T Nation

T=152, Expecting to Start HRT


#1

I've been reading through as much as I can but would appreciate it if some of the more knowledgeable here could check my lab results and point out anything I should be aware of. For instance the Crisler document says what things should be tested, but doesn't say what the ideal result is (high # or low#).

I'm a 42 year old male with Crohn's disease. Used to be very ill, was on high dose of prednisone for 4 years, now the Crohn's is much more under control and I've been off prednisone since 2002. Since stopping the prednisone I've been exhausted all the time. I've been active because with the Crohn's under control I feel a lot better, but it's all been by force of will.

I broke a rib (somehow while lifting) and got a DEXA scan showing osteopenia (just under full osteoporosis). I saw several doctors and finally an endocrinologist.

Every doctor assumed the bone density problems were from either Crohn's disease or the prednisone use, but the endocrinologist was willing to run a testosterone test.

TSH, 3rd Generation 1.88 range 0.40-4.50 mIU/L
T4 total 6.8 range 4.5-12.5 ug/dL
T3 uptake 32 range 22-35 percent
T4, free, calculated 2.2 range 1.4-3.8 Units
T3 total 100 range 97-219 ng/dL

Testosterone Total 152 range 260-1000 ng/dL
Testosterone %free 1.8 range 1.0-2.7 percent
Testosterone free 27.9 range 50.0-210.0 pg/mL

Follow up tests:

FSH and LH

LH 2.4 range 1.5-9.3 mIU/mL
FSH 1.5 range 1.6-8.0 mIU/mL

Prolactin 3 range 2.0-18.0 ng/mL
Estradiol 50 range <= 54 pg/mL (no idea if this was a sensitive test)

This got me a pituitary MRI which as near as I can understand didn't show any tumors.

I don't see the endocrinologist until Jan 26 and I'd like to be prepared as best as possible.

Looking at symptoms of low testosterone listed on wikipedia, I've been complaining about most of them since 2002 when I finally weaned myself off prednisone. Every doctor told me they were just symptoms of Crohn's.

I had been on prednisone, usually between 20mg/day and 60 mg/day from 1998 to 2002.
I had peaks while hospitalized (4 hospitalizations of about 10 days each) of around 150mg/day or more.
As near as I can understand, prednisone can also shut down the pituitary just like anabolic steroids do. Can anyone confirm or deny this?

Priorities:

I want to make sure I know everything I need to say to the doctor and everything I should hear back from them. I've already suffered a lot of unnecessary bad stuff at the hands of doctors.

  1. Get my testosterone up to a good level. Number-wise, I'd like to have some idea what number I'm shooting for so that I don't just have a doctor who's satisfied to get me up to 260.

  2. Watch the Estradiol. As near as I can tell, that should be more like 22 instead of 50. Crisler's document says this can sometimes come down on it's own. I'm thinking I'll want to make sure the Dr. is going to monitor it and is willing to add an aromatase inhibitor if needed.

  3. I want to both maintain testicular size and function to be able to have kids one day. So I should insist on HcG right from the start, right?

  4. If possible, I'd like to not lose my hair. It is last on the list, but I'm the only male in my family (both mother & father side) with hair. As I understand it, this is related to DHT levels, which my doctor has not tested. If this is going to possibly be affected by raising testosterone, would Rogaine be an appropriate thing to start?

  5. Are there any other options that anyone would suggest? Like I saw a thread where Bill Roberts was discussing using letrozole for someone with low testosterone, but the details were all way too over my head.

There seem to be some tests recommended by Crisler that haven't been run yet - SHBG, DHT, Cortisol, CBC, CMP, Lipid, PSA, IGF-1. How vital are these - are they worth insisting on?

If you see anything else in my bloodwork that I should be aware of to be prepared for seeing my Dr. on the 26th, please let me know. I'd appreciate the help.

For some of the long story leading up to this, you can read my previous post before I knew about the low testosterone levels.
http://www.T-Nation.com/free_online_forum/sports_body_training_performance_bodybuilding_senior/help_for_osteoperosis_


#2

One huge red flag I see in your labs is your current E2. Try two months of Adex at 1mg a week in divided doses and see what that does. (Thyroid might be an issue too but I don't know enough to comment on that one.)

