T Nation

Secondary Hypogonadism Treatment?

Im 38 years old and have had libido and ED problems my entire life. I’ve had a gut, man boobs, and fatigue since I can remember. It has gotten much worse in the last few years as I started have bouts of severe depression, and anxiety. I have been on psych meds for about 5 years now and they help but I want to treat the source of the problem. Ive been seeing an endocrinologist for a few months and have been on T therapy since. Unfortunately, none of my issues have changed at all. My doc wants to do more lab work but I’d like to understand this better.
Thyroid labs [basic first line]
TSH - LC 1.990 uIU/mL 0.450 - 4.500 uIU/mL
T4,Free(Direct) - LC 0.73 ng/dL 0.82 - 1.77 ng/dL
-are you getting enough iodine? Started supplementing yesterday
Adrenal labs
-Cortisol - 10AM - LC4.5 ug/dL 6.2 - 19.4 ug/dL and Cortisol 5PM- LC 7.8 ug/dL 6.2 - 19.4 ug/dL (I work nights)

General health labs
WBC - LC|5.9 x10E3/uL|3.4 - 10.8 x10E3/uL|
RBC - LC|5.97 x10E6/uL|4.14 - 5.80 x10E6/uL|
Hemoglobin - LC|16.7 g/dL|13.0 - 17.7 g/dL|
Hematocrit - LC|50.2 %|37.5 - 51.0 %|
MCV - LC|84 fL|79 - 97 fL|
MCH - LC|28.0 pg|26.6 - 33.0 pg|
MCHC - LC|33.3 g/dL|31.5 - 35.7 g/dL|
RDW - LC|13.9 %|12.3 - 15.4 %|
Platelets - LC|238 x10E3/uL|150 - 379 x10E3/uL|
Prolactin - LC 13.2 ng/mL 4.0 - 15.2 ng/mL
-Lipids: Fasting Cholesterol and related
Estradiol - LC 13.9 pg/mL 7.6 - 42.6 pg/mL
TSH - LC 1.990 uIU/mL 0.450 - 4.500 uIU/mL

Testosterone, Serum - LC|310 ng/dL|264 - 916 ng/dL (b4 treatment)
Free Testosterone (Direct) - LC|5.1 pg/mL|8.7 - 25.1 pg/mL (b4 treatment)
Testosterone, Serum - LC|643 ng/dL|264 - 916 ng/dL (After treatment)
Free Testosterone (Direct) - LC|11.9 pg/mL|8.7 - 25.1 pg/mL (After treatment)
Insulin-Like Growth Factor I - LC 214 ng/mL 83 - 233 ng/mL
ACTH, Plasma - LC 10.2 pg/mL 7.2 - 63.3 pg/mL
Prostate Specific Ag, Serum - LC 0.7 ng/mL 0.0 - 4.0 ng/mL
FSH - LC 3.5 mIU/mL 1.5 - 12.4 mIU/mL

Symptoms: ED, no morning wood, fatigue, moobs, belly fat, obesity, ADHD, anxiety, depression, smaller than normal testes (Per urologist), hot flashes (with sweating), patchy bald scalp
-Brain fog- my baseline
-Social withdrawal - I don’t go out at all anymore

-pituitary MRI- soon to be scheduled

I’m just trying to gather as much info as possible. Thank you for your time.

Your T4 is low, we don’t know your T3.
What’s your dose and what are you taking?
I’m guessing you are on a hefty dose of Anastozole, your E2 is too low. Your dose is also too low, your free T should be higher.
Any numbers for SHBG?
How many weeks in were the second labs?
What are you doing for exercise?
What does your diet look like?

Free t is bottom of the range

I’m taking 200mg T biweekly IM. I’m not taking any Anastozole.
The second labs are 4 months after the first.
I don’t have the energy to exercise like I want but I do 30 mins of cardio 4X a week.
I’m 5ft 9" and 230 lbs. The symptoms have always been with me but I think they’re getting worse as I age.

You have to get your free T way up before you are going to feel better

Please describe your TRT protocol, describe in mgs. Vials come in 100 or 200mg strengths.

Seems like your doctors is aiming for suboptimal Free T levels do to inexperience and being handcuffed by insurance companies. SHBG testing is the most important test for someone about to undertake TRT.

Men with high SHBG are basically screwed if using insurance based doctor because do to insurance guidelines are not allowed to let your Total T levels >800 which is exactly what’s needed since your SHBG is elevated and binding up most of your useable testosterone.

Total T is bound to SHBG and is not bioavailable, so having a high Total T and low Free T is no good, therefore a very high Total T is needed to increase Free T to the optimal ranges which is where you will start showing benefits on TRT. Estrogen is low because Free T is low, Free T is converted to ->estrogen.

