Symptoms & next steps

Hi everyone. I've been doing plenty of reading, and I still can't find a similar case containing labs and symptoms like mine, so I thought since I am striking out with doctors here, I would get some 'net SME advice!

Demographics:
39 years old
6'5"
270 lbs.
Body fat 26.2%
Powerbuilder - Powerlifting / Strongman strength based workouts for main lifts and hypertrophy accessory lifts. Follow Renaissance Periodization's Diet and training methodology when I am able to (details below).

Symptoms:
Workouts - I have been weight training for 25+ years, and have been mixing high intensity and lower weight, higher volume pump/recovery workouts (to prevent overtraining) for years working out 6x/week. In the last year, I have started breaking down and being unable to recover. I dropped to 4x/week, and I am currently unable to squat more than once/week. My hips, abductors, adductors, etc. remain too sore. Still doing cardio and lifting, but not recovering.

Sleep - I have slept for 6 hours/night for years, and now I am still tired even after 8 hours.

Libido - No more morning wood, and while I can still perform, I don't chase the girlfriend nearly as much as I used to.

Body Comp - Always had gyno, even as a kid, but it is getting worse, even at lower bodyfat.

Mood / Cognitive - Still competitive at work and able to get things done, but not nearly as sharp.

I went to my doc and had my labs done (AM fasting). My total test bounces around in the last 4 years between 300 & 400. Free Test between 10 & 17. Basically, I'm on the low end, but they don't do anything until you go under 175.

Also my E2 & SHBG is always in the mid to high 40's.

Does anyone have any idea what I should do next? My PCP doesn't know. My urologist doesn't think it is low T as much as a E2 / SHBG problem, and the endocrinologists won't see me until my levels go below the 175.

Thanks !

Can you post your full lab results with the associated reference ranges? Some questions - what other medications/supplements are you taking/have taken? Head injury? You have had full-blown gynecomastia, or chest fat? They can be two different things.

With a bit more information the conversation will be more focused. Thanks!

Lab Results have been hard to get because of no one wanting to discuss what to do about my symptoms. I have been told that unless my labs come back out of the range they have identified, they won't even do an investigation. The Endocrinologist won't even see me! What I was able to get below was from my PCP & Urologist last year.

Lab Results
SHBG 44 Range 11-56
ESTRADIOL (E2) 44
Prolactin PROL 9.9 Range -<13.0
Luteinizing Hormone LH 6.4
Follicular Stimulating Hormone Range FSH 5.9
Testosterone TES 400 Range 175-781

Testosterone Free TESF 16.9 Range 5.1-41.5

Q&A:
Only medication taken is Lexapro 10mg
Supplements: Fish Oil, Joint (Glucosamine, Chondroitin, MSM, Tumeric), Raw Multi-Vitamin, Bioperine, D3 w/K2, Boron, Choline Bitartrate, Ashwaganda, Probiotic
Workout Related - Beta Alanine 5g, Creatine Monohydrate 5g, Ascorbic Acid 2g
Coffee - 2-3 cups/day

No head injuries

Gynecomastia came on during puberty while I was lean. I stayed lean throughout college (bodyfat sub 20%), but had bad gyno. Had a male breast reduction removing 400cc tissue during college. It came back to a lesser extent, and can look bad depending on how heavy I get.

FreeRangeYeti said:

Lab Results have been hard to get because of no one wanting to discuss what to do about my symptoms. I have been told that unless my labs come back out of the range they have identified, they won't even do an investigation. The Endocrinologist won't even see me! What I was able to get below was from my PCP & Urologist last year.

