T Nation

My Case: 37 Yrs Old

Hi folks,

This board has been a great resource to me and have spent a lot of time lurking reading posts. Thanks for the information. I have also spent many countless hours reading and reading to try and find answers as we all do. I have an endo that is willing to Rx but I dont think is really willing to go all the way to determine causes. So I thought I would put my case out here for everyone and see if there is any ideas. Thanks in advance.

37 years old
6’4" 255 lbs
23% body fat per bodymetrix scanner
never done AAS
Avid crossfitter/olympic lifter, life long athlete

About a year ago began to feel really run down and not like myself. Normal symptoms: fatigue, loss of libido, loss of sociability, isolation, depression, lack of erections, no morning or nocturnal erections, no spontaneous erections, decreased seminal volume (on the off chance I could force an erection), inability to lose fat, inability to gain muscle, poor recovery, etc.

First had T checked in May 2012:

Serum T: 487 (348-1197)
Free T: 58 (52-280)
Free T%: 1.2 (1.5-3.2)

Other related tests:
ALT: 55 (0-40)
AST: 133 (0-55)
Total Cholesterol: 206 (100-199)
LDL: 145 (0-99)
Glucose Serum 110 (65-99)

Doctor didn’t know what to make of it so we just kinda went along. Symptoms worsened. Work performance suffered. Social life has suffered. Almost a total shut in due to low energy except for my 6am work outs which I just willed myself to do. Progress in workouts very poor.

Got new doctor and after some pushback, got her to do the following tests among others on 12/18/12:

Glucose Serum: 99 (65-99)
BUN: 27 (6-20)
BUN/Creatinine: 23 (8-19)
AST: 40 (0-40)
ALT: 45 (0-44)
Total Cholesterol: 164 (100-199)
LDL: 101 (0-99)

TSH: 4.760 (.45-4.5)
T4 Free: 1.42 (.82-1.77)

Vit D: 53.2 (30-100)

Angry she didn’t order T or E2 or anything else like I asked, I talked to her boss and then had the following done 1/15/13:

TSH: 3.6 (.45-4.5)
Estradiol: 23.9 (7.6-42.6)
FSH: 2.6 (1.5-12.4)
LH: 4.6 (1.7-8.6)
Prolactin: 3.0 (4.0-15.2)

CBG: 3.0 (1.7-3.1)
Free Cortisol: .38 (.2-1.8)

Test Serum: 233.4 (348-1197)
Test % Free: 15.9 (9.0-46)
Test F+W Bound: 37.1 (40-250)
SHBG: 23.2 (16.5-55.9)

Obviously test levels have continued to worsen and make sense with worsening symptoms. Notable here to me were the low/normal FSH LH with low Test. TSH continues to indicate subclinical hypothyroidism. And then the low prolactin.

Got referral to Endo. More tests:

2/8/13

Test Serum: 356 (348-1197)
Free Test: 8.4 pg/ml (8.7-25.1)
SHBG: 24.4 (16.5-55.9)

2/10/13

Test Serum: 297 (348-1197)
Free Test: 9.3 (8.7-25.1)

T4 Free: 1.49 (.82-1.77)
TSH: 3.1 (.45-4.5)
Prolactin: 8.8 (4.0- 15.2)
TPO: 26 (0-34)
Antithyroglobulin: <20 (0-40)
Triiodothyronine Free: 3.3 (2.0-4.4)
SHGB: 21.6 (16.5-55.9)

At this point doctor said that I could/should start a weight loss program. Which I already had been doing. Two months of caloric deficit and HIIT with no progress on scale weight or body fat%. So he said then that next step would be to begin treatment.

So he said Test Cyp at 100mg/ week. .5ML of a 200/ml IM injection on Tuesdays.

Scheduled an MRI for tumors in 12 days.

He gave me a shot right there in the office.

Now, I was a little surprised/excited that I was finally getting some answers and getting somewhere so I took the shot and was feeling good about it (not from the shot).

