T Nation

Urologist Says Bioavailable T Means Not a Good Candidate for TRT

I have been visiting a Urologist who has been slow playing TRT. Since my last visit with my urologist, he had me on clomid 50mg day. Absolutely no effect. Honestly, I think TRT would help but am a little hesitant so I have been working with him as he moves slowly.

He called me with the latest blood work today and gave me the results you see below. Then he said, “with that bioavailable T you probably aren’t a good candidate for TRT.” I was a little surprised. He wants me to keep my appt with him so he can discuss it in more depth.

Latest blood work shows (Quest)
TT = 294 (250-827)
FT = 37.4 (46-224)
Bioavailable T = 75.3 (110-575)
FSH = 13 (1.6-8)
LH = 3.1 (1.5-9.3)
IGF 1 = 164 (50-317)
Estradiol ultrasensitive = 13 (<=29)
DHEA = 232 (147- 1760)
Prolactin = 8.6 (2-18)
TSH = 1.3 (.4-4.5)

Symptomatically, over the last 3/4 months, ED and diminished libido are extremely real and prevalent. Morning erections are maybe 2x a month. Body composition is worsening Dad bod with fat depositing on breast and midsection. My energy level is 6/10 compared to 4 months ago of what I would say was 9/10. My weight has dropped, so I know I’m on a weight-loss track (10 lbs over the last 3 months). Unfortunately, I have also lost lean muscle mass. Recovery times are a concern as recovery from a lifting session takes 2-3 days and I’m not lifting anywhere near 70% of max. Likewise for an MTB ride of 5-7 miles, long recovery time. I know some of this may be age.

So my question is since I cannot find a bunch of info related to Bioavailable t and appropriateness of treatment (I have moderately good google-fu I think), Have any of you heard of this? If so why would I not be a candidate based on this number? Have any of you had good outcomes and experience with online providers?

At the end of the day, I don’t think he wants to deal with it and is attributing all of this to my age (55). But I feel significantly different than even 6 months ago.

Thanks for your feedback, guidance and info.

Cancel that appointment, use the $$ to start at a good clinic. This guy is not gonna help you

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Find someone who will get your free testosterone to at least 150.

You doctor is most likely uncomfortable with TRT and probably wants nothing to do with it.

By the way according to the guidelines (<300) you quality for TRT and are at risk for cardiovascular problems at these levels.

Also low estrogen is not good for bone health, I have two sisters with low estrogen (after menopause) and both have osteoporosis.

If you trust in your doctor–if you think he’s ethical and knowledgeable–you should keep your appt with him, and afford him an opportunity to answer your questions. Further, at that visit be an advocate for yourself: Bring up all your concerns, including your sense that he is being too quick to dismiss your symptoms as inevitable manifestations of aging. If he’s still reluctant to start TRT, ask if he’d consider a trial run of a few months to see if/how your symptoms and labs respond.

What I would advise against is what many here will advocate for, which is that you decide (with their ‘help’) what therapy you need, then doctor-shop until you find someone willing to prescribe it. Despite what you’re told, one cannot reliably bootstrap their way to the knowledge and experience needed to diagnose and manage a complex condition like hypogonadism (Google-fu abilities notwithstanding).

Don’t misunderstand: I don’t doubt that the people doling out medical advice on this subforum are well-intentioned, and are possessed of a genuine confidence re the appropriateness of their recommendations. But the truth is, like all such forums this one is an echo chamber, with most discussants repeating ‘truths’ they themselves learned right here, some time ago. The confidence you detect in their recommendations is a manifestation of the Dunning-Kreuger effect (suggest you Google it if not familiar).

As others who have lurked on this subforum for a while will attest, the specifics regarding that which is widely agreed to be ‘good labs’ and/or an ‘appropriate TRT regimen’ have changed wildly over time. Did they change because of widely-accepted advances in our understanding of the male hormonal milieu? No–they changed because someone who was a better internet-jouster came along and browbeat the subforum into accepting his opinions on the subject. I can recall at least three such ‘regime changes’ over the past ~12 years. Each time, the dominant poster’s recs became received wisdom–the ‘law of the land.’

