T Nation

My Case - Low T and Thyroid Problems

Greets all.

Name: Chris
Age: 46
Height: 5’9"
waist: 32 in.
Weight: 168 lbs.
body/facial hair: hair over most of body, very little on back and shoulders. Plenty of facial hair (which I shave regularly).
Fat: Most is carried in midriff. Total body fat last measured at 16-17%.

History:
I’ve been experiencing throat symptoms and psychological symptoms for a few years now. Throat: Choking sensation, a tightness/pain in throat that comes and goes. Feeling of something stuck in throat. Frequent need to clear throat. Difficulty swallowing food (I usually need to drink water at the same time as chewing). Hoarse voice. Psychological: occasional depression (despite being on Wellbutrin XL 450 mg/day). Low energy.

Sometimes mentally foggy, forgetful. In general often don’t feel “myself” – energetic, confident, social, mentally sharp and present. Repeated tests have shown low or below normal T levels. For thyroid, repeated blood tests have shown low or below normal levels for certain thyroid hormones (T3, TSH), and one test showed slightly above normal levels of thyroid antibodies (suggesting possibility of auto-immune system attacking thyroid, aka “Hashimoto’s disease”. But no doc has confirmed that I have Hashimoto’s).

The most recent doc I went to see is Dr. Raphael Kellman here in NYC. He did several blood panels. Started me on T cream (175 mg/ml, 1 ml/day) and anastrozole (0.5 mg, 3 times/week). So far, has said little about thyroid, but he upped my dosage of Liothyronine (from 10 mcg/day to 15 mcg/day). Tests showed that I have a genetic condition (which may or may not be related to either) – I have a MTHFR C677T mutation (heterozygous). This has to do with the body’s ability to convert folic acid into methylfolate. Dr. Kellman has loaded me with a number of supplements with regards to this, but my research indicates that C677T heterozygous is likely not a big deal:

“Experience demonstrates that those with 1 copy of the C677T MTHFR mutation do not need much methylfolate beyond what is found in the Optimal Multivitamin line. The MTHFR enzyme is working at nearly 70% or so effectiveness in heterozygous individuals, while in homozygous individuals, it is working at only 30% effectiveness.”

Prescriptions:
Bupropion XL (450 mg/day)
Liothyronine (15 mcg/day)
Anastrozole (1.5 mg/week)

Most recent lab results:

From Lipid Panel (I include thyroid and adrenal here):
Testosterone: 423.4 (ref range: 348 - 1197 ng/dl)
TSH: 0.47 (ref range: 0.5 - 6.0 ulU/ml)
Free T3: 2.52 (ref range: 2.0 - 4.9 pg/ml)
Free T4: 1.11 (0.75 - 1.54 ng/dl)
Cortisol: 12.8 (10.4 - 26.4 ug/dl)

From Free & Total Testosterone Tests:
Testosterone Total: 3.41 (ref range: 1.75 - 7.81 ng/mL for males 18 - 66 years)
Testosterone Free Calculated: 24 (ref range: 24.3% - 110.2% for males 20 - 50 years)
Sex Hormone Binding Glob: 50 (ref range: 13.3 - 89.5 nmol/L for males 20 - 50 years)

My diet is about 40% protein, 40% carb, 20% fat. I’m currently cutting, so I eat 1,500 calories per day plus whatever calories I burned off that day from exercise (which puts me on a 500 calorie/day deficit). For breakfast I typically have eggs, fruit, Isopure Zero Carb, almond milk, shredded wheat, and 2 tbsp of phophatidylcholine.

For lunch I typically have a sandwich (deli turkey on 100% whole wheat bread), salad (greens, tomatoes, carrots, celery, olive oil), Greek yogurt (Fage 0%) and banana, plus Isopure Zero Carb. For dinner, it varies. In general, I get my protein from salmon (wild), chicken or turkey (organic, no hormones or antibiotics), eggs, tofu, quinoa, nuts, and Isopure Zero Carb. I avoid cow dairy. I avoid breads other than 100% whole grain. I tend to avoid sugar and saturated fat.

