Advice on whether or not to start TRT or look for other causes

[VA-Hiker]

I am trying to decide whether or not to start TRT or keep looking for another root cause as to why my bloodwork and symptoms are the way they are. I am 46 years old, decided to get labs checked and found a normal total T with low free T and high SHBG. Borderline hemoglobin A1c. I decided to get healthier, lost 40 lbs (since March), exercise a lot, starting to lift now. No alcohol, other drugs. I had typical non-specific symptoms of being tired, skinny fat appearance, no libido, ED (I had never had this until the months leading up to my first lab work. Fast forward from March until now, 40 lbs lights, in shape, have more energy (seems better, not always great), still a small amount of belly fat that just won't go away, still not much of a libido. I'm on 2.5 of tadalafil so that issue is better at least. Blood pressure is solid (110/70), resting HR in the 50's. With my latest lab work, total T was great, high actually, Free T was even lower (6), and SHBG >100. A1c up another 0.1 so it really didn't improve.

I talked with the doctor at the clinic and he suggested proceeding with TRT (he had offered me this in March but I want to try weight loss first). Hope is my Free T will improve, SHBG will decrease, and adding muscle mass will help with the A1c. I understand what he is saying is accurate. I am concerned about whether or not I should keep searching for other causes for the high SHBG before I commit to something that could be lifelong.

Sorry for the long post, I'm just quite conflicted about this and I'm hoping to obtain some insight from others. I thought about giving it a try for 4-6 months and seeing what my numbers do and how I feel. I am also concerned about coming back off of it and whether my endogenous production will return to baseline.

March 2023
Weight 193
Total Test 566
Free Test. 8.8
SHBG 59
LH 2.9
Estradiol 15.6
IGF-1 164
DHEA-S 144

November 2023
Weight 153
Total test 923
Free Test 6
SHBG 103
LH 3.8
Estradiol 14
DHEA-S 117
IGF-1 186

My starting regimen would be, 100 mg test cyp Monday and Thursday (200 a week), HCG 500 iu Monday and Thursday (1000/week). AI 0.125 only for symptoms. I have everything, just haven't started taking it yet.

 

[Systemlord]

I am trying to decide whether or not to start TRT or keep looking for another root cause as to why my bloodwork and symptoms are the way they are. I am 46 years old, decided to get labs checked and found a normal total T with low free T and high SHBG.

Your pituitary gland is malfunctioning, the pituitary gland should be cranking up the LH value to bring the Free T level up. That’s not happening.

The sooner you accept that you have low-T, due to aging and other factors, the sooner you can move on with your life.

The majority of men who start TRT can regain their natural levels once stopping TRT. The longer you’re on TRT, the longer it can take to return to baseline hormone levels/sperm production.

Most men don’t wish to return to baseline, you have to be crazy to want to return to a low T state.

I talked with a guy in the gym in his late 70’s on TRT for over 20 years, he said that he doesn’t have the aches and pains of other men his age.

Is optimized testosterone on TRT for life really that bad?

My starting regimen would be, 100 mg test cyp Monday and Thursday (200 a week), HCG 500 iu Monday and Thursday (1000/week). AI 0.125 only for symptoms. I have everything, just haven't started taking it yet.

This protocol is excessive, bordering on a mild cycle, even without the hCG!

Start at 100 mg weekly, without hCG and the AI.

Most of the symptoms on TRT are NOT from estrogen, so taking an AI simply because you have symptoms is not recommended. If your dosing is excessive, which it is, lower your dose.

Most men on replacement dose do not need anastrozole.

 

[VA-Hiker]

Thanks so much for your response. I do understand the age related decline of testosterone and certainly don't expect to have my 20 y/o levels anymore.

I was surprised at my total testosterone being as high as it is (900 is pretty solid). The free testosterone seems to be what matters and might explain how I have been feeling, being less now that before.

I will say, the improvement I have seen with what I done so far has been great. If TRT helps that further along (like the joint pain, build muscle, not be as tired), great. I was advised to only take the AI for symptoms and he did tell me that we could lower the dose, I will avoid it.

