Low Energy / Low Libido / Poor Sleep / High Cortisol / Low (Free) T (?)

[John123]

Hi guys,

I would really appreciate your help.

I am 29 years old. I have problems with low energy, low libido, weak erections (and no morning/spontaneous erections at all) and poor sleep (trouble falling asleep, waking up in the middle of the night). It’s been really bad in the last year, but I have all the symptoms to some degree for many years now.

I had thrombocytopenia in my childhood and adolescence. My thrombocytes are now in the low normal range.
I also had a surgery for undescended testicle in my childhood.

I go to the gym 3 times a week, go for a run once or twice a week and eat a balanced diet.

I got my blood tested 3 times in the last 2 months.


1st blood test results, general lab:
S-TSH: 3.00 mIU/L (lab’s normal range: 0.27 - 4.20)
S-Prolactin: (H) 533.5 mIU/L (86 - 324)
S-Estradiol: 131.8 pmol/L (41.4 - 159)
S-Progesterone: (H) 1.39 nmol/L (0.16 - 0.47)
S-Testosterone, total: 18.41 nmol/L (n. r.: 8.64 - 29.0)
S-DHEA-S: 7.54 µmol/L (n. r.: 4.34 - 12.2)
S-Cortisol: (H) 589.2 nmol/L (n. r.: 166 - 507)
S-Vitamin D: (L) 26.87 µg/L (n. r.: > 30)


Based on high prolactin, progesterone and cortisol my lab doctor suggested I visit endocrinologist.


2nd blood test results, endocrinologist:
S-TSH: 2,75 mE/L (0,59 - 4,23)
S-pT4: 18,3 pmol/L (11,3 - 18,8)
S-pT3: 5,61 pmol/L (3,79 - 6,05)
S-Progesterone: 1,0 nmol/L (0,86 - 2,9)
S-25-OH Vitamin D: (L) 54,7 nmol/L (75-200)
S-Cortisol: 430 nmol/L (138-690)
S-DHEA-S: 8,01 µmol/L (2,17 - 15,20)
S-SHBG: 27,2 nmol/L (10 - 57)
S-Testosterone, Total: 13,90 nmol/L (5,55 - 25,17)
S-Free Testosterone: 48,5 pmol/L (30,15 - 189,8)
S-Androstendion: 4,3 nmol/L
S-Prolactin pool: 4,7 µg/L (2,5 - 17,0)
Hemoglobin: 154 g/L (130 - 170)
Hematocrit: 0,448 (0,400 - 0,500)


Obviously, endocrinologist’s lab ranges are different than ranges from previous lab. Progesterone would still be high for the previous lab, but here it’s normal. Prolactin values are different in this test, so I’m not sure.
Cortisol seems high to him, he suggests a Dexamethasone suppression test. I’m still waiting for the results.
Vitamin D still low, endocrinologist prescribes Vitamin D supplementation.
Total testosterone is low for my age, so he suggests additional test.
Free T also seems a bit low to me, considering the ranges, but endocrinologist doesn’t comment on it clearly.


3rd blood test results, endocrinologist:
S-FSH: 10,7 E/L (0,7 - 11,1)
S-LH: 9,0 E/L (0,8 - 7,6)
S-SHBG: 27,0 nmol/L (10 - 57)
S-Testosterone, Total: 17,5 nmol/L (5,55 - 25,17)
S-Free Testosterone: 48,5 pmol/L (30,15 - 189,8)
Hemoglobin: 153 g/L (130 - 170)
Hematocrit: 0,445 (0,400 - 0,500)


Total T is now better, free T exactly the same.
Endocrinologist says it's possible there might be a problem with my testicles, since LH is pretty high in his opinion. He suggests ultrasound of the scrotum.
He also suggests testing for sleep apnea.
He said that my results do not suggest urgent treatment, but based on my symptoms and my otherwise healthy lifestyle he has no problems prescribing me TRT if I choose so.
He suggests that I wait for my vitamin D to be in the normal range and wait for my ultrasound, DST and sleep apnea results, and then, if I still feel weak, start the TRT treatment.
But I can also choose to start TRT immediately.


I have two options for TRT:
- 50mg Androgel satchets
- Testosterone Undecanoate (Nebido) 1000 mg injection every 3 months


My questions:
1. What is your general opinion of my lab results?
2. How do you interpret my free testosterone? Is it logical that it was the exact same number twice in a row? How low is it in your opinion? Low enough to be the cause of my symptoms?
3. Should I start TRT immediately (I really feel horrible) or wait?
4. Would you rather start with Androgel or Nebido?
5. Is it possible I would not need TRT if I get my Vitamin D and my sleep in order?
6. How big of a risk is it to start TRT with undiagnosed sleep apnea?


Thank you in advance!

 

[Vince Carter]

You're not Low T by any means and I would not recommend TRT. Most of the guys on this forum would love to have those numbers without TRT. I would work on the sleep, Vit-D. I don't really see the Thyroid problem, TSH is a little elevated but your T3 and T4 look fine to me.