My training is mostly with weights. I’ve been lifting regularly for about 6 months. I’m seeing a personal trainer for an hour every Friday. Previously I was working out only 1 or 2 times a week, but I’ve upped that to 4 or 5 times a week (starting 2 weeks ago). I try to do at least 30 minutes of cardio at least once per week, but aerobic exercise really irritates my throat after 20 minutes or so. My ultimate goal is to get down to 10% body fat, weighing 170-180 lbs.

Morning/evening wood: Used to be virtually nonexistent, especially in the morning. Since starting on the T cream, that’s changed - I now get morning erections more times than not. Nocturnal ones less frequently, but now and then.

Like many newcomers I suspect, I’ve had a hard time trying to find a doc qualified to handle my low T problem. I appreciate Dr. Kellman’s thorough set of lab tests, but I sense that TRT isn’t exactly his specialty, given the fact that just about everything I know about TRT I’ve gotten from my own research and not from him. He also prescribed me anastrozole without testing my e2 levels first, which leads me to question if he’s the right doc for me.

Fortunately, I saw an old post on this forum in which a member recommended three andrologists here in the NYC area, so I’m going to see one of them (Dr. Natan Bar-Chama) on the 27th.

As for finding a doc for my thyroid, so far that’s been even trickier. I’m almost positive my throat symptoms are from a thyroid that gets swollen and inflamed throughout the day, from some as yet unknown cause. But most endocrinologists, it seems, don’t want to bother dealing with thyroid conditions (other than thyroid cancer). That’s how I found Dr. Kellman - supposedly he does treat thyroid conditions, but so far he hasn’t has much to say about it. It could be something as simple as an iodine deficiency, but again, I had to find out about that possibility from my own research.

Ideally, I’d like to find a doc who can identify the underlying causes of my low T and of my thyroid condition, and determine if they’re at all interrelated.

Thyroid issues sometimes cause T to not be absorbed when using topical. I would suggest that you switch to sub-Q injections. 175mg/day is a very large amount for a topical, and hasn’t raised your T levels at all. I’ve seen some on half that dose with sub-optimal levels, who increased their dosage and their T actually went down. With injections you take the guesswork out. You know you’re getting it.

1.5mg anastrozole/week is a very large dose as well. We don’t have any E2 data for it, either.

If you haven’t read through all the stickies at the top, please do so. Lots of good info there.

I hope this bump gets someone more knowledgeable on the thyroid to give you some comments on that.

[quote]Kaynon311 wrote:
Thyroid issues sometimes cause T to not be absorbed when using topical. I would suggest that you switch to sub-Q injections. 175mg/day is a very large amount for a topical, and hasn’t raised your T levels at all. I’ve seen some on half that dose with sub-optimal levels, who increased their dosage and their T actually went down. With injections you take the guesswork out. You know you’re getting it.

1.5mg anastrozole/week is a very large dose as well. We don’t have any E2 data for it, either.

If you haven’t read through all the stickies at the top, please do so. Lots of good info there.

I hope this bump gets someone more knowledgeable on the thyroid to give you some comments on that.[/quote]

Yes, I’m insisting on shots next time I see the doc (I’m actually going to see a new doc, Dr. Natan Bar Chama, who was recommended on this forum by Bricknyce, but I have to wait until the 27th).

Yes, I’ve read several of the stickies, including the one on e2 – extremely informative and helpful. This Friday, I actually started to experience depression and felt very out of it, even after a good workout (which usually puts me in a great mood). I don’t know if it was the anastrozole, but I feel that’s the most likely culprit, so I’ve stopped taking it for now (until I see the doc again this week). Today (Monday) I feel a lot better. I do feel it was very irresponsible of my current doc to put me on anastrozole with no starting e2 data, so I’ve pretty much lost confidence in him. I’ve stopped taking most of his supplements, in fact, and stopped taking the liothyronine. I’m not taking any thyroid medication until I find someone who can clearly identify what the underlying problem is, be it Hashi’s or something else.

SO right now I’m just taking my antidepressant meds and the T-cream. As for the T-Cream - my lab stats above are from before I started TRT, so I don’t have any hard data on what it’s done for my T-levels so far, but it feels like it’s has some positive effect. Even so, you’re absolutely right - doing it with shots removes a number of unknowns. No need to worry about sweating, incomplete absorption, or transfer to other household members. I’m not sure why my last 2 docs haven’t been able to appreciate that.