Lab Results
SHBG 44 Range 11-56
ESTRADIOL (E2) 44
Prolactin PROL 9.9 Range -<13.0
Luteinizing Hormone LH 6.4
Follicular Stimulating Hormone Range FSH 5.9
Testosterone TES 400 Range 175-781

Testosterone Free TESF 16.9 Range 5.1-41.5

Q&A:
Only medication taken is Lexapro 10mg
Supplements: Fish Oil, Joint (Glucosamine, Chondroitin, MSM, Tumeric), Raw Multi-Vitamin, Bioperine, D3 w/K2, Boron, Choline Bitartrate, Ashwaganda, Probiotic
Workout Related - Beta Alanine 5g, Creatine Monohydrate 5g, Ascorbic Acid 2g
Coffee - 2-3 cups/day

No head injuries

Gynecomastia came on during puberty while I was lean. I stayed lean throughout college (bodyfat sub 20%), but had bad gyno. Had a male breast reduction removing 400cc tissue during college. It came back to a lesser extent, and can look bad depending on how heavy I get.

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If you live in the United States your lab results, all your medical records, belong to you - that's federal law. All you have to do is ask for them (though a nominal copying fee can be charged). It's important to build your own archive in order to become your own advocate.

Ranges are critical since every lab establishes its own reference points. Do you have those for LH and FSH? Was your estradiol measured with the standard or sensitive test? Men should only rely on the sensitive, LC/MS, MS, estradiol test. Your lab report should tell you - if not, the range will typically let us know.

No thyroid values?

I have to go collect the labs from the different doctors. They are supposed to be available online, but only pieces have been loaded in. I've called on the doctors and asked them to prepare them so I can pick them up. I completely agree with making my own archive. With sources like excelmale and the several books I have read, I feel like I am usually more aware than my doctors. It feels like they don't want to help me or don't have enough information to be able to. Really frustrating.

For E2, LH, & FSH this is what I have:
E2:
ESTRADIOL (17B):EstradiolMale < 47 pg/mLFollicular 27-122 pg/mLMidcycle 95-433 pg/mLLuteal 49-291 pg/mL
LH:
Male 1.2-8.6 mIU/mLFollicular 2.8-8.8 mIU/mLMidcycle 19.2-103 mIU/mLLuteal 5.2-18.6 mIU/mL
FSH:
Male 1.3-19.3 mIU/mLFollicular 3.8-8.8 mIU/mLMidcycle 4.5-22.5 mIU/mLLuteal 1.8-5.1 mIU/mL

The thyroid values were only run once in the last 3 years.
T3 Free FT3 3.0 Range 2.1-4.1
T4 Free FT4 1.02 Range 0.61-1.85
Thyroid Stimulating Hormone TSH 1.30 Range 0.34-3.00

ALT/SGPT ALT 51 Range 10-63
AST/SGOT AST 19 Range 15-41
Lipid Panel C/H 4.0 Range 0.0-4.0CHOL 159 Range 130-200dHDL 40 Range 29-71LDLmt 110 Range 0-130TRIG 45 Range 35-190VLDL 9 Range 0-130

THyroid appears to be pretty good based on your posts, probably no reason to dig further there.

What's your hematocrit? Have you explored the posibility for sleep apnea?

Why would any doctor wait until your testosterone gets down to 175 ng/dL??

I had the hemocrit tested last year. It was in the normal range but at the high end:
HCT 46.8 Range: 38.8-50.0

I've actually had a lot of bloodwork done. I had a DVT in my right leg in 2015. It was treated with IV Heparin & then Xarelto. I was tested for everything under the sun both while I was on bloodthinners, and then 7 months later after I was taken off of them, and my HCT was never found to be out of the normal range, and there were no genetic markers identified for Factor 5 Leiden or any other clotting disorders. The hemotologist and vascular surgeon marked it up as a freak occurrence.

I was also tested for Sleep Apnea multiple times at the sleep clinic at my hospital, and they couldn't find any way to get me to sleep where my breathing would stop.

I am not sure why they would wait until my testosterone is under 175 before doing anything, or why none of my symptoms matter to anyone. It has to be $ based. I'm betting the insurance is doing it so that the doctors are not able to prescribe anything, which leaves me screwed until things get so bad that I'm under the 175 & my symptoms are even worse.

You are based in the United States? If so, are you open to paying for your own TRT out-of-pocket? The leading practitioners in the States typically don't accept insurance (but it's likely not as expensive as you think it may be).

