T Nation

TT = 3064, E2 <12... How Is This Possible?


#1

After reading the stickies, I figured it's time to start my own thread.

-age: 36
-height: 5'9
-waist: 36
-weight: 160
-describe body and facial hair:
*Facial hair growth is slow - even during puberty. I shave once a week.
*Small amounts of body hair is present in many areas

-describe where you carry fat and how changed:
*Between ages 15-26, I weighed 120lbs with <4$ body fat.
*Since age 27, I've added weight in my mid-section, but still have skinny arms and legs.
*At 28, a hydrostatic body fat test showed 25% body fat.
*My weight gain started when I went on Lexapro (see below).

-health conditions, symptoms [history]:
*In 2002-2003, I took sam-e in 2002-2003 for depression.
*2004, started on Lexapro 20mg daily.
*2007 my shrink added Wellbutrin XL 450mg for ADHD. This worked okay.
*2008 I switched to Straterra. This made me an emotional wreck, and prevented orgasm. This was my first sexual side effect from medication. I switched back to Wellbutrin, but orgasm problems persisted.
*2009, I learned that I snore loudly. A sleep study revealed moderate OSA (sleep apnea). Doctor put me on CPAP therapy which works well.

*Jan 2012, my GF and I get together. Our sex life sucks. I have no libido. Erections are possible but require a lot of work to sustain. Orgasm is still not possible.
*Feb 2012, my shrink lowers Wellbutrin to 300mg and added Adderall XR 15mg. This works okay - but ADHD symptoms persist. The shrink wants to increase Adderal, but I don't. Sexual problems still persist. No interest, motivation, or energy...
*June 2012, minor surgery to correct a fistula. CT and MRI scans covered the testicles and prostate, and showed nothing abnormal.

-Rx and OTC drugs, any hair loss drugs or prostate drugs ever:
*Used a minoxidil pack sparingly in April 2012, but have stopped.

-Lab results with ranges:

From 7/27/2012 Quest Diagnostics:

Hemoglobin A1C - 5.4% [<5.7 decreased risk of diabetes]
Mean Plasma Glucose - 115 mg/dL [no range given]

T-Total - 220 ng/dL [250-1100]
T-Free - 53.4 pg/dL [35-155]

A compounding pharmacy referred a urologist. His website indicates that he does TRT for men and researches men's health. I saw him earlier this week and got these labs:

From 8/23/2012 LabCorp:

Albumin, Serum - 4.9 g/dL [3.5-5.5]
Testosterone, Serum - 307 ng/dL [348-1197]
Free T (Direct) 9.7 pg/mL [8.7-25.1]
LH - 6.0 mIU/mL [1.7-8.6]
FSH - 2.3 mIU/mL [1.5-12.4]
Prolactin - 9.1 ng/mL [4.0-15.2]

Bio-available T w/SHBG using HPMS for improved accuracy:
Testosterone, Serum - 335 ng/dL [348-1197 for Adult males >18]
Bioavailable T - 206 ng/dL [128-430 for males 20-39 years old]
Bioavailable T % - 61.5% !!!
SHBG (TRMA) 14 nmol/L [20-60 adult males]

The urologist forgot E2 and Vitamin D-OH. He gave me a cialis trial pack and scheduled a September follow up.

What I gather from this data:
-Why is FSH so low? Someday, I want kids. The urologist said this disqualifies me from TRT.
-LH levels are so-so.
-The higher percentage of bioavailable T suggests that my body is increasing unbound T because the total T levels are low - hence low SHBG and slightly higher albumin numbers. This suggests that HPTA feedback is working.

-describe diet:
*Not good. I rarely eat breakfast. For lunch I get an entree at a cafeteria which has some healthy options. For dinner we usually eat out. Diet is mostly meat and potatoes. No soda, and drink socially.

-describe training:
*None

-testes ache, ever, with a fever?
*None

-how have morning wood and nocturnal erections changed.
*Got them while in college, but now I don't get them at all.

