T Nation

Please Help. High SHBG, Normal TT


#1

I have been lurking on this forum as well as others over the last couple of weeks to try to get answers to my situation. I have read through many of the stickies on this site, and have acquired a couple of books on TRT. In short, I have attempted to figure out how to handle my situation but have not found the answers I have been looking for. Sorry in advance for the long post, I just want to try to give a full picture of my situation.

Some background:
I am 41, 6'0 and 162#. Over the last 2-3 years I have noticed increasing tiredness, loss of libido, mental "fog", poor memory, general slight "grey" mood, and some ED. Last January, I went to see my primary care physician (Internal Medicine) to see if I could find an explanation. I suspected thyroid, vitamin D levels, or testosterone insufficiency. He ran a full panel for liver, thyroid, vit D, chemistry, and CBC. TT was found to be ~530, vit D levels on the lowest end of normal, all liver/thyroid/chemistry normal. Sorry for the lack of values, but nothing was out of the ordinary. He said testosterone wasn't the problem. I did start taking vitamin D supplements in addition to my MVI and fish oil in hopes that it would improve things. I also decided to "get off the sofa", since I hadn't found any real culprit. At the time, I had not started to experience any real ED, just a lack of morning wood. I had spent most of my 30s not getting any exercise at all, so I thought that being more active would probably solve the problems. I started running last spring, and have since completed many races of varying distances up to 1/2 marathons. Over the last year that I have been running, I haven't noticed any improvements in my symptoms....they actually worsened. I could never seem to get enough sleep, and was exhausted throughout the day and started using caffeine as a crutch ( Im not overtraining). I would take naps after work several days per week, and weekend naps were a regularity. My ED also got markedly worse, with a lot of "half staff" or worse. I have let all my hobbies fall by the wayside, and really just want to go home and stay home when given the opportunity. I would not call myself "depressed", but I don't have the zest for activities that I used to have.

Fast forward to January 2013:
After the increasing symptoms over the last year despite regular exercise and taking care of myself, I became determined to find the cause of my problem which I suspected was low T based on all of my symptoms. On a Monday I found a testosterone clinic a few minutes from my house, and in a spur of the moment decision decided to go in to get evaluated. After talking with the nurse staffing the clinic and explaining that I had not tested "low" a year earlier, he decided to draw a SHBG level as well as TT and PSA. He also went ahead and gave me 160mg Test Cyp in anticipation that that was the most likely problem (and wouldn't hurt). My results came back the next day as TT 691 (348-1197), SHBG 61.8 (16.5-55.9), Hgb 15.1, free T 10.1. In talking with the RN about the results, he said that the consulting physician for the clinic felt that in absence of any other problems that the high SHBG was likely genetic. It concerned me, so I made an appt for my yearly physical to try to eliminate other causes. ( I had a MRI of the brain last spring r/t headaches that was normal). Two days after the Test Cyp injection, I had my first morning wood in recent memory. This continued for the rest of the week, as my energy and libido also improved. Voila!

My second injection (160mg) was one week later the next Monday. Over the course of that second week, libido was still good, less frequent morning wood, and energy levels were lower. I wasn't taking naps, but did feel a lot more tired than the week prior. The next Monday for injection #3, I talked with the RN about the course of the previous week and he thought it might be related to E2 conversion. He sent me home with Anastrozole 1mg cut in half and instructed me to take half the tablet every 3 days if the tiredness continued/got worse or if I had any high E2 symptoms. On Wednesday, my nipples started "burning" continuously over the course of the day. I took the 0.5mg Anastrozole to see if it helped. By Thursday (this week), no more nipple problems and slightly? increased energy. By Friday, my energy levels were significantly better and I had awakened overnight twice with morning wood. Great, i'm thinking, now I have to take an ADDITIONAL drug to combat that problem. It's now Sunday, libido is low, energy not the best. I feel a bit like I'm going down the rabbit hole, so to speak. I have been very healthy my whole life, and don't really like to take medications.....looking at the side effects of AI therapy isn't comforting. I got my lab work back on Friday from my physical: thyroid panel and liver panel normal, TT 1029 (3 days post injection), all other labs in normal range, cholesterol 178.

So on to my questions:
Assuming my high SHBG is genetic and all other things are in check, is TRT my best option? I have always been slim and found it difficult to gain any significant muscle. I always ended up small/modest increases but more toned. Possibly this was related to low free T?

If my SHBG was related to high E2 from the start, what are the odds that I didn't have any obvious physical appearance symptoms?

