T Nation

Need Help Interpreting Labs to Tweak TRT Protocol

Thanks in advance for any help any of you can provide. I’ve been on TRT for a few months. I just got my first labs done since I started. My doctor just had the nurse call me to let me know the highlights and to tell me he wants me to keep things steady for another few months before tweaking, but I think I need some tweaks now, so I’m looking for help to prepare for that conversation.

-Age: 39 years old
-height: 6’1"
-Waist: 38"
-weight: 238 (up about 10 lbs since starting TRT)
-Body and facial hair never really changed noticeably
-Fat tends to distribute everywhere but my arms pretty evenly
-Symptoms prior to TRT ran the gamut of the usual–low libido, low energy, weak erections, less frequent morning wood, difficulty recovering from workouts or building strength or muscle
-Not much history of meds. I took ADD meds for a few years but haven’t for at least 4 years. Zero alcohol consumption. Very high stress career.
-Diet generally consists of about 200 grams protein, good amount of fruits and veges, and variable amount of carb intake. I’d say it’s generally cleaner than most, but my success at staving off the sweet tooth varies.
-Training before and after TRT is weights 3x/week with occasional bike ride on off days. I gave up on training more frequently when I realized recovery wasn’t like it used to be.
-No noticeable aching of testes, perhaps occasional discomfort.
-morning wood much more pronounced since starting TRT

Looks like initial labs were done by Pathology Associates Medical Laboratories in Spokane WA, but second labs look like a company called Cleveland Heart Lab.

TT Initial: 378 ng/dL (range 332-896);
3 months in: 1188 (250-1100)
FT Initial: 7.9 (4.3-30.4)
3 months in: 28.52 (35-155)
E2 Initial: 20 pg/mL (range 0-40) Lab done by local hospital
3 months in: 42 (20-56) (by different lab than initial)
SHBG initial:
3 months in: 34.6 (no range given)
PSA initial: 0.21 ng/mL
3 months in: 0.203
Cholesterol initial: 174
3 months: 142
HDL initial: 39
3 months: 36
LDL 117
3 months: 93
Triglycerides initial: 90
3 months: 64
TSH initial: 2.47 (0.450-5.1)
3 months in: did not test

TRT Protocol consists of 200mg cyp 1x/week and 250iu HCG E3D. Doc said he’d add AI when E2 goes up enough, but despite it doubling, he said to continue as is for now. Based on what I’ve read here, I’ll cut the dose and begin injecting 2x/week. Should I go to EOD for HCG?

Improvement in symptoms was noticeable within a couple weeks of starting. Sex drive was improved, and erections much better. My bench and deadlift both went up by 50 lbs or so within a few months (and the starting points were less than impressive, so in percentage terms, 50 lbs was significant). Since then, I’ve developed some acne, and libido and erection quality has tapered off.

My primary question: do you think adding AI will improve libido, erections, and skin?

What else should I be considering?

I forgot to add my other big question–what could be the cause of my free T being so low? Seems I can’t expect to continue to see any benefits from treatment if that continues.

I think you messed up ranges for your free T. 28 in a range of 4-30.4 sounds more accurate with your TT than in a range of 35-155. Though the latter range is bogus. It’s basically 3.5-15.5 when converted to the former units.

Your free T looks fine as your SHBG is 30 or so. SHBG bound T is not bio available and your SHBG is not high.

The lab I use has FT range from 47-255. So labs vary a lot.

No doubt in my mind that your backslide is caused by your high E2. Needs to be near 22. You need an AI and should consider reducing T dose and pinning twice weekly. Hcg is ok if you don’t care about fertility.

As others said, I think your FT range is wrong. With your TT being that high and your SHBG being normal range, you would have more than adequate FT. 200mg/week is a high dose for TRT. Monitor your blood with a CBC too for hemocrit concerns. Your E2 is high-ish, but not grossly. I would talk to him about adding an AI too, its probably the right move but I don’t think your levels of E2 would cause issues. Just my two cents.

