Lowish SHBG but T levels look ok

[Runnerman]

I have been feeling a bit down lately and my mood has been a bit up and down. It certainly could be related to work and life stress but I wanted to see if my testosterone levels were too low given I'm only injecting 70mg of cypionate split in two doses per week subq. I did the lower cost labs at my trough point and although the T levels aren't bad, my SHBG was a bit low on their scale.

This was the Quest TESTOSTERONE, FREE, BIOVAILABLE AND TOTAL, MALES (ADULT), IMMUNOASSAY test bundle through DiscountedLabs.

Here is a snippet of my results:

Test Name	Result	Ref range
TESTOSTERONE, TOTAL, MALES (ADULT), IA	444	250-827 ng/dL
ALBUMIN	4.5	3.6-5.1 g/dL
SEX HORMONE BINDING GLOBULIN	16 L	22-77 nmol/L
TESTOSTERONE, FREE	100.2	46.0-224.0 pg/mL
TESTOSTERONE,BIOAVAILABLE	206.0	110.0-575.0 ng/dL

Is this level of SHBG a concern? I'll have to look back and see what it measured in my previous labs. Some other reference ranges I've seen show > 10 being normal.

Thanks!

 

[Systemlord]

Is this level of SHBG a concern?

The TRT will have a suppressive effect on SHBG. You have no reason to be concerned about it.

I'm only injecting 70mg of cypionate split in two doses per week subq.

That's a below average TRT dosage and there's nothing wrong with starting out low and going slow.

It's better to start out low rather than too high. If I were you I would bump the dosage up to 100 mg weekly.

TESTOSTERONE, FREE

100.2

46.0-224.0 pg/mL

Most men on TRT feel good with Free T at the top end of the ranges.

 

[Cataceous]

... Is this level of SHBG a concern? ...

Possibly, but probably not. First you need to be sure it's not in any way reflecting metabolic syndrome. Second, it's kind of a mid-low value. Guys with even lower numbers have been known to struggle with TRT for reasons that aren't entirely clear.

...
Most men on TRT feel good with Free T at the top end of the ranges.

I have to challenge this as a blanket statement. When it comes to injections probably relatively few men have even tried lower levels. Xyosted is shaping up to be an exception, and there's no indication that men don't do just fine in the middle of the range, if not below. Additionally, I regularly post a list of guys who explicitly state that they do not do as well at higher levels.

 

[Systemlord]

I have to challenge this as a blanket statement.

This statement comes directly from Dr. Saya, based on blood biomarkers (lipids) and overall health. The late Dr. Crisler said the same thing.

The same applies to prostate cancer, top 25% of the ranges reduces the risk by 53%!

As for cardiovascular risk, there are multiple indications that even midrange levels puts you at risk. Loss of libido is shown to occur <500 ng/dL and other studies show 440 ng/dL is strongly associated with cardiovascular risk.

 

[Cataceous]

This statement comes directly from Dr. Saya, based on blood biomarkers (lipids) and overall health.
...

As I said, "When it comes to injections probably relatively few men have even tried lower levels." You should enquire about the typical starting injection protocol at Defy.

...
The same applies to prostate cancer, top 25% of the ranges reduces the risk by 53%!

As for cardiovascular risk, there are multiple indications that even midrange levels puts you at risk. Loss of libido is shown to occur <500 ng/dL and other studies show 440 ng/dL is strongly associated with cardiovascular risk.

But you're unable to cite the absolute free testosterone levels, which is what matters. Older guys have higher SHBG on average, which means total testosterone is corresponding to lower free T levels than how you probably define "top end of the ranges".

Bottom line: produce some credible scientific evidence that overall men do better near top-of-range than near the middle. If you can't then stop making the claim. Perhaps we can agree to use the Vermeulen free T scale for healthy younger men? If so then top-of-range is about 20-23 ng/dL, and mid-range is about 15 ng/dL.

Are we talking about midrange levels at trough?

If so then for half the week levels are closer to high normal.

The interesting thing about Xyosted is that the half-life is double that of conventional TC/TE formulations, about 10 days. This leads to more stable levels over the course of a week, comparable to what's seen with twice-weekly injections of regular products. Titration instructions call for trough testosterone to be in the range of 350-650 ng/dL.

 

[Runnerman]

Thank you for all the info. I appreciate the feedback. I've been on TRT for a while and originally was at 100mg weekly in one shot and then split into two. I decided to lower the weekly dose to hopefully have decent T levels and try to keep my hematocrit in check. Frequent blood donation crashed my ferritin levels ridiculously low in the past, although the local blood bank was happy.

 

[Systemlord]

Bottom line: produce some credible scientific evidence that overall men do better near top-of-range than near the middle. If you can't then stop making the claim.

I was mistaken, Dr Saya made the comment that most of his male patients feel optimal with Free T levels (20-25 ng/dL) near the top end or slightly higher.

So considering he's had 10,000+ patients, that's saying something.

 

[Cataceous]

I was mistaken, Dr Saya made the comment that most of his male patients feel optimal with Free T levels (20-25 ng/dL) near the top end or slightly higher.

