Considering TRT based on bloodworkx2

[zillapod]

Hi All,
40 yr old new member here. After experiencing symptoms over the last decade or so (fatigue, brain fog, reduced libido and erection quality more recently) my primary care Dr. ran a bloodwork panel including Testosterone, which was done at 9am and fasting. Testosterone results were:

Test - 3.72 ng/mL (range 2.8-8.0)
SHBG - 40 (range 17-56)
Test-Free - 61 (range 47-244)
Test Free %, Caculated: 1.6

It seemed fairly low considering my age and given that I've got a pretty good diet and exercise regimen, rarely drink, don't smoke, etc. and get plenty of hours of sleep consistently. My Dr. said it was in the normal range so nothing to be worried about, so I decided to go to a local TRT clinic (GameDay Health) for a free test one month later. The result of this blood test is:

Total Testosterone: 282 ng/dL

That was the only number given, apparently I need to repeat the test again next week and if below 300 then it would be covered by insurance, and that is when I will sit down with the Dr. to go over the more comprehensive results (and of course ask the suggested questions from the excelmale sticky!) Over the phone they gave me the price of a flat $295 per month cash pay for T, hcg injections weekly, plus all labs and followup appts.

Any feedback on the above test results is greatly appreciated. Also any feedback on using a TRT clinic vs. a traditional endocrinologist, etc? I'm guessing they'll want to rush me into starting next week. There is another TRT clinic in my general area that was listed on the suggested excel male provider link (Total T clinic), so I may do the free consult there as well. They are in a much less convenient location for me though so it would have to really make a difference being a suggested provider.

Thanks to all, I know there is a lot go digest here but appreciate any and all feedback!

 

[blinkyvx]

you can get better pricing for TRT clinics, i started at a place they want 130$/month for instance.

other labs done as well,
estradiol [E2],
prolactin [ if ED or emotional issues]
DHEA-S, DHT, full thyroid panel
fatigue; possible iron,ferritin etc
Includes many thyroid tests docs wont order for you and argue over, but its useful info.

Most docs once your numbers are normal range will stop increasing your dose FYI regardless of symptoms.. If insurance covers i would start with the doc route and get something started. As well as look into clinics.

dont do weekly or bi weekly or monthly whatever you do. Every day is even a option. Numbers like that i would argue to start ASAP.. High SHBG means much of your T is locked cant be used

 

[Sean Mosher]

I would focus on whether or not they are going to give you a cookie cutter protocol or actually treat you as an individual.
That's one of the biggest things to consider if not THE biggest thing to consider.
Wouldn't hurt to see a little bit more extensive labwork including thyroid.
You can check out discountedlabs.com for some ideas on what to test.
Pre-TRT panel, TRT follow-up panel, etc....

 

[Systemlord]

Your doctor is right about one thing, your levels are normal, for my 87 year old father. This is nothing more than an attempt at insurance institutions setting the bar low, but for your doctor to tell you that your levels are normal is a slap in the face and an insult.

No loss because he probably doesn't even know how to manage men on TRT anyway, it's a blessing in disguise. Defy Medical is another option and is a telemedicine clinic staffed with doctors that don't play game, they are skilled at replacing hormones.

And another thing, in range doesn't mean its healthy.

 

[zillapod]

Thanks so much! Below is additional bloodwork my primary Dr. ran initially, all of which she again said was in the normal ranges. Does this list cover everything other than prolactin and estradiol? Also should I be concerned if they don't suggest a rectal exam for prostate? I've never had that done before to check. Also, the second result of 282 was not in a fasted state, the TRT clinic said I didn't need to fast for that. Is that concerning that the TRT clinic wouldn't want/need a full panel of fasted labs?

Regarding the price as well, interestingly enough they said the cash pay would be cheaper, since i have a $30 copay each weekly visit and 30% coinsurance on the medicine and that Hcg was not covered by my insurance so it would be $70-$80 per week vs $295/month.

Thanks for all your help in this very big decision process for me!