They are going to draw an E2 level on Monday when I return for my next injection. I realize this will give my current level based on TRT so far including conversion, but I am concerned that I didn't know what my baseline was before TRT. I guess I will never know if E2 might have been my only problem? Should I have them discontinue TRT, restart my natual system with HCG and allow things to stabilize to get a full baseline endocrine profile?

If I have to continue TRT, I would love to avoid the use of an AI if possible. My body fat is under 10%. I have read of other individuals that have been able to get by without an AI by going to a more frequent dosing schedule of testosterone, E2d or E3d to avoid the peaks/troughs. I talked to a Urologist I work with that would be willing to let me self inject and follow my labs every 3 months. He does TRT, but is not a specialty for him. My goal is to figure out how to manage this myself in as physiologically a manner as possible, so I really want to get away from the weekly dose. I plan to use insulin syringes to minimize muscle damage from the more frequent injections.

I'm not sure how I feel about the addition of HCG. I had a vasectomy, so kids are not an option. I don't mind a little atrophy as long as it is not excessive. I am more concerned about an increase in aromatization leading to the necessity of Anastrozole. Is it absolutely necessary?

Any help would be appreciated, thanks in advance.

EDIT---
The reason I did not originally post lab results was that I did not actually have them in hand at the time. I had them faxed to me this afternoon:
2/7/13
Hgb 15.5 (12.9-16.5)
Hct 47.7 (36-51)
Plt 208 (131-435)
Wbc 5.3 (3.7-10.1)

Albumin 4.4 (3.5-5)
Alb/Globulin ratio 1.9 (1.0-2.1)
Alk phos 76 (40-150)
BUN 16.7 (8.4-25.7)
BUN/Cr ratio 16.5 (6-22)
Calcium 9.5 (8.2-10.8)
Cl 103 (95-113)
CO2 26 (22-31)
Cr 1.01 (0.72-1.25)
eGFR calculated 8 (>60 ml/min/1.73 msq)
Globulin 2.3 (2.2-3.9)
Glucose 77 (70-99)
Potassium 4.1 (3.5-5.3)
SGOT /AST 23 (5-41)
SGPT / ALT 26 (6-55)
Sodium 140 (136-145)
Total bili 1.062 (0.200-1.200) mg/dl)
Total protein 6.7 (6.4-8.3 g/dl)

Cholesterol 178 (50-199)
HDL 51 (>39)
LDL calculated 117 (0-130)
Triglycerides 51 (25-149)
VLDL 10.2 (0.0-40)
Chol / HDL ratio 3.5 (1-4.5)

Testosterone (total) 1064 (3 days post injection 160 mg Test Cyp)

Total PSA 0.9 (0.0-4.0)

TSH 0.34 (0.35-4.94 uIU/L) In January 2012 this was 1.214 (0.35-5.5)

25OH VIT D 35 (32-100) ----This result from Jan 2012, and is the latest I have


#2

Your testes also produce pregnenolone.

What side effects of AI? You cannot go by the side effects of women taking AI to get near E2=0. In those cases, the side effects are from the low E2 levels, not the AI itself. With TRT, the objective is modulation of E2, not elimination and the doses are very much smaller. With anastrozole, 1mg/week instead of 1mg/day.

E2 management can be mission critical.

Yes, your pre TRT labs were totally bogus. And injecting once a week has the problems that you have noted.


#3

KSman,
Thank you for the quick response. Yes, I have read here about pregnenolone production of the testes. I guess I’m concerned about the addition of even more components to the therapy…I guess I will adjust mentally over time. Going from being “healthy” to injecting 2 different items plus an oral med is a shock, so to speak. I was hoping to just be able to get away with testosterone alone.

With my baseline TT as 691, do you expect that it will drive up my TT levels by itself? I am wondering if it’s addition may allow me to reduce exogenous T dosing in the long term. I am also concerned about increased estrogen conversion from the HCG…which would be controlled by the AI…but I don’t want to create a cycle.

I only took the one dose of Anastrozole on Wednesday, and my thought was not to take it again until after my E2 levels are drawn Monday. Is that a valid course of action?

I am currently still going to the Testosterone clinic until I can get my charts transferred to the Urologist next week. Once I am seeing him, should I continue with the ~150 mg dosing per week (divided) until the 6 week point with labs? I see that normally 100 mg is the starting point, but I have received 3 injections so far as that dose. In this early stage, how often would you recommend labwork?

Thanks again!


