T Nation

Labs; Advice, New Doctor, New Start


#1

Hey All,

Cliff Notes:
- I'm at the end of my rope and am here to try and get a handle on my TRT
- Lost my job about a year ago due to how I'm feeling.
- Can't focus, concentrate, memory is bad, very tired and hard to get up in the morning, temper is very short and unpredictable, I've turned anti-social and hate going outside the house.

I was not getting results from my last doctor of over 2 years, so I switched. Lab wise, I've always had metabolic syndrome, hypo type thyroid numbers, insulin resistance and I'm told, some type of internal inflammation due to my CRP number being over .1 (1.4).

My protocol when these labs were taken was, 50mg test cyp 2x weekly. I was on HCG in the past, but not for these labs.

Based on these labs, below is what the doctor prescribed.
1) Thyroid - Prescribed NP Thyroid 60mg, once daily
2) Adrenal - DHEA 25mg, once daily
3) Hormone - Stop test and start 1,000mg HCG 3x weekly, 1mg a-dex 2x weekly
4) He says I have metabolic syndrome and that the above will help straighten it out.

Any feedback on my labs and his treatment plan would be greatly appreciated.

Age: 39
Height: 5"10
Waist: 36
Weight: 195

Describe Body and Facial Hair: Easy to grow facial hair, but since starting TRT it's become thicker and coarse/stiff. Only had some chest, belly and mild back hair before TRT. Now all of the mentioned areas are thicker and blacker. My upper arms, shoulders and mid-back now have hair.

Describe Where You Carry Fat and How Changed: I carry everything in my gut. My new TRT doctor did a body scan (dex?) and it yielded 15% in arms, 14.8% in legs and 29.6% in Trunk. My body has not changed the way it's carried fat since I can remember.

Health Conditions, Symptoms [History]: High Blood Pressure, High Anxiety, Depression and Migraines.

Rx and OTC Drugs: No hair loss drugs. Lexapro - Depression, NP Thyroid 60mg, Verapamil - Reduce migrains and symptoms, Lisinopril - Blood Pressure
Vitamin D - 15,000iu, DHEA 25mg, Niacin, TMG

Lipid Panel,
Cholesterol, Total, 220 mg/dL (125 - 200)
HDL Cholesterol, 31 mg/dL > or = 40
LDL-Cholesterol, 142 mg/dL <130
Triglycerides, 237 mg/dL <150

Cardio
Cardio CRP (R), 1.4 mg/L -- Range for this is 1.0-3.0 average cardio risk -- I've been told it means inflammation and could be the start of something bad.
Homocysteine, 10 umol/L <11.4
Glucose, 74 mg/dL (65 - 99)
Vitamin D, 25-OH, Total, 44 ng/mL (30 - 100)

Thyroid Panel
TSH, 3rd Generation, 2.24 mIU /L (0.40 - 4.50)
T4, Free, 1.1 ng/dL (0.8 - 1.8)
T3, Free, 3.7 pg/mL (2.3 - 4.2)

Testosterone
Testosterone, Total, 871 ng/dL (250 - 1100)
Free Testosterone, 204.7 pg/mL (35.0 - 155.0)

SHBG, 15 nmol /L (8 - 48)
Estrogen, Total, Serum, 111 pg/mL (130 or Less) -- Never had this type of E test done, but doctor says he likes it around 7?
C-Peptide - Insulin, 3.49 ng/mL (0.80 - 3.10) -- Doctor said this shows insulin resistance

Adrenal Stress Profile
Morning (6:00-8:00 AM), 13.7 (13.0 - 24.0)
Noon (12:00-1:00 PM), 4.3 (5.0 - 8.0)
Afternoon (4:00-5:00 PM), 5.7 (4.0 - 7.0)
Night (10:00 PM-12:00 AM), 0.4 (1.0 - 3.0)

Describe Diet: Nothing special. Last 3 years I've just been a breakfast, lunch and dinner person. Oats and protein in the morning. Lunch varies, but I try to stick to sandwiches. Dinner is always a protein, carb and fat.

Describe Training: I've felt so bad the past 3 years that I haven't lifted at all. In the past, I would do a typical body split over 5 days.

Testes Ache: Never

How Have Morning Wood and Nocturnal Erections Changed: Almost non existent. No libido or sex drive to speak of.


#2

Your doctor is in the right church, but wrong pew. He seems to be pretty in tune with the body and is willing to push the envelope with meds and does in depth testing, but I don't think he is on the right track with his conclusions.

This is the likely cause of your ALL your issues and indicates a relatively serious lack of cotisol output. DHEA (which your doctor prescribed) is not likely the answer. DHEA is produced in the adrenals, but it is not in the cortisol production line. You need cortisol support.

I recommend pregnenolone, which is basically the "mother" hormone. Take transdermal, not oral if you can help it (some can't absorb transdermals and end up with no choice, but start with TD and adjust). You could also consider Progesterone, as this is further down the cortisol production line chain and may be more likely to convert to cortisol. Life-Flo also makes this. They also happen to make a preg/prog combo.

