Is this primary or secondary hypogonadism?

[FunkOdyssey]

I'm a couple weeks into TRT now so that decision has been made, however I am wondering how I would be classified based on these labs. I took some tests twice, about a week apart, to verify the results. I'm a high SHBG, low Free T type of guy, with an elevated FSH. I haven't been able to find much information about the significance of high FSH in the absence of high LH. The sertoli cells are not happy I guess?

I suppose a second question would be, would you also have started TRT with these lab values combined with the full compliment of low T symptoms?

	Test #1	Test #2	Range
LH	3.8 mIU/mL	3.6 mIU/mL	1.5 - 9.3 mIU/mL
FSH	10.5 mIU/mL	10.0 mIU/mL	1.6 - 8.0 mIU/mL
Total Testosterone	612 ng/dL	609 ng/dL	250 - 1100 ng/dL
Free Testosterone	66.7 pg/mL	63.9 pg/mL	35.0 - 155.0 pg/mL
Estradiol (Sensitive)	24 pg/mL		<= 29 pg/mL
Progesterone	<0.1 ng/mL		<= 0.2 ng/mL
Prolactin	2.7 ng/mL		2.0 - 18.0 ng/mL
SHBG	56 nmol/L	51 nmol/L	10 - 50 nmol/L

 

[tareload]

Door number 3: Eugondal.

Where is your low fT number? I see an in range fT by Quest ED (it appears). For your reference:

Realistic TRT Recomp Progress

Yep, same dose of T

forums.t-nation.com

 

[tareload]

 

[FunkOdyssey]

Door number 3: Eugondal.

Where is your low fT number? I see an in range fT by Quest ED (it appears).

Thank you for your reply readalot. I've been reading alot here and on t-nation and find your posts very informative and well-researched. You are probably saving some lives by highlighting the risks of high hematocrit.

I don't think a diagnostic algorithm that depends on a certain threshold of total testosterone before considering free testosterone is useful in scenarios where SHBG is out-of-range high. It makes more sense to jump directly to free testosterone in that case. I have observed that my free testosterone, which you well know correlates better with hypogonadal symptoms than total testosterone, is actually lower than many men whose total testosterone is below 300 ng/dL.

So what value of free testosterone threshold should be used to define hypogonadism? I found a useful table in Nelson's book:

It seems I would be considered hypogonadal based on the thresholds of multiple medical associations above. I don't know how exactly Quest established their reference range, but I would assume they have included old and obese men. In my opinon, the most useful reference range for both total and free testosterone is based on a cohort of healthy, non-obese men ages 19-40 from the Framingham Heart Study: Reference Ranges for Testosterone in Men Generated Using Liquid Chromatography Tandem Mass Spectrometry in a Community-Based Sample of Healthy Nonobese Young Men in the Framingham Heart Study and Applied to Three Geographically Distinct Cohorts

These are the sort of men I want to compare myself with, and my free T values are below their 2.5th percentile and would be flagged as out-of-range low.

The calculated values you provided are interesting but I don't know how relevant they are when I have actual measurements via "gold-standard" equilibrium dialysis already.

Beyond the T values, I also respond yes to 9 out of 10 items on the ADAM survey and have long-standing borderline anemia of the normochromic, normocytic variety which supports the diagnosis.

 

[tareload]

Thank you for your reply readalot. I've been reading alot here and on t-nation and find your posts very informative and well-researched. You are probably saving some lives by highlighting the risks of high hematocrit.

I don't think a diagnostic algorithm that depends on a certain threshold of total testosterone before considering free testosterone is useful in scenarios where SHBG is out-of-range high. It makes more sense to jump directly to free testosterone in that case. I have observed that my free testosterone, which you well know correlates better with hypogonadal symptoms than total testosterone, is actually lower than many men whose total testosterone is below 300 ng/dL.

So what value of free testosterone threshold should be used to define hypogonadism? I found a useful table in Nelson's book:

View attachment 23565

It seems I would be considered hypogonadal based on the thresholds of multiple medical associations above. I don't know how exactly Quest established their reference range, but I would assume they have included old and obese men. In my opinon, the most useful reference range for both total and free testosterone is based on a cohort of healthy, non-obese men ages 19-40 from the Framingham Heart Study: Reference Ranges for Testosterone in Men Generated Using Liquid Chromatography Tandem Mass Spectrometry in a Community-Based Sample of Healthy Nonobese Young Men in the Framingham Heart Study and Applied to Three Geographically Distinct Cohorts

View attachment 23566

These are the sort of men I want to compare myself with, and my free T values are below their 2.5th percentile and would be flagged as out-of-range low.

The calculated values you provided are interesting but I don't know how relevant they are when I have actual measurements via "gold-standard" equilibrium dialysis already.

Beyond the T values, I also respond yes to 9 out of 10 items on the ADAM survey and have long-standing borderline anemia of the normochromic, normocytic variety which supports the diagnosis.

Excellent summary and thanks for taking the time to provide your analysis and thoughts on approaching T therapy. Until free T measurements get standardized we don't know what all these different ranges on ED methods and calculated ranges really mean. I wish you much success testing the hypothesis raising your fT levels will improve your symptoms. You have an ED fT benchmark and can compare against that with subsequent testing so way to go. Looking forward to hearing more!