So considering he's had 10,000+ patients, that's saying something.

What fraction of these patients have tested lower levels for a prolonged period? You have also posted that study showing that full symptom resolution after starting TRT can take many months. In this clinical setting the path of least resistance is to allow guys to increase the dose earlier when they're still complaining of symptoms. This buys more time for things to resolve, but it doesn't demonstrate that higher levels are better overall than mid-range levels.

I've argued in favor of the hypothesis that mid-range testosterone levels are optimal in that they were selected by evolution to give the best chance of reproductive success. Reproductive success should be a pretty decent proxy for doing well overall in life. It means a guy can successfully attract a mate and also has the resources to provide for and protect offspring until they reach maturity.

 

[tareload]

I'll leave this here. You will have to do a little work with some of my other posts/threads to see some of the above is ridiculous. Because some dudes go cash pay to get more generous T treatment does not support in any way the statement that "MOST men on TRT feel good with Free T at the top end of the ranges".

TRT: Most Probable Weekly Dose Range for Treating Male Hypogonadism

Unburied this from another thread in case guys were curious about TRT dosing in the world of hypogonadism. Google xyosted, a vastly overpriced** testosterone enanthate (TE) sub-Q delivery system designed for mass in-network medical provider use to treat hypogonadism. Then look at the three...

forums.t-nation.com

Tool to Assess your TT Dose Response -- Percentile Curves

Summary: Tools to estimate your individual dose response for injectable testosterone ester in comparison to a normal distribution (95 percentile confidence estimate) of adult males (Ref). Plot below shows a summary of data from (1) clinical trials gathered from the literature + (2)...

forums.t-nation.com

 

[Systemlord]

Because some dudes go cash pay to get more generous T treatment does not support in any way the statement that "MOST men on TRT feel good with Free T at the top end of the ranges".

I misspoke and my next post reflected that, which is most of Dr. Saya's male patients on exogenous T feel better at the top end or slightly higher.

Dr. Crisler said the same thing.

If you have issue with this statement then I suggest you bring it up with Dr Saya.

I'm sure with some digging you can find that post right here on this forum.

I'm just the messenger.

On a side note, a lot of these healthcare providers target mid-range levels and that might be a reason to seek out a place like Defy Medical.

 

[Systemlord]

What fraction of these patients have tested lower levels for a prolonged period?

I don't question Dr Saya's integrity, when he says something, it carries a lot of weight, more than any forum member.

 

[tareload]

On a side note, a lot of these healthcare providers target mid-range levels and that might be a reason to seek out a place like Defy Medical.

Testosterone - Drug Usage Statistics, ClinCalc DrugStats Database

Testosterone drug usage statistics for the United States (2013 - 2021). Statistics include drug synonyms and therapeutic classes, including: Testosterone Cypionate, Testosterone Enanthate, Testosterone Propionate, Testosterone Undecanoate, Testosterone, Androderm, Androgel, Axiron, Fortesta...

clincalc.com

***I assume above does not cover compounded Rx and patients only retail Rx and patients. **

Let's say this number is within 50% and let's triple 10k to 30k.

What is 30k divided by 1M?

What is 30k divided by 500k?

Now you may say well how about add up all the cash pay clinics.....

Ok what is 500k divided by 1.5M?

How about 500k divided by 1M?

Kinda hard to get the fraction to match the term "MOST".

If someone has the cash pay numbers I would love to see them. Perhaps the cash pay clientele have now swamped the in network patients?

I did another estimate here of what an example cash pay clinic is doing with their patients.

 

[Cataceous]

I don't question Dr Saya's integrity, when he says something, it carries a lot of weight, more than any forum member.

As you know, it's not his integrity that's in question. Rather, it's the conclusion you're ascribing to him. Dr. Saya is an excellent clinician, but when it comes the expansive claim you're making I have more confidence in peer-reviewed scientific research. Essentially you're saying that most guys would do better with more testosterone than they would make naturally if young and healthy. This is not something I'll accept if argument from authority is the only evidence offered. It is possible to find some piecemeal evidence on the other side. For example, with respect to erectile function: "Available data suggest that in most men circulating levels of testosterone, well below the normal range, are essential for normal erection and that higher levels of serum testosterone may not have major impact on erectile function."

 

[Systemlord]

Essentially you're saying that most guys would do better with more testosterone than they would make naturally if young and healthy.

That's oversimplifying what I said, I said at the top end, then I referenced the prostate cancer study and Free T at the top quartile.

Now other science is showing the same thing, top quartile is healthier with regards to cardiovascular risk.

I have more confidence in peer-reviewed scientific research.

Here you go.

Giving Testosterone Levels a Boost | Dynamic Chiropractic

www.dynamicchiropractic.com

Defining "Healthy" Testosterone

Multiple peer-reviewed papers state that "testosterone deficiencies" are more prevalent and "desirable testosterone" levels in men are actually much higher than what is currently being considered as "normal" in doctors' practices across the country. Case in point: A cross-sectional study of Swedish men ages 69 to 80 years showed the risk for premature death from any cause and the risk for suffering a major cardiovascular event were inversely correlated with the total serum testosterone concentration (i.e., the higher the testosterone levels, the lower the risk of death).