I am just wondering why the SHBG is so high, and if there is something else that is going on.

Again, I appreciate the advice. Starting it would not be a bad thing, I have all the supplies to start as it is.

 

[Systemlord]

I was surprised at my total testosterone being as high as it is (900 is pretty solid).

Total T is a function of SHBG, men with higher SHBG are have a higher Total T. Free T is what drives the effect of testosterone, not Total T. There was once a member with a Total T @ 1195 ng/dL, SHBG 148 and had the lowest Free T levels I’ve even seen.

Solid Total T, abysmally low Free T and symptoms to go along with it.

I am just wondering why the SHBG is so high, and if there is something else that is going on.

Androgens lower SHBG, so the high SHBG can be the direct result of low Free T produced within the testicles. What I find interesting is your SHBG increased by almost 50% in a short period of time.

Starvation, cutting can raise the SHBG and lower the Free T.

I would look more closely at your liver since that’s where SHBG is made.

The TRT is expected hammer your SHBG down and bring the Free T ^^.

 

[VA-Hiker]

This is great information thank you! I did recently start tracking my calories with the weight loss. I went from an unhealthy diet in March to a very low carb diet, also with calorie restriction (estimate about 1200-1500 calories a day), so what you are saying makes sense and could have contributed.

Since I actually started paying attention I have upped the calories, seemed to have stabilized the weight loss, and added more protein along with a little higher carbs (still low from where I used to be).

The free T was not great even before this journey though, so it is starting to seem like trying TRT is the way to go. My LFTs have always been fine. I haven't checked a ferritin. TSH was ok too (no full panel).

 

[Systemlord]

I went from an unhealthy diet in March to a very low carb diet, also with calorie restriction (estimate about 1200-1500 calories a day), so what you are saying makes sense and could have contributed.

That’s why your SHBG increased! Your Free T dropped as well.

Ferritin is an important one, before and after initiating TRT, because TRT can drop the ferritin in some individuals, myself included.

If you really want to lose weight, while eating to your hearts content, I recommend the carnivore diet.

You body gets it’s energy from fat, so no carbs, no sugar!

I can eat 8000 calories or 6 pounds of red meat a day and while putting on muscle while still losing weight!

I’ve been on the carnivore diet for 3 months and the weight is just dropping off.

 

[VA-Hiker]

Honestly that is something I have been considering for a diet. I really have hit the bottom of where I want to loose though, I really need to add muscle. I am 5'11" and only 152-153 lbs now. I did get the lab order for an Iron panel and ferritin, along with a thyroid panel so I will have those numbers. My free T numbers sucked before the weight loss and certainly are not better!

I really do appreciate your advice, this helps a lot!

 

[Belekas]

You are eating girls calories so no surprise your libido is tanked and you have ED and feeling meh. Key is to eat as much good food as possible and not deprive yourself of nutrients. So take Chronometer app and input everything you eat per day and see what minerals and vitamins you are lacking. I'm sure the deficit will be huge. Hows potassium, magnesium, calcium, sodim, etc? Up the good fats as well as they are crucial. Thing is if your goal is to lose some fluff you should be thinking about exactly it and not about libido/ED. Trying to do both is not how it works. Specific goals have specific outcomes and everything has a trade off. Remember we all are very different and unique and to know thyself will take a long time. For some of us its a lot easier and for others its a never ending puzzle.

TRT is no magic and a lot of guys end up feeling worse with time. 4-6 months is nothing and not even worth doing anything to be fair. Remember that TRT shuts down not only testosterone but tons of other hormones as well. Some guys develop adrenal insufficiency with time as it messes up cortisol production as well. Also TRT elevates E2 which impacts digestion and esp bile flow. So its not all rainbows and sunshines as most think it is. Just to name a few. And give you some different perspective. So you will never know until you try and give it a good go. Coming off won't be a problem but once you start seeing muscle/gym gains and other benefits that becomes harder and harder with time. The grass is always greener on the other side hehe

 

[VA-Hiker]

Appreciate the feedback and advice. I pretty much have lost the weight, I just want to build muscle now and gain weight. I did recently start using an app to track calories, however I'll look at Chronometer too. At least by tracking my food I've been able to concentrate on getting my calories to around 2200-2500/day now with about 160 grams proteins/day. Small steps, but it's going to take me a while to get this dialed in.