TLDR Your urologist knows more than anyone here about TRT, and should be given every opportunity to help you before you bail on him.

Disclosure: Am a doctor, but not in a men’s-health related field. Am a TRT pt.

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There is a lot of validity to what you are saying. However, in this guy’s case, I think he needs to look elsewhere. This is why:

That simply is not the case.

I have plenty of patients starting with low free testosterone levels who do just fine, actually much better than fine, on TRT. In some instances, a lower free t means they’ll need to get the total test fairly high to reach an effective free test level. That’s the problem.

If this urologist is like many of those who guys have seen prior to seeing me, he is willing to take the total test up to the mid level range, and that’s it. Systemlord is at least partially correct. He is not necessarily uncomfortable with TRT, but uncomfortable with running levels up to the top of the “normal” range. He likely knows a mid range total test level will leave KCChuck with a very pedestrian free/bioavailable testosterone level and not address his symptoms.

That’s just my take. Nonetheless, if Chuck is willing to take the time, delay needed therapy, spend another copay, maybe the guy would reverse course. He’d have to walk that comment back quite a bit to convince me he is the best solution there is.

Thasnk for all the input. I appreciate all perspectives as it helps me make an informed decision. I met with the Urologist today and one of the things I asked was why wouldn’t I be a candidate for TRT with low TT, FT, and bioavailable. He asked where I got that idea. I said from your nurse who called me with the blood results and your comments. He replied that she misspoke, and said I appear to be a candidate given the bioavailable T being low. He could not explain why everything else appears solid but my T is not. Then mentioned genetics and age. I talked very directly about libido and ED and told him that is what initially started me on this journey. The other symptomology is outside the AUA guidelines so I stuck to “evidence-based” symptoms. In the end, he agreed to a trial of TRT and a recheck in 3 months. Thank you @highpull for your always insightful counsel, I have a direction to go because of your wisdom and clinical experience. Thank you @EyeDentist for your discussion on talking with him frankly. I may be delaying moving to another clinic but movement in the correct direction makes me hopeful. I am concerned that he may only get me up to a level he feels comfortable with, but I told him if I don’t feel better at those levels we will have to discuss dosage adjustment and adjunct therapy. He wasn’t averse but did throw in his two cents that I should stay off the internet. To which I replied, peer-reviewed literature and looking at treatment guidelines on the internet is never a bad thing, is it?

Thank you all for helping me work through this and begin the journey. I know there is a way to go and I’m willing to put in the time and realize that TRT isn’t a magic bullet. But I do believe it is a bullet that can help.

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For some of us, its just that. I’m 56 and had all the issues you describe except at 41 or so. I messed with a ton of Drs, some who were ok and some who were clueless and did me harm.

Just be alert to your Dr focusing on numbers and not how you feel. Don’t buy this bullshit that there is some magical upper limit to TRT. Everybody is different and we all react differently to treatment.

I can personally tell you that TRT has restored my life, my desires, my confidence, my joy, all the positives in life. I feel young again but not only in heart but physically.

Don’t be afraid or timid. Its definitely worth it.

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I see that as well, no explanation most of the time.

He may not have been referring to actual research, but to forums like this instead. I encourage them to get on the internet, with the caveat that they consider a story on a discussion board to be anecdotal and refer to me with questions. I will prepare them somewhat, tell them that if they get on the internet they’ll probably read, this or that, then explain why it is wrong.

It can be frustrating, for example, a while back I had a new guy come back in telling me he read I committed malpractice by not giving him a “blocker”. This was after I explained, in detail, the pros and cons of aromatase inhibitors and why he especially did not need one. He was very thin and starting with an E2 of 16. Yikes!