But then I read more and more and more and more and realized that I still don’t know what the cause is and that there are still more questions to be answers, is it time for treatment already?

For example:

What is the actual diagnosis? Why is my LH/FSH low/normal while Test is so low? From what I have read, low test should be accompanied by high LH/FSH. Or in this case do I really have hypogonadotropic hypogonadism?

And if there is no tumor, do I really have idiopathic adult onset hypogonadotropic hypogonadism which is apparently an exceptionally rare genetic disorder?

What about my TSH? He said we could start treating that too but with beginning two treatments at once it is hard to determine what is working or not. I agreed.

What about low prolactin?

He also wants me to get re-tested 36 hours AFTER last injection which to me would be measuring a peak level not a trough level. Thoughts on that? He said target range was 700-900.

I don’t have much more than questions at this point and am also just kind of venting. Thank you for all the information I have found in these forums and thank you for your feedback in advance.

DC1000

-37 years old
-6’4"
-will re-measure waist tonight, but wear a 38-42 in pants
-255
-hairy, beard. but beard growth has slowed notably
-carry fat in belly, love handles, chest.
-history of autoimmune conditions including pericarditis, optic neuritis, arthritis
-no other Rx drugs. supplements: protein, creatine, fish oil, vitamin D, ZMA, taurine/potassium. history of adderall use/abuse. was Rx’ed 40MG/day for years and at times abused. nothing for more than 3 years.
-strict paleo diet currently 2100kcal/day.
-olympic lifting 2-3 times per week. HIIT/crossfit 2-3 times per week.
-no teste ache
-rare morning wood or nocturnal erections

Do not understand cortisol labs…

Read the thyroid basics sticky and come back with body temps and iodine intake.

E2 is not high, but low T makes you quite estrogen dominant.

Your state is not surprising given your weight and waist.

What is your blood pressure [BP]?

Secondary hypo is low T and lower LH/FSH.

Body temp has always been normal 98-98.6. I consciously eat iodized table salt. salt with every meal. We cook 90% of meals at home.

I will re-check body temp today though.

blood pressure has always been great 115-120/60-60. though my last reading last week at the endos had 140/80. which really surprised me, just attributed it to being nervous for lab results. bp has been consisten for years. resting heart rate 60 bpm.

Need waking and mid afternoon body temps

afternoon temp was 98.6

Your TSH is an issue.
Doesn’t sound like iodine deficiency, antibodies are ok, and your temps aren’t low.

There could be something secreting TSH form the pituitary gland which the MRI could show.
Or something secreting from the thyroid which an ultrasound could reveal.

Additional test I’d suggest.

Lupus panel
HBA1C
Insulin

Your blood sugar tends to be high normal. You could be prediabetic or on the way.
Maybe a paleo diet could help.

morning temp was 97.0

will redo afternoon today

[quote]Tunapancake wrote:
Your TSH is an issue.
Doesn’t sound like iodine deficiency, antibodies are ok, and your temps aren’t low.

There could be something secreting TSH form the pituitary gland which the MRI could show.
Or something secreting from the thyroid which an ultrasound could reveal.

Additional test I’d suggest.

Lupus panel
HBA1C
Insulin

Your blood sugar tends to be high normal. You could be prediabetic or on the way.
Maybe a paleo diet could help.[/quote]

oddly, i was in ketosis at the time of the test that had me 100+ glucose. i went from ketogenic to normal paleo since then, strict. only carbs from fruits and veggies.

The basic temperature test for thyroid function was originally waking temperature only. I added mid afternoon temperatures as an additional data point. One can have a low waking temperature. PM temperature then shows how one recovers to day time temperatures.

It is good to have the 98.6 data point as a normal reference.

Get more waking temperatures.

97.6 at 4pm today

Pardon me if this has been asked/answered elsewhere but:

Doctor wants me to get tested 36 hours after last injection of 100mg test cyp. which says he wants a peak reading.

i’ve read that trough readings are better?

he told me target range would be 700-900 for total test

if i get a peak reading of 900 how much different would that be than a 900 trough reading?

