T Nation

Lack of Confidence in my GP

New to the forum, but as it seems to be the most knowledgable on the net, thought I’d post for advise here. I was prescribed 200mg Test Cyp e10d and 40mg Simvastatin ed for my high chol, at the doctors office this afternoon, as a result of my labs. I can’t help but believe that my high cholesterol, high TSH, and low testosterone are all related, but doc didn’t seem to be concerned about that. No discussion of whether I am type 1 or 2. Basically just “take these pills and this T, and you’ll be good. We’ll take labs again in 25-30 days”. During those labs he intends to retest my total and free test, along with TSH and T4 to take a better look at the thyroid. I am home injecting, so I will be doing 100mg e5d instead of the 10 day prescribed, but lost with the rest of this. Any help is appreciated.

38-age
6’1"-height
38-waist
236-weight

Okay goatee, cannot grow a full beard, significant chest and back hair-describe body and facial hair

Have always had gyno and belly fat-describe where you carry fat and how changed
Weight up to 300lbs 6 years ago. Dieted and hit gym to get down to 209, but have been between 225-240 for the last two years. Low libido and fatigue since I was about 27. Began to get significant brain fog about 4 months ago, leading me to go to my GP and him to check T levels, among other things.-health conditions, symptoms [history]

No regular scrips, was prescribed Simvastatin at the same time as Test cyp-Rx and OTC drugs, any hair loss drugs or prostate drugs ever

Since deciding to lose the fat 6 years ago, my diet has been consistantly low carb/high protein, but I have cycled calories. Diet since then has never been more than 2400 cals/day, but has sometimes been 1500 cals/day for 90 days or more-describe diet [some create substantial damage with starvation diets]

Lift heavy weight / low reps 3 days/wk. Run 3+ miles twice/wk-describe training [some ruin there hormones by over training]

Never-testes ache, ever, with a fever?

Still get them sporadically, but not as strong as before-how have morning wood and nocturnal erections changed

lab results with ranges:
Cholesterol, Total 277mg/dL 100-199mg/dL
Triglycerides 222mg/dL 0-149mg/dL
HDL 49mg/dL >39mg/dL
VLDL 44mg/dL 5-40mg/dL
LDL 184mg/dL 0-99mg/dL
Test, Total, LC/MS 335.4ng/dL 348.0-1197.0ng/dL
Free Test (Direct) 5.2pg/mL 8.7-25.1pg/mL
TSH 5.420uIU/mL 0.450-4.500uIU/mL

Please read the ‘thyroid basics’ sticky

  • report oral waking and mid afternoon body temperatures
  • report your history of iodized salt and iodine in vitamins

Hypothyroidism causes:

  • low body temperatures
  • fat gain
  • inability to loose fat
  • low testosterone, not so much the other way around.

You T Rx is 20mg/day. Consider injecting 70mg twice a week. And that dose seems high!

Read the protocol for injections. If you end up with elevated E2, that will reduce your benefits and will create some resistance to fat loss.

Statin drugs reduce the activity of certain liver enzyme pathways. This reduces cholesterol production but also reduces CoQ10 production. CoQ10 is mission critical for Mitochondrial function. That reduces the metabolic activity in all of your cells and again, can reduce ability to burn fats and loose weight. There can be major effects on muscles and the heart. A weakened heart can create high blood pressure in the lungs with fluid leakage and a persistent cough, the mechanics of congestive heart failure.

TRT can reduce BP

Supplements:
fish oil caps for EFAs, also nuts or flax seed oil or ground flax seed
25m DHEA
high potency B complex multi vit and mineral that contains 150mcg [0.15mg] iodine
CoQ10 100mg in the form of ubiquinol
100mg vit C
natural source vit E
might need high dose iodine after we get more data from you
5000iu vit D, look for tiny oil based capsules

Do not take oils, oil based items or DHEA with high fiber foods, take with a meal that has fats or oils.

Steroid hormones are created from cholesterol. When sex hormone levels fall, the body can increase cholesterol production to compensate. And HRT can reduce cholesterol to some extent.

Your labs should have had LH/FSH or followed up with those. We have no idea if you are primary or secondary. After you start TRT, its too late to get that.

Thyroid tests:
TSH
fT3
fT4

T4 alone is not very useful as the amount that is free varies greatly from person to person from different degrees of thyroid binding globulin.

Is your thyroid enlarged, symmetric or lumpy? Does your neck appear thick around your larynx?