I'm in Michigan, and I'm open to getting whatever this is fixed, but I don't want to just get TRT if it isn't what I need. I don't understand why the E2 & SHBG are so high when my test is low? Would more test just make the problem worse?

I do admit that I feel like I know more than the doctors I am talking to, or that they really don't care about helping me get better. Frustrating.

Thanks again for helping with this!

You could always get a consult with Defy Medical regardless if you end up using them as your TRT provider or not. It would be worth the money to get a solid baseline and some solid advice.

Lexapro is good for anxiety etc... but not for your libido. When I was on 10mg I stopt from one day to another to exercise.
I just wasn´t motivated anymore. Maybe you could have a look at some side effects and if needed complement with Wellbutrin to make you more alert to counter the side effects of Lexapro. (Talk to you doc about it). Regarding morning wood you can find a lot of tips in this forum (Gene's Nitric Oxide Stack).
Personally I am 55 years old and I just need 4000mg/4grams of L-Citrulline a day and 2,5 mg daily of generic Cialis. And my wood is almost annoying during the night.

Thanks, I will check out the Nitric Oxide Stack. I used to take L-Citrulline, but moved to just Beta Alanine for my intraworkout shake. I will look at benefits outside the gym.

Lexapro was something I was on for the last 8 months or so. I am naturally a high anxiety, type A, go-go-go person. High performing (well trying to be, long levers suck for squatting & bench press, but hey, deadlift!) in everything. With a divorce, not being able to make basic bills, my kids getting sick requiring long term care, and the job going nuts, I was just crashing & burning for the first half of last year with anxiety attacks. I had the symptoms I spoke in my initial post for three years before I started taking the Lexapro, so I don't think it caused my motivation problems. Definitely didn't hurt in the bedroom, except that until I got used to it, I could never finish. Lots of good sex is great...after you learn the hard way the first time that everyone needs lube when the sessions go into the multi-hour range

I will see what my doc things about Wellbutrin. I dropped him a text this morning after your note. Thanks again !

FreeRangeYeti said:

I'm in Michigan, and I'm open to getting whatever this is fixed, but I don't want to just get TRT if it isn't what I need. I don't understand why the E2 & SHBG are so high when my test is low? Would more test just make the problem worse?

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The why's are debatable but those are common markers for the aging male...low T and rising Estrogen, almost becoming Estrogen dominant. Some men are running more Estrogens than women of similar age. "normal" seems like a crap answer but it's so very commonplace...that's what we strive to treat, reversing that.

So the high E2 & SHBG are likely just symptoms of LowT? I've been reluctant to take any further steps because my urologist thought that my T was good enough, but he was concerned about the E2, cortisol, and SHBG all being so high; potentially causing me to need AI, but not TRT. He wanted an endocrinologist to confirm what he was thinking, but they won't even see me with or without insurance unless my labs are off. I tried to get on the waiting list at two different doctors here, but the office manager had me pulled at both when they reviewed my labs and basically said that they wouldn't have time to see me unless the labs were off.

FreeRangeYeti said:

So the high E2 & SHBG are likely just symptoms of LowT? I've been reluctant to take any further steps because my urologist thought that my T was good enough, but he was concerned about the E2, cortisol, and SHBG all being so high; potentially causing me to need AI, but not TRT. He wanted an endocrinologist to confirm what he was thinking, but they won't even see me with or without insurance unless my labs are off. I tried to get on the waiting list at two different doctors here, but the office manager had me pulled at both when they reviewed my labs and basically said that they wouldn't have time to see me unless the labs were off.

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Visit www.defymedical.com. Then call them. Ask them the hardest, most direct questions you can (cost, the way medical services are delivered). Then plug the term Saya into the search box here. Dr. Justin Saya is Defy's medical director. He's one of the leading practitioners in the field of androgen replacement in the US. He's a moderator here at EM and a good guy, too.

I am not a patient, but many members here are. I believe the telehealth model works. Yes - there are fees associated (ask exactly what they are when you contact Defy). You deserve far better care than you've received.