Your goals for this support are upper quartile in the first two tests of the day, and lower quartile in the PM tests (maybe even lowest 10% at the pre-bed test). But you can't really control this, so use it as a guide only.

I don't understand the rationale behind this. Both your Total T and Free T, along with SHBG were fine. 3,000 mg/week of HCG is pretty high and can't see a good reason for this. Possibly could result in leydig cell desensitization, but I'm not sure the threshold. But I do know that about 750 mg/week keeps the testes functioning during a standard TRT protocol, so take that for what it's worth.

2 mg adex/week is really high. Your doc is using the wrong estrogen test to make this determination. You want E2 (Estradiol) not total estrogens. E2 competes with T for receptors, not the other estrogens.

This is codeword for "I don't know what's happening and my expertise is not thorough enough to actually help you.

Poor lipids are likely a result of low cortisol--your body senses this and coaxes the liver to produce more cholesterol to (ideally) be synthesized into hormones. Your body is not taking the building blocks to build the house.

No idea about CRP, but no surprise your cardio is bad given your poor hormone levels.

You left out the number, but I wouldn't be surprised if it was low.

Good

Again, right church wrong pew. 7 for total estrogens doesn't make a bit of sense. Ideal E2 (not total estrogens) is in range of 20-30.


You have some work ahead of you.


#3

Sorry, having trouble with the quotes.

First, thank you very much for the detailed response.
He's a huge Christian, so great analogy. He was referred to me by the local compound pharmacy. Recently converted GP to hormonal/anti-aging practice. I really like him and his staff a lot better than my previous doctor, so what to try and make this work.


I've suffered from MAJOR anxiety all my life. I feel like my body is always in the flight/fight response mode. Do you think this could be the result of years and years of putting my body through this? I'm just curious if preg/prog/dhea supplementation would get me back to a "normal" state, but if the anxiety still exists put me back or with the supps keep that from happening?
Do you use Life-Flo? I researched their site and always thought you needed scripts for that stuff. Have you had success with their products?


The doctor was ok with Total T, but not Free T. He felt it was too high and being converted into estrogen, which in his opinion was way high. He likes it around 7 and mine was 111.. His reason for going to HCG was to see if my body would restart itself with everything else he was doing. He didn't test E2 or SHBG. I wrote SHBG in on the script, but the E2 slipped past me. Not sure if he's connecting the dots with those 2 yet.

Over my head, but interesting and will have to research this more. Lipids have been like this for a long, long time and hope by correcting cortisol levels it will balance everything out.

No idea about CRP, but no surprise your cardio is bad given your poor hormone levels.[/quote]

T3, Free is 3.7 pg/mL (2.3-4.2). Is he running all the right tests to properly diagnose my thyroid?

111 is the total, he wants to see 7. I have contacted his office and got E2 put in the next script. Only problem is, if he does not know how to interpret it, he'll just look at it cross-eyed. Same with SHBG.


I know man. I hope I'm in the right hands to get this done. It's hard to get out of bed sometimes, you know? My previous doctor looked at all of my numbers and told me the reason everything was out of whack was because my test was below the low range and bringing that up would fix everything else. You seem to think it's more cortisol related and hope that's the case because I really think getting on T made me worse.

Thanks again for all your time in looking at me labs.

And miles to go before I sleep, And miles to go before I sleep......


#4

When was your blood drawn in relation to your last dose of T? Right after injection, or 3 days after...it makes a difference.

I am rather amazed your doctor knew you had low DHEA, and prescribed a supplement, without actually testing it. It might be worth it to test DHEA-S, only because if your DHEA is fine with cortisol being low, than pregnenolone/progesterone might not be the problem and it may makre more sense to supplement cortisol directly. Cortisol is definitely your problem, the question is which link in the chain is broken.

Additionally, something you can do yourself in the meantime to determine the likelihood of a thyroid problem on top of your adrenals: By a cheapass digital thermometer and take your temps at waking, and at 3/6/9 hours after waking. Look at the average daily waking temp... and then average the three other measurements to determine your average daily temp (seperately from the waking measurement). My guess is that your avg temps will vary widely from day to day, but a 7-day average will be below 98.6 daily and below 97.5 waking (which would indicate poor adrenal and poor thyroid function).


#5

I inject Sunday mornings and Wednesday nights. My blood was drawn Wednesday morning.

I think he's basing the low DHEA on the attached image, but never tested it directly?

I had read the stickys on the whole body temp/thyroid and plan to get a digital one today since I have the onld school kind.


#6

Wow, there are so many contradictions between that test (plus the notes at the bottom) and his prescription. The ratio is going low, not high. Clearly the body is not dumping everything to cortisol if your cortisol is low and your DHEA is in range. It is in fact doing the opposite of what he seems to think is going on. It seems impossible he'd be that wrong, so someone correct me if I'm off my rocker here.

If you want more info on temperature testing, a good resource is http://drrind.com/therapies/metabolic-temperature-graph - the only thing is he doesn't measure waking temps, which I would advise adding in addition to the 3/6/9 hour tests.