Specifically with regards to cardiovascular events, men in the highest quartile of testosterone (at or higher than 550 ng/dL) had a lower risk of cardiovascular events compared with men with lower testosterone.

More importantly, details from this study show that it did not matter if a man's total testosterone was very low (below 340 ng/dL ) or moderately low (up to 549 ng/dL ) – all men with T levels below 549 ng/dL had a similar increased risk for suffering a cardiovascular event. Only when total testosterone exceeded 550 ng/dL did cardiovascular risk drop.

This is truly alarming, as cardiovascular disease is the No. 1 killer of men in the United States and even more – this study was published in the Journal of the American College of Cardiology. These researchers documented a 30 percent reduction in cardiovascular events as well as a decrease in cerebrovascular disease incidence. Men with the highest total testosterone had a 24 percent reduced risk of transient ischemic attack or full-blown stroke. Clearly, based on this study, the only target for "healthy testosterone" is to maintain total testosterone at or above 550 ng/dL.

As a health care practitioner, please note the following:

• According to LabCorp, the "healthy reference range" for total testosterone is 348–1,197 ng/dL. So, the lower part of this range completely ignores recent science that shows total testosterone levels need to be maintained above 550 ng/dL.
• Subjectively, this broad range is ridiculous. As any 45-year-old man who has suffered with low normal testosterone knows,there is a world of difference in how a man feels and performs (both mentally and physically) when testosterone is "low normal" versus higher up the healthy "normal" reference range.

 

[Systemlord]

If we go by that study above and also the prostate cancer study, targeting mid-range T levels is putting men at risk.

There are also studies showing low libido starts <500 ng/dL. More studies showing cardiovascular risk as low as 440 ng/dL.

 

[Cataceous]

That's oversimplifying what I said, I said at the top end, then I referenced the prostate cancer study and Free T at the top quartile.
...

Evidently you didn't bother to look at the range for this particular study. Average FTV appears to be around 5.5 ng/dL. There are only two data points above 15 ng/dL. Is 15 ng/dL the top-of-range you had in mind? This is about average for healthy younger men.

...
Here you go.

...

Specifically with regards to cardiovascular events, men in the highest quartile of testosterone (at or higher than 550 ng/dL) had a lower risk of cardiovascular events compared with men with lower testosterone.​

​

Ok, let's look at this in more detail. What's the demographic? "A cross-sectional study of Swedish men ages 69 to 80 years..." What is the average SHBG for this age range? Going by this page let's just call it 50 nMol/L. What is FTV? It is about 9 ng/dL. That's an interesting coincidence. I've been suggesting that 10 ng/dL should be the lower cutoff for healthy FTV.

In sum, you're arguing that it's better to have top-of-range testosterone, but your ranges are for old men. At best that top-of-range is about average for younger men. That sounds familiar. Where have I seen somebody arguing that mid-range for healthy young men is a good TRT target?

 

[Systemlord]

In sum, you're arguing that it's better to have top-of-range testosterone, but your ranges are for old men.

My ranges top out at 33.6 ng/dL for a 50 year old. So whatever the range is when adjusted for age, top 25% is the healthy range.

If the bottom 25% if we can agree are unhealthy, then mid-range levels are in the gray area where symptoms start to develop like a dimmer switch dimming down the lights.

There would be a world of difference having a trough at mid-range while peaking at the top end as opposed to peaking at mid-range and ending up in the bottom 25% at trough.

So you talk about targeting mid-range but don't clarifying if they are peak or trough levels that you're targeting. If the goal is to end up with mid-range levels at trough, then avergae levels are somewhere in between mid-range and top end.

Now for talking about natural men not on TRT, mid-range levels in the morning, that could be a problem.

 

[Systemlord]

I think we should do a poll and see at least where our members feel optimal.

 

[tareload]

we should do a pole

Maybe a poll? Count me out on any pole(s).

Smiley face with the little bead of sweat on the forehead.

 

[Cataceous]

My ranges top out at 33.6 ng/dL for a 50 year old. So whatever the range is when adjusted for age, top 25% is the healthy range.
...

The number 33.6 ng/dL has no relationship to what we're discussing. Until recently there's been no standardization of free testosterone assays. That's why I stated above that ranges should be in Vermeulen calculated free testosterone (FTV). The prostate cancer study you cited uses FTV. The normal range for younger men in FTV is something like 8-22.5 ng/dL. The average is about 15 ng/dL.

You're backtracking by adding the caveat that the ranges must be "adjusted for age". This again leaves you with no evidence. Try finding studies on younger men showing better outcomes/quality of life with top-of-range free testosterone. You can't extrapolate results from an older cohort to a younger cohort when absolute levels of testosterone are so different.

Reference ranges refer to daily peak testosterone. With respect to TRT, there's no ambiguity for daily injectors. Ideally others should also use peak values, but all bets are off when the variation in testosterone is large and over many days.