T Nation

Preparing to Talk to TRT-Resistant Doctors at Kaiser


#1

EDIT NOTE: As requested by responders, I’ve updated the test results below to include the reference ranges provided by LabCorp.

First post, but I’ve visited the site many times for research. I’m preparing to talk to my doctors at Kaiser Permanente (in Oakland, CA) about TRT. This won’t be the first time I’ve tried talking to them, and as you may know, Kaiser doctors are notoriously resistant to prescribing TRT. I’m hoping to get feedback on the results of independent blood work I’ve had done (see below), so I can go into the exam with a good idea of what questions to ask, what optimal treatment might look like, and what arguments to make if they refuse necessary treatment.

Some basic background:

  • 45 year old male
  • Have had all classic signs of Low-T for several years, especially complete lack of libido
  • Complicating matters is that I am on long-term daily opiates for a chronic pain condition. But my Low-T symptoms were still present when I took a break from opiates for almost two years. And since I may be on the painkillers my whole life, even if some of the Low-T symptoms are caused by this, they have to be treated.
  • In my mid-20’s I had some testicular trauma and chronic testicular pain for several years that was resistant to treatment. That pain mostly faded away, but I suspect it may have caused some long-term issues.
  • So, between the opiates and past trauma, I may have both primary and secondary hypogonadism at the same time.
  • Have never used any hormones for performance enhancement or bodybuilding.
  • I have a vasectomy, so don’t care about sperm count, but want to avoid any testicular shrinkage/atrophy, which could cause recurrence of testicular pain.

A couple of years ago, I managed to get Kaiser to test my Testosterone levels. Even just getting the tests was like pulling teeth, and the doctors (Primary and Endocrinologist) looked at me like I was asking them to test for midichlorians or demonic possession. They really act like it’s a ridiculous request. Well, after several tests, my Total Testosterone then was around 177-225. A lot of places would consider that low enough to start TRT, but Kaiser shrugged it off and wouldn’t even consider it.

Since then, my symptoms have gotten worse, and frankly, are putting my marriage in jeopardy. So, in order to be prepared before going back to Kaiser about this again, I recently ordered a range of blood tests from DiscountedLabs.com, completed through LabCorp. The results are pretty dramatic, and I’m hoping that not even Kaiser can argue with me about them. The new relevant results are:

  • Testosterone, Total, LC/MS: 66.9 ng/dL (LabCorp Range: 264-916)
  • Free Testosterone (Direct), LC/MS: 3.0 pg/mL (LabCorp Range: 6.8-21.5)
  • Prolactin: 29.2 ng/mL (LabCorp Range: 4.0-15.2)
  • LH: 1.2 mIU/mL (LabCorp Range: 1.7-8.6)
  • FSH: 2.8 mIU/mL (LabCorp Range: 1.5-12.4)
  • TSH: 3.0 uIU/mL (LabCorp Range: 0.450-4.500)
  • T3 (Triiodothyronine), Free, Serum: 4.2 pg/mL (LabCorp Range: 2.0-4.4)
  • Estradiol, Sensitive: 7.1 pg/mL (LabCorp Range: 8.0-35.0)
  • *SHGB, Serum: 12.1 nmol/L (LabCorp Range: 16.5-55.9)

So, obviously my T levels are now without question ridiculously low, and I’m hoping even Kaiser will recognize it. Even though finances are tight, I’m prepared to go through a clinic like Defy Medical and self-pay, but first I’d like to see if I can finally get what I need through my Kaiser coverage. I paid for these tests before going back to kaiser so that I can have something tangible and scientific to show them when they try to brush aside my symptoms again.

Based on these new results, are there specific treatment protocols or additional tests I should push for? What protocol would you want for yourselves for with these numbers? The super-high Prolactin and the low SHGB definitely stand out, and I’m not as sure how to interpret them. Is it strange that LH is low, while FSH is normal? Also, with low Estradiol, I wonder if it would actually be good to skip using an AI, at least in the beginning?

Also, do any of you currently receive TRT through Kaiser and have any advice? I’m afraid that even if they agree to TRT, all they’ll do is prescribe Androgel with no HCG or ability to carefully balance all my levels. Based on my research, I think I’d prefer frequent self-injection, but I don’t know if that’s even an option at Kaiser. (Another reason to avoid gels is that my wife is worried about transfer, as she is already dealing with her own hormonal issues and endometriosis.)

Thanks for any feedback or advice any of you can offer. I know this is a long post, but if you have tried getting TRT through Kaiser, you will understand that you need to be super prepared and educated first to have even a small chance of getting treated.


