This sticky is maintained by KSman. This lead post is the sticky. DO NOT ATTEMPT TO DISCUSS YOUR PROBLEMS HERE! This is for technical reference use. KSman will compile information here and it will be a conservative approach. The next post will be for a broader approach that will be more expensive than most will tolerate and beyond what most insurance will pay for. Keep suggestions and contributions on topic. Some things might be better as PM’s to KSman to keep down the clutter.
To understand what the lab work means, what needs to be done, when it needs to be done and what is a waste of time, you need to become an amateur endocrinologist. Or in my case “Endocrinology is my hobby!” This however does give way too much credit to Endocrinologists as most of them really are the amateurs and make some of the worse blunders and have pathological ego problems that keep them from learning what they need to know. I hold most Urologists in the same high esteem. Some of the best TRT docs are not formally medical specialists, but are self taught enthusiasts. But we will save all of that for a [controlled] “Finding a TRT Doc” sticky.
This will be a mix of simple recommendations, explanations and the occasional rant.
FT is T that is not bound to SHBG or other proteins.
SHBG: Sex hormone-binding globulin - Wikipedia
Note that SHBG does not transport and release T, SHBG bound [SHBG-T] is not bioavailable. You will find many incorrect references to the contrary.
SHBG-T is tightly bound. Estrogens bind weakly to SHBG and SHBG can transport estrogens and release the estrogens throughout the body. Note that SHBG occurs in blood, but does not exist in tissues. So all T in tissues is considered FT. Secretions, such as saliva, can be used for hormone lab work and the results are considered FT, thus there is no TT in saliva testing. Many feel that saliva testing is quite useless.
Weakly bound T: T can be bound to other proteins [not SHBG] such as albumin in the blood. Those are weakly bound and the albumin bound T can be release T to tissues and this is considered hormone transport. There are other proteins to which T can be weakly bound. Note that some males loose serum albumin levels as they age. This is thought to also reduce bio-T:TT to some extent. In reality, these guys have low T, and lower albumin is one of the catabolic effects of low T. TRT would be expected to improve albumin levels.
With age, we see E2 and SHBG increase. This tends to increase TT, as FT/bio-T are falling and that can be misleading.
Bio-T is FT plus weakly bound T. Both measures are technically useful. Bio-T and FT are roughly proportional. So you typically do not have any need to do both of these types of labs.
TT is FT + weakly bound + SHBG-T. Note that for a given production rate of T, or a given TRT dose of T, the more SHBG you have, the more TT you will have. In this regard, TT can be the wrong therapeutic target and can be a simplistic and inappropriate concern if one does not understand the larger picture.
From a practical point of view, lab results should be useful. So the results need to be something that others are sufficiently familiar with to interpret. Most here are familiar with FT and not with bio-T. So FT will be better from that point of view.
To put the whole picture together, you also need estradiol numbers. With FT, TT and E2, there is very little need for SHBG lab numbers.
Note that some labs produce high FT ranges and results compared to other labs. FT lab numbers always need the lab ranges for interpretation. In this regard, I expect that bio-T has the same problem and bio-T results will always needs the lab’s ranges for interpretation.
In HPTA intact males, LH is released in pulses and diurnal patterns. This leads to changing FT levels. FT has a short half life. When you test FT in these males, the absolute number is not very important as the result is partly a factor of when the lab work was done. With TRT using transdermals, the swings in FT are more extreme and lab timing greatly determines the lab values. With frequently injected T, TT, FT and E2 levels can be very steady and FT lab results thus are more valuable in that case.
Labs to be done before you start TRT
-LH and FSH [LH/FSH]
-FT or bio-T
-Prolactin [optional in most cases]
-DHT [sort of a waist of time and blood if your testosterone levels are low]
-DRE: the dreaded digital rectal exam, doc gives you the finger.
Labs to be done when on TRT
-FT or bio-T
-Implications of injections VS transdermals [and injection frequency]
-Prolactin [optional and almost never on-going]
-DHT [should be checked, but perhaps not on-going]
-LH/FSH [optional and one last time -do I have cancer?]
-DRE: the dreaded digital rectal exam [Your doc does not enjoy this either!]
Labs to never do and timing issues:
-DO NOT test E2 ultra sensitive
-DO NOT do saliva testing for T or E2 and expect any help here
-DO NOT test for free E2
-DO NOT test total estrogens
-DO NOT test PSA within 48 hours after a DRE [digital rectal (prostate) exam] or ejaculation
-DO NOT test prolactin with 48 hours of orgasm, avoid hugging puppies and babies
-DO NOT do lab work when muscles are sore from training or injury as your “liver markers” will show high levels. Those “liver tests” are really not liver specific.
-DO NOT waist time and money on tests that you cannot take any action on. Example, testing IGF-1 for growth hormone status if there is no way you could every pay for GH or actually legally qualify for GH.
-DO NOT routinely test for LH/FSH when on TRT, perhaps once to rule out certain testicular cancers and never again
-DO NOT test for serum DHEA, must test DHEA-S
-DO NOT do saliva testing for T, DHT, DHEA, pregnenolone if taking sublingual/buccal T, pregnenolone OR DHEA OR other steroid. The tests will be wrong and you do not want cross reactivity unknowns
-Testing E2&TT&FT makes also testing SHBG sort of useless.