Maybe KSman will chime in but I'm fairly sure E2 plays a large role in bone density. For instance if you run to much Adex, creating low E2, bone density becomes an issue. Strange that you presently have that problem and your E2 is high now???? I think your labs are somewhat curious. You might want to run a Rhien 24 urine and compare.

How high would you like your T to be? If you're looking for midrange HCG alone at a maintenance dose might do it. How old are you? If not yes use HCG from the start with TRT.


#3

I'm currently 42 years old.

Although when I started exercising I was still very sick, I've now had several years of being able to put in good lifting effort and it really doesn't show.

To put it into non-specific terms I'd like to:
1. Not be exhausted all the time
2. Not feel so depressed and non-social all the time
3. Be able to make some progress with getting leaner
4. Be able to add muscle
5. Be able to sleep through the night without getting up every hour to pee (and be able to sleep better in general)
6. Reduce my anxiety (which is pretty constant)
7. Repair the osteoporosis damage
8. Be able to think clearly like I used to

I've felt like crap since I stopped taking the prednisone in 2002. I can usually "fake" being healthy for about 5 hours, then I need a nap. This limits how much I can interact with normal people.

My gastroenterologist and GP have told me since 2002 regarding all those complaints that "that's normal" for people with Crohn's. But the Crohn's itself seems pretty much under control now with Remicade. My last colonoscopy showed that my intestines are pretty healthy now -- but I still have no energy.

Had I not broken a bone and then insisted on seeing every doctor possible, I never would have gotten to the point of knowing that my testosterone is off-the-bottom-of-the-charts low.

As near as I understand it, low testosterone is a possible cause for osteoporosis. And even the numbers cited as medically low are twice my current level.

When I see my doctor, I'll see if I can get an order for the Rhein test. Thanks for that info -- I've not heard of that test before.


#4

To non-specifically answer items 1 thru 6
These are classic symptoms of elevated E2.
ALL of them. I don't know enough about Crohns to comment on the associated side effects, but It would appear you are not uptaking the calcium you ingest.. are you taking 1500 or more mg's of calcium every day now? I also agree the long term prednisone usage may have caused the low bone density, and after stopping the usage of it, you may have close to complete adrenal shutdown.(fatigue)

I used to have adrenal fatigue and have been treated by a doctor for it. If you want the specifics of my treatment PM me as not everything I take is prescription only. Getting your T to E ratio near an optimum level will give you more energy and a much brighter outlook on life. Your T3 total is also on the bottom of the scale; T3 is another source of energy and mood elevation you desperately need. With the exception of the Crohns, I had the same symptoms you are having now, so I understand the way you feel as I used to feel that way every day.


#5

Thanks for the info.

When I was on the prednisone, my ex-wife suggested taking Viactiv calcium supplements (they had just come out around that time). That's about all I did then.

Now I take MUCH more Vit D and my level is something like 47 which I think I'd rather have it up in the 50 or 60's as per Mercola. Crohn's is known for poor Vit D absorbtion and poor Calcium absorbtion. It must have been WAY low back when I would have needed it much higher.

Of late I had probably only been getting around whatever 100% RDA of calcium is -- mostly through multiple servings of Metabolic Drive plus what's in my vitamins.

It seems there's no way to tell when the bone damage occurred.

I do know that in April 2007 I was deadlifting 270 for 10 sets of 3. When I broke my rib in Oct 2008 I was struggling to deadlift 260 for 5 reps. I'm lighter than I was in 2007, so not being as strong is expected. But I'd think my bones should be as strong - unless the bones are getting weaker.

I have a friend who is a kidney specialist who was telling me that now when someone is even going to be on prednisone for 4 weeks he usually orders a bone density scan to get a baseline.
He also told me that he sees a lot of people with Crohn's who have kidney stones from being unable to absorb calcium.

So Crohn's disease, prednisone, low Vit D, low calcium, low Vit K (also associated with Crohn's), and low testosterone are all possible causes.

