he’s just staring at me with an expression somewhere between curiosity and suspicion. After about a minute he tells me to get dressed, I’m thinking WTF is going on here!

We spent about 30 minutes together discussing how I felt and we reviewed the previous lab work my Dr. had ordered, and towards the end of the session he says “You are a mystery, most of the patients I see are obese and have diabetes. You appear perfectly healthy and have a substantial amount of lean body mass.” He wanted to order more labs to aid in determining if I have primary/secondary hypogonadism. He did not like that my last lab was @09:00 and wanted me there as soon as the lab opened.

Here are the results of the 2/20 lab (blood drawn @07:50 AM no fasting @University of Kansas Hospital):
Component Value Standard Range


Testosterone, Total 238 NG/DL 270 - 1070 NG/DL
Cortisol-AM 13.0 MCG/DL 6.7 - 22.6 MCG/DL
T4-Free 0.7 NG/DL 0.6 - 1.6 NG/DL
Estradiol (E2) 33 PG/ML 10- 44 PG/ML
Ferritin 67 NG/ML 30 - 300 NG/ML
Iron 98 MCG/DL 50 - 185 MCG/DL
Iron Binding-TIBC 468 MCG/DL 270 - 380 MCG/DL
% Saturation 21 % 28 - 42 %

On 2/22 the Endo reviewed the lab results with me, by this time, I had discovered T-Nation and came prepared with a few questions of my own. During our discussion I inquired about our initial consultation and why he was so pre-occupied with my physical appearance as compared to the lab results. I had told my wife I knew what he suspected, but I wanted to hear it from him. My hunch was correct, he thought I had done an AAS cycle and crashed post cycle. I reassured him that I’ve been lifting cleanly off and on for 30+ years and that this crash was sudden, extreme and that I was more confused than he because I document everything and I’m very anal about my routines.

He prescribes a protocol of administering one 200mg injection of Testosterone Cypionate every two weeks. Thanks to T-Nation, I knew this was a bad idea. I countered and suggested we do 100mg once weekly and he agreed. Nice, he seems open to working with me here!

Then I inquired about my E2 being in the upper third (33 PG/ML) and if I may need an AI. He said no. I pressed him again, and he firmly said no again and that it wasn’t going to be a problem. I guess we’ll see what the next labs have to say.

I started injecting on 2/27 and have been doing 100mg every Monday since. He wanted me to follow this protocol for ~90 days and my next lab work is scheduled for 5/15 (morning of an injection day) with follow-up office visit on 5/18. Once we establish my maintenance dosage, he just wants labs and a review once annually as long as I’m feeling fine.

On 3/31 I had an MRI performed so they could determine if the root cause was the pituitary. It is not, the MRI was clean!

So, how do I feel after 6 weekly injections?

So far, I feel no different than before I started TRT. My routine is to inject every Monday evening when I get home from work, about 6:00 PM. Some days the fatigue almost brings tears to my eyes, I can hardly maneuver under my own body weight, and I typically get ~ 4 hours of sleep a night and have zero energy, motivation or any semblance of well being.

What I have noticed is that on Tuesdays at about 4:00 – 6:00 PM I experience a reduction in the fatigue, it seems it takes Cypionate about 24 hours post injection for the spike to reach high-enough levels to knock the edge off. And that’s really all it does, the fatigue is still present but it reduces the peaks and makes it manageable. This experience is consistent through Wednesday, and begins to wear off every Thursday evening. I seem to get a 48 hour window of comfort, and then Friday – Sunday the fatigue has its ‘A’ game back on with a vengeance!

Perhaps I’m burning through it this fast, I dunno.

Since October I have cut back on my workouts considerably and I’m essentially just going through the motions at the gym – I have lost strength in some exercises (as much as 50% on dumbbell curls), I have lost lean muscle mass, and have gained 2” in my waste while maintaining the same body weight. Sad times for me gentlemen…

I’m going to stick it out for 4 more weeks and see what the next labs reveal, but in the spirit of transparency, I’m losing my patience, I’m beginning to feel desperate, and the daily battle with being discouraged is really bringing me down. Once I am able to establish my maintenance dose with the Endo (100mg/wk, 120mg/wk, whatever the script is) I do plan to inject every 3.5 days.