#2

Am I reading this wrong, 66.9 ng/dL? First you need to include lab ranges as every labs has different ranges, your numbers are useless without them. I’m with Kaiser and their endos I’m afraid are a little behind the times and my endo doesn’t have any clue what HCG is used for and even told me I would need to come off TRT is I was having problems getting the wife pregnant, their decades behind in their protocols.

Thankfully when I expressed I wasn’t interested in biweekly injection, my endo understood completely and explained to me why it usually fails people, started out on weekly injection and recently requested twice weekly injections and met zero resistance.

I was on TRT before I joined up with Kaiser and recently was taught how to self inject and they gave me 21 gauge syringes which I’m learning from others is completely unnecessary, 25-29 gauge is what experience endos prescribe. Opiates can not only decrease your testosterone levels but also destroy neurotransmitters over time, do you really want to degrade your cognitive function? Your insurance might reimburse you for labs if you went with Defy.


#3

I remember going to Kaiser and I got the “Your numbers are normal” bullshit. If I remember correctly, Kaiser is tied to numbers, meaning, if your numbers are low enough, they will treat it, (hopefully). Whatever you do, don’t expect that just because YOU did your homework, that your endo or PCP did theirs. You will probably be the SME in the room to be honest. To avoid gels definitely bring up the need to prevent transfer to kids and wife.

Also your TSH is high, there is plenty of info around the site regarding the need for iodine. I don’t know too much about that so ill let you search that on your own. Or KSman might come in here and set you straight.


#4

We need lab ranges, not low, normal, high…

Please directly edit your post above to add the Labcorp ranges.

Thyroid lab ranges are really insane. TSH=3.0 is a real problem and should be closer to 1.0. This may be a direct result of not using iodized salt and often that affects everyone in a household. Please check oral body temps as per below to further eval this issue.

Thyroid labs should be TSH, fT3, fT4 avoid T3, T4
Suspect that your fT3=4.2 has a midrange near 3.2 and that is where you would want to be.

With high fT3 and low body temperatures or elevated TSH and high fT3, we can suspect elevated rT3 blocking fT3 and stress and adrenal fatigue is suspected. Read the thyroid basics sticky.

SHBG is very low. Sometimes that is indicating diabetes.

You have some primary and secondary hypogonadism.

low FT causing low E2

Prolactin can be high from some meds. List everything please.

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

  • advice for new guys - need more info about you
  • things that damage your hormones
  • protocol for injections
  • finding a TRT doc

Evaluate your overall thyroid function by checking oral body temperatures as per the thyroid basics sticky. Thyroid hormone fT3 is what gets the job done and it regulates mitochondrial activity, the source of ATP which is the universal currency of cellular energy. This is part of the body’s temperature control loop. This can get messed up if you are iodine deficient. In many countries, you need to be using iodized salt. Other countries add iodine to dairy or bread.

KSman is simply a regular member on this site. Nothing more other than highly active.

I can be a bit abrupt in my replies and recommendations. I have a lot of ground to cover as this forum has become much more active in the last two years. I can’t follow threads that go deep over time. You need to respond to all of my points and requests as soon as possible before you fall off of my radar. The worse problems are guys who ignore issues re thyroid, body temperatures, history of iodized salt. Please do not piss people off saying that lab results are normal, we need lab number and ranges.

The value that you get out of this process and forum depends on your effort and performance. The bulk of your learning is reading/studying the suggested stickies.


#5

Thanks for the reply.

to clarify, my Total T is 66.9 ng/dl. The ranges used by LabCorp for these tests are:
Testosterone, Total: 264-916 ng/dl
Testosterone, Free: 6.8-21.5 pg/ml

And I understand the drawbacks of opiates, and that’s a whole other discussion. But it comes down to a compromise between side effects and quality of life. But, one thing I am looking forward to exploring is the effect of TRT on chronic pain. There are a couple of promising studies showing that TRT can help some men with chronic pain drastically reduce the amount of opiates needed. Normal testosterone levels may help with pain perception. (Though of course there’s a whole chicken-egg cycle of pain-meds-testosterone that can be difficult to parse out…)


#6

Thanks for the detailed response. I’m not at my regular computer right now, but when I get hime in a couple of hours, I’ll definitely update all the lab results with the ranges.

You’ve definitely given me a bunch of new issues to research. Thanks.