I have felt like crap since I got off the prednisone. I hated that stuff. I used to shake so much all the time that it was difficult to write. Ultra volatile temper too. And my face was unrecognizably fat.

According to wikipedia on Adrenal Insufficiency

One possible cause is
Discontinuing corticosteroid therapy without tapering the dosage (severe adrenal suppression with ACTH suppression)

I have no idea how long of a taper I needed after 4 years of use. I don't think I dropped ultra fast -- but I was pretty eager to stop it. I didn't get any guidance on that from my gastroenterologist. He didn't feel there was anything wrong with me being fat. I think that all you have to do is look at how fat I was and it's clear that that's wrong.

I do know I told him I felt exhausted all the time. And he didn't think there was anything wrong with that. There's something wrong with my bloodwork -- and it probably could have been caught in 2002 instead of 2009.

To understand me better:
[photo]20047[/photo]
I entered the hospital in Feb 2002 after not having eaten for a month. I was rail thin. This is after that first hospitalization -- all weight gained from IV steroids and glucose, no eating food. That photo is not even my worst. I had about another 20 days in the hospital after that in which I got even fatter, also while not eating any food. To the point that I couldn't walk. There weren't any photos of me like that because everyone was expecting me to die. It was YEARS before I lost enough weight to even be able to fit my wedding ring back on. That's fat.

[photo]20048[/photo]
This is a current photo. While I look better, I don't think it looks like I lift weights and I still have a bit of a belly. It's taken me years to make progress that I regularly see other people do in months.

Despite that I've put in a lot of personal effort to get myself healthier, I've yet to run into a doctor that wants to see me do that. Mostly they treat me like I'm supposed to be fat and weak and sickly and anything I want to improve is just a waste of time.

I'm so frustrated with doctors at this point.

A funny point that makes me want to be prepared to deal with my endocrinologist and find a backup: When she discovered I had low testosterone, she accused me of using steroids and thus having killed my natural production. Do I LOOK like I've been on steroids, with those huge bulging muscles I have? C'mon. I've seen plenty of guys on this site accused of using, and they don't look like me.

I find this a lot like my problems with gastros -- the first rule of medicine is to blame the patient. The second rule is it is OK for your treatment to cause problems for the patient -- as long as the new problems need to be treated by a doctor with a different specialty.

Everything I'm reading about all this hormone stuff suggests that it's very easy for a doctor to seriously mess you up. I've been being messed up by doctors since 1992 and I'd love to be done with it for a while.

I guess I'm ranting a bit 'cause it's 1am and all I'm doing is more and more research on this because I can't see trusting the endocrinologist to be competent. I have no idea what doctors go to school for if you can't trust them to be competent.

To end on a brighter note - thank you to both brentf13 and KNB. And to anyone else who chimes in with any suggestions. I'm hoping that the more good questions I can hit the doctor with, the more likely I won't wind up with even worse problems.


#6

E is considered important for bones. T is needed to maintain/restore collagen that is the matrix on which bone minerals are built.

Get Eugene Shippen's book, The Testosterone Syndrome - cheap at Amazon.com

Look up prednisone in the index

Your metabolism may be permanently changed by the prednisone. You need to be checked for adrenal function.

Transdermals create more E than injections and your E is way high now.

Do not start TRT without Arimidex or E will be higher.

You have estrogen poisoning. Get E2=22 and you may feel like a new man.

Do not do weekly injections. Inject twice a week or E2D, E3D. This will reduce E2 levels VS weekly injections.

Ask to start:
100mg test cyp per week, injected more than once a week. [Your levels should be TT=800-1000. FT will be low as E2 has your SHGB jacked up.]

250iu hCG EOD SC, IM not needed!

1mg Arimidex per week in divided dosing. You may need more than that! Find and understand Arimidex / anastrozole over responders.

Next level:
Clip/shave and apply .5ml test cream 5% to scrotum and penis.


#7

Thank you KSman. That will be useful for dealing with the endocrinologist. I hope you don't mind these follow up questions:

The following two paragraphs are not to doubt you -- I just want to understand why you suggest what you do since I understand that my case is a specific case with specific hormone values and what Crisler says is just general treatment guidelines.

