T Nation

What to Ask in Blood Test Follow-Up?

Hey everyone, I’ve lurked this forum for a bit when doing research for my symptoms and finally signed up.

I’ve been having a fatigue issue for the last year, now I found that one of my nipples is sore, I have zero libido whatsoever and while I keep my diet in check and workout 5 days a week, I’ve been dropping weight over the 6 months. About 30 pounds. So I went to the doc. They ran blood tests, my CBC, lipids, blood sugar, liver values, etc were all in range however these were the tests the doctor ordered for sex hormones and thyroid:

Total Testosterone: 558.40 ng/dL (249-836)

Sex Hormone Binding Globulin: 54.99 nmol/L (7-49)

Testosterone Free/Total (calculated): 78.92 pg/mL (35-155)

Thyroxine: 6.7 mcg/dL (4.5-12.0)
Triiodothyronine Uptake: 28 % (24-39)
Thyroxine Free Index 1.9 (1.2-4.9)

I believe that in my case, the calculated Free Testosterone may not be accurate due to my higher than normal SHBG. I have a follow up appointment in ten days. What other tests should I request in the event that the doc says I’m fine?

You are correct, normally when I see Total T near mid-range, SHBG at the top end of the ranges, the majority of the time you’ll find these men right here on T-Nation complaining of low T symptoms. I don’t see any estrogen testing, needed for men about to undertake TRT.

Most manage healthcare doctors will not be very helpful with hormonal problems, it’s because their daily life is ruled by reference ranges and little thought process goes into it, in range is normal and that’s the end of it.

If I were a managed healthcare doctor and didn’t really know much about hormones, seeing Free T is “in range” I would tell you you’re levels are within the normal range and you are fine. You’re looking for trouble going to a managed healthcare doctor for hormonal problems, it’s just not taught in medical school.

Your T4 should be mid-range and is on the lower end and isn’t optimal. Free T4 isn’t the main thyroid hormone, Free T3 provides energy to every cell and organ in your body and increases metabolism and your doctor thought it was a good idea not to test it.

Corners are being cut with thyroid testing, it’s difficult to determine thyroid status with these limited labs. We need to know how much active thyroid hormone is making it into the cells, for this you need Free T3 and Reverse T3.

No TSH testing?

No TSH testing. I am going to request that the doc tests LH, TSH, FSH, Estrogen, Prolactin, and any others suggested at my follow up appointment.

Followed up with an Endo, did another round of fasted bloodwork at 0730.

Results:
Vitamin D, 25-Hydroxy 21.2 ng/mL (L) (29-100)

Estradiol 21.5 pg/mL (7.63-42.6)

Thyroxine Free 1.12 ng/dL (0.93-1.7)

TSH 2.35 mcIU/mL (0.27-4.2)

Prolactin 5.7 ng/mL (4.04-15.2)

FSH 3.1 mIU/mL (1.5-12.4)

LH 2.75 mIU/mL (1.7-8.6)

Cortisol 19.3 mcg/mL

Total Testosterone 406.7 ng/dL (249-836)

Sex Hormone Binding Globulin 112.80 nmol/L (H) (7-49)

Free Testosterone 31.88 pg/mL (L) (35-155)

I have a follow up appointment with an Endo tomorrow morning. What should I expect moving forward and what do my results tell me?

Thanks!

Yikes, your SHBG levels are insanely high!

Well if your endo has a blind spot for sex hormones, he will latch on to the Total T and say it’s normal or in-range. Your T production is quite low indicated by your LH, the high SHBG is making things look better than there are. The usable testosterone is extremely low, the bound T (Total T) is irrelevant.

You’ll need a hefty dosage to suppress SHBG and increase Free T, but I think your endo will crap his pants if you go over 800> which is exactly what you need. Insurance guidelines are strict, levels 800> is usually an automatic suspension of TRT.

Private doctors are not bound by insurance guidelines because most do not take insurance.

Thank you for the reply. What kind of dosages should I be pushing for? I definitely want to go the injection route.

It’s also a military doc on tricare. Not sure how strict they are.

You should push for 150-200mg weekly split up once or twice weekly, normally I would recommend less but you have high SHBG levels. You might be able to get away with using 27 gauge 1ml syringes.

I don’t expect your doctor to be the most knowledgeable in TRT.

I find it unusual that SHBG doubled between the two lab tests.

Do you have any liver function tests?

Albumin 5.1 g/dL
(3.5-5.2)
Alkaline Phosphatase 83 U/L
(40-129)
Alanine Aminotransferase 17 U/L
(0-41)
Bilirubin 0.2 mg/dL
(0.15-1.2)
Urea Nitrogen 15.5 mg/dL
(6-20)
Calcium 9.8 mg/dL
(8.6-10.2)
Carbon Dioxide 27 mmol/L
(22-29)
Chloride 102 mmol/L
(98-107)
Creatinine 1.37 mg/dL
Higher Than Normal (0.7-1.2)
Glucose 103 mg/dL
(74-106)
Potassium 4.5 mmol/L
(3.5-5.1)
Protein 7.6 g/dL
(6.6-8.7)
Sodium 143 mmol/L
(136-145)
Anion Gap 14 mmol/L
(7-16)
GFR Calculated Non-Black 71.7 mL/min
(60->=60)
GFR Calculated Black 82.9 mL/min
(60->=60)
Aspartate Aminotransferase 19 U/L
(0-40)

I’m not really sure why it doubled either.

Update: Got a new Endo, super cool guy who seems to understand it. He wants to do one more round of bloods in two weeks to confirm low t and low IGF-1, especially because I am in my 20s. My IGF-1 was 103 on a range of 115-355 (don’t remember the units off the top of my head).

He talked about the clomid route vs. TRT. He talked about HCG and AI. He also mentioned further testing for a gh deficiency. So it sounds like I got a good doc for moving forward.

Your doctor sounds like a cool guy.

HCG will not do anything for your high SHBG problem, you will not be able to increase Total T enough before estrogen/water retention starts overwhelming you. HCG can negatively affect the adrenals glands. TRT is more useful in this situation, clomid is not recommended for men with high SHBG because clomid will increase it significantly worsening your Free T situation.