I think he understood the second time around and I give him credit for at least coming in and confronting me face to face. If he did not get it by then, he certainly did when I told him, “Look, we make money off prescriptions. If you want to buy anastrozole, we’ll sell it to you, just don’t be upset when you do not like it.”

You know what? It might be. Usually, it is. Glad it worked out with the doctor and good luck going forward.

I think mentally it is. I didn’t get tons of energy and build pounds of muscle while losing fat and hitting PR’s on TRT, but my mindset, mood, motivation, everything was like a switch clicked on. Total life change

150 in what units? What would 150 translate to in ng/dl?

On a related note, I recently came upon so-called Brandolini’s law which captures well some concepts in Thinking, Fast and Slow - Wikipedia and helped me understand the frustration I often felt posting on here. I had read the book but didn’t know anyone had coined the phrase. BS asymmetry principle a good way to describe it as Brandolini originally did.

Posting something thoughtful is often met with an order of magnitude more work combatting utter slop or poor information.

Learn something new every day.

Another good one:

Good rule of thumb as you state: If you think you are smarter than your Physician/Provider, you probably aren’t.

Thanks for taking the time to write that post. Excellent and I appreciate your time.

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Good stuff. I would add that several other forms of cognitive bias contribute to making TRT forums fraught places to get one’s health info. For example: New members come in wanting to be told they have hypogonadism, and current members want to tell them they have it. Another: The hyperfocus on TRT leads to single-factor thinking, ie, the tendency to assume any and every health issue stems from suboptimal sex-hormone levels (aka ‘If all you have is a hammer, everything starts looking like a nail,’ aka posts like ‘Saliva stickier than usual. Estrogen too high?’).

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pg/mL 15ng/dL
Quest range 35-155pg/mL

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Do you find for that for your patients symptoms resolve above 15ng/dl on the labcorp test?

Actually just noticed that labcorp is reporting my free as 26.8 but in pg/ml which now makes me confused.

Can anyone here, including yourself, make any sense out of what the doctor said about his bioavailable T? If not, then he shouldn’t go back. There’s no reason to go back to someone who says something nonsensical.

I had an endocrinologist who, when I pointed out that my free T was low, told me “Free T is a tricky one. To be honest, we in endocrinology really don’t know how free T comes into the equation. We only look at it when total T is low.” I not only never went back, I gave him a bad review.

And these are too high for him to prescribe TRT?

Find a doctor who cares about your health!

I do not interpret labs online–because being a doctor, to do so would be both unethical and illegal. (As an important aside, note that when people who are not doctors interpret labs online, that is also arguably both unethical and illegal.)

We don’t know what the doctor said, much less what he meant. While OP seems intelligent and thoughtful, it is not difficult to imagine that he may have misunderstood his doctor’s remarks (or that those remarks may have been poorly phrased). To advise ‘Stop seeing your doctor’ at this juncture, and with this paucity of information, is irresponsibly rash, and speaks to the points I made above.

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I didn’t say anything about you interpreting labs. He told us what his doctor said about bioavailable T. I was asking whether the doctor’s statement seemed sensible in any way. Of course we don’t know what his doctor said; we weren’t there. But I take him at his word. Otherwise what’s the point of answering anyone.

There’s thread after thread of users posting blood results and asking for (and receiving) advice and opinions. You don’t have to do it, but to say it’s unethical and illegal is…well, it’s pretty stupid. Sorry, but I can’t think of a more appropriate word. It’s stupid.

You don’t have to be a doctor to interpret that these levels are low, a child could unstandstant the implications. This is as simple as 1-3 = 2 and still the doctor misinterpret these labs. It’s not like the OP is in a grey area (325 ng/dL) on his labs, he is clearly low not by my opinion, but based off the guidelines.

I don’t know about you, but I wouldn’t want this doctor treating me because he/she has demistated something is wrong upstairs.