T Nation

Started TRT, Have Some Questions


#1

Hi, I'm a 34 years old guy from NE AL and was recently diagnosed with low testosterone (218 TT out of a range of 348-1197) after developing general malaise, low libido, and decreased sexual function. My GP wanted to prescribe Androgel with no further discussion. I found another doctor who at least would dig a little deeper: LH 2.7 (1.7-8.6 range) and FSH 1.9 (1.5-12.4 range), TSH 2.83 (.45-4.5 range), PSA .5 (0-4 range), Free Test 10 (8.7-25.1) all Labcorp tests.

After discussing these results, he also wants to prescribe Androgel. From what I've researched, I seem to have secondary vs primary hypogonadism and I would much rather get it treated without TRT if possible because my wife and I are planning on having another child. I managed to get this guy to refer me to an endo at UAB, but from what I'm reading, I might not have much more luck there.

Anybody in my area have any suggestions as to a good doctor or any comments on my bloodwork? I realize I'm missing E2 tests and possibly Prolactin and I'm hoping the endo will check those. A little further background, I'm 6'1" and 290, pretty much been the same size most of my adult life. I got down to 250 when I was lifting pretty heavy and again when I went on a low carb diet a few years ago. Hell, I was running 3 miles a day at 260 lbs. in the police academy. Never had any other health problems aside from having a tonsillectomy/adenoidectomy earlier this year. Blood sugar and blood pressure normal even though I know I'm overweight. Cholesterol and triglycerides slighly high: 215 and 176.

Any input or advice would be greatly appreciated, I'm tired of feeling like crap all the time and want to get back in shape, just seems to be an uphill struggle.


#2

Lets call a spade a spade my friend....at 6'1" and 290 lbs you're morbidly obese...not over weight. Furthermore, although you may have not been diagnosed with any other comorbidities I can almost guarantee they are in their infancy or already exist and are undiagnosed. Obese people just do not have normal hormonal profiles (not entirely true but if you have low T it's true for you). First and foremost you need a complete work up to be sure nothing else is going on.

If every thing checks out and you really are secondary then here are my thoughts. I started at 6'3" and 300lbs and a total T of 150. I too am secondary. I've never had a measured elevated E2. Presumably it was elevated initially. I lost 35 lbs through a clean diet and nearly doubled my tT. Clomid doubled my tT again but I still didn't fell great. Obesity-induced hypogonadism is it's own little animal in my opinion because it's both the weight and the dietary factors that lead to the obesity that also lead to the hypogonadism.

There's good literature out there suggesting the following:
1. Obese people convert test to E2 via aromatase initially but as test levels fall eventually E2 levels fall as well. The deranged part is as E2 levels fell the hypothalamus should have sensed this and produced more GnRH and LH but it didn't....why?
2. In addition to aromatized test, diets high in high-glycemic index foods DIRECTLY suppresses testosterone production both in the testicles and in the hypothalamus. This can explain why you're body never called for more T production and/or why your testicles were unable to supply it. If you've been obese for a long time your axis maybe shut down.
3. Most obese people should also look at sleep apnea - another common cause of low T

The "real" treatment in these cases is weight loss. The question then becomes how do you achieve that with the test levels of your grandma? Also, how do you get the axis rebooted?

You can try a restart with clomid and HCG but to be honest without significant weight loss this is a temporary bandaid. Clomid also can have nasty side effects. Weight loss through just dieting will help but it VERY difficult. You have to appreciate that in your low T-obese state you are metabolically setup FOR insulin resistance, FOR high abdominal fat stores, FOR poor exercise tolerance, etc.

There is also very good literature out there suggesting TRT should be implemented in obese secondary hypogonadal men to:
1. Decrease visceral fat
2. Decrease insulin resistance
3. Increase lean body mass and reduce adiposity
4. Increase exercise tolerance

If those four things can be achieved on TRT then a restart with clomid/HCG would be appropriate. But, the KEY TO IT ALL IS REDUCING ADIPOSITY which is 100X easier on TRT then not being on TRT. If you're not willing to reduce adiposity then I'd go for TRT as it will likely be your only way of elevating test levels while being obese.

My two cents....


#3

Thanks for the reply. I had actually read your thread on here before posting mine and saw that you had a similar situation. I realize I'm missing some pieces of the puzzle by not having all my labs. Since you seem to be pretty well researched on the obesity/insulin resistance correlation, do you think that obesity alone could result in the lab results I have?

I guess what I'm trying to determine is if this could purely be from testosterone to E2 conversion from body fat? I've never had an elevated blood glucose level when tested and pretty much avoid any sugary foods, but I'm guessing that since all the test results I've ever had have been fasting results I really don't know what my body is doing after I eat high glycemic foods.

