New Guy Here. TRT has been prescribed--but does my bloodwork warrant it?

[Gizmo12]

I'll try to keep it brief. I'm 36, 5'9", 183 lbs, single, work from home. For as long as I can remember, I've had recurring issues with fatigue, stress, anxiety, libido, ED, memory, "brain fog," fat deposits in my midsection, and a general sense of not feeling so great. This summer, I decided to investigate the possibility of having low testosterone. Though I wound up qualifying for TRT therapy, I wanted to do further examination of my thyroid, cortisol, etc. before making the commitment. My complete labs are below. Abnormal values per the lab are in bold. Labs I find concerning are in italics.

Testosterone,Free and Total
Testosterone , Serum 244 Low ng/dL (348 - 1197)
Free Testosterone(Direct) 6.1 Low pg/mL (8.7 - 25.1)
LH 1.4 Low mIU/mL (1.7 - 8.6)
FSH 1.5 mIU/mL (1.5 - 12.4)
Prostate Specific Ag, Serum 0.6 ng/mL (0.0 - 4.0)

Thyroid/Pituitary/Cortisol
TSH 0.81 miU/L (Reference Range of .5 to 5.0)
T4 0.96 ug/dl (4.5 to 12.5)

Free T3 2.9 pg/ml (2.3 to 4.2)
Free T4 1.00 ng/L (.8 to 1.8)
Reverse T3 17.3 ng/dl (9 to 27)
Prolactin 4.3 ng/ml (2.1 to 17.7)

DHEA 2 ng/ml (3-10).

Cortisol "load” is 27nM (22-46).
Salivary Cortisol test, 24 Hours:
8 AM: 20 (13-24nM)
1 PM: 3 (5-10nM)
5 PM: 3 (3-8nM)
10 PM: <1 (1-4nM)


CBC With Differential/Platelet
WBC 6.0 x10E3/uL (Reference Range 3.4 - 10.8)
RBC 5.60 x10E6/uL (4.14 - 5.80)
Hemoglobin 15.5 g/dL (12.6 - 17.7)
Hematocrit 44.9% (37.5 - 51.0)
MCV 80 fL (79 - 97)
MCH 27.7 pg (26.6 - 33.0)
MCHC 34.5 g/dL (31.5 - 35.7)
RDW 14.3% (12.3 - 15.4)
Platelets 207 x10E3/uL (155 - 379)
Neutrophils 61 % (40 - 74)
Lymphs 30 % (14 - 46)
Monocytes 6 % (4 - 12)
Eos 2 % (0 - 5)
Basos 1 % (0 - 3)
Neutrophils (Absolute) 3.7 x10E3/uL (1.4 - 7.0)
Lymphs (Absolute) 1.8 x10E3/uL (0.7 - 3.1)
Monocytes(Absolute) 0.4 x10E3/uL (0.1 - 0.9)
Eos (Absolute) 0.1 x10E3/uL (0.0 - 0.4)
Baso (Absolute) 0.0 x10E3/uL (0.0 - 0.2)
Immature Granulocytes 0 % (0 - 2)
Immature Grans (Abs) 0.0 x10E3/uL (0.0 - 0.1)

Comp. Metabolic Panel (14)
Glucose, Serum 95 mg/dL (65 - 99)
BUN 15 mg/dL (6 - 20)
Creatinine, Serum 0.98 mg/dL (0.76 - 1.27)
eGFR If NonAfricn Am 99 mL/min/1.73 >59
eGFR If Africn Am 115 mL/min/1.73 >59
BUN/Creatinine Ratio 15 (8 - 19)
Sodium, Serum 143 mmol/L (134 - 144)
Potassium, Serum 5.9 High mmol/L (3.5 - 5.2)
Chloride, Serum 104 mmol/L (97 - 108)
Carbon Dioxide, Total 26 mmol/L (19 - 28)
Calcium, Serum 10.1 mg/dL (8.7 - 10.2)
Protein, Total, Serum 7.0 g/dL (6.0 - 8.5)
Albumin, Serum 4.8 g/dL (3.5 - 5.5)
Globulin, Total 2.2 g/dL (1.5 - 4.5)
A/G Ratio 2.2 (1.1 - 2.5)
Bilirubin, Total 0.3 mg/dL (0.0 - 1.2)
Alkaline Phosphatase, S 76 IU/L (39 - 117)
AST (SGOT) 16 IU/L (0 - 40)
ALT (SGPT) 22 IU/L (0 - 44)

Lipid Panel
Cholesterol, Total 215 High mg/dL (100 - 199)
Triglycerides 68 mg/dL (0 - 149)
HDL Cholesterol 60 mg/dL >39
VLDL Cholesterol Cal 14 mg/dL (5 - 40)
LDL Cholesterol Calc 141 High mg/dL (0 - 99)

I exercise 4-6 days a week, take zinc, fish oil, Vitamin D, and Zoloft. TRT doctor would like to put me on 150mg of Test Cyp (no HCG or AI to start with) based on my labs. I went to an endo to get my thyroid looked at, but he did not find anything that he felt would warrant treatment. I do not smoke or drink.

