T Nation

Questions about Labs (After Reading the Stickies!)


#1

Hello! I have put in a lot of work to understand this topic, but I am left with a few questions that are causing some frustration. I’ll rattle off the basic stats and add questions to the end.

Complaints: Primarily brain fog, serious mental fatigue, lack of motivation, poor short-term memory and concentration, low or low-ish sex drive. Progressively worsening over the past 6 years.

Pre-TRT labs (03/13-04/14):
8am Total (300-1080 ng/dL) - 354, 340
Free (47-244 pg/mL) - 106, 101
2pm Total (300-1080 ng/dL) - 102
TSH (0.3-5.0 uIU/mL) - 1.204, 1.95
FT4 (0.8-1.8 ng/dL) - .97
Glucose (70-100 mg/dL) - 94, 88
Albumin (4.2-5.2 g/dL) - 4.5
Protein Total (6.7-8.4 g/dL) - 6.6, 7.2

Pre-TRT labs (05/10):
LH (1.5-9.3 mIU/mL) - 4.6
FSH (1.4-18.1 mIU/mL) - 6.3
E2 (10-40 pg/mL) - 25
SHBG (17-65 nmol/L) - 20.0
Prolactin (2.1-17.7 ng/mL) - 6.9

Post-TRT lab (05/23):
8am Total (300-1080 ng/dL) - 340

Protocol: 100mg test cyp weekly (injections on 05/10, 05/16, 05/23)

QUESTIONS:

  1. What are the implications of my SHBG level relative to E2?

  2. I see lots of information about high and low SHBG, but what is the threshold for good low-normal SHBG (more free T) and problematic low SHBG?

  3. It’s been 2.5 weeks since first injection, and I feel significantly MORE tired than I did before. Today is 3 days after my third injection, and my test level should be well above baseline, but I feel absolutely exhausted despite sleeping 10 hours last night.

  4. The total of 269 prior to third shot is obviously too low. Any suggestions on adjustment to protocol in light of test results on the whole?

Thanks so much to anyone who can help me out with this. I would see an endo, but the earliest appointment is in mid-October.

EDIT w/ additional information:

  • age: 32

  • height: 5’11"

  • waist: 36"

  • weight: 218

  • describe body and facial hair: Beard is very dense along jaw with thinner patches on cheeks and center of chin. Body hair is thick on arms and legs and moderate on torso, but the hair is very fine. I do have semi-bald patches on the backs of calves, but I assume that’s from wearing long pants every day. Hair online forehead hairline has rapidly thinned (not receded) in the past year, which has not happened to any other males in my family.

  • describe where you carry fat and how changed: Fat is heavily concentrated in torso, especially “spare tire” (but no pot belly), chest, and back. Fat is also disproportionately stored subcutaneously. Even when my body fat was low enough to see my abs, I still felt “flabby” to the touch. There hasn’t been a change to this distribution, but I’ve had a much harder time losing fat and an easier time gaining fat since about 6 years ago.

  • health conditions, symptoms [history]: Dx with adult ADHD in 2013. Dx with Restless Leg Syndrome in 2011. Father also dx with RLS and with low T at age 50 during routine screening after about 10 years of symptoms.

  • Rx and OTC drugs, any hair loss drugs or prostate drugs ever: Vyvanse 50mg. Mirapex .25mg.

  • describe diet: No appetite for breakfast due to Vyvanse, but I’ll sometimes eat a cup of Greek or Mexican yogurt. Amy’s frozen dinner for lunch at work. Dinner is usually 4-5 eggs with protein and salsa or a grilled sandwich with a half pound of shaved turkey/chicken, one slice of cheese, and some chips/crackers. On weekends I eat lots of street tacos, and overeat corn chips and salsa. I don’t drink anything with sugar, but I do drink a lot of Fresca and Crystal Light (trying to phase out the aspartame).

  • describe training: From 2007-2010 I lifted 3-4 days per week and did cardio 2-3 days per week. From 2012-2016 I lifted with a trainer for 30 min x3-4 days per week with 30 min cardio after lifting. Haven’t been to the gym in about a year due to recovering tennis elbow and lack of motivation.

  • testes ache, ever, with a fever?: No, with the exception of blue balls one time when I was 18. I get a fever 1-2 days every 2-3 years during flu season.

  • testes more generally: Definitely descended. Also on the small side and almost always “high and tight.”

  • sex drive/performance: This one is hard to explain. My sex drive is definitely intact, but it’s missing the part where I feel motivated to actually have sex. I never had a problem getting a functional erection, but sensation has definitely diminished. It also tends to lose rigidity and sensation in proportion to how vigorously it’s handled, which is frustrating. In other words, hard and fast is a boner-killer and vice versa. This has lessened somewhat with first few injections.

  • how have morning wood and nocturnal erections changed: Morning wood mostly disappeared but has reappeared since my second injection. I’m not sure what a nocturnal erection is.

  • get cold easily?: Yes, constantly. When I was in peak physical shape (165lb, 14% BF), cold was intolerable. My fingers and feet still get very cold, but this is a side-effect of Vyvanse.