I would suggest if you do more labs and money allows you to do them as Thryoid encompasses a few more tests that youve been given to get a good picture. Ferritin/Iron can effect T4 conversion to T3 and/or T3 getting in the cells.

TSH
Free T3
Free T4
Antibodies
Reverse T3
Ferritin
Iron

 

[Gman86]

You're not Low T by any means and I would not recommend TRT. Most of the guys on this forum would love to have those numbers without TRT. I would work on the sleep, Vit-D. I don't really see the Thyroid problem, TSH is a little elevated but your T3 and T4 look fine to me.

I would suggest if you do more labs and money allows you to do them as Thryoid encompasses a few more tests that youve been given to get a good picture. Ferritin/Iron can effect T4 conversion to T3 and/or T3 getting in the cells.

TSH
Free T3
Free T4
Antibodies
Reverse T3
Ferritin
Iron

I don't think many guys on here would “love” to have free testosterone levels in the lower quartile of the range, and E2 in the upper quartile of the range. Sounds like the opposite of what we want. When my free testosterone was similar to this I was definitely symptomatic. And that was with my E2 within range. If my E2 was as high as his with low free t, I would imagine I would of felt even worse.

I agree with you Vince about getting those other labs done though. To rule out thyroid being an issue, you'd have to get those labs above done. The thyroid can look perfect, but if reverse T3 is high, you're most likely going to have all the symptoms of hypothyroidism.

 

[ratbag]

If his morning cortisol is high then it's likely his diurnal rhythm is off and would explain why he's not sleeping at night. He would have to verify this with 4 x cortisol saliva labs

 

[lexer]

Many guys here have had similar issues until they had their thyroid checked. Get your thyroid levels checked.
tsh, free t4, free t3 for starters.

 

[Vince Carter]

I don't think many guys on here would “love” to have free testosterone levels in the lower quartile of the range, and E2 in the upper quartile of the range. Sounds like the opposite of what we want. When my free testosterone was similar to this I was definitely symptomatic. And that was with my E2 within range. If my E2 was as high as his with low free t, I would imagine I would of felt even worse.

I agree with you Vince about getting those other labs done though. To rule out thyroid being an issue, you'd have to get those labs above done. The thyroid can look perfect, but if reverse T3 is high, you're most likely going to have all the symptoms of hypothyroidism.

Point taken but most of the guys here wouldn't be on TRT if they had those numbers, just as in they show up here with much worse in that regard.

 

[Vince Carter]

Many guys here have had similar issues until they had their thyroid checked. Get your thyroid levels checked.
tsh, free t4, free t3 for starters.

and you left off two of the crucial ones. No test for antibodies so no idea about Hashi's, and no reverse T3 so no idea if T3 is pooling. In the effort to be helpful you're not quite making it here.

 

[Gman86]

Point taken but most of the guys here wouldn't be on TRT if they had those numbers, just as in they show up here with much worse in that regard.

We'll have to agree to disagree, because most guy's Ive seen post here started because their testosterone was low in the range, not necessarily below range. I was definitely one of them. Also, I would say the majority of guys with low T have either low E2 or mid range E2 pre TRT. We have to factor in that this guy has high E2 along with low free T. I would assume anyone with low free T and high E2 would feel absolutely horrible. I think it's safe to assume any guy in that scenario is going to feel a lot worse than a guy with low T and low/ normal E2.

Reverse T3 and antibodies are absolutely necessary when testing thyroid. If you don't test those, might as well not test thyroid at all. It's not a complete waste, but you're just not getting the whole picture if you don't test them.

Sorry if it feels like I'm arguing with you Vince, don't mean to be disrespectful or anything. I agree with what you say 99% of the time. I just feel like we shouldn't be like every general practitioner in America and tell this guy he is fine just because he isn't below the "normal" ranges. His free T is 18 points away from the bottom range. How much lower would his free T need to be before he should be considered a candidate for TRT? But you are probably right, he should get his sleep problems figured out along with optimizing vitamin D first. If that fixes things, great, but if not, I think it's clear he is a candidate for TRT. At the very least AI monotherapy to see if getting his E2 down will raise T levels.

 

[John123]

Vince Carter, Gman86, ratbag, lexer, thank you all for your kind advice!


I will now definitely wait for all my results before I make a decision to start TRT.


TSH (labeled as S-TSH) was measured in the 1st and 2nd blood tests.
3.00 miU/L (0.27 - 4.20)
2.75 mE/L (0,59 - 4,23)


S-pT4 and S-pT3 in the 2nd blood test are actually Free T4 and Free T3.
Free T4: 18,3 pmol/L (11,3 - 18,8)
Free T3: 5,61 pmol/L (3,79 - 6,05)


Iron was tested two times.
1. S-Iron (III): 18,4 µmol/L (10,7 - 28,6)
2. S-Iron (III): 26,9 µmol/L (10,7 - 28,6)


Vince, I’m not sure if Antibodies, Reverse T3 and Ferritin were tested, but I will ask my endocrinologist about it soon. Thank you for this tip.


ratbag, thanks, I will talk to my doctor about 4 x cortisol saliva test.