Thanks, KSman. I really appreciate the advise on supplements, as I take them now and was curious if/how I should modify them. No LH/FSH test done. How does that hinder me finding the proper treatment path, not knowing if I’m type1 or 2? I asked my GP for an Endo referral before I left the office, which he agreed to, so hopefully he’ll take a more specific look at my thyroid function. With my T dosage being high, should I push hard for an AI? I intend to ask him to include ft3 and ft4 in the lab panel I’m getting in 3 weeks, so at least I’ll have them for the Endo visit.

I’ll take and post temperatures tomorrow.

I have had periods of swelling and soreness around the larynx that was not a “sore throat”, but it lasts no more than a week or two and happens only 3 or 4 times a year. I have not had that experience for a month or two prior to the labs.

I take a popular wieghtlifting multivitamin (not sure if I can mention brand name but initials are ON). 5-10g of creatine mono, protein shakes, BCAA’s, L-Glutamine, along with pre and post workout supplement powders, but none are significant sources of iodine. We did use exclusively iodized salt until about 1-1/2 years ago. Now it’s either Kosher or Celtic Sea Salts, only.

Thanks again, bro. Having never been a medication guy, I’ve been worrying over all of this. And don’t get me wrong, my GP is FANTASTIC, just didn’t give me a lot of comfort with his knowledge level on TRT and thyroid function.

Read the sticky on Thyroid issues, so I guess my next step is iodine supplementation. Took mid-day temp yesterday of 97.7 degF and an early morning (as soon as I woke up and still in bed temp) this morning of 97.7degF. No change in temp during the day???

Waking up at 97.7 is good. Keep checking day time temperatures. Use oral thermometer when you have not been exercising, eating, drinking, been out in the cold or talking for a while.

Is your thyroid enlarged, symmetric or lumpy? Does your neck appear thick around your larynx?

Most who are studying these things think that your TSH is a very serious problem. We often see doctors ignoring situations like this. Your doc appears wants to see if TRT will correct TSH. If you start with iodine replenishment and TSH improves, doc might get confused or pissed off. You should ask doc why he did not ask about something as fundamental as iodine and state that you had no identifiable iodine intake other than trace amounts in food which is known to be inadequate.

Remember that if one has picked up a load of bromine compounds, iodine replenishment will kick those off of iodine storage sites and bromine in circulation can make you stink and/or feel sick until the bromines are excreted. Low iodine levels promotes bromine storage.

Any issues with muscle pains or cough? A CoQ10 deficiency can also show up as low energy and lethargy, many problems will do that. You might have compound effects. Statin drug was prescribed just a few days ago. With TRT often lowering cholesterol, your statin dose may end up needed to be reduced. Ideal total cholesterol is around 180, 160 and lower are associated with increased all-cause mortality. Drug reps have trained doctors to think that very low cholesterol levels are ideal. They are ideal for the drug rep. Study this and note how major hormone systems are based on cholesterol: http://en.wikipedia.org/wiki/Steroid_hormone

See this wiki: http://en.wikipedia.org/wiki/Statin#Available_forms
You are at twice the recommended starting dose.

TRT shuts down LH/FSH, so once you start TRT, you cannot get the pre-TRT data. Cruelly, we often see a doc make a guy quit TRT for a while to see where LH/FSH levels are. We can expect that one may not recover and LH/FSH can then be lower than pre-TRT. When this is done, guys feel really bad having what relief they had been experiencing removed.

It is promising that you doc is communicative and seems to want to inform. Hopefully the door swings both ways.

You do not have E2 data? Seems safe to assume that you were estrogen dominant with your build and BP issues.

No fasting glucose data?

BP and arterial disease [endothelial dysfunction]: You should be testing and tracking homocysteine which is specific to destructive inflammation in the arteries. And also test CRP for general inflammation. With your build and BP, might be time to track PSA is you are having any reduced urine flow.

Note that you will need hCG to maintain your tests and support pregnenolone production, see the steroid hormone wiki. Note that pregnenolone is made in the mitochondria and there is another CoQ10 link. http://en.wikipedia.org/wiki/Pregnenolone

Gyno: You need to manage E2 in the lower 20’s [pg/ml] and you need to have lab work for prolactin.