I completely agree TRT is not magic, and hence why I'm asking about it here. I have been very concerned about the downstream numbers other than fixing my Free T and lowering the SHBG. My E2 is also fairly low (even before I started losing weight it was too).

I am actually ok with staying on it for life if it really helps me. I'm trying to determine that timeframe for stopping if it is not helping, when/how do you know? Not seeing bloodwork changes, I would expect a honeymoon period if you will, but also expect a bit of a downturn as I adjust to it.

You are 100% correct though, I won't know unless I try it.

 

[Systemlord]

I'm trying to determine that timeframe for stopping if it is not helping, when/how do you know?

It can take years to reach the maximum benefits of TRT, most start to see significant improvements in 4 to 6 months. That’s not to say you can’t start experiencing benefits sooner.

I know someone who didn’t feel anything until after 5 months.

 

[Belekas]

Appreciate the feedback and advice. I pretty much have lost the weight, I just want to build muscle now and gain weight. I did recently start using an app to track calories, however I'll look at Chronometer too. At least by tracking my food I've been able to concentrate on getting my calories to around 2200-2500/day now with about 160 grams proteins/day. Small steps, but it's going to take me a while to get this dialed in.

Focos on nutrients, like vitamins and minerals each and every day. Many ignore and just go by calories. That will work as well but will be not optimal and with time you will run into issues. Fruit and vegetables, whatever you can tolerate, also great source of antioxidants. Yes, takes time to learn so baby steps, take notes, observe how you feel, log everything in Chronometer, and before you know it, it will be second nature.

I completely agree TRT is not magic, and hence why I'm asking about it here. I have been very concerned about the downstream numbers other than fixing my Free T and lowering the SHBG. My E2 is also fairly low (even before I started losing weight it was too).

Only one way to find out. It might work, might not. You must give it a fair go if you decide to pull the trigger. I'd say a year to know more or less if its benefiting you or not. Because most likely you will need to make a dose change or injection frequency change and all that takes time till stable hormone levels. And feeling like shit and having to wait ain't no party, if you know what I mean. But on the other hand you might feel great and barely any modifications to the protocol will be needed. Its all trial and error.

I am actually ok with staying on it for life if it really helps me. I'm trying to determine that timeframe for stopping if it is not helping, when/how do you know?

If you feel great in all areas that you want to see improvements thats all that matters. Then ofcourse the blood test numbers. So if you decide to start theres plenty of great advice in this forum. Go low and go slow would be my advice. Def don't start at 200mg right out the gate. 100mg/week and split into 2 injections E3.5D. Some do great on 1 injection per week, others opt for more frequent injections like EOD or even ED. With your high SHBG I would personally focus on bigger dose and less frequent injections so maybe 50mg E3.5D, give 8-12 weeks, see how you feel and run required bloods. Then reasses and take it from there. Def no AI and hCG is debatle, but more moving parts the harder to understand whats working whats not.

p.s. also make sure your thyroid, iron and ferritin, etc, is looking ok before starting so run some blood tests to know what your baseline is, besides all the hormone tests.

 

[Cataceous]

It's not clear if you have actually measured free testosterone. What is the lab? What are the units? What is the reference range? If this is Labcorp and the so-called "direct" test was used then it is useless and must not be relied on. The Vermeulen calculator puts your free testosterone at about 9 ng/dL, which is borderline, but should be adequate for most men. However, the accuracy of the calculator is also not a sure thing with your elevated SHBG. If you want to be more confident about where you stand then ensure your free testosterone test is based on equilibrium dialysis or ultrafiltration.