I'm not very knowledgeable about the sleep apnea angle. I did snore very loudly prior to having my tonsillectomy, but not afterwards. I am trying to get back in shape and lose weight, but it is an uphill battle when you feel like crap. Again, thanks for the information and if anyone else reading is from my area (Alabama), I would appreciate any suggestions as to a knowledgeable doctor.

So far all anyone wants to do is give me Androgel (without HCG or any AI) which they claim will not make me infertile (everything I've read says otherwise).


#4

You appear to have hypothyroidism and that can lower T, make you fat, lower your energy etc.

We see that guys with hypothyroidism cannot absorb transdermal T, perhaps at first then not. This lack of T absorption is a symptom of hypothyroidism.

Read the advice for new guys thread and pay attention to iodine, sea salt, body temperatures.

Get a full thyroid panel and E2. Check and post your body temperatures here. Do not start another thread, everything needs to go here. You can pay for your own labs is need be. Explore the other stickies.

Do not expect to have a doctor take care of everything, you need to become knowledgeable and manage your own health care. You may have to educate a doctor, but few of them are open to learning anything new.

In a hot climate, if one sweats a lot, transdermal T may not work.


#5

Yes, obesity could be the sole reason for your labs but as KS suggested you may have other issues as well. Obesity is always a dead end in terms of health and it's not IF your health with fail but WHEN your health will fail. Obesity affects every organ system, deranges nearly every endocrine system, and is probably THE NUMBER ONE cause of all chronic disease.

As for diet. Assuming there isn't something else going on I know you think you "try and avoid sugary foods" but what exactly does that mean to you? Are you talking about avoiding soda and candy but a pound of pasta and a loaf of bread is OK? Or are you talking about no pasta, no breads, no starchy vegetables, no simple carbs and you try and eat all complex carbs?

There's a fact that needs to be dealt with here.....no one becomes morbidly obese eating appropriate amounts of low glycemic-index foods. It just doesn't happen so I urge you to really cut out most of the simple carbs as they really don't have much of any place in the human diet IMHO. The paleo diet is a good place to start....I'd say I eat a paleo-like diet and I like the reasoning behind it but I'm not a nut job about it either.

I also track calories daily but the interesting thing is on the paleo diet I need to track calories to be sure I've eaten enough.....not too many.

I know you haven't had any elevated glucose tests. Think of insulin resistance and type II diabetes as a continuum. People eat high glycemic index foods and that increases adiposity. Visceral fat stores build up and the pancreas just keeps pumping out insulin. Eventually high visceral fat stores start dumping large amounts of free fatty acids into the hepatic portal vein and you get inflammation and fatty liver (elevated ALT).

From this point on in response to the inflammation and increased adiposity the peripheral body tissues decrease their insulin sensitivity in an attempt to stop fat formation and limit weight. Peripheral tissues stop taking up glucose and serum levels rise. The pancreas responds to this increased rise in serum glucose by trying to pump out even more insulin until eventually it can't pump out anymore and frank type II DM sets in.

Your are correct that many with insulin resistance with have normal or high normal fasting glucose tests but elevated if you do a glucose challenge and also C-peptide will be elevated. This is a marker that is made along side insulin in the pancreas and when it's elevated with normal fasting glucose it means although your pancreas is able to keep up with demand it working really hard to do so.....that is in a nutshell insulin resistance. I'd have your C-peptide checked too.

As for sleep apnea. The basic idea behind low t and sleep apnea is LH is released in a pulsatile manor during REM sleep....if you're having apnea that is disturbing REM sleep you may not get any (or very little) LH release and thus little if any testosterone production. This is also the proposed pathophysiologic mechanism behind poor sleep or sleep deprivation and low T.

In my mind, obese guy who snores with low T.....couldn't makeup a better candidate for sleep apnea. I'm amazed not a single physician has mentioned this to you - it's about the only thing all my doctors consistently brought up and I barely snored at my heaviest. If you decide to go on TRT I think you really need to be evaluated with a sleep study as TRT can make mild sleep apnea worse.

My 4 cents.....as has been said.....almost all doctors suck at treating these issues.....educate yourself.....let your physicians help you as much as possible but as you can read on this board most people here need to go "out of bounds" occasionally to get what needs to be done....done. This may be the AI that you need but your doctor won't give you or whatever. The key is educating yourself!


#6

Thanks for the replies. I'm working on getting more bloodwork done and I will start checking body temperature also. I'm pretty sure portion control is going to be my diet problem. I actually added up all the calories I took in yesterday and came up with 2900, that was a little wake-up call. As for sleep apnea, is there any possibility of having it if you don't snore? My wife swears I no longer snore after having my tonsils out.