The next step is compiling a list of lab tests. E2 and a thyroid panel for sure. Are there any aromatase enzymes that are worth checking?

Thanks for taking the time to read my thread!


#2

Welcome.
I would definately get your E2 checked. Getting on an AI after I started test injections made a huge difference for me.

One challenge about your situation is that the other drugs youre on can have side effects that might seem like symptoms of low T. - Not saying you dont have low T - your numbers show you do. - It might just be hard to differentiate between them. ie libido issues, mood, sleep etc
Are most of your symptoms sexual then? Fatigue? Brain fog? or anything else?
How is your physical activity/exercize?

Joe


#3

Thanks for bringing that up. There are also problems with my ability to self-motivate. Example: my house is a disaster. I always keep saying I'll clean up, but it never happens. Same with doing laundry, or taking my dog out more, or getting engaged with new hobbies and activities. I want to do them, but don't have the energy, drive, or desire to get started and follow through.

Brain farts are happening more and more. I have to proof-read work e-mails a couple of times before sending them, otherwise they may come across as nonsense. Even my posts here - I have to go back through them and ask myself, "Does this make sense?" before submitting.

There could be a dopamine contribution as well... I haven't ruled that out.

I have not been exercising much lately. After my fistula surgery in June, I couldn't ride my bike to work - or maybe that was just an excuse. I got in a minor hit-from-behind accident in late June as well, and my back started acting up a few weeks later. Chiropractic treatment seems to have helped. The doctor thinks that a lot of the spinal subluxations are muscle-related. When the massage therapists work on me, they find all kinds of knots in my upper to mid back.

So it seems like a downward spiral... my T levels are down because I don't exercise, and I don't get any muscle benefits from exercising because my T levels are still down.

Does any of that make sense??


#4

Hypothyroidism and hypogonadism share a spectrum of symptoms. Review the advice for new guys sticky for iodine, iodized salt, sea salt and body temperature concerns. Checking your body temperatures is really informative.

Adrenal fatigue can also make you weak.

You might have some degree of primary hypogonadism, your testes are not responding well to your LH.

LH is released in pulses and has a very short half life. So the lab results do not tell you much. FSH has a longer half life and is a better indicator of what it going on. That suggests that your pituitary output is low; "secondary".

Based on your SHBG, your E2 levels are probably low as often seen with your T levels. So we can probablyrule out HPTA repression from E2. But in this situation, the T:E2 ratio is still adverse.


#5


Thanks. I did not see a sticky on iodine, but I did find your thread with dosages and the subsequent changes to body temp. Curious that my usual body temp is around 97.6. It's almost always been 0.5 - 1.0 deg under "normal".

I sent a message to my PCP asking for these lab tests:

CBC/diff/PLT
CMP
Lipid Panel
LFTs
Folic acid
Vitamins A, E, B3, B12
C-reactive protein
Total Iron, and TIBC
Ferritin
Magnesium
Iodine
Androstenedione
Whole blood selenium levels (WBSL)
DHEA-S
Levels of TSH, Thyroglobulin (Tg), and Thyroxine binding globulin (TBG)
Tg and TPO antibodies
T3 â?? Total and Free. Also T3 Resin Uptake and T3 Reverse
T4 â?? Total and Free

No response yet. I will follow up today. He is really bad at getting back to me, so it may be time for a new PCP.

I also sent an e-mail to the urologist asking for these follow up tests w/LabCorp test codes. I asked for these tests so we can see if the testosterone biosynthesis is taking place.

Estradiol E2 array â?? 140244
Ultrasensitive TSH â?? 004259
Progesterone â?? 004317
17-OH Progesterone â?? 070085
Pregnenolone â?? 140707
17-OH Pregnenolone MS â?? 140715
Vitamin D25-OH â?? 081950
Iodine â?? 070034

From what I recall reading, T is produced in the Leydig cells. The exact synthesis is somewhat complex (see attached pic courtesy of Wikipedia). So my hope is that with this information, we can determine if there's a hormonal or supplement deficiency, or if there could be a deeper problem.