#7

I've found basal thermometers more useful than plain old digital. Women use it to determine their ovulation and what not for pregnancy reasons so they are very accurate with low variability (which is key)

Ill have more to say later when I'm on my CPU. I think you are misremembering your doctors goal for total estrogens (7=70? That would make more sense)


#8

If your body doesn't have the cortisol to support the demands that T will place on your body, you will see no improvement from exogenous T supplementation. If you have cortisol, thyroid and T problems, the order of fixing them is cortisol->thyroid->T. In other words, cortisol needs to be optimized to support the body's demands when you increase thyroid or T. And thyroid needs to be optimized to support your body's demands when you increase T.

Cliffs notes: Fix cortisol, then we will have a true reading on what the rest of your body is doing. Your will dump everything it can to try to get your cortisol up, as it is essential to living.


#9

So if this is correct, I would need to supplement cortisol directly?

I pulled my old labs on DHEA-S and I look to be in range. Unfortunately, my latest test that includes DHEA-S is about a year old.
340.9 ug/dL (88.9 - 427.0)
276.7 ug/dL (88.9 - 427.0)
361.0 ug/dL (120.0 - 520.0)


#10

He actually wrote 7 down on the labs to indicate where he wants that number to be. Again, I don't know how this relates to E2 since it's TOTAL.


#11

I've been off T for about a month and a half. This is per my doing. I was feeling so bad and out of control, I didn' know what else to do.

So.. Is it better to fix cortisol now while I'm off T then tweak it as needed? Or would it be better to put my body in the state it's going to be in (on T) then work on cortisol?


#12

Fortunately, the math is not hard here.

You have 3 types of Estrogen. E1, E2, E3. He wants E1 + E2 + E3 = 7

It is pretty well accepted that men do best with E2 = 22 (or 20-30)

So therefore, E1 + E2 = 7 - 20 = -13

Since it would be impossible for E1 or E2 to be negative, this is an impossible result. Therefore, your max E2 can be no greater than 7 (even assuming E1 and E2 are both zero). Ask a guy with E2 = 7 how he feels and he is probably going to tell you he has joint pain, no libido, and brain fog.

Either your doctor is absolutely clueless on estrogens in men (possible since his goal is for total estrogens and not E2) or he wrote down the number wrong. 70ish seems more likely for totals, but again, E1 and E3 don't have much bearing as far as I know, so concentrating on a group rather than just E2 only needlessly complicates things.

I would ask him what he is basing Total E = 7 on. Medical literature. Random trials. Patients anecdotal evidence.

His conclusion that you need DHEA support based on that graph and previous bloodwork is iffey, at best. Your DHEA-S results are in the upper half of the range, which is probably fine. Your Cortisol/DHEA Ratio is 3.5 whereas it needs to be 5-6 (according to the graph). Increasing DHEA will only lower the 3.5 ratio, not raise it to the 5-6 range, so that is essentially unexplainable....

Anxiety could certainly be a result of hormone issues. I've not used Life-Flo myself, but many people have had success with it while raising their preg/prog levels. Some people don't absorb well and have to take an oral (Microlipidized matrix I think).

If your Free T is too high, then you just lower your dose. Not rocket science we are dealing with here. To go off and change treatment methodolgy on this alone is asinine. It sounds like he may have other motives (to restart you) which I guess is ok if you are otherwise normal, but given the fact that your issues are with cortisol (which he does not seem to be noticing)...

If you like this doctor, great. But I think he is missing a lot of big bright easy corner pieces of the puzzle.


#13

Cortisol first, because there is a chance that once you fix cortisol, everything else will fall into place on its own.


#14

I like this doctor better than my previous one of 2 years, but I'm running out of time and patience. The only other doctor I know to turn to is the one that practices in the that city in Michigan(don't know if we can mention names here). My doctor can work with him over the phone for a large fee.


#15

Dr Crisler is a very good resource. I would maybe take the concerns that I myself raised that you feel are relevant up to your doctor and see his response. If unsatisfied with the answer, then you know what your other option is. Otherwise, stick with current.


#16

Perfect. Thank you


#17

Great advice. My wife and I went for a walk and I told her my concerns and we agreed that of all of my doctors I've tried this one would be the most open my questions and concerns w/o shutting me out.


#18

hrmm...I'm going to have to send you a PM on this one....


#19

I just got off the phone with one of the staff members at my current doctor's office. Adrenal fatiuge is without a doubt one of the more common things he treats. He does prescribe HC, Preg and sometimes Progesterone. The reason he did not treat me for adrenal fatigue is because he wanted to try the thyroid first. I'm assuming it's a phased approach where they try to treat one thing at a time instead of throwing the kitchen sink at you. Do you agree?

My only concern is, he's not having me do another cortisol saliva test so are there enough markers in a blood test to determine how my adrenals are? Or will he look at my lipids, thyroid, etc and if those numbers haven't improved after treating me with NP thyroid then he'll tackle adrenals?

Sorry for all the questions...... Still learning.


#20

I don't know why you would treat thyroid first since thyroid can't function without proper cortisol support, but it sounds like you may be on track now.

New bloodwork (and especially saliva) is always helpful and if you can get it, go for it. But if your actual bloodwork and symptoms haven't changed any, I can't really see a huge reason for this.