Strangely enough, it was not long after the surgery and starting back to lifting weights that I really began noticing all my symptoms of low testosterone. This is just starting to get to me, mainly the sexual and relationship issues, but also the fact that I've always prided myself on being a strong person, physically. I always used to think that as long as I was benching more than my body weight and that my chest stuck out further than my gut, I was doing good.


#7

Okay, I finally have some missing bloodwork results (Labcorp).
Estradiol, sensitive 9 pg/mL with range of 3-70
Prolactin (23 when range topped out at 17) Endo set me up for MRI re: possible prolactinoma
TSH 2.6 uIU/mL range of .45 to 4.5, down from 2.8 (started multivitamin w/ iodine, wonder if that helped?)
Free T4 1.14 ng/dL with range.82 to 1.77
Free T3(Triiodothyronine) 3.2 pg/mL with range of 2 to 4.4
Reverse T3 12.2 ng/dL with range of 9.2 to 24.1
Also, I did the body temperature test and came up with steady mid 97s first thing in the morning. I haven't checked it since starting the new vitamin and adding iodized salt, however. From the limited knowledge I have gleaned from the internet, it appears that my thyroid numbers are good and estradiol is actually low. Is this correct? Am I looking at a possible prolactinoma or are there other possible issues to check?

Prior labwork results:(218 TT out of a range of 348-1197), LH 2.7 (1.7-8.6 range) and FSH 1.9 (1.5-12.4 range), TSH 2.83 (.45-4.5 range), PSA .5 (0-4 range), Free Test 10 (8.7-25.1) all Labcorp tests.


#8

With sleep apnea there are many symptoms snoring being one. It is possible to still have it. The goal is to reduce or eliminate the stoppage of berating during sleep. I too had the Tonsils, Adonoid and uvula surgery. All that just make a larger airway. Fortunately I do not use CPAP though some people still require it after such a surgery. You Doc should have done another sleep study after to see how things turned out.

It is possible that is working against you with the low T especially I the fatigue dept. Sleep apnea puts stress on several body systems that need to work together for one to have a good quality of life. Best thing you can do is continue to monitor you weight and get cardiovascular exercise regularly. Keep an eye on how you feel a follow up sleep study may not be a bad thing. I too am considering it.


#9

So you were on TRT when you got: Estradiol, sensitive 9 pg/mL with range of 3-70 ?

150 micrograms of iodine is not sufficient to recover from low iodine stores. See what you can get at the health food store, ask for higher potency. 1mg is nice, but still not up to the task.

Have you read the protocol for injections sticky?


#10

No, I haven't started TRT yet. I was waiting to get the MRI and the results before proceeding.


#11

Update: Didn't want to start a new thread, but unsure how to edit the title of this one.
MRI came back with a pituitary microadenoma, which may or may not explain my low LH/FSH levels. I found a doctor who seems like he will really work with me. I'm beginning a paleo/primal diet, taking Lugol's iodine, and I started back working out too.

Anyway, to the main question: I started on .5ml of 200ng/ml test weekly (100 a week right?) this past Friday and I'm wondering how long it will take to really feel any effects? I seem to have a little more energy, but my libido seems to have vanished, worse than before. It also felt like somebody kicked me in the balls for the first couple of days.

Is this normal and it just takes a while to get results? Surely my E2 hasn't jumped too high when it was only 9 to start with, could it be too low? I'm scheduled to see the doc again in three months and I'm going to ask about HCG then too, but I don't want to feel crappy in the meantime.

I'm thinking about having my own bloodwork done in a month or so, to see how things are going. Appreciate any advice or comments.


#12

Many of the effects of TRT are mental. Gene expression gets altered, bulk tissue/brain physical changes need time to occur, then mental patterns need to evolve. Will not happen over night!

Your LH/FSH gets shutdown fast and you appear to be feeling that. No need for labs to figure that out. Getting Rx hCG will be driven by your symptoms and your salesmanship.

Have you read these stickies:
- advice for new guys
- protocol for injections
-- many do not do well injecting once a week


#13

Did you get cabergoline for the prolactinoma? Should be 0.5 mg split the pill to take twice a week.

Have other pituitary functions been checked aside from TSH? (ACTH, Cortisol, IGF1,)

  1. Suggest you break up the 100 mg a week into EOD dosing. To help even out your levels and lessen peaks or estrogen issues.
  2. Try Calcium d glucarate twice a day for a total of 400 mg. Recommend LEF. 300 mg of DIM. This will help keep E2 in check somewhat.
  3. Take HCG research to your doc and sell him on the need for it. Also push for AI if possible.
  4. Next labs get CMP, lipid panel, HBGA1C, vitamin D, IGF1, Cortisol, ACTH, Total T, free T, E2, Dhea-s, TSH free T3 free T4.