I’m working on a plan ‘B’ in the event my Endo isn’t willing to work with me; he’s previously made a comment about “not believing everything you read on the internet…”

I did as KSman suggested in the stickies and looked for compounding pharmacies in my area (KC Metro); I reached out to MCP (I believe this is who KSMan uses), and asked for their top N list. Last week I received 5 names and all of them appear to be clinics with monthly installments some of which are $300/month! If I have to use this path, it’s going to require more leg work to sort out viable professionals to work with.

Sorry for the lengthy post and I appreciate any feedback the community has to offer.

Larry


#2

Hang in there. My guess is you’ll need 200mg/week, and an AI as well. See what your blood work indicates. It would be nice to see fT3, SHBG, free Test, and DHEA-S labs.


#3

Your E2 was already high at 33. You want E2 = 22. Now on trt, I’m guessing it’s higher now. You need 100mg test per week split into 2 doses plus .5mg anastrozole with every 50mg injection. Labs should have been done 4 weeks after starting trt to see where you are. Labs that you need are TT, FT and E2


#4

Thanks for the replies Gentleman,

I suspect you are correct regarding my E2 already being high prior to TRT. I inquired during our session and he said it wouldn’t be a problem. Since finding a professional to work with is such a pita, I felt lucky to have the script and decided I could work this out with him over the coming weeks.

I reached out to him over a week ago via their patient portal to see if we could perform the next lab immediately and also described how I feel. I still haven’t heard back.

I will move forward with finding another pro in the KC area and may ping KSman to compare notes with what MCF has told me.

Larry


#5

Greetings from Lawrence.

Your E2 and low-T was making you horribly estrogen dominant, E2 vs T. Now your E2 is getting way to high. The problem is that doctors typically are quite idiotic about these things and endo’s are really bad as a group.

I am worried about your thyroid. Thyroid lab ranges are bogus and indicate that your thyroid function is fine, even when it is not. Please see the last paragraph in this post. Your thyroid issue may be from using sea salt instead of iodized salt. Respond to that issue and post body temperatures.

FSH and LH typically have roughly similar values. Your MRI was looking for a FSH secreting pituitary adinoma, very rare. But testicular cancers are not rare and many secrete FSH. Did doc examine your testes? Testes ever ache. Typically, testicular cancer is a young man’s disease, but you still need to be screened.

fT4=0.7 is low, should be near midrange 1.1 or a bit higher.
TSH=2.58 should be nearer to 1.0

You are iron deficient. You should have an occult blood test to see if there is blood in your poop. Had a colonoscopy lately? Ferritin should be >80.
That been said, your hematocrit [HTC], hemoglobin and RBC seem fine.

https://labtestsonline.org/understanding/analytes/tibc/tab/test/
TIBC=Transferrin

Had you donated blood recently?
Strange diet?

Have your testes become smaller and softer yet? Would your or your wife care?

Please read the stickies found here: About the T Replacement Category

  • advice for new guys
  • things that damage your hormones
  • protocol for injections
  • finding a TRT doc

Evaluate your overall thyroid function by checking oral body temperatures as per the thyroid basics sticky. Thyroid hormone fT3 is what gets the job done and it regulates mitochondrial activity, the source of ATP which is the universal currency of cellular energy. This is part of the body’s temperature control loop. This can get messed up if you are iodine deficient. In many countries, you need to be using iodized salt. Other countries add iodine to dairy or bread.


#6

Order tests out of pocket at privatemdlabs .com

Discount code is HEALTHY12.