E2 effects everyone differently. I have pretty noticeable symptoms at much lower numbers than he has. I’d be miserable at his levels. The main reason I think it’s high E2 is that he was good and now not so much. If we agree his T is good, most common culprit is E2.

I’ll definitely go to twice weekly. Could E2 doubling explain why free T isn’t even in range now (not sure why different labs were used).

What might be a good starting dose of an AI to get E2 back to around 20?

You’re interpreting your FT wrong. Your ft is good. Get your e2 down. You can use 1mg a week in divided doses and do labs 4 weeks later to for potential dose changes.

I would encourage you to consider reducing your T dose. 200mg/week is a lot and probably will lead to hematocrit issues. I’m with the others, your FT is probably okay.

So I’d go with 75mg of T and 0.5mg of Adex twice weekly. The combo of a 25% reduction in T and Adex will bring down your E2 but you will have to retest in 4 weeks and make more adjustments.

FT is low. Range looks like Quest Diagnostics.

If you get E2 managed, you will feel hugely better.

No CBC lab work?
LH/FSH never tested? - which is criminal…
fasting glucose
AM cortisol - at 8am please

Please read these stickies found here: About the T Replacement Category

  • advice for new guys
  • things that damage your hormones
  • protocol for injections
  • finding a TRT doc

E2=40 and doc will not do anything… Idiot

Total cholesterol=142 is getting too low. <160 associated with increased all-cause mortality.

The ranges are stupid. You would be better closer to 1.0
Have you been using iodized salt and/or vitamins listing iodine+selenium to support thyroid function?

Thyroid hormone fT3 regulates body temperature by regulation of mitochondrial metabolic rates, which creates ATP, the universal currency of cellular energy. If thyroid function is low, body temps are lower and you loose energy and gain fat.

Check you oral body temperatures as per the thyroid basics sticky.

Do you get much sun exposure? Could need 5,000iu Vit-D3

Normal anastrozole responders need around 1mg anastrozole for every 100mg T cyp/eth. See the stickies.

Lab numbers one week after injecting are sort of useless as levels have crashed.

Tell doc that you want to modulate E2 to get near 22pg/ml.

How is ft low? Look at SHBG and total T!

Thank you all so much for the input.

Prior to TRT, other things were tested. Here are some KSman mentioned:

AST: 25 U/L (range 15-46)
ALT: 32 U/L (range 21-72)
fasting glucose: 86 mg/dL (65-99)

CBC test Before TRT/3 Months In. Also done by two different labs. Reference ranges provided where given, omitted when identical in the post-3 months test.

Hematocrit: 45.1% / 48.3% (42-52) UP 3.2%
White blood cells: 4.5 k/uL (3.8-11) / 5.7 (4-11)
Red blood cells: 5.12 m/uL (4.2-5.7) / 5.36 (3.8-5.2) HIGH
Hemoglobin: 15.6 g/dL (13.2-17.0) / 16.3 (14-18)
MCV 88 fL (80-100) / 90.1
MCH 30.4 pg (27-34) / 30.4
MCHC 34.6 g/dL (32-35.5) / 33.7%
RDW 13.5% (11-15.5) / 13.7%
Platelet Count 217 k/uL (150-400) / 201 (140-150)
Lymphocytes 33.7% / 27.3% (21-49%)
Monocytes 8.7% / 10.1% (0-9%) HIGH
Eosinophilis 2.0% / 2.6% (0-7%)
Absolute Neutrophils 2.5 k/uL (1.9-7.4) / 3.37 (1500-7800) Is that right? why such a different range? Same weird ranges for values that follow. Lab flagged them as low but the ranges seem absurd.
Absolute lymphocytes 1.5 k/uL (1.0-3.9) / 1.55 (850-3900)
Absolute Monocytes: not tested / 0.57 (200-950)
Absolute Eosinophils: not tested / 0.15 (15-500)
Absolute Basophilis: not tested / 0.02 (0-200)
Neutrophils %: 55.1 / 59.4% (48-73%)
Basophils % : not tested / 0.4% (0-2%)

Multivitamin does include 100 mcg selenium and 75 mcg iodine. Been taking 5,000iu Vit-D3 daily for quite a while (I live in the northwest and work indoors).