My hypothesis is that some significant topical hydrocortisone use as a kid (for eczema), coupled with a stressful upbringing and sleep issues did something to my HPTA that affected my hormonal output and led to some adrenal fatigue. I know SSRIs can also deplete test, and I've been on Zoloft for nearly 14 years at a moderate (50 mg) dose. I've also had three sleep studies, which ranged from "nothing wrong" to "moderate sleep disordered breathing." CPAP did nothing after a one-year trial. I just don't know if there's anything worth exploring here, or if I need to address the symptom--the low testosterone--in order to try and bolster my quality of life. Any help appreciated.

 

[Vettester Chris]

Gizmo, welcome to EM. Glad you joined! You provided a lot of information, which is appreciated! It might take a few segments to address everything, and hopefully others will chime in as well ...

Although the cortisol burden (aka "Load") is still in range, it's obviously on the low end of the reference range. Going off the DiagnosTech - Cortisol/DHEA correlation mid-day average system, your square definitely falls into the bracket of "Adrenal Fatigue". I know you had mentioned SSRI's, and at one point when you were younger you were on HC therapy. Not that I'm trying to get too personal, but have you been doing any anabolic cycles lately?

The circadian rhythm of your cortisol (AM towards the top, the other 3 at the bottom) and low DHEA can be indicative of anabolic usage (PH's, Nor19's, C17's, etc ..). Not that AAS usage is "always" the cause, but the symptoms fit it, plus the fact your HPTA is also suppressed, which appears to be the culprit for your low testosterone value (secondary hypo). If not, it could be a myriad of possibilities, and either way it would probably be good to have a physician take an MRI to ensure you don't have any complications with the pituitary like an adenoma.

Again, total test serum is low, which appears to be just following suit with the low gonadotropin values that are suppressed with the pituitary, better know as the HPTA. Your direct free testosterone is low, but the amount is relevant to the amount of your total serum. Your free test % is right at 2.5%, which IMO is about spot-on for what you want (decent SHBG & Albumin values).

So there's nothing you need to do there except get your total serum to an adequate level that you and your doctor find to be best for you, and you 'should' anticipate your free test to be in the "approx" area of 2.5% or close thereof. For the meantime, get with a physician that can properly diagnose your condition, and then you can start the foundation for a game plan to getting everything on track again like you desire ...

I want to delve into your thyroid numbers, but I'm cooked on this end! I'm dealing with my own Monday fatigue at this point For now, let me know if you have any thoughts on what's been posted? Maybe you have gone through some of this with your doctor? If so, are you getting some feedback on what steps to take?

 

[Hydranted]

If you're going to start out on 150mg/wk, talk to your doctor about splitting the injections into 75mg/E3.5D to ensure that your E2 stays in check. If you can avoid having to take an AI, that would be ideal.

 

[Gizmo12]

Thanks for responding, Chris. To address your comments:

Although the cortisol burden (aka "Load") is still in range, it's obviously on the low end of the reference range. Going off the DiagnosTech - Cortisol/DHEA correlation mid-day average system, your square definitely falls into the bracket of "Adrenal Fatigue". I know you had mentioned SSRI's, and at one point when you were younger you were on HC therapy. Not that I'm trying to get too personal, but have you been doing any anabolic cycles lately?

I should've made this part of my original post: I've never done any cycles at any point in time. Owing to the anonymity of this forum, I would have no problem in saying so in my effort to get some help. But--nope.

If not, it could be a myriad of possibilities, and either way it would probably be good to have a physician take an MRI to ensure you don't have any complications with the pituitary like an adenoma.

I did this bring this possibility up to the endo I saw a few weeks back--this was pre-prolactin test--and he kind of shrugged, saying he'd do it if prolactin was high, but he very much doubts there's a lesion/growth there, citing that I lack other symptoms (hair distribution, etc). Since prolactin is in the basement, I don't know on what basis I could request the test. His general attitude is: "thyroid's fine, you've got some kind of malfunction in your hypothalamus/HPTA, I don't know what, try test for 12 weeks and see how you feel, doesn't matter to me." (He's not prescribing it.) When I mentioned my sleep issues, he referred me to a sleep lab. But I've had three studies in the past, and a year on CPAP resulted in zero difference in my fatigue issues. I don't sleep in labs, I don't sleep well on CPAP, and initiating that all over again seems like the definition of insanity.