One week later. An unpleasant week - bottomed out on Thursday moodwise, had a fairly constant headache. A “ginger ale in my skull” feeling that Tony Soprano described. Possibly due to quitting the liothyronine and/or anastrozole so suddenly.

Improved over the weekend, but still feeling mentally sluggish and foggy, down. I’m wondering if my e2 has shot up now that I’m no longer taking the anastrozole. Obviously I need to see where my T and e2 levels are at this moment, but I’m basically flying blind until the 27th, when I see Dr. Bar Chama. Unless I can find a lab that offers same- or next-day results, I’m considering taking a small dose (0.5 mg) of the anastrozole this week as a test to see what happens.

By the way, I was wondering if anyone can enlighten me on the relative strengths of T compound cream, the range of concentrations. The one I’m using is 175 mg/ml.

[quote]X99 wrote:
One week later. An unpleasant week - bottomed out on Thursday moodwise, had a fairly constant headache. A “ginger ale in my skull” feeling that Tony Soprano described. Possibly due to quitting the liothyronine and/or anastrozole so suddenly.

Improved over the weekend, but still feeling mentally sluggish and foggy, down. I’m wondering if my e2 has shot up now that I’m no longer taking the anastrozole. Obviously I need to see where my T and e2 levels are at this moment, but I’m basically flying blind until the 27th, when I see Dr. Bar Chama. Unless I can find a lab that offers same- or next-day results, I’m considering taking a small dose (0.5 mg) of the anastrozole this week as a test to see what happens.[/quote]

Did you quit cytomel and anastrozole around the same time? Why did you quit the cytomel?

[quote]X99 wrote:
By the way, I was wondering if anyone can enlighten me on the relative strengths of T compound cream, the range of concentrations. The one I’m using is 175 mg/ml.[/quote]

It can be compounded into many different concentrations at a compounding pharmacy. Brand names like androgel, fortesta, testim, axiron, etc are around 10-20mg/pump.

Generally speaking, the absorption rate for topicals is around 10%, UNLESS one has thyroid issues.

Please list the antibody tests…

Cortisol is low… What time were these labs taken.And did you fast.

If taken at 8 am and fasting you have a problem and you need to get a 4 point cortisol test cortisol is highest in the morning so the rest of the day u may be real low. all the endocrin systems work together as a unit. get to a homeopath and start healing your body!!

Recommend going to stop the thyroid madness and learning about the thyroid.

Has rt3 been tested?

What do you eat and Is stress an issue for you?

[quote]Kaynon311 wrote:
Did you quit cytomel and anastrozole around the same time? Why did you quit the cytomel?
[/quote]

I did quit them around the same time - I quit the Cytomel because I’d lost confidence that this doc knew what he was doing. My current doc agrees that I don’t need it.

[quote]iw84aces wrote:
Please list the antibody tests…

Cortisol is low… What time were these labs taken.And did you fast.

If taken at 8 am and fasting you have a problem and you need to get a 4 point cortisol test cortisol is highest in the morning so the rest of the day u may be real low. all the endocrin systems work together as a unit. get to a homeopath and start healing your body!!

Recommend going to stop the thyroid madness and learning about the thyroid.

Has rt3 been tested?

What do you eat and Is stress an issue for you?[/quote]

Antibody test – Thyroid Peroxidase (TPO) Ab – 14.3 (ref range: 0.0-5.5 iU/mL)
(This is above normal range, but doc it wasn’t that huge. He’s seen far higher)

Cortisol test - this was taken in a different set of tests. Taken in the afternoon around 3, didn’t fast.

None of the tests I’ve had done tested reverse t3.

My diet – I eat pretty healthy. Don’t eat out much; cook my own food. Mostly avoid red meat, sat fat, and sugar. Don’t drink alcohol very often. Certain veg/fruit I only eat organic. Typical breakfast might be egg whites, banana, almond milk, spoon size shredded wheat.
Typical lunch - whole wheat bread, deli turkey, salad (w/o dressing), greek yogurt, piece of fruit (orange, apple, banana).
Almonds or hazelnuts as a snack.
Dinner - Fish or chicken, vegetables, brown rice.

The only stress that’s an issue for me is the stress produced my as yet undiagnosed throat problems. I was fine until all of this began.