I don’t see cortisol, LH/FSH, or DHEA-S in either test.

Thanks again. I have an appointment for next week. Could E2 doubling, even if total isn’t super high, explain the low FT? I suppose if I’m sensitive to E2, that could explain why I’m a moody bitch right now and my mind is horribly fogged for the past few weeks? For the first couple of months, I felt like I was growing muscle and feeling more decisive and confident. For past few weeks, I can barely focus on a task. (Yes, I have ADD, but still, it’s been worse lately. I’d hoped TRT might help with that, because I’d read that some see better ability to focus when T is fixed.)

I really appreciate all of your input. Will re-read the stickies.

If you want to feel better, you need to take the high E2 seriously. Your level is not a little high. It’s way too high. I’m telling you that I feel like shit and lose all the positive effects of TRT at 35, so mid 40’s is bad. Get it under control and you’ll be back on track.

Initial FT was ~26% of top range
3 months in it was ~18% of top range

Some wild differences in the lab ranges. Was the second lab coded for a female?

Are your vitamins without any iron? Normal men should not take supplemental iron.

There’s obviously an error with ft ranges that OP has posted. You’re more intelligent than that. Total T being high and SHBG being normal indicates good FT. For clinical purposes, calculated free T is the best indicator regardless.

He said TT: 1188
SHBG :34

Low FT is not possible. Issue most likely with E2.

I got the actual labs. Apparently, some of the data got messed up when it was entered into whatever system the doctor’s office uses. According to the Cleveland Heart Lab, actual hormone profile was as follows:

E2: 42 (27-52)
TT: 1188 (249-836)
T Free: 28.52 (4.5-25)
T Free %: 2.4 (1.1-3.0)
SHBG: 34.6 (16.5-55.9)
Albumin: 4.5 (3.5-5.5)

Hematocrit was 48.3 on a range of 36.7-48.6. Should that concern me yet?

Doc started me on Anastrozole 1/2 pill 3x per week.

Question: how preferable is aromasin over anastrozole?

I of course welcome any other feedback as well. Thank you.

Your HCT will most likely become an issue over time if you continue at 200mg of T per week.

Glad you are addressing the high E2.

How much Adex to take depends on whether you plan to reduce T dose or not. Can’t really advise on amount of Adex without that info.

Yeah, most of us called that one. Actually for such a high dose, your numbers are not that high. I would probably talk to the doc about reducing it a bit. As Nash said, you don’t want your blood to turn to syrup.

I ended up stretching the dose from 200mg per week to 200mg every ten days (which I split to 100mg every 5 days)

HCG every other (or every third) day

Moved to Adex 1/2 pill every week after the 3x protocol dropped E2 to 10 or 12. Then I switched to Aromasin using the same 1/2 pill weekly protocol.

Recent labs had TT at over 1000 using the same lab’s scale that tops out below 900. E2 was in high 20s. I told the doc I’ve been feeling quite good, hematocrit hadn’t gone higher, etc…, so I’d prefer to stay on same T dose. He agreed and said to dose the Aromasin on same days as T dose. Change therefore is 1/2 pill every 5 days instead of every 7 days as before.

I filled a script for Aromasin and lost it, so I’ve been using Adex that I filled and never used when I switched from it to the other.

Fatigue has been crazy over the past 3-4 weeks since making that change. At the same time, work has been nuts, I haven’t been sleeping as much, and I haven’t worked out for 3 weeks. So, I know there are too many variables to know what the biggest factor in the fatigue is, but I suspect it’s the Adex.

How likely to you all think it is that going from every 7 to every 5 with only 1/2 pill (with E2 levels starting in high 20s) AND switching from Adex to Aromasin would cause a big enough drop in E2 for that to be the cause?

I’ll try to manage the schedule for more typical sleep and get back on a workout program to “control” those variables, but this isn’t my first busy patch, and the effects on energy levels aren’t usually so pronounced, so I’m interested to hear if others have had similar experiences.