If you are determined to see if more testosterone is helpful then ask for a prescription for testosterone nasal gel. The name brand is Natesto. Generic versions are also available. With a nasal gel there is less of the hormonal disruption that @Belekas warned about. In my opinion this is the safest way to determine whether low testosterone is actually your problem.

 

[VA-Hiker]

Focos on nutrients, like vitamins and minerals each and every day. Many ignore and just go by calories. That will work as well but will be not optimal and with time you will run into issues. Fruit and vegetables, whatever you can tolerate, also great source of antioxidants. Yes, takes time to learn so baby steps, take notes, observe how you feel, log everything in Chronometer, and before you know it, it will be second nature.


Only one way to find out. It might work, might not. You must give it a fair go if you decide to pull the trigger. I'd say a year to know more or less if its benefiting you or not. Because most likely you will need to make a dose change or injection frequency change and all that takes time till stable hormone levels. And feeling like shit and having to wait ain't no party, if you know what I mean. But on the other hand you might feel great and barely any modifications to the protocol will be needed. Its all trial and error.



If you feel great in all areas that you want to see improvements thats all that matters. Then ofcourse the blood test numbers. So if you decide to start theres plenty of great advice in this forum. Go low and go slow would be my advice. Def don't start at 200mg right out the gate. 100mg/week and split into 2 injections E3.5D. Some do great on 1 injection per week, others opt for more frequent injections like EOD or even ED. With your high SHBG I would personally focus on bigger dose and less frequent injections so maybe 50mg E3.5D, give 8-12 weeks, see how you feel and run required bloods. Then reasses and take it from there. Def no AI and hCG is debatle, but more moving parts the harder to understand whats working whats not.

p.s. also make sure your thyroid, iron and ferritin, etc, is looking ok before starting so run some blood tests to know what your baseline is, besides all the hormone tests.

This is great advice, thank you! I am getting the other labwork done before I start. Along with nutrition. I actually eat a clean diet, just have not been eating enough of it.

 

[VA-Hiker]

It's not clear if you have actually measured free testosterone. What is the lab? What are the units? What is the reference range? If this is Labcorp and the so-called "direct" test was used then it is useless and must not be relied on. The Vermeulen calculator puts your free testosterone at about 9 ng/dL, which is borderline, but should be adequate for most men. However, the accuracy of the calculator is also not a sure thing with your elevated SHBG. If you want to be more confident about where you stand then ensure your free testosterone test is based on equilibrium dialysis or ultrafiltration.

If you are determined to see if more testosterone is helpful then ask for a prescription for testosterone nasal gel. The name brand is Natesto. Generic versions are also available. With a nasal gel there is less of the hormonal disruption that @Belekas warned about. In my opinion this is the safest way to determine whether low testosterone is actually your problem.

Thanks! You are correct, the lab is Labcorp. Attached is the report itself. I'm getting more labs done anyways, I can always add on a free testosterone via ED or UF as you suggested.

I really do appreciate the advice, this is not a decision I take lightly, if I start it I want to be sure. The clinics are happy to put you on I have found. Maybe it is the right answer, but I want to be sure.

 

[onetwonine]

I wouldnt consider trt with those numbers tbh

Especially if libido/ED is one of the issues you are trying to address. Search "libido" or "ED" on this or other trt forums and you will see how many problems you are risking.

 

[Golfboy307]

I had SHBG in the low 60's on total T of 400 when I started TRT 8 years ago at age 48. Fast forward after several protocol changes, and I run around 900 total T with SHBG at 32. The exogenous T had the intended effect, keeping my free T now in the upper middle range. More importantly, I continue to enjoy the physical, mental and sexual benefits of TRT. My protocol is 90 mg/week Test Cyp IM, split in three doses.

 

[Systemlord]

I wouldnt consider trt with those numbers tbh

His Free T is below the normal ranges and even if they were in the bottom 25 percentile, which many experts agree is a sign of hypogonadism, how does this not warrant treatment when symptoms are present?