#4

Getting T only creates major problems and doctors mostly have a narrow perspective and do that. The problems that guys have with that are really the reason that is forum exists. You have to stop wishing that things can be simple as that is making you learning resistant. You seem to be shifting in the right direction.

Read the stickies.

Please redo your opening post with [edit]

  • need numbers and ranges, not “were normal” we see many problems in “normal” results
  • put lab values in a list, not readable in paragraphs

#5

Actually one of the respected TRT doctors often referred to on these forums recommends injecting only once a week when SHBG is high, at least initially, probably because high T peaks tend to drive SHBG lower over time. This can take a few months.

To the OP, you cannot really judge the effectiveness of TRT after 2 weeks. Some of the effects kick in after 3 months, six months, even a year. A lot of people keep making changes based on day-to-day feelings and never have success because they don’t stick with a regime long enough.

Here is a good reference: If you look at the graph on the page, you will see that effects on morning erections take on average about 6 weeks to start, and improvements in erections can take up to 6 months, so your expectations at this point are premature. Effects on quality of life and mood take anything from 3 to 6 weeks to become detectable and improvements can take up to 30 weeks.

“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.”


#6

PSA on TRT can drop if E2 is managed and E:T drops.


#7

Please see original post above that was edited to include latest lab values. I hope I did not come off as resistant to learning…that was never my intention. I guess I explained my state of mind a little too much. I value highly any and all input from members of the forum…it is why I decided to post here in the first place. I have been really impressed with not only the knowledge I have seen, but also the helpful attitude towards posters. In short, I really appreciate everyone’s time.

As I stated above, I actually got my hands on my results this afternoon. Much to my surprise, my TSH level was markedly lower than last year…actually below the reference range. I do not exhibit any of the s/s of hyperthyroidism. I don’t know if this is a lab error, but I will be following up in the next couple of weeks with a thyroid panel to investigate further. I mentioned it today at my appointment for my weekly injection, and they said my 6 week blood work is in two weeks, and they would add a thyroid panel to it. Seems like a reasonable plan to me in case it is an error.

I guess the reason for all my second guessing the issue of TRT for me is that I want to make sure I am treating a root problem rather than the symptom of another problem. I am also one of those 'immediate gratification" people, which doesn’t help in a situation like this. I do realize that if I continue down this road that it involves long periods to achieve results, and 'tweaking" to achieve my personal optimum combination. While I’m not in love with the idea of injections for the rest of my life, it is something I will do to protect my health. I just wish I had gotten to this forum before my first injection so I could have gotten more compete lab work to set my mind at ease that this is the primary problem.


#8

Labs look good. Yes, low TSH is suggesting that you are going open loop.

Read the ‘thyroid basics’ sticky and come back with waking and mid afternoon body temperatures and history of iodine intake from iodized salt and vitamins that might contain iodine [150mcg typ].


#9

Body temp late this afternoon was 98.6, waking body temp is 97.6. To my surprise, our salt at home is non-iodized. After looking to see which foods supply iodine, I would say that I get most of my dietary iodine from milk (1-2 cups/day), eggs (2 eggs, at least 3 days per week), and turkey ( maybe 2 days per week). I eat other foods that contain iodine, but in smaller amounts. In addition, I take a MVI most days that has 150 mcg iodine.

I had a friend run a thyroid panel on me today, with results below. Unfortunately, free T3 was a “send-out” lab…so I couldn’t get that test. I realize that the free T3 is vital, but I will have to wait until my labs in 2 weeks to get that result. My TSH was in normal range this time, so I’m wondering if the other result might have been an error.

TSH 0.91 uIU/ml (0.34-5.6)
TT3 1.19 ng/ml (0.87-1.87)
TT4 6.42 ug/dl (6.09-12.33)
Free T4 1.07 ng/dl (0.58-1.64)


#10

I have been on my TRT for 6 weeks now, and just received my repeat lab work. I have been receiving 160mg Tcyp 1x/week at at clinic. I felt really good for the first 2-3 weeks of treatment, but worse since then with low libido and weak erections. Erectile strength is better some days than others, I’m sure due to peaks/troughs.

At one point about 3weeks in, had nipple burning and was advised to take my Anastrozole. I took 0.5mg on day 3 post injection, followed by another .5mg on the next injection day and .25mg 3 days after that. What resulted was a big problem with ED and loss of libido r/t low E2. The labwork below was 12 days after my last dose of AI.