  • dry skin, brittle nails?: Dry skin my entire life. No brittle nails as far as I’m aware.

  • use iodized salt?: Yes, and I am a lifelong over-salter. I also eat a LOT of eggs (18-24 per week).


#2

Please find the edit icon below your post and add lab ranges!

Endos are often poor choices. There is a sticky re finding a doc.

Your problem seems to be your testes. Doctor examined?

Inject twice a week.
Always do labs halfway between injections.

TT=269 after 7 days suggests that you are a T hypermetabolizer and typically 300mg/week is needed [$$$]. And the half-life is equally shortened, thus your results.

At your age, shrinking testes and risk of infertility needs to be part of your conversation and after you ?read? the stickies you do not mention this. AI most often needed too.

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.


#3

Hey KS, thanks for the reply. I made edits as requested. Reading the stickies and following them are very different things! =)

Also, I made an error with the 269 test result. That was a different reference range, but PCP tested that sample at two labs. The second result was 340 on the 300-1080 reference range.

A few follow-up answers:

  • Urologist examined testes. Size is smaller than average but not too small. They do hang high and tight, but I was told this is not a problem in itself. Prostate is normal. Urologist said he would also recommend TRT, but he couldn’t specifically diagnose why it was low in the first place or dropping so precipitously from morning to afternoon.

  • PCP is currently treating with TRT. She is admittedly not a specialist, so she starts with a treatment guideline. However, she is very open-minded about reviewing published research and making adjustments based on the data. We already had that discussion about the injection protocol since the guideline advises starting at 100mg every 2 weeks. PCP is an excellent, empathetic doctor, but she tends to be conservative with medications.

  • I also see a neuropsychologist due to the overlap in cognitive symptoms between ADHD and low T, and the impact that both have on my marriage. She is the best doctor I’ve ever seen, and she advocates for me with PCP when necessary. It was actually the neuropsych that first identified this problem and told PCP to run all the tests.

  • The point of seeing an Endo is to determine whether my symptoms are a cumulative effect of several low/low-normal results across the board, as opposed to having a single cause. There’s also the fact that I have not yet been diagnosed, but low T is rarely an isolated problem and is often a symptom. I’m not comfortable with the uncertainty. What are your thoughts on that?

  • Waking body temp is around 98, resting body temp is between 98.4 and 98.6.

  • I do not mention infertility because I’m married to a man. Shrinkage doesn’t bother either of us, as long as everything else works well. With that context, it’s worth noting that my comparisons (body, testes, erections, etc) are more informed than most.

Follow-up questions:

  1. If the problem was my testes, would we expect LH and FSH to be high? I thought that mid-range results on those would effectively rule out primary hypogonadism.

  2. I cannot find any science or non-forum sourcing for “T hypermetabolizers.” Additional information or scientific search terms would be very helpful.

  3. I understand many men need AI, but that is dependent on variables. My understanding is that my E2 level is fine, but an AI may be needed due to low SHBG and 25% body fat. It’s also my understanding that and AI isn’t automatically indicated since I am not on HCG. Please let me know if that’s not right.

Thanks so much for your time and effort!


#4

Update:

I just went in for my 4th shot and asked for a dosage increase. Nurse consulted with PCP, and PCP replied that she wanted to continue with 100mg/weekly for 3 more weeks. But she wasn’t seeing much improvement, so “testosterone injections might not be right for me.” I made an appointment for tomorrow morning to argue with her about that.

So this feels like a bit of a crisis. I need to go to my appointment tomorrow armed to the teeth with information, most of which I have at the ready. However, I have absolutely nothing about individual variation in testosterone metabolism, and I really need to have that information to show her in the morning.

Issues I’m planning to raise:

  1. You can’t judge levels by a pre-injection lab.
  2. Even if pre-injection level is no different from baseline, there are still benefits earlier in the week.
  3. Even if lab levels are bad, TRT still has the benefit of eliminating the huge circadian swing from 350 to sub-100.
  4. If she’s not happy with pre-injection total T level, she can lower trough with E3.5 protocol

#5

Target is E2=22pg/ml and you were 25 pre-TRT. So probably nothing fine about this at all.

You need high normal TT and FT all of the time. Inject twice a week and do labs halfway between injections. Looks like you got that.

If you are a T hypermetabolizer, you might need 300mg T per week to get where others are at 100mg.


#6

Do you know the scientific term for “T hypermetabolizer?” I cannot find any published information to confirm that this is a thing. I need to read up on that, because there’s a 0% chance that PCP will prescribe 3x the guideline dosage without seeing hard science.

Do you have a ballpark reference range for E2 symptoms? I thought my E2 was fine because it was the exact middle of the lab range (10-40).

Thanks again!

EDIT: I actually stumbled across the answer while reading about individualized symptom thresholds. The term I was looking for is “metabolic clearance rate.”


#7

Nothing published. But have seen this several times. When normal T dosing yields very low T lab results and guys feel like the labs suggest, T dose simply needs to be increased to get high normal T levels where guys respond well. When it comes to an individual, only that patients responses matter and science and stats about normal populations mean nothing when guidelines clearly do not apply.