Glycosated HGB(A1C): 5.3
Triglycerides: 43
Cholesterol: 147
HDL: 52
LDL: 86
Non-HDL: 95
TSH, Blood: 1.73

Glucose: 100
BUN: 17
Creatinine: 0.96
Sodium: 141
Potassium: 4.3
Chloride: 102
Bicarbonate: 27
Anion Gap: 12
Calcium: 9.0
Total Protein: 6.7
Albumin: 4.9
AST: 19
ALT: 11
Alkaline Phos: 53
GFR: >60
Bilirubin: 0.86

Vit B12: 715
Vit D: 33
WBC: 6.3
RBC: 4.69
Hgb: 14.2
Hct: 41.8
MCV: 89.1
MCH: 30.3
MCHC: 34
RDW: 12.9
MPV: 10.4
Pit Count: 226
ANC-Auto: 4.4
Abs Lymphs: 1.5
Abs Monos: 0.4
Segs: 69%
Lymphocytes: 23%
Monocytes: 6%
Eosinophils: 2%
Basophils: 1%
Abs Eosinophils: 0.1
Abs Basophils: 0.0

 

[Vince]

Did you have your LH and FSH to see if have secondary or primary hypogonadism. Also I would have my thyroid checked at least once TSH, free T4, free T3, reverse T3 and both antibodies.

 

[zillapod]

Hopefully they check those things at this TRT clinic. It's tough to tell because they need two blood tests under 300 to see confirm insurance coverage, so I did the first one and got the total T result but nothing else, so I don't even know what all they test for. I will repeat the test again this week and actually meet with the Dr. so my hope is that I will then get a more thorough report including all of the above FSH, LH, thyroid and estradiol, prolactin, etc.

I'm a cynic by nature, and approaching this cautiously so any other advice on how to verify if this clinic knows their stuff? They are newer, opened in Jan 2018. I'm hoping to see all the bloodwork results mentioned above, not get a rushed sales pitch like I'm buying a gym membership or something, and also an honest discussion of the pros and cons to this. They don't require any fasting for the bloodwork at this clinic, is that common or a possible red flag?

I'm also wondering about how quickly I'll get tired of the 20 minute one way drive to/from the office each week, I'm assuming that at some point most people move toward self injection for that reason? Is it a red flag if they never "allow" people to progress to that? My wife has administered flu shots so I'm guessing this is somewhat similar and not too difficult?

 

[Systemlord]

If this clinic doesn't allow self injection at home, it tells me they only care about profit, they charge you for administering the injections. You're a grown man, you can self inject at home and there is no reason why a clinic should treat you like an invalid.

Visiting the clinic 52 times a years, this gets old fast and will ruin any week long vacation. Besides not everyone will do well on weekly injections, treatment needs to be tailored to the individual.

I self inject daily using 29 gauge insulin syringes.

 

[Vince]

Hopefully they check those things at this TRT clinic. It's tough to tell because they need two blood tests under 300 to see confirm insurance coverage, so I did the first one and got the total T result but nothing else, so I don't even know what all they test for. I will repeat the test again this week and actually meet with the Dr. so my hope is that I will then get a more thorough report including all of the above FSH, LH, thyroid and estradiol, prolactin, etc.

I'm a cynic by nature, and approaching this cautiously so any other advice on how to verify if this clinic knows their stuff? They are newer, opened in Jan 2018. I'm hoping to see all the bloodwork results mentioned above, not get a rushed sales pitch like I'm buying a gym membership or something, and also an honest discussion of the pros and cons to this. They don't require any fasting for the bloodwork at this clinic, is that common or a possible red flag?

I'm also wondering about how quickly I'll get tired of the 20 minute one way drive to/from the office each week, I'm assuming that at some point most people move toward self injection for that reason? Is it a red flag if they never "allow" people to progress to that? My wife has administered flu shots so I'm guessing this is somewhat similar and not too difficult?

I've never had anyone inject testosterone for me. I learned by watching Nelson Vergel video on injecting testosterone and HCG.

 

[blinkyvx]

it should be a medical assistant visit for free, i.e if i go to docs for lab draw its no co pay, as i dont see the doctor.

if they don't let you do your own shot go somewhere that will so you can dose how you see fit on your schedule. Many do daily and find benefits.