Nothing unusual about the size/shape of my thryroid. I’ll continue to monitor daily temps. No real issues with muscle pain (other than DOMS from lifting) and no persistent cough. Having read around the board, I was expecting the same thing wit my statin. I had read the wiki on statins when he prescribed it to me and was concerned about the dose as well. He told me he likes to have a higher initial dose then reduce to maintenance levels (kind of like creatine loading I guess). I read about a similar approach on http://www.drugs.com/dosage/simvastatin.html but even there the initial dose was 20mg.

Though I haven’t met a doctor without an ego yet, my GP doesn’t seem to let it show that much. Having not been tested for E2 levels, I’ve got a call into him to see if he’ll add it to the labs I’m getting done in a little over 2 weeks, along with adding ft3 to his already scheduled retest of TSH and ft4. We’ll see how truly open he is then.

Probably be good to go ahead and list the labs he has already scheduled for me in two weeks:
TSH
ft4
Prolactin
Antithyroid peroxidase antibodies
Tot Test
Free Test
Full Lipid Panel (Chol, Trig, HDLC, calc LDL, calc VLDL)
Hepatic Function (TBili, DBili, TP, Alb, ALKP, ALT, ADT)

I did have fasting glucose in the last panel, it was 72mg/dL with a range of 65-99mg/dL. Also, you referenced my BP being high several times. Sorry if I mis-typed that somewhere, but my BP is good at 112/78. Luckily for me, my BP has never been an issue, even when very obese. No signs of prostate issues (pressure, discomfort, urine flow).

Also, I’d like to take some study information with me when I talk to him about an AI and hCG. I looked around the boards but couldn’t find specific studies referenced. Does anyone have them?

Thanks again.

Studies?
Guys do better with E2 in the lower 20’s. To get there you need an AI.
Testes and scrotum shrinks without hCG, risk of fertility, loss of pregnenolone levels
TRT shuts down LH/FSH

New labs after three weeks of TRT:

         Reading         Range

TSH 6.26 uIU/ml .45 - 4.50
T4, Free 1.07 ng/dL .82 - 1.77
Chol, Tot 180 mg/dL 100 - 199
Trigl 170 mg/dL 0 - 149
HDL 51 mg/dL >39
VLDL 34 mg/dL 5 - 40
LDL 95 mg/dL 0-99
Test, Tot 1081.6 ng/dL 348.0 - 1197.0
Test, Free 30.8 pg/mL 8.7 - 25.1
Prolactin 17.6 mg/nL 4.0 - 15.2
Estradiol 41.7 pg/mL 7.6 - 42.6
TPO (Ab) <6 IU/mL 0 - 34

Just got my labs back today (signed up to get them electronically without an office visit). Labs were taken midway between my 10-day injection schedule, following my third injection. Test is higher than the 900 he was targeting. Simvastatin seems to have gotten my cholesterol in line. After seeing a high TSH on the initial lab, my GP ordered more thyroid tests. TSH was actually higher this time and Prolactin was high, but free T4 was normal and free T3 was not tested. Been referred to an Endo. Not sure what will happen with my thyroid, but considering my E is double the optimal, I’m going to push for an AI. If the Endo doesn’t prescribe, I’ll go back to my GP and request. He’s been pretty accomodating.

Instead of jumping on an AI directly, you should perhaps first try some combination of either reducing your T dose or injecting less more often (at least once a week if not more) or both. Both of these steps will reduce your E2. Unless you are unable to sustain sufficient T with good E2 levels, it is better to avoid AIs.

Resist the common temptation of wanting an AI because you want to take as much T as possible. More is not better. Many men do much better on lesser dosages.

Normal? "T4, Free 1.07 ng/dL .82 - 1.77 "

So everything is good in a 2:1 range?

fT4 should be near mid range, near 1.3, fT4=1.07 is a problem

What news re body temperatures and iodine?

Yes, E2 is high. Part of that is from injecting every 10 days and from T peaks.

Prolactin result requires consideration of an adinoma. But can be up for a while after sex or a cuddle response.

“Normal” was a bad choice. Was simply referring to it being listed as “within range”. Point taken…

I’ve tracked body temperatures on intermittent days both upon waking and mid-day. I’ve had a low of 97.2 (morning) and a high of 97.7 registered in both a couple of morning temps and every afternoon temp. I have switched back to normal table salt and refrained from sea salt.

seekonk: thanks for the advice. I self-inject, so I have purchased #29 5/8" insulin pins and will be following the dosing protocol in the sticky on this forum, with EOD subq injections to see how that impacts my levels of T and E2.

Will update after Endo visit. Thanks again for the help.

You cannot do IR with iodized salt alone. Treading water.