Basically, I'm feeling a little roadblocked. I do feel as though something--likely a combination of sleep issues, early-onset stress/anxiety, and later on, SSRI use--messed with my HPTA. But my numbers aren't out of range for most endos. I'm not adverse to TRT, but if I could somehow fix the problem "higher up," I imagine that would be preferable. If I go that route, though, I sense I'd be in for a year's worth of doctor-shopping to find someone willing to think outside the box.

If you're going to start out on 150mg/wk, talk to your doctor about splitting the injections into 75mg/E3.5D to ensure that your E2 stays in check. If you can avoid having to take an AI, that would be ideal.

I agree, and would split the dose, or possibly even reduce it to 60mg, as I've read 150mg is a little high to begin with. Better to start low and titrate up if needed.

 

[Gene Devine]

I didn't see an estradiol (sensitive) lab on here...or did I miss it???

 

[Vettester Chris]

OK, thanks for clarifying the AAS subject. It's just the pattern with the cortisol rhythm and LH/FSH values had presented that as a possibility. I don't fully agree with the way your endo is looking at this. I know several HRT physicians that would want to run an MRI based on your current labs, and would not make the prolactin lab contingent with further exams. His doubts are speculation and he could rule it out real quick. Good chance the HPTA is experiencing suppression due to other factors, possibly previous and current medications, but I'd want to know with an MRI just to be safe (just my .02).

I agree that if you can correct the issue so that your HPTA produces more LH & FSH, then that's the route to go. However, depending on the length of time that your axis has been suppressed, it might be difficult to sustain a level of secretion that will provide optimal production of endogenous testosterone. Possibly running a proper PCT or HPTA restart with clomid & HCG would more than likely increase your values. Again, the million dollar question is would it hold?

Like Gene mentioned, there's no E2 sensitive assay mentioned. That would be good to know at this point, and will definitely need to be reviewed regularly "if" you elect to go on some form of HRT.

OK, on the thyroid ... Again, not to break skulls with your doctor, but I just don't agree with his assessment. Actually, it's not as much me as it is some of the trained specialists that are at the top of their field like Dr. Bruce Rind, Dr. Jeffrey Dach, Dr. James Yang ... The list goes on ...

I had an endo once tell me that only guys like Manny Ramirez take HCG, and there's "no place for it" in HRT and hypogonadal males. I sent that doctor a paper from the Journal of Endo Society, and a paper from Dr. Crisler, which disputed his claims. Well, the long and short of that was that endo fired me as a patient. It was indeed the best thing that ever happened to me!!

Anyways, back on topic ... I would gather to say that your pituitary function is suppressed and not responding to any feedback from your T4 and T3 levels, thus your TSH is tanked and probably does not deviate much, otherwise it would be elevated somewhat in relation to the current T4 and T3 readings. FT4 is at 20% of range, FT3 is at 47%. Ideally, if everything is working correctly and T3 is adequately getting to the cells, one would probably like to see both FT3 and FT4 in the 50% to 80% area of the reference range (aiming to keep both relatively close together), along with a FT3/Reverse T3 ratio that is > 20 (25 would be even better).

Your FT3/RT3 rato is at 16. Your FT3 is sitting to the right of FT4 (47% compared to 20%). Considering your cortisol situation, I suspect your T3 is pooling, which in turn in turn could create excess conversion of RT3, causing a down-regulation effect of ATP. I would be curious to know your body temperature throughout different times of the day if you are checking it?

In addition to the E2 sensitive lab that was mentioned, it would also be good to see iron serum, TIBC, ferritin, B12, and thyroid antibodies TPO & TgAb, and an ACTH in relation to your cortisol. I highly encourage you to consider getting a few more opinions from some other qualified physicians. There are several good doctors and clinics that post on this forum .. Just let us know if you are looking for a referral. Regardless, I think you have a situation that needs addressed and not "shrugged off".

None of this is going to just auto-correct itself. IMO, I'm not convinced that jumping on TRT is the best thing at the moment without addressing some of the other talking points. TRT isn't going to correct the cortisol or thyroid situation, and the last thing you need is more stress and demand being put on the body when it can't properly react to it.