Gman86, thank you so much for your kindness and understanding, your last post gives me a lot of hope.

 

[Gman86]

Vince Carter, Gman86, ratbag, lexer, thank you all for your kind advice!


I will now definitely wait for all my results before I make a decision to start TRT.


TSH (labeled as S-TSH) was measured in the 1st and 2nd blood tests.
3.00 miU/L (0.27 - 4.20)
2.75 mE/L (0,59 - 4,23)


S-pT4 and S-pT3 in the 2nd blood test are actually Free T4 and Free T3.
Free T4: 18,3 pmol/L (11,3 - 18,8)
Free T3: 5,61 pmol/L (3,79 - 6,05)


Iron was tested two times.
1. S-Iron (III): 18,4 µmol/L (10,7 - 28,6)
2. S-Iron (III): 26,9 µmol/L (10,7 - 28,6)


Vince, I’m not sure if Antibodies, Reverse T3 and Ferritin were tested, but I will ask my endocrinologist about it soon. Thank you for this tip.


ratbag, thanks, I will talk to my doctor about 4 x cortisol saliva test.


Gman86, thank you so much for your kindness and understanding, your last post gives me a lot of hope.

Ya anytime man. Glad to help. Definitely get your thyroid fully checked out, get the results of the ultrasound, get the results of the sleep apnea test, and optimize your vitamin D levels. But just know that if you address all those things and still have issues, and still have low free T and high E2, getting your T up and E2 down through therapy should absolutely decrease the symptoms you reported, if not get rid of them all together. I would absolutely expect any guy with your free T and E2 levels to have those issues, along with other issues such as being very easily stresed, irritable, moody, low energy and lack of zest for life. So exhaust all avenues, but in the end if they all turn up empty, TRT or AI monotherapy should give you what your looking for. It did for me, and my free T was almost identical to yours. I had almost all the symptoms, and now I don’t, simple as that. Free t is what matters, not total t.

 

[John123]

UPDATE

Hi guys,

I did a lab test for Antibodies, Ferritin and Iron. Reverse T3 will be tested next week.

Iron: 13.8 µmol/L (10.6 - 28.3)
Ferritin: 109 µg/L (20 - 250)
Anti TG (H): 6.06 kU/L (<4.11)
Anti TPO: 1.08 kU/L (<5.61)

Any opinion on high Anti TG? Is it high enough to speculate my symptoms are thyroid related?

 

[StepbyStep]

Here's a possibility than I'm dealing with right now. My Dinural x4 saliva cortisol tests showed high in the morning, like off the charts high, and then slightly elevated for the rest of the day, but follow diurnal rhythm and I'm not having any sleep issues. My ft4, ft3, and TSH are similar to yours, and I have high rt3. I think that this is the reason for many of my symptoms, and our states are similar.

If your cortisol is elevated that can indicate that your body is in a stress like state, and you'll produce more rt3 as a result, which allegedly blocks the active thyroid hormone ft3.

 

[ratbag]

RT3 is all about cortisol and ferritin. You have to know your ferritin. Without this your making an assumption.

 

[StepbyStep]

My ferritin was 109 ng/mL (30-400ng/mL). I've been under the impression that this was normal. Just thought I had similar we had similar thyroid labs, and high cortisol.

 

[ratbag]

109 for ferritin should be ok but some need 120-150. This is posted in many places so perhaps you may need more. I doubt your cortisol labs are causing high RT3. It's not like cushings. Also any illness also causes higher RT3, something we often overlook.

 

[John123]

UPDATE 2

My Free T3 and Reverse T3 results are here:

Free T3: 3.9 pmol/L (2.63 - 5.70)
Reverse T3: 199.0 pg/ml (90 - 215)

Reverse T3 is pretty high, but still within range. I’m not sure if I calculated fT3/rT3 ratio correctly (different units), but I think it’s in the lower side of normal (1,28). What do you guys think about these results?

 

[Systemlord]

These results are far from idea, high Reverse T3 is negating some of that Free T3, so the affect is as if Free T3 is lower than stated. I don't expect an insurance based doctor to take action, really depends on the quality of your insurance.

 

[StepbyStep]

Once again similar to me, but my rt3 is higher. Defy has me starting on T3 only to knock the rt3 down.

 

[John123]

Once again similar to me, but my rt3 is higher. Defy has me starting on T3 only to knock the rt3 down.

How much higher is your rt3?
What will your T3 protocol look like?

 

[StepbyStep]

Sorry for the late response John123,

My Reverse T3 on my last labs was 27.0 ng/dL(9.2-24.1).

The protocol is:
5mcg T3 Morning for 1.5 weeks
5mcg T3 Morning, 5mcg T3 Afternoon 1.5 weeks
10mcg T3 Morning, 5mcg T3 Afternoon 1.5 weeks
10mcg T3 Morning, 10mcg T3 Afternoon 1.5 weeks

If I notice any hyper symptoms when titrating upwards, I am to revert back to my previous dose. Also, medication is supposed to be taken 30 minutes prior to eating.

I hope this helps!