Labs that are stupid after you start TRT
Thyroid labs [basic first line]
-T3 no see fT3
-T4 no see fT4
-are you getting enough iodine? probably not! KSMan? - Testosterone Replacement - Forums - T Nation
-? stuff that Hardasnails will suggest to me via PM
Thyroid symptoms [hypothyroidism or subclinical] Dry Skin, sparse outer eyebrows [observe others], feel cold easily, low body temperatures, general non-pattern hair loss, enlarged, lumpy, sore or asymmetrical thyroid gland. Many symptoms are the same as low-T.
-Cortisol four sample saliva testing [the gold standard]
-Pregnenolone [the foundation of the adrenal hormones and all steroid hormones *]
-DHEA [can’t make T without it] no see DHEA-S
-DHEA-S [DHEA Sulphate]
- Vit-D is multi-step derived from cholesterol directly, not via pregnenolone. Pregnenolone is also direct from cholesterol. Cholesterol is really the root of all steroid hormones. [Because cholesterol can be considered a precursor of testosterone, and testosterone a metabolite of cholesterol under Federal Statute [http://www.justice.gov/dea/pubs/csa/802.htm], cholesterol is technically a schedule III controlled substance and is subject to criminal penalties as an illegal anabolic steroid. Attempts by John McCain and others to explicitly classify DHEA as a schedule III anabolic steroid have nonetheless failed. See http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=110_cong_bills&docid=f:s762is.txt.pdf ]
General health labs
-CBC: Complete Blood Counts
-Hematocrit: Part of CBC but needs its own discussion
-Lipids: Fasting Cholesterol and related
-Vit_D25 hormone -yes vitamin D becomes an essential steroid hormone
-Glucose: Fasting levels indicate insulin function
-Liver markers -are they really liver specific? [Hint: not]
Things that you can determine without lab work
Symptoms: Why are you here
-Brain fog, no one knows what that means but everyone knows if they have it!
-Social withdrawal - “I would rather not go out”
-Why do I have boobs? This really is depressing if prolactin is the cause!
-Why do I carry fat like a woman?
-Why am I a moody bitch?
-Can’t get it up?
-It is up, now it’s gone.
-My penis is numb -your nerves love T too. Things to do with testosterone cream.
-My testes are softer and smaller
-My testes ache 24x7
-My scrotum is up-tight, gives “how are they hanging” a whole new meaning.
-Nocturnal erections -necessary but not sufficient
-“morning wood” -things are working
-Why do really hot looking women and girls now look like art instead of lust?
-I felt great when I started TRT, where did that go? Neural transmitters rule your life.
-My TRT seems ineffective or never was. Things that crash in the night.
-On TRT and still do not feel right, something else is wrong.
-Loss of hair on lower legs, skin below the knees is smooth and shiny.
-Why do I feel cold easily or all of the time?
-Why do really stressful situations leave me feeling physically beat up. Adrenal fatigue.
-Dry skin, brittle hair and nails
-Skin on the back of hand is thin, crinkly. Pinched skin does not recover
-Gum disease, the ugly killer
-Why do I have a chronic cough [when taking a statin drug]
-I have visual field disturbances such as reduced peripheral vision
-My joints have started to ache
-TRT and now leg cramps
-TRT and wife says I am snoring more
-I am not depressed, I just don’t care about anything, no joy, no motivation, no reward
-I want sex twice a day and my wife/GF is freaking out. What do do about her.
-We fixed my wife’s hormones and I can’t keep up with her needs. [Give me her phone number!]
-I want sex twice a day and my wife/GF loves it. Why are you still here?
-pituitary MRI for younger cases of hypothyroidism “what is in there”
-testicular ultrasound exam, detects cancer [please help with other uses]
Serum E2 testing:
E2 is estradiol - in case you were wondering [E1=estrONE, E2=estraDIol, E3=esTRIol]. There are different lab tests to choose from and docs often get this wrong. Some testes have limited reporting ranges and will not report actual values below a certain level and might report <17 pg/ml instead of the actual value. The reason for this is that these tests were developed for work on women’s hormones. Women who are fertile have very high levels of estrogen and some tests are appropriate for those levels. Women who are post menopausal have low levels of estrogens and the need tests that are sensitive for those low levels. For post menopausal women with breast cancer, SERM drugs are used to push there already low estrogen levels even lower. Ultra sensitive tests are used to detect these very low levels to determine the effectiveness of the treatment.
For TRT, use the basic LabCorp serum E2 test or Quest Sensitive 4021x. DO NOT USE Quest ULTRASENTIVE! There are some similar issues with other testing labs as well.
DO NOT test for free estradiol
DO NOT test for total estrogens
DO NOT do Saliva testing, simply because very few people know what to do with that data.
Note that many older men, getting fat with low testosterone, can have more estrogen than their post menopausal wives! And old men and women can end up having similar body shapes.
E2 levels are modulated with low doses of aromatase inhibitors such as Arimidex/anastrozole. Optimal level is near serum E2=22pg/ml. Some doctors will prescribe 1mg/day which is a TOTAL disaster unless you are female and have estrogen positive breast cancer. Another idiot doctor mistake.
See this thread concerning problems with Labquest FT testing:
Note that Labquest can also report FT ranges that are about 5 times higher than reality. So you cannot compare Labquest results to Labcorp and others. FT lab results must be reported with lab ranges.