I also ordered liquid iodine through Amazon. I take enough pills every day, so drops are much preferred, even if they do taste terrible. The iodine will probably arrive on Saturday or Monday, so I'd like to get this bloodwork and a 24 hr cortisol draw in before I start the iodine.


#6

Iodine labs are sort of bogus. If you have not been using iodized salt or taking vitamins with iodine, you are deficient. You need about 1 gram of iodine in your thyroid.

Your low body temps really suggest a functional thyroid problem, which can be low fT3 and/or fT3 is been blocked by rT3 which typically is a result of adrenal fatigue, which doctors do not believe exists.

More info here:
http://tnation.T-Nation.com/free_online_forum/sports_training_performance_bodybuilding_trt/ksman_has_a_thryoid_problem

Start taking 4000-5000iu vit-D3 before your lab work.

Hypothyroidism can lower T levels and correcting thyroid levels can sometimes reverse T level losses in younger males.


#7

Oops. It looks like I left out my vitamin D usage...

So my sister got me into taking vit D to boost my immune system. I get the liquid drops. Lately I've been taking 4-5 drops at least once a day. Each drop is 4000 IU.


#8

I managed to finally track down my (soon to be former) PCP and get him to order some lab tests. I got him to order a CBC, CMP, LFT, a fully thyroid panel, and some others. The blood was drawn on Tuesday morning at Quest.

I also found a new PCP who ordered Vit-D-25OH, E2, progesterone and pregnenolone and both of their 17-OH to check for proper T-biosynthesis. She also ordered Iodine, and ultra-sensitive TSH. Those were drawn yesterday (Wednesday) at their in-house labs.

This morning I had another visit with the idiot urologist to review his blood work orders. According to him, SHBG, Albumin, and PRL levels are good. He also said that SHBG is produced by the liver and is not produced based on feedback from the HPTA loop, so my low SHBG is a good sign. He said that my bio-available T levels were in the "normal lab range". I questioned him as to whether that meant optimal or healthy, and he said that he thought it was healthy.

He also went on to say that perhaps my low serum T is because the bio-available feedback levels are in a good range. i.e. the bio-available T is good, therefore the HPTA loop tells the pituitary to produce less LH/FSH. That may be a reason why my FSH is on the lower of normal side. Still... serum levels that low just don't sit well with me.

I explained to him that the last two times my gf and I had sex, one time was a day after I took cialis. It did make it easier to get an erection, but it did nothing to improve my libido, drive, or interest in sex. It also did nothing to my ability to climax, which didn't happen that time. The second time we had sex was without any ED medication. I lasted at least a couple of minutes, and had no problem climaxing. For the past month though, the overall libido was very low. Morning erections are still non-existent. He suggested that perhaps a sex psychologist may be helpful, although he could tell that I wanted to address the physical culprits first.

He then advised me on Vitamin D intake, and said not to take more than 1000 IU per day. I told him that you can get drops at 4000 IU. He said that I need to avoid those, and cited a study in Australia where women with bone problems took vitamin D. Apparently their rate of bone fractures went up tenfold.

At the end, he gave me an Rx for Clomid. He said this will stimulate the pituitary to produce more LH/FSH. It's a 25-day on and 5-day off cycle. He also wrote a blood work order since "his girls screwed up" last time, and forgot the E2 and Vit D-25OH. When I got the lab form, it had the wrong E2 test marked. I then had to explain to the girl that I wanted LabCorp test CPT 140244 and not the other one they checked off.

The doc told me that his girls are used to writing up "routine" lab orders, and that if you request a different one, they get confused. That became evident when I had to spell E-S-T-R-A-D-I-O-L E-2 A-R-R-A-Y to her. Talk about clueless!!! This didn't sit well with me.