Best.

 

[Systemlord]

I haven't been able to find much information about the significance of high FSH in the absence of high LH. The sertoli cells are not happy I guess?

The high FSH likely means infertility, in other words no sperm is causing an increase in FSH.

So what value of free testosterone threshold should be used to define hypogonadism?

Recommendations on the diagnosis, treatment and monitoring of hypogonadism in men

Hypogonadism or Testosterone Deficiency (TD) in adult men as defined by low levels of serum testosterone accompanied by characteristic symptoms and/or signs as detailed further on can be found in long-recognized clinical entities such as Klinefelter syndrome, ...

www.ncbi.nlm.nih.gov

Unfortunately, no consensus has been reached regarding the lower TT threshold defining TD, and there are no generally accepted lower limits of normal TT [60]. This lack of consensus follows from the fact that no studies have shown a clear threshold for TT or free T that distinguishes men who will respond to treatment from those who will not.

Meanwhile the number of CAG (cytosine–adenine–guanine triplet) repeats in androgen receptor differs in men and influences the androgen receptor activity. Hence testosterone sensitivity may vary in different individuals.

The same applies to androgen receptor gene CAG repeat lengths >24 in the presence of symptoms and normal testosterone levels may be considered as a state of preclinical hypogonadism

 

[Vince]

I'm a couple weeks into TRT now so that decision has been made, however I am wondering how I would be classified based on these labs. I took some tests twice, about a week apart, to verify the results. I'm a high SHBG, low Free T type of guy, with an elevated FSH. I haven't been able to find much information about the significance of high FSH in the absence of high LH. The sertoli cells are not happy I guess?

I suppose a second question would be, would you also have started TRT with these lab values combined with the full compliment of low T symptoms?

	Test #1	Test #2	Range
LH	3.8 mIU/mL	3.6 mIU/mL	1.5 - 9.3 mIU/mL
FSH	10.5 mIU/mL	10.0 mIU/mL	1.6 - 8.0 mIU/mL
Total Testosterone	612 ng/dL	609 ng/dL	250 - 1100 ng/dL
Free Testosterone	66.7 pg/mL	63.9 pg/mL	35.0 - 155.0 pg/mL
Estradiol (Sensitive)	24 pg/mL		<= 29 pg/mL
Progesterone	<0.1 ng/mL		<= 0.2 ng/mL
Prolactin	2.7 ng/mL		2.0 - 18.0 ng/mL
SHBG	56 nmol/L	51 nmol/L	10 - 50 nmol/L

I would check your magnesium levels. Even if they're in a good range, you may want to increase it because of your High SHBG. Higher magnesium levels will increase your testosterone and free testosterone.

 

[FunkOdyssey]

I would check your magnesium levels. Even if they're in a good range, you may want to increase it because of your High SHBG. Higher magnesium levels will increase your testosterone and free testosterone.

Thank you for the suggestion. I do have normal range magnesium on the tests I've taken. I have trouble with magnesium supplements because they tend to aggravate my reflux problems. I suspect they relax the lower esophageal sphincter.

The high FSH likely means infertility, in other words no sperm is causing an increase in FSH.

That's interesting. I was able to have a child a few years ago in spite of the elevated FSH, which has been consistent since I first tested it in my early 20's. Maybe its a borderline case.

 

[Systemlord]

	Test #1	Test #2	Range
LH	3.8 mIU/mL	3.6 mIU/mL	1.5 - 9.3 mIU/mL

The lower LH and low testosterone is secondary hypogonadism. The is a blurry line here because so much is unknown, like your AR gene CAG repeat lengths.

If you have insensitive receptors, or are experiencing symptoms of low-T, then this is secondary hypogonadism.

 

[FunkOdyssey]

I don't want to get too excited, but I'm 2 1/2 weeks into 10.5 mg test cyp daily and I just had sex without a PDE5 inhibitor for the first time in 15+ years! Nocturnal erections and morning wood have also returned after many years absence.

 

[Systemlord]

don't want to get too excited, but I'm 2 1/2 weeks into 10.5 mg test cyp daily and I just had sex without a PDE5 inhibitor for the first time in 15+ years! Nocturnal erections and morning wood have also returned after many years absence.

I'm not surprised at all, seen this 100x over the years on these TRT boards.

Please do enjoy all the benefits coming your way, because this is just the tip of the iceberg.

 

[FunkOdyssey]

We talked about the accuracy and comparability of free testosterone testing on other threads, and I've said I feel good about Quest because it's equilibrium dialysis and it's so mainstream that I have lots of men to compare to. Well, check this guy out and his Quest labs:

Am I Just Lazy? (Reddit)

His total T is 268 ng/dL and free is 68.1 pg/mL. A clear cut case of hypogonadism where everyone feels bad for him and encourages him to jump on TRT. He'll have the support of everyone in the medical field, including mainstream endocrinologists. And, he's got more free testosterone than I did at 600+ ng/dL total! This is why I'm so vocal for the high SHBG guys -- we are falling through the cracks with standard diagnosis methods.