My E2 was 30.9 and that was enough to give me gyno. I had gyno surgery once. Doctor didn’t wanna prescribe anything for E2 management and the gyno came back. In the end it was my fault for not trying to find another doctor but some times you get to feeling like no one is ever going to help and you just give up.

You had low T and high E. Now with higher T you will have even higher E for sure. Try getting private labs done to see where your T and E are and try taking it to a doc and see if they’ll accept outside labs. Luckily mine was willing to work with me even though I didn’t get lab work done with him. I’m a cash patient though

You can get liquid anastrozole aka arimidex aka dex online if you do a search for research chemicals… Can’t say much more than that. But really try to get it with prescription


#7

Hi KSman,

To be honest, I don’t use much salt at all, I don’t cook with it and we don’t have salt on the table. In my annual checkup 2 years ago my Dr. said “Wow, I’ve never told a patient to bump their sodium up before!” I thought I did, but should I look at sodium tablets w/Iodine? If so, what would be a good mg starting point.

The Endo said FSH and LH were “close enough to the range” and that they weren’t something to be concerned about. He did examine my testicles and said he didn’t feel any lumps or such, but did state he thought they had shrunk about 20-25% and that they were soft. My wife has made a comment recently, and I’m still thinking through how big of a deal it is to me:-(

He also mentioned I was iron deficient and I since bought an iron supplement and now take 65mg daily.

I have not donated blood for several years.

My diet is nothing outrageous, MRP shake for breakfast, 2 meals during the day where each contain 5oz chicken breast, 5oz broccoli and 7oz of potatoes. I have a normal meal with the family at night, and try to keep red meat to 1-2 times/week. I also have a routine post workout shake of 2 scoops powder, 16oz milk and 1/2 cup of oats. Typically, an average of 2200 – 2400 cals/day. Snacks would be fresh fruit and raw nuts.

I will review the stickies (I did last week because I wanted to have an informed first post) again with particular attention to the thyroid section.

I’m really struggling with just hanging this up and walking away from the gym. I won’t yet, but I feel worse now than before I started six weeks ago, and now I can’t even get him to respond to me…

I appreciate everyone’s time!

Have a great evening,

Larry


#8

Thanks mrphoenix,

I will review their site in more detail. I have a question from my first pass; which lab would you recommend based upon the labs/work I’ve had performed to date?

Larry


#9

The Endo finally responded to me today.

My questions were:

  1. Can we add E2, Total Test, Free Test, SHBG and DHEA to the next lab?
  2. Can we perform the next lab this week because I don’t feel like waiting another month?

His response copied directly from their portal:
“I don’t think those additional tests will be very helpful, especially the free testosterone. And your lab must be performed MIDWAY between your last and next injection.”

I spoke with a Pharmacist at MCF, she was really awesome and shared 20 minutes of her time with me. Thanks Jackie, you’ve certainly been the bright spot to this week!

Seems like the Drs they recommend are mostly of the boutique model. I may take an inquiry to KSman to pm so I don’t violate any policies here – MCF provided me with four Drs she said they frequently fill scripts for.

Larry


#10

E2 and FT are not helpful? lol.

You might have to go private on this one. There’s a panel on privatemdlabs that has TT, FT, E2 for $103.99 minus the discount code. E2 will show high and he HAS to help you. If not then find a new doc.


#11

I sent a note to the Endo’s nurse last night requesting she add them, I’m going in for labs tomorrow morning. This will be 3.5 days since a 100mg injection- curious what we’ll learn!


#12

You are iodine deficient. Wife and children too.
Please check your oral body temps for yourself and others.

You need more red meat. In any case, low iron in males implies GI blood loss or poor absorption which in some cases is from low stomach acid or use of heartburn medications. You need an occult blood test to rule GI blood loss in/out.

LEF.com has labwork on sale right now, annual event. Labs are via Labcorp and there are a few blood draw stations near you.

My doc in KC is booked up solid.

MCF is good, but there are many and they accept Rx from out of state and mail/ship anywhere.