On Monday I also saw my colon/rectal surgeon as a follow up for the fistulotomy recovery. He had to inject some silver nitrate to burn away some excess granulation tissue (ouch!), and gave me an Rx for topical nitroglycerin ointment - which I had to get filled at a compounding pharmacy. I have to use it 4 times a day, and it's giving me pretty bad headaches.

I also took my temp last night before bed - 97.1. I took it this morning at 97.0. The urologist's assistant took it at my appointment and reported 98.0.

I am thinking I should hold off taking any supplements for now, and wait till I get these labs back while taking body temps during the interim. Once I get some feedback on the lab results, I'll consider building up on iodine (while monitoring body temps), then maybe re-testing T, Free-T, and thyroid... and if there's still problems, maybe the Clomid.


#9

I got some of the lab results back. This is from the new PCP.

9/12/2012 Results:

Estradiol: 24 pg/mL [0-39.8 pg/mL; males 16 and older]
TSH: 1.67 uIU/mL [0.49-4.67 uIU/mL]
Vit. D 25-Hydroxy Total 63 ng/mL [30-100]
This Total 25-OHD assay measures the sum of 25-hydroxy (D2 and D3) vitamin D metabolites. Therapy indications are based on Total 25-OHD, as follows: Sufficiency Level: 30-100 ng/mL

Total T: 337 ng/dL [250-1100] (measured by LC/MS)
Free T: 83.8 pg/mL [35.0-155.0]

Iodine Protein BO: 4.0 ug/dL [4.0-8.0]
Iodine Total Serum: 5.6 ug/dL [4.5-10.0]
Inorganic Iodine: 1.6 ug/dL [0.5-2.0]

17-alpha Progesterone-OH: 29 ng/dL [42-196] LOW
17 Pregnenolone-OH: 33 ng/dL [< or = 905]

9/11/2012 Lab work from Quest:

Thyroglobulin: 9.6 ng/mL [2.0-35.0]
Thyroglobulin ABS: <20 IU/mL [<20]
TPO Antibodies: <10 IU/mL [<35]


#10

I had an appointment with an endocrinologist this afternoon. He reviewed the available lab results and said the following:

-Free/bioavailable T measurements are more inconsistent between labs b/c the levels are so low. He tends to rely more on Total T serum than on Free T.
-He gave me a one month trial of Axiron - topical watery chemical that is applied on my underarms. His thinking is that we should try to boost the T levels and see if my mood/behavior/libido improves.
-He doesn't think the urologists recommendation of Clomid is a worthwhile option. The reason is because we don't know if raising my T levels will result in any improvement. All I have so far is lab data but no treatment. So the first thing to do is a month trial by attempting to raise the T levels, remeasure them, and compare that with mood/libido/well-being.
-He think the Lexapro may be the SSRI that could contribute to the sexual dysfunction even though it didn't give me problems when I first started it.


#11


I got a bunch of the lab panel tests in. Rather than type out all the results, I figured it would be easier to scan the results and highlight the ones that caught my attention.

Here's the metabolic panel and some of the liver tests.


#12

CBC and more LFT...


#13


... T3 and T4 results:


#14


Finally, the Iodine, DHEA and CRP results.


#15

I wanted to comment on the Axiron experience so far...

Some people have talked about how much of a pain it is to apply the stuff, and I tend to agree. It is very watery and must be applied to your armpits. There's a very strong alcohol smell which leads me to believe that the alcohol is just a soluble for the testosterone. Once it dries, you're left with a white powder - all of which you wanted absorbed into your skin. So it sucks if you see white powder in your pits b/c that's T that should have made it through...

The first day I used it was late Wednesday morning. I could feel the effects kick in within almost 30 minutes. I started to sweat more. My hunger grew to a new level, and I could feel some of the androgenic effect in my feet. Normally a foot muscle in my foot aches and pains but now I could feel the pain going away. Most of my muscles were itching a little. I could concentrate MUCH better, focus on tasks at hand. I felt calmer, much more cool and collected... much more, "in the zone". My posture improved. I felt more social and outgoing.