Update - Saw Dr. Natan Bar-Chama for the first time on Aug 27. Explained to him my current situation. He agreed that I didn’t need to be taking Liothyronine. He also agreed I shouldn’t be on anastrozole without my e2 being tested first. I explained to him that I wanted to be taking shots instead of using T compound cream, but was concerned about peaks and valleys between shots. I want a nice, steady T level. He suggested I get the pellet implants – said that a lot of his patients have been happy with it. We’ve initially scheduled Sept. 18 to get it done (the only question is, will insurance cover it? His office is going to talk to my insurance about it).

I got T test results from that visit today (taken in the afternoon, no fast. This is with me having used T compound cream since July 11):

Total T - 370.45 [170 - 780 NG/DL]
Free T - 7.2 [4.0 - 29.0 ng/dl]
Sex hormone Bind. Glob - 41.0 [13.0 - 89.0 nmol/l]
T bioavailable - 135.0 [77.0 - 357.0 ng/dl]
PSA, total - 0.26 [0.0 - 4.0 NG/DL]
Estradiol - <20

Being from different doctors, the 4 sets of blood tests use different units, so it’s difficult to compare previous tests to this one. But after doing some math, it doesn’t look like Total T or Free T have changed much since I started the T compound cream. I suspect it isn’t absorbing too well. Sweat is a fact of life during summer in NYC. Though it is absorbing some – ultrasound shows that the testes look slightly atrophied, which wouldn’t happen if it wasn’t absorbing at all.

On the thyroid front - seeing an endo later this month. Also a different one on Oct 31 who was highly recommended.

[quote]X99 wrote:
Throat: Choking sensation, a tightness/pain in throat that comes and goes. Feeling of something stuck in throat. Frequent need to clear throat. Difficulty swallowing food (I usually need to drink water at the same time as chewing). Hoarse voice.

X99 wrote:
Antibody test – Thyroid Peroxidase (TPO) Ab – 14.3 (ref range: 0.0-5.5 iU/mL)
(This is above normal range, but doc it wasn’t that huge. He’s seen far higher)
[/quote]

I believe this would point towards Hashi’s. See link below.

Yes, too much anastrozole, your dose was based on the assumption that you would absorb your high transdermal dose and you did not. This is one of the problem with transdermals. Suggest that you try the “standard” injection protocol here.

Free T3: 2.52 (ref range: 2.0 - 4.9 pg/ml)
Free T4: 1.11 (0.75 - 1.54 ng/dl)

  • suggest that your thyroid dose was not high enough, you need to be mid range on the above

Have you read the thyroid basics sticky?

[quote]KSman wrote:
Yes, too much anastrozole, your dose was based on the assumption that you would absorb your high transdermal dose and you did not. This is one of the problem with transdermals. Suggest that you try the “standard” injection protocol here.

Free T3: 2.52 (ref range: 2.0 - 4.9 pg/ml)
Free T4: 1.11 (0.75 - 1.54 ng/dl)

  • suggest that your thyroid dose was not high enough, you need to be mid range on the above

Have you read the thyroid basics sticky?[/quote]

I have, and thanks much for the info. I’m hoping that the endo I see soon will be amenable to getting rt3 tested and adrenals, in addition to TSH/T3/T4/Free T3/Free T4. And if not, I’ll ask my primary. I live in NY, so getting labs done w/o a doctor’s Rx is a little more complicated, but not insurmountable.

Regarding iodine - I’ve considered trying supplements as a test; I have been using non-iodized salt at home for quite some time. My one concern with that has been, if it solves the problem and I start taking it regularly, making sure I’m not gradually increasing my body’s iodine levels until one day there’s a toxic buildup. I’m researching this further, but I imagine that the body would make it apparent if levels started getting too high.

Looking over the tests again, I see that one of them did have my Reverse T3:
RT3 - 14.3 [ref: 9.0 - 27.0 ng/dl ]

So, figuring the ratios of my T3 and Free T3 to my RT3 I get:

T3 total/RT3 = 74 ng/dl / 14.3 ng/dl = 5.2. STTM says this ratio should be higher than 10.

FT3/RT3 = 2.52 pg/ml / 14.3 ng/dl = 17.6. STTM says this ratio should be higher than 20.

So according to STTM, I’m producing an excess of RT3 relative to T3 and FT3.