Especially if libido/ED is one of the issues you are trying to address. Search "libido" or "ED" on this or other trt forums and you will see how many problems you are risking.

This represents the minority of men.

Testosterone replacement therapy is associated with high satisfaction rates: results of a survey study - PubMed

Despite a well-documented increase in both the prevalence of Testosterone Deficiency (TD) and prescription of testosterone replacement therapy (TRT), few studies have investigated the preferences of patients receiving TRT and factors associated with increased treatment satisfaction. To...

pubmed.ncbi.nlm.nih.gov

 

[onetwonine]

His Free T is below the normal ranges and even if they were in the bottom 25 percentile, which many experts agree is a sign of hypogonadism, how does this not warrant treatment when symptoms are present?


This represents the minority of men.

Testosterone replacement therapy is associated with high satisfaction rates: results of a survey study - PubMed

Despite a well-documented increase in both the prevalence of Testosterone Deficiency (TD) and prescription of testosterone replacement therapy (TRT), few studies have investigated the preferences of patients receiving TRT and factors associated with increased treatment satisfaction. To...

pubmed.ncbi.nlm.nih.gov

It's up to him. I'm just offering my opinion.

He could try lower SHBG naturally. It's what I would do if i had a 900 TT.

I don't think 63% positive is a glowing endorsement for TRT. I don't have access to the full text of that study. But from the bits and pieces that are available:

I would point to the fact it seems to be limited to patients of a clinic that are currently recieving treatment, I can't see any mentions of treatment drop outs. (surely this skews the results positive - why would you be on treatment if you didnt see some sort of benefit)

It makes no mention of pre treatment levels (how many started with a TT of 900)

It is of limited scope in terms of time (6 months - I have had had many months where i felt incredible that were not sustainable)

Whatever the case. I'm just pointing out to OP that trt is not always the fix and that there are risks. Especially to EQ and libido - and that he has to go no further than read these forums which are inundated with people are dealing with negative outcomes for both.

Its not that easy to stop once you've been on for a while (the 37% who are unhappy with trt but still at the clinic being case in point). I'm in the middle of trying and its tough. Took me years to even start getting off.

Spent a lot of time trying to nail down the perfect protocol that was the answer to all my issues. Many gurus online and off gave me one thing to change or another saying that it would work. It never happened. My experience has lead me to have a negative bias on TRT.

Maybe it is his silver bullet idk. There were certainly moments of sunshine for me.

End of the day- Not a desicion I can make for him. Just urging caution.

 

[Systemlord]

He could try lower SHBG naturally.

Either his Free T levels are low and warrant treatment or there not, which is it?

Lowering high SHBG is a fools errand.

Also, lowering SHBG will not increase Free T. SHBG doesn’t increase Free T, no mechanism for that.

LH stimulation within the testicles is the main driver of T production. In some cases high SHBG is a direct result of low testosterone, since androgens suppress SHBG.

His SHBG is over 100 (!), let’s not fool ourselves here, there’s no fixing this naturally.

My experience has lead me to have a negative bias on TRT.

If you had an extremely positive experience on TRT, would you not be giving this guy your glowing recommendation?

These’s an old saying, a drowning man will drag you down with him.

 

[VA-Hiker]

I had SHBG in the low 60's on total T of 400 when I started TRT 8 years ago at age 48. Fast forward after several protocol changes, and I run around 900 total T with SHBG at 32. The exogenous T had the intended effect, keeping my free T now in the upper middle range. More importantly, I continue to enjoy the physical, mental and sexual benefits of TRT. My protocol is 90 mg/week Test Cyp IM, split in three doses.

My initial numbers weren't too far off where yours were. So far my efforts (while significant with >40 lb weight loss) resulted in a much higher SHBG and lower free testosterone. Exogenous testosterone certainly would help improve the numbers.

One of the things I really appreciate about this forum is I am getting opinions on the good and bad. I know my experience may differ and it will take time to fix, and may not always be great there may be benefit to doing it beyond making labwork look better. Thanks!