 

[zillapod]

Followup re-test at the TRT clinic today - 220 total T. Got to meet with the provider/prescriber who is a nurse practitioner. I'm a little hesitant and said no to starting today because:

- They make you come in to inject every week if covered by insurance, but allow home injection on cash pay. That seemed strange and a little fishy as they really seemed to push toward the cash pay for whatever reason. I qualify for insurance based on levels below 300, so I'd like to use that option if possible. They seem to make the numbers line up to be roughly the same cost ($295 per month cash pay all inclusive) whether cash or insurance. I'm not going to be able to drive there every week indefinitely.

- They only test Total T, Hematocrit and PSA prior to starting you on testosterone injections, then at 6 months test other stuff like SHGB and estradiol. They don't seem to monitor bloodwork other than a monthly total testosterone and hematocrit, So other than maybe the 6 month check, I gathered that they leave you to monitor your Lipids, CBC stuff with your primary care Dr. or other. I'd love to have a one stop comprehensive approach to this. Are the online clinics more comprehensive with screening, establishing a diagnosis, and treatment monitoring?

- They start everyone at 100mg injections per week along with HCG and adjust from there regardless of starting point, up to 200mg as needed. No option of creams, starting with just Test, or just HCG or anything to stimulate your own production like some other members have mentioned doing first.

- I'm sure the nurse practitioner is competent, but I'd somehow feel more comfortable with someone who looked at the total picture? I really got the feeling I should go see a traditional endocrinologist, tell them I'm considering TRT and ask to check out the complete picture before I start. Not sure how willing they will be to play that game though, if they aren't a fan of TRT. Then if everything else is fine and low testosterone is the only flag, then I go back to the TRT clinic and start (assuming the endocrinologist is more old school and won't prescribe me). I set up an endo appointment for 11/6, hopefully I don't get the runaround there as well. I'm checking out the other TRT clinic next week as well.

Not sure who is better to work with on this, an endocrinologist that doesn't prescribe TRT much, or a nurse practitioner with 300+ current patients?

Feedback on the above concerns appreciated! I just want to be extra thorough before making such a big commitment.

 

[zillapod]

So I finally got the endo to run the FSH and LH tests, and re-do T test as well:

FSH - 10.9 (range 1.4-18.1)
LH - 2.6 (no range given)
Total T - 542ng/dL (range 240-870)

Big curveball, as previous total test was at 372, then 282, then 220, and now 542? What the heck? The 372 and 542 were fasted at 8am, the 282 and 220 were not fasted and were at 9am.

Anyone seen huge swings like this before? I definitely have symptoms, but if I'm believing the 542 number then it has me thinking differently about starting TRT?

Thanks for any insight! I meet again with the Dr. next week to review results.

 

[fifty]

Most blood tests are a magic 8-ball

 

[Systemlord]

Anyone seen huge swings like this before?

Fluctuations in SHBG can cause fluctuations in TT and therefore FT as well. When SHBG is higher, TT is expected to increase while FT decreases, so when TT is lower, FT is higher.

You need consistency, high TT with high FT in the high normal ranges the majority of the time and not just on occasion or there will be symptoms. Give it a couple more years and you be consistency below range most or all of the time.

 

[prouser]

I know your post is a bit old, but appreciated your feedback in re: to GameDay. I considered going there, but after watching the videos they produced (which it appears they have taken down now/replaced) I just didn't get a good vibe. Felt very amateurish/cash grab.

If it helps any, I've been to Total T Clinic although I never started treatment with them. They have a one time $295 lab-work fee (my insurance covered). After that the first 6 months are $299, months after that $249. Pretty expensive.

They take insurance, but at least in my case were really wishy-washy as to whether or not it was covered.

They will let you inject at home after initially starting in-house, but you have to go in once a month to pick up the drugs.

They don't test for LH, FSH, SHBG, or E2 Sensitive. I asked about the LH and FSH, they said they don't really care what those values are because the treatment is the same regardless. They do weekly butt injections, no sub Q. After reading more about the impact of SHBG I became a little concerned they didn't test that and thought they may cookie-cutter treatment.