Libido is another issue... I'm not feeling all that horny. I'll still look at hot women, but it still takes some work to get hard. With my GF it's possible for me to get hard but it's still somewhat limited. Last night I think she wanted me to go further but I just couldn't sustain it.

This morning I cut my Lexapro dosage in half, down to 10mg. I want to see if this will improve my libido. Doing this may raise my overall anxiety levels, but I wonder if the T therapy and ADHD meds will be adequate to allow me to overcome that. I've also developed more coping skills with the anxiety so this should be interesting.

So - this tells me that there is definitely some benefit to T therapy, but the lingering question of why they're still so low remains open. I'm looking at the lower levels of 17-OHProg and 17-OHPreg as well as lower androstenedione levels... maybe there's an enzyme lacking?

Do you guys have any thoughts on this?


#16

Now it's Thursday and I'm still on the 10mg Lexapro. My libido is definitely going up, but only in the evenings. During they day there is none. Anxiety is back on a small scale, as well as some ADHD. I told my GF last night that I cut my dose so she can watch for changes in my behavior and call me out on stuff. I feel much quieter at work, but I'm also not having trouble concentrating.

The "androgenic" feel that I had when I first started Axiron isn't there anymore. I really can't be sure if there's any effect of testosterone - or what effect there is.

Not sure if this is normal.... I suppose only blood work will tell.

Also, I looked over my lab work some more and did some research. If I have a problem synthesizing T, it might be at the very first step - mitochondrial breakdown of cholesterol. For the last two nights I've taken some alph-lipoic acid before going to bed, as well as a few drops of iodine. Let's see what effect the iodine has on body temperature. Free radical repair won't happen overnight, so I'll need to reassess in a month or so.


#17

I'd be careful reducing the Lexapro so rapidly. That said, I know that Lexapro is considered the "purest" of the SSRIs, ie it works on Serotonin exclusively, which can lower Dopamine/Norepinephrine levels and perhaps -- perhaps -- reduce the effectiveness of the Wellbutrin/Adderall.


#18

Good information. I didn't realize that Lexapro may exaggerate on ADHD. This may explain why my attention problems aren't manifesting. If anything, it may be better without the Lexapro.

I was on 20mg for quite some time, and decided to cut to 10mg as of Monday. I'm still at 10mg. Normally I stay at step dosage for a week before stepping up/down. If I still feel well, I may drop to 0mg at the middle of next week. That would be 10 days at a step dosage of 10mg before going off. Then I would have another 10 days before my follow up with the endocrinologist and more blood work.

I think 10mg is a safe step to adjust. My shrink told me that 5mg is available but few people use it.


#19

If you're looking for an alternative SSRI, both Zoloft and Prozac are considered the most "activating" (ie least sedating) of the SSRIs. Zoloft is a minor dopamine reuptake inhibitor, so that may be better for the libido and ADD symptoms. Probably won't help much with the orgasm elusiveness, unfortunately. That seems to be universal for SSRIs.


#20

The thing is, I've been on Lexapro since.. gosh 2004 I think? At one time I wanted to integrate CBT so that I would eventually no longer need it. Now I'm wondering if I'm at that point. The recent cut back to 10mg is a good indication.

I've had to invest a lot of time and effort to get my mental game to the right place. Now it's a hormone problem. The orgasm problems seem to be subsiding. It seems like eevening I'm still getting in the mood, and have no problems self-serving.

What I don't like is the idea of needing SSRI's for the rest of my life. I see them as an aid to help you work through your problems with a clearer head. Then you develop coping mechanisms so you don't revert back into earlier destructive behavior. Then you go off them.

But... I'll be miles happier if my T levels get to a healthy level in the process.