From what I've understood so far (and I'm VERY new at learning about this) -- I thought that transdermals created less E than injections because the create lower peak levels of testosterone and thus less conversion to E. Is your suggestion to go straight to injections because my testosterone is so low?

Crisler says he does not use an AI initially because treatment can cause E2 to drop on its own. Is your suggestion different from this because my E is so high?

I just want to know what I'm asking for and WHY so that I'm prepared for whatever comeback the endocrinologist has.

AND here's an interesting follow up question:

If the endocrinologist wants me to start with just transdermal and hcg (which is what I'm expecting based on what I've read) -- should I take what I'm offered or wait another month until I can get an appointment with a different doctor? Because I'm thinking that she's probably got to do SOMETHING for a T of 152, and if I can start getting my thinking clearer and feeling better it would be a lot easier to deal with all this.

Also - and I don't know if this is relevant - I tend to respond to minimal amounts of medication. For example, anything like benedryl, sudafed, advil, etc. -- I always take a children's dose. An adult dose of benedryl can put me right to sleep.

The Borders website says the local Borders has that book in stock, so I'm going to go there tonight and look up prednisone. Thank you again for this suggestion.

I'm having a lot of difficulty understanding why my gastro has never brought up or tested for any long-term consequences of all the prednisone. Nor any of the other doctors I've seen. Searching literature, I've found references like:

patients who should be assumed to have functional suppression >of hypothalamic-pituitary-adrenal function include:

  • Anyone who has received more than 20 mg of prednisone a
    day for more than three weeks [22].

  • Any patient who has clinical Cushing's syndrome.

and
"The first well-documented case of adrenal insufficiency after exogenous glucocorticoid withdrawal was reported in 1961"

Searching around for self-injection I found this video: A DIY Guide To Injecting Testosterone

But I'm going to have to psych myself up just to watch it far enough to even see what they're showing.

I couldn't even watch when my ex had to inject our ferrets with sub Q fluids. I'd just hold the ferret and close my eyes.

Not that I don't get tons of needles now -- but I've just managed to learn to hold myself still even though I'm freaking out. That's not the same as actually giving the shot to myself.


#8

Overall, I'm not happy with a medical system where it's the patient's obligation to double-check everything their doctor says to make sure it's right.

I understand the need to be proactive about your own care. But shouldn't an "expert" know enough about their field of expertise to do the job right?

If my doctor came to me to get her portrait done, I wouldn't be interested in her input on how I should set up my studio lights or hold my camera. That's my expertise.

My mechanic doesn't want to hear crap from me about how he should install the brake master cylinder on my car (which is probably just as much a life-and-death issue as any medical stuff). My mechanic knows what he's doing. That's his expertise.

But you get to medical topics and there's always doctors who haven't learned anything new in the last 20 years.

Again... my mechanic learned how to repair fuel injected cars. I learned how to use a digital camera. Doctors?

This has a good post by tawney at the bottom of the thread
http://www.T-Nation.com/free_online_forum/sports_body_training_performance_bodybuilding_senior/back_from_the_endo_results


#9

You might want to investigate your Vitamin D levels.

www.vitamindcouncil.org


#10

You sound a lot like me, I was on large doses of cortical steroids for asthma and sinus inflammation....low test, high E2. After weaning off all the cortical steroids my body ached for weeks. My test and E2 are great now but still battling fatigue.

I have another thread about that but I wonder if our adrenals are messed up, possibly T3 (I think brentf or KNB suggested that as well for me). Have you had your cortisol levels checked? Mine was normal till I weaned off the cortical steroids...


#11

My vitamin D was tested on November 18 2008

47 on a reference range of 20-100 ng/mL.

That's with taking about 2500 IU of Vit D per day.

My endo thought I'm taking too much D, but I think I'm having absorbtion issues from the Crohn's. I'd prefer to get it up to something over 50.

As far as I know, I have not had cortisol checked. That's the kind of thing I want to make sure the endo does on monday.