#7

I for one have heard of guys claiming pain is significantly reduced on TRT since it builds muscle and bone tissue and are able to reduce or eliminate medications completely. No need to post FT values with super low TT numbers, but I’m sure it would be interesting. If you don’t mind me asking how long have you been on opiates? I was on Klonopin for 28 years and doctors believe it was the cause of my low testosterone (119 ng/dL) and FT was near the bottom of the range.

I had more problems with my TT numbers the moment I started withdrawing and had muscle atrophy throughout my body. Forgot to mention with low SHBG like yours injecting once weekly won’t work, you need injections E3.5 or EOD to have TRT be effective since you’ll be dumping your FT quickly! That low estrogen is hell on your joints, my estrogen was even lower and I’m slowly recovering.

https://naturalbiohealth.com/2015/05/06/shbg-critical-to-your-health/


#8

The iodine comments are interesting, and not something I’d thought of before. And come to think of it, the past year or two we’ve been using ‘fancier’ sea salts and the like, without added iodine. So it’s very possible my levels are too low. I’ll correct that asap.

As far as adrenal fatigue: I don’t know a lot about it, but I’m hesitant to bring it up to Kaiser doctors at the same time as TRT. It’s going to be difficult enough to break through Kaiser’s reluctance to do modern TRT protocols. As far as adrenal fatigue, I’m guessing the party line at Kaiser is that it may not be a ‘real’ condition. I may need to pick my battles and wait till TRT is sorted before even mentioning adrenal fatigue to them.


#9

I don’t really have anything to offer except that I like you’re writing style…oh and yeah, when I was with Kaiser they didn’t even want to talk about TRT…one of my docs basically said straight out, “Yeah we don’t really do that here.”

I did get them to order a total and free testosterone test but they made me pay the full amount for the test and wouldn’t cover any of it.

At that point I said F these guys and just found a good TRT doc and paid cash. He also charged me much less since I was paying cash. Likely you will find the same. I am on a new insurance company now and as a matter of fact, just today I went and saw my new primary care doc for the very first time. I filled her in on my TRT regime and she sounds very ill-informed and conservative. She seems resistant to officially referring me to my TRT doc so that the insurance will cover it. She said, “If your testosterone is low, I can prescribe you testosterone and you don’t need to see that doctor…and you don’t need HCG so I won’t be recommending or paying for that.”

So typical for a general med doc thinking they KNOW BETTER THAN SPECIALISTS.

All that said, if it turns out they will not refer or otherwise cover my other doc, I will simply continue to pay cash. Because frankly it’s worth it.


#10

More on SHBG: Low E2 can lower SHBG, but lower T would increase it. Your level is low in any case and it would be helpful if you posted fasting glucose and/or A1C.


#11

KSman,

I haven’t had an A1C test, but on my metabolic panel after fasting the night before, I have the following result:

Glucose, Serum: 86 mg/dL (LabCorp range: 65-99)

I’ll follow-up with kaiser regarding any diabetes screening, but it seems that on this initial, basic test my glucose wasn’t too bad. But I do understand that some of the numbers you’re pointing out may be troublesome.

I should also clarify that I have no problems getting Kaiser to order tests or treatment for any standard conditions or screening for things like diabetes. It’s only regarding TRT treatment that Kaiser is extremely difficult. I do sincerely appreciate all the advice and suggestions, and I will follow-up with my doctors regarding the things you have mentioned. So, I’m definitely noting any suggestions for further testing, but I’m not necessarily asking for members of this board to put effort into trying to diagnose me over the internet.

I guess the primary question I have, based on my test results as a general/hypothetical guide, is: What kind of TRT protocol would be considered ‘optimal’ and most current for someone with these numbers? Would it be a full program of injectable T, with HCG and AI? Or would you hold off on an AI? If i’m only offered a topical gel and nothing else, should I take it, or is it worth just going out of pocket to Defy Medical?

Basically, given how reluctant Kaiser is to properly do TRT, I’m trying to be prepared to advocate for myself and push them to provide the best possible protocol. I’m still learning about this subject, and want to be sure that I know what questions to ask and what treatments to put effort into insisting upon. When I walk in the door at Kaiser, I want to be as prepared as possible to ask for the best TRT protocol for my situation.


#12

Glocose is fine. Some guys simply do have high or low SHBG that is not attributable to anything. There is a lot more info about you that is missing that can be very useful as you will see reading the stickies. Doing that reading will be the best thing that you can do now.


#13

I doubt you’ll have much of a problem getting TRT with numbers as low as yours, being covered has more to do with whether your insurance pays TRT under your plan.