Also, took my temperature this morning - 96.5 deg.

Update - I bought a new digital thermometer and have started keeping a Rind temperature graph (http://www.drrind.com/therapies/metabolic-temperature-graph). I was tempted to get a professional grade ear thermometer for $64, but I think this one will do fine. So far, my average temp seems low, but stable.

One odd thing - I just got back from a half-hour run, took my temp just to see what it would be after exercise, and the reading was colder than when I got up this morning. That can’t be right. Must be it’s cooler under the tongue as a result of heavy breathing.

Want to see if I can get a 24-hour cortisol saliva test done before I see my doc again. Then when I see him again I’ll have those test results AND a couple weeks of temperature data.

That’s what I suggested, but my doc said he’s seen antibody counts much higher. A subsequent TPO test showed antibodies in the normal range (<33.4 IU/ml, with normal being anything <60IU/ml). Want to get a new TPO test done along with a Tgab test.

Okay current plan of attack is:

  1. See Dr. David Borenstein next Wed Sep. 18. Will discuss tests he did on our first visit. I’m telling him I want to approach finding the root problem this way:
    A. Rule out pituitary or hypothalamus problem, with either MRI or Insulin Tolerance Test (the latter of which sounds unpleasant, but valuable). I want to do this because my TSH has been low, but so has everything else. Research says that could indicate hypopituitarism.
    B. Assess state of adrenals with 24-hour Cortisol Saliva Test kit (which he has)
    C. Rule out Hashimotos with both PTO test and Tgab test, and fine needle aspiration if both of those tests indicate no Hashis
    D. Rule out iodine deficiency with Iodine Load Test.
    E. If appropriate, resume my previous dosage of T3.

  2. See Dr. Natan Bar-Chama on October 2 to have Testosterone pellets implanted. It’s unclear if insurance will cover this, and I have some concerns to discuss with him first (such as the possibility of responding poorly; I have no intention of spending the next 3 months feeling awful). Definitely want HCG to avoid gonadal atrophy. (After reading about HCG, I’m curious – why isn’t low T treated with HCG rather than TRT?)

Have had a dull ache in the testes, most likely from atrophy. Stuck in an undesirable situation at the moment – getting all of the negs and none of the positives. the T cream hasn’t increased my T any, yet it has caused some testicular atrophy and pain to go with it. In addition, it’s making it necessary to take precautions against exposure to my wife.

I’d just as soon stop using the cream altogether if it’s just leaving me at the same T levels as before, but I don’t need to experience a T crash, or have any idea how long it would take to recover from one. So I’m continuing to use it until Oct 2, when I get the pellets. I’ve started experimenting with rubbing the cream on the tops of my feet instead of my delts. Going to call Dr. B and see if he can Rx me some HCG in the meantime.

One question I’d like to throw out to anyone reading this - do you know of anyone who’s had a bad experience with the pellets? Though a negative reaction doesn’t seem likely, my concern is that however I react to them, I’ll be stuck with them for 3 months.

Just stay off the T and try and get the thyroid in order!!

See how you feel after you get that under control!!

You have hashi’s or graves I bet… Can u ask for a thyroid ultrasound?

Sorry I haven’t been on in a while, dealing with my own problems a lately…

Good luck man

Exhausted the past few days. Exhaustion seems to lift in the late afternoon/evening/night, and I’ve been craving sweets and caffeine – all symptoms of adrenal fatigue.
Also, my temp in the morning after waking up has consistently been low – 97.0 or 97.1 degrees.

Plus, another doc told me he saw extra heartbeats, an indicator of chronic stress. I’m under very little stress as far as lifestyle, but probably under chronic stress from whatever condition is affecting thyroid. Low libido, and full-on ED.

Saw Dr. David Borenstein today. Going to get another slew of tests done. I’ll post results as soon as I get them. He said for E2, you want it to be somewhere between 20 and 30; my last tests put me below 20. I’ve heard you want to be down at 13-20, and definitely no higher than 30. So, I need to get an exact number on that.

He prescribed me Nature-throid, and said I can start taking it – he didn’t think my adrenals are in such bad that shape they can’t handle it. Only problem is, I won’t see him again for 3 months – I’d like to get some interim testing done to see how well it’s working, and if I need a higher dose.