TT 677 (348-1197)
E2 14.8 (7.6-42.6)
SHBG 50 (16.5-55.9)
Free T 11.5

I am still getting morning wood most days, but low quality. I realize that my E2 is low, and that will cause problems with ED, libido, etc. My TT and free T on injections are now roughly equivalent to what they were when I was producing my own (Total T down, but free T up slightly)…I do feel better, but not nearly as good as my first 2 weeks on TRT. My testes have shrunken / softened and ride high.

I have now found a physician to work with me and he is has prescribed the T/HCG/AI regimen. Since my natural T production was almost 700 to begin with, I’m not sure of how much my levels will now rise with the addition of HCG on top of TRT.

  1. Should I expect my natural production to go back to full pre-TRT levels (necessitating a tapering of my T dosing downwards dramatically as my production ramps up)? Over what time frame should I expect my natural production of T to top out and level off?

  2. Last night I picked up my prescriptions, and decided to do the following:
    I was at day 3 post weekly injection of 160mg Tcyp, so I decided to go ahead and inject 50mg T IM. In addition, I also did a SubQ injection of 250iu HCG. Where should I go from here?

  3. What are your thoughts on the low E2 in the lab work? My guess is that either I was not actually having E2 symptoms, or that I may be an over-responder. I am not inclined to add the AI right at this moment due to this, but to wait and see if problems develop…bad idea?


#11

Inject twice per week or EOD. This will level off T levels and then AI dose can be found that matches your T levels.

With weekly injections, your lab work is a snap shot of a moving target. Do not know what your lab data means.

So you stopped IA then did those labs? No evidence there that AI is needed.

T production from hCG depends on your testes.


#12

Hello,

Did you get anywhere like this? I am in a smilar boat. TRT helped somewhat for 1 week then felt worse in some areas.

I have tried so many things over the years. Now it seems whatever i do to my hormones it does not help much.

I think I have low GH. Have you ever had any head trauma?

Did you ever do a HGH test?

Thanks


#15

"SHBG is important but usually it is self-corrected by addressing more important problems - such as hypothyroidism, diabetes, chronic inflammatory illness - prior to testosterone replacement.

When it does become a significant problem is when it is too high - such as with high dose T3 treatment in cases of peripheral thyroid resistance. When SHBG is high, a normal 100 mg a week dose of testosterone cypionate can achieve blood levels past 1500 ng/mL. A concern at that level when coupled with high SHBG is that the lower free testosterone levels may become a significant factor in reducing the effects of testosterone. SHBG bound to testosterone does have signaling function on its own - what it does is unclear - but it is interesting to speculate that if the testosterone-bound SHBG signal is too high, perhaps it may inhibit libido." - Dr. Mariano

Increases SHBG:
Estrogens (particularly Estradiol)
Progesterone (by increasing Estrogen receptors)
Thyroid Hormone (particularly Hyperthyroidism)
Liver Disease
Anorexia, Starvation
Hypoglycemia (low insulin)

Reduces SHBG:
Insulin (and insulin resistance)
Testosterone
Growth Hormone
DHEA
Other Androgens
Obesity
Hypothyroidism
Excessive Cortisol (Cushing’s Syndrome or Disease)
Progestins (such as by blocking progesterone’s effects)


#17

I believe the issue is more complicated than hormones. Hormones are secondary to the problem. Something else is happening in the body.


#19

In my case I feel I have a local or systemic infection. Maybe both, infection in the tooth or systemic infection like lyme, qfever, ehrlichia,babesia or something.


#21

Not sure what that is suppose to mean.


#23

Because my platelets dropped to the bottom of the range when the problem started.


#25

Hi halppls,
I’m due to start TRT due to really high SHBG 90 and also over 100 on an afternoon test. I’ve had MRI of pituitary gland, a UT of liver etc, also had bloods taken along with an injection to see how my body reacted to something they injected me with, can’t remember what it was though. I’ve had numbers tests to figure out what’s caused my high SHBG, in not really happy with my Endo, he doesn’t seem very knowledgeable about test problems and it was my persistence that I eventually got any tests at all, my total testosterone was apparently normal (maybe for an older man it’s normal) 15 in morning and 11 in afternoon but with excessively high SHBG it resulted in very low free useable testosterone.
I was reading your post and was wondering of that’s the recommended way of taking the gel trt at I woukd have thought when you wake up in morning woukd have been better and then your levels would naturally dip towards the end of the day as it would be naturally. Just curious as I may be getting the gels myself over the 5 injections a year nebido (Aveed in USA)