Do not ever test DHEA, needs to be DHEA-S


#13

Hey KSman,

I’ll continue to follow your guidance/advice; I’ll take it a step at a time.

We have an older thermometer and two consecutive mornings I’ve been around 97.8/97.9.

We’re going to pick up another unit this week.

I had lab work performed on Friday morning; this would be 3.5 days from a 100mg injection. I’m concerned the lab may be reading a peak, but it is what it is at this point.

KU should have the results posted tomorrow and I’ll post them here once available, and I also plan on calling around this week for doctors in the KC metro area so I can get plan B rolling.

Larry


#14

Just received lab results, he only tested Total Testosterone and the result was 329 NG/DL on a 270 - 1070 NG/DL scale… Again this was 3.5 days after 100mg injextion.

I have more questions out to him…


#15

Some guys, not rare, are hyper T metabolizers who need ~300mg T per week to get where others are at 100mg/week. The elimination half-life is then shorter as expected and thus 3.5 days can produce a low result. So these guys need to inject EOD and always do labs on the off-days.

You have no idea where FT or E2 are. Not good. But dose should be changed as suggested, then get TT, FT, E2.

Do not expect to find a doctor who understands this hyper T metabolizer issue, its not in the literature and may never be seen by a doc.

You do need more iodine. Get mid-afternoon body temps as well. Both are important. Check others as well.


#16

The Endo finally responded to me; he feels 329 is ‘in range’, and said “Unfortunately testosterone replacement does not cure all ills. If not’s helping I suggest you stop it.

So, prior to starting I was 163 and diagnosed as primary hypogonadism and he suggests I JUST STOP!

I have countered asking if we can try 150mg/week; holy crap this is depressing the hell out of me…sigh

I’m still searching for another doc, but continue to get further discouraged…

Larry

ps - KSman, I will follow your additional guidance in respect to monitoring my body temp and getting iodine incorporated into my diet. I just gotta get my Test/E2 lined out first…


#17

There is a lot of pseudoscience written here, such as you need your E2= 22. That kind of writing is indicative of little understanding of the variability of lab assays and biological variance. You want your estradiol to be in a range and anyone that gives you an absolute value to aim for does not understand biology.
The literature is full of information ( yes I am one of those stupid MDs) that show that estradiol even in the 40s, 50s, and higher is not necessarilya problem. I have seen patients with testosterone in the 200 to 300 range that are muscular, cut, and full of energy. So stop focusing on hormones as the problem. They may be but they don’t have to be. There are myriad conditions that can cause such symptoms - something as simple as Vitamin D deficiency to complex as autoimmune conditions, mitochondrial disease, Lyme disease etc. I am not saying to go searching for this but it reminds me of the story of Diogenes and the lamp.
lo
Your initial hemoglobin and hematocrit was normal so you do not need to have a fecal occult blood test. KSMan is correct: your TIBC is too high and you have severe iron deficiency anemia. There is a condition called pernicious anemia and the ability to absorb iron due to a deficiency of intrinsic factor resulting in B12 absorption will cause this.

So…have your B12 level checked ( if you are on a proton pump inhibitor, even more so). I suspect your symptoms are due to B12 deficiency/pernicious anemia/ severe iron deficiency).It has ZERO to do with your testosterone and your estrogen and your hormone levels.

My two cents worth with the caveat being I am a stupid MD:) so i probably have little business commenting in this forum…but nevertheless…Good luck


#18

Good Morning Agent 007!

I appreciate you taking the time to comment on my thread. Last week I sought a second open and went to another Doc; I’m not going to cancel with the Endo until I see where this is going.

I took my full lab history and we walked through it, he is initially suspicious of my thyroid and has ordered a full work up in addition to total test, free test, shbg. He also ordered a psa.

I anticipate having the results on Monday and will post here for additional insight.

I continue to lose strength and muscle mass and the fatigue is unrelenting 24x7 - it wakes me up every couple of hours at night. He doesn’t think the fatigue is hormone related stating if this were so I ‘should’ feel better early in the morning.