Also their back end/overall communication is IMHO really poor. I've sent them emails and tried to get in contact with their billing person. No responses. I literally signed up, but feel like I have to chase them to respond... not the way it should be IMHO.

I haven't signed up w/ Defy yet, but spoke to their onboarding person. The communication there and overall response blows Total T out of the water. Not even the same ballpark.

If only there were well known/knowledgeable Endo's in this area that took insurance...

 

[Systemlord]

If only there were well known/knowledgeable Endo's in this area that took insurance...

A knowledgeable TRT doctor is a premium service and are in high demand and therefore can demand a premium price and need to cut out the cancer that is insurance companies if they are going to show a positive health outcome.

There's nothing worse than a doctor starting treatment only to have the insurance company deny reimbursement for services rendered.

 

[zillapod]

THank you prouser for the feedback/warnings on Total T!! Maybe I'll talk to someone at Defy and just get a feel for everything with them. I guess I'd wonder why pay the $300 per month if there is no real fine tuning of treatment with Total T, when Defy would be what looks like half the price.

Are there even any TRT knowledgeable endos or other Dr's around San Diego that don't do insurance? I'd cash pay for a good local Dr. I'm seeing a new primary care Dr. in 2 weeks, his bio online says "primary care with special interests in men’s health, testosterone replacement therapies" so I'm hoping at least he'll be knowledgeable.

I'd like to do something like Defy, but have an annual checkup with a knowledgeable primary care Dr. to run our own labs and have someone local I can independently consult if issues arise (assuming this primary care Dr. would not write a script but maybe he will). My only concern is if he tells me in 2 weeks that I don't need TRT, then I start with Defy anyway, would he be insulted by that and not help me?

 

[Systemlord]

My only concern is if he tells me in 2 weeks that I don't need TRT, then I start with Defy anyway, would he be insulted by that and not help me?

If you doctor feels insulted because you want to go on TRT to improve your health, who cares about his feelings, this is about you increasing your T to healthy levels. If you GP is strongly against you going on TRT, then he is probably not well educated on the subject of hormone therapies.

 

[prouser]

THank you prouser for the feedback/warnings on Total T!! Maybe I'll talk to someone at Defy and just get a feel for everything with them. I guess I'd wonder why pay the $300 per month if there is no real fine tuning of treatment with Total T, when Defy would be what looks like half the price.

Are there even any TRT knowledgeable endos or other Dr's around San Diego that don't do insurance? I'd cash pay for a good local Dr. I'm seeing a new primary care Dr. in 2 weeks, his bio online says "primary care with special interests in men’s health, testosterone replacement therapies" so I'm hoping at least he'll be knowledgeable.

I'd like to do something like Defy, but have an annual checkup with a knowledgeable primary care Dr. to run our own labs and have someone local I can independently consult if issues arise (assuming this primary care Dr. would not write a script but maybe he will). My only concern is if he tells me in 2 weeks that I don't need TRT, then I start with Defy anyway, would he be insulted by that and not help me?

Just to be clear - I haven't actually been treated by Total T. They may be amazing once you actually get started. IMHO they dropped the ball prior to that though for failure to communicate effectively and less than ideal initial blood work. Which, at least in my mind, is pretty important for something like this.

I'd be curious to know if your new doctor is any good.

I have also considered what you are thinking as well. My primary endo has been prescribing TRT for something like 20 years and seams knowledgeable on the subject. That said, he was against prescribing anything as my levels seem to bounce just below and just above 300 pretty frequently. He also said his hands are tied with results over 300 (big practice). I told him I might go private then, and he still discouraged it but didn't seem overly against continuing to help monitor my health, etc. I suspect doctors would be open to it, as the legal risk is on the prescribing doctor.

In theory one could overlap the follow up bloodwork with [Defy/Insert any other provider here] with the regular doctor/endo. That would give 2 sets of eyes, and additional bloodwork (covered by insurance).

Still though, an ideal world would be a one stop shop without additional costs. The drugs are dirt cheap even w/o insurance, and insurance covers basically all blood work. It's just a matter of finding a good knowledgeable doctor who can prescribe and is on the ball.