It is good to have a peak AND a trough reading, because different people metabolize depo-testosterone at different rates.

If you are the average man, your levels will fall to about half the peak roughly 8 days after the peak, but there is a lot a variability. So if your peal is 900 AND you are average, you should still be around 500 at the time of your next injection, which is still good.

100 mg per week is pretty much the standard dosing at which most men would feel pretty good. First give it some time to see how you feel at the current dose and then maybe later you can ask him for a trough level test as well. But don’t expect an immediate miracle: Here is how long you can expect to wait for different effects:

"Effects on sexual interest appear after 3 weeks plateauing at 6 weeks, with no further increments expected beyond. Changes in erections/ejaculations may require up to 6 months. Effects on quality of life manifest within 3-4 weeks, but maximum benefits take longer. Effects on depressive mood become detectable after 3-6 weeks with a maximum after 18-30 weeks. Effects on erythropoiesis are evident at 3 months, peaking at 9-12 months.

Prostate-specific antigen and volume rise, marginally, plateauing at 12 months; further increase should be related to aging rather than therapy. Effects on lipids appear after 4 weeks, maximal after 6-12 months. Insulin sensitivity may improve within few days, but effects on glycemic control become evident only after 3-12 months.

Changes in fat mass, lean body mass, and muscle strength occur within 12-16 weeks, stabilize at 6-12 months, but can marginally continue over years. Effects on inflammation occur within 3-12 weeks. Effects on bone are detectable already after 6 months while continuing at least for 3 years."

If one injects frequently, there are no peaks or troughs, then those issues are gone. Focusing on peaks and troughs is really measuring the negative aspects of a flawed delivery system, should focus on things that are obviously more important.

[quote]KSman wrote:
If one injects frequently, there are no peaks or troughs, then those issues are gone. Focusing on peaks and troughs is really measuring the negative aspects of a flawed delivery system, should focus on things that are obviously more important. [/quote]

i appreciate that notion and will definitely bring it up with the endo. I may even just start splitting the 100mg does into two.

nevertheless, is there a general consensus on peak vs trough and what the decline between the two may be?

Depends on how fast one metabolizes T and clears T+SHBG which depends on liver health/function. Focus on TT can be misguided in some situations.

[quote]KSman wrote:
Depends on how fast one metabolizes T and clears T+SHBG which depends on liver health/function. Focus on TT can be misguided in some situations. [/quote]

so i have been rx’ed 100 mg test cyp weekly to be done one shot .5 ml.

i have my shot on sunday.

bloodtest on tuesday 8am.

doctor said he wants me to have bloodwork 36 hours after last shot.

that means last shot 8pm sunday night.

clearly, this means i will be going in at a peak level.

what should I tell him about this? should I object to the reading? should I object to the protocol? should I object to the timing of the bloodwork?

should I do something before hand to mitigate/prevent results that might skew things unfavorably for me?

thanks

Update:

After 5 or 6 weeks of 100mg Test Cyp/week, I got my latest labs.

Total T was 950
and free T was something just slightly over normal.

Doctor will be uploading the results into their online system for me today to get exact details.

I asked him about HCG and he said sure thing, but we would have to reduce Cyp to 50mg/week because we dont want to “blow the roof off.”

I am reluctant to mess with what is a good thing. I am feeling much, much better these days.

I have a question:

Is there any chance that I am still producing natural T? I.e. is there any chance that my 950 number is a combination of natural T and test cyp that will perhaps decline as my natural T production ceases?

Or said another way - how long until before and to what degree to the testes shut down all normal t production, as little as it was, it was something.

Another data point:

IGF-1: 316 ng/ml (range: 69-226)

Any ideas?

and finally, I had my MRI which revealed a “possibility” of a “tiny” micro adenoma.

doc thinks that is just Radiologist CYA talk, so nothing there