I developed a new symptom last week which is hormone related; my breast are becoming tender and the nip is extremely sensitive - I stopped my injections 8 days ago to give the new Doc a shot (pun intended)

I appreciate everyone weighing in and look forward to feeling better.

I will ask the new Doc to check B12 too!

Larry


#19

That suggests that E2 is too high to too high relative to a backdrop of falling T.

We have lots of guys with elevated-normal E2 that do a lot better with E2 in the lower 20’s. If knowing what works by observing outcome is pseudo science then someone’s opinion is wrong.

With elevated-normal E2 we see:

  • low libido, even with great TT, FT levels
  • sexual performance problems
  • short tempered, intolerant and bitchy, social withdrawl
  • low energy
  • mood problems - depression
  • adverse fat patterns

Dr A007 likes to pop in here every 7-8 years and kick the can. He has not been here making any effort here to improve anyone’s quality of life. He did not know anything about estrogen management in 2009 but was doing gear 500mg/week. He has not earned any credibility here.

You need an occult blood test to rule out a GI bleed. It is not invasive and certainly not as invasive as a colonoscopy that one should have at your age. But that only looks as the lower intestine and there are many other potential GI bleed sources higher up. Do not be talked out of this reasonable screening.


#20

I had a great visit with the new Doc today; below are the results from the initial lab. Note, this lab was pulled 3 days after a 100mg injection.

Test Name - Value - Reference Range
Reverse T3, Serum 26.5 9.2 - 24.1 ng/dL
TSH 2.280 0.450 - 4.500 uIU/mL
PSA, Serum 0.5 0.0 - 4.0 ng/mL
Thyroglobulin Antibody 0.0 0.0 - 0.9 IU/mL
Triiodothyronine,Free,Serum 3.5 2.0 - 4.4 pg/mL
Thyroid Peroxidase (TPO) Ab 9 0 - 34 IU/mL
Testosterone, Serum 507 348 - 1197 ng/dL
Free Testosterone(Direct) 15.2 6.8 - 21.5 pg/mL
LH <0.2 1.7 - 8.6 mIU/mL
FSH <0.2 1.5 - 12.4 mIU/mL
Estradiol 46.8 7.6 - 42.6 pg/mL
T4,Free(Direct) 1.22 0.82 - 1.77 ng/dL

He drew for additional labs today in respect to the thyroid; his initial approach will be to address Reverse T3. He is convinced this is likely driving my fatigue, and I’ll share more as this develops.
I anticipate it will take ~10 days like the last set did for thyroid.

New script for Testosterone/Estrogen:

HCG/B12 1250 Units (0.5 CC) SQ Twice Weekly.

Testosterone Cypionate 200 mg/week (100mg/.5 CC IM Twice Weekly).

Anastrozole 1 mg Tab Take 1 tablet(s) by mouth 2X a week.

He asked if I was ‘Ok’ with self-injecting; I said “No, but my wife has become quite good at it - Why?” He said "Because I prefer my patients to inject TWICE WEEKLY as it works better to establish a more even blood/serum level. I almost feel out of the chair, and shared this would be no problem at all:-)

Then he said, “Your E2 is a little high, how do you feel?” I said “My breasts are tender and that the nips were super sensitive.” He said “Yeah, this is just a range and some guys are more sensitive than others. I will prescribe a blocker.” I said, "Can we talk about AI’s too?"
He LOL, smiled really big and Said “That’s awesome, you actually came prepared - I am prescribing an AI, but most men don’t understand when I explain it, and it’s easier to just say Estrogen BLOCKER!”

My question back to the team here, if I’m injecting .5ml of Cypionate and .5ml of HCG/B12 twice weekly; should I start out dosing .5mg or 1mg of Anastrozole with each injection?

Edit: When injecting Cyp/HCG every 3.5 days, when should I take the AI, the day of injection, the day after, …?

Thanks,

Larry