Free T is the only portion of testosterone that matters and it is low. The experts state men with Free T <15.0 pg/mL are more than likely going to benefit from TRT, you’re still way under the threshold from benefiting from TRT.

Your Free T needs to be in the optimal ranges to truly show any benefit from TRT, 20-26 pg/mL and you may need to go seek out a private doctor since sick care doctors are handcuffed by insurance companies.

Thyroid testing is incomplete, no Free T3 or Reverse T3. Free T3 (not Free T4 or TSH) increases metabolism and optimal levels are needed for TRT to work. Free T4 is abnormally low which is a red flag if I’ve ever seen one and yet your doctor obviously didn’t investigate it.

Even if your doctor was educated and knew what the next move should be, he’s not his own mater as long as he is working is managed healthcare where in range is normal which ends all further discussions.

Lots of things matter in this equation, but low free T is an indication that your dose is too low. Do you lift weights? 30 mins of cardio 4x a week isn’t going to do a lot for you, honestly. And what’s the diet like?

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I take one 200mg vial every other week. I have more labwork (TSH,serial cortisol, T4, T3) scheduled. I’m taking your advice and adding SHBG. Should I add anything else?

It looks like I took an SHBG last november. It was 38.5 16.5-55.9 nmol/L.

There’s your problem, your doctor is an idiot. A study came out in 2005 men were injected with 200mg every 2 weeks and results were poor. Your Free T in the first week is probably close to optimal, but by the second week is low and this is why you see no benefit.

You’re basically experiencing low testosterone every other week, Free T levels need to be high normal 24/7 or no benefit. When my Total T is 500 ng/dL Free T is 21 pg/mL because my SHBG is on the lower end and binds less testosterone enabling higher Free T.

Your SHBG will be elevated since Total T is almost high normal and Free T is still low. You need a minimum one injection per week, preferable two. Most men inject one or more times per week, high SHBG men can getaway with one inject per week, minimum once weekly.

These every 2 week protocols are very common and most men end up here asking why they are seeing no benefit, these protocols were used back in the clinical trials decades ago and is a very poor way to replace testosterone and only clueless doctor prescribe them because it’s what the insurance companies want.

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You need to GET A NEW DOCTOR that specializes in hormones replacement. Not an end. Go private. Please hear me when I say this ~ you are being screwed my man.

Your T is low . Just two years ago this serum has a max of 1200 or so. Now it’s 900!l? Follow me here you are new. Don’t believe lab ranges . They keep lowering it because they are in the pocket of insurance. Less dose means less money paud out.

For your age you would benefit from
Being on the 20s and some need 30s. Jsut remember that a decade ago the max free T was probably in the high 20s. These new ranges are based on a sick population and they mix in many age groups as well. Very wrong.

Your doc doesn’t realize this and is keeping you low. If I had the levels you have on trt my doc would start me on trt. Make sense?

This is why you need a new doc. So that you would Not need a bunch of strangers to help. Although we’re happy to help. But you really should be able to get some actual therapy and not this nonsense levels he’s keeping you at.

Thyroid will help you big time brother … trt might not even really work until thyroid is working. You will lose fat and gain muscle quick when this is hormone therapy is dialed in.

If you can inject yourself and have enough to last you, go ahead and take 75 or 100 twice a week. I’m guessing what your dose is.

If you take 100 weekly go to 150. If at 150-160 go to 200. If at 200 already please tell us.

Stop working with your doc. Get a new doc tomorrow. Fuck this guy. He’s torturing men with his lack of knowledge. This is rediculous.

I bet no matter what he does the weight doesn’t budge. His thyroid (metabolism) and test levels are a shit storm. This is one of those cases where you need hormones to find the energy to actually perform.

Can’t wait to hear him talk about life in some months when he’s got this all figured out.

We all remember the low t days. Gah… torture.

Cardio isn’t gonna help with moobs is my point, and more muscle means more calories burned even at rest. Plus, you’ll feel better overall if you lift and don’t manage to hurt yourself.
200 mg every two weeks actually is a lousy protocol. 100 mg a week is way better, even though it sounds like the same thing. Cypionate has a half-life of 7-9 days, so you need to inject it every 7 days or less for a smooth ride.

I’m secondary as well. Zero sex drive.

I’ve been in every protocol. Tried gels and shots. Nothing worked.

I’m more thinking something is off w neurotransmitters.

Hopefully your self injecting. If so do 100 mg weekly. See how your feel after 2 months. Redo basic labs.

Total t
Free t
Also retake fsh and LH should both be near 0.