 

[Gizmo12]

In addition to the E2 sensitive lab that was mentioned, it would also be good to see iron serum, TIBC, ferritin, B12, and thyroid antibodies TPO & TgAb, and an ACTH in relation to your cortisol. I highly encourage you to consider getting a few more opinions from some other qualified physicians. There are several good doctors and clinics that post on this forum .. Just let us know if you are looking for a referral. Regardless, I think you have a situation that needs addressed and not "shrugged off".

None of this is going to just auto-correct itself. IMO, I'm not convinced that jumping on TRT is the best thing at the moment without addressing some of the other talking points. TRT isn't going to correct the cortisol or thyroid situation, and the last thing you need is more stress and demand being put on the body when it can't properly react to it.

Thanks, Chris. I'll inquire about an MRI, but yes, if it's possible to solicit a referral to a doctor or clinic to further investigate my situation, I'd appreciate the help.

 

[Vettester Chris]

Thanks, Chris. I'll inquire about an MRI, but yes, if it's possible to solicit a referral to a doctor or clinic to further investigate my situation, I'd appreciate the help.

Just click the "Referrals" tab at the top of the forum ^^

 

[Gizmo12]

Thanks. So I'm clear: there seems to be evidence of a pituitary issue (low FSH/LH), which is failing to "order" the testes to produce an adequate amount of testosterone. In the absence of a lesion/tumor or other physical disruption, it's possible my thyroid is failing to offer my pituitary enough motivation to make more FSH/LH.

Additionally, my adrenals/DHEA are fatigued. I know the adrenals make a small percentage of test, but aside from that, is there a correlation between my adrenal issue and my pituitary?

 

[Vettester Chris]

Thanks. So I'm clear: there seems to be evidence of a pituitary issue (low FSH/LH), which is failing to "order" the testes to produce an adequate amount of testosterone. In the absence of a lesion/tumor or other physical disruption, it's possible my thyroid is failing to offer my pituitary enough motivation to make more FSH/LH.

Additionally, my adrenals/DHEA are fatigued. I know the adrenals make a small percentage of test, but aside from that, is there a correlation between my adrenal issue and my pituitary?

Gizmo, I view it as your thyroid is providing more than adequate motivation for the thyrotrope cells in the pituitary to produce TSH. However, the pituitary (for whatever reason) is not responding to the feedback loop when thyroid hormone is low.

The correlation between your adrenals and the pituitary is ACTH, which also secretes from the anterior pituitary and works on a negative feedback loop with the adrenals.

As I see it, you have two (2) key issues that are no brainer (sorry for the pun) pointing directly to the pituitary (gonadotropins for test, fatigued production of TSH for thyroid), and one questionable issue with cortisol that could very well be impacted by ACTH secretion; all HPTA related.

Also noticed your potassium is elevated, which should prompt your physician to look in the lines of Addison's. I would think that itself would prompt an ACTH assay, along with aldosterone .. I could be wrong.

 

[Gizmo12]

Gizmo, I view it as your thyroid is providing more than adequate motivation for the thyrotrope cells in the pituitary to produce TSH. However, the pituitary (for whatever reason) is not responding to the feedback loop when thyroid hormone is low.

The correlation between your adrenals and the pituitary is ACTH, which also secretes from the anterior pituitary and works on a negative feedback loop with the adrenals.

As I see it, you have two (2) key issues that are no brainer (sorry for the pun) pointing directly to the pituitary (gonadotropins for test, fatigued production of TSH for thyroid), and one questionable issue with cortisol that could very well be impacted by ACTH secretion; all HPTA related.

Also noticed your potassium is elevated, which should prompt your physician to look in the lines of Addison's. I would think that itself would prompt an ACTH assay, along with aldosterone .. I could be wrong.

Thanks. I'll take some time to digest all this, but one wrinkle: I mislabeled some of the units of measurement for my thyroid labs. For the record, the correct units are all ng/dl:

REVERSE T3 17.3 ng/dl (9.0-27.0)
FREE T3 2.9 ng/dl (2.2-4.0)
FREE T4 1.00 ng/dl (0.76-1.70)
PROLACTIN 4.3 ng/dl (2.5-17.4)

Don't know if that changes anything, but I thought I'd correct it. They're still all technically "in range," just all ng/dl and not pg/ml or ng/L.

 

[Vettester Chris]

Thanks. I'll take some time to digest all this, but one wrinkle: I mislabeled some of the units of measurement for my thyroid labs. For the record, the correct units are all ng/dl:

REVERSE T3 17.3 ng/dl (9.0-27.0)
FREE T3 2.9 ng/dl (2.2-4.0)
FREE T4 1.00 ng/dl (0.76-1.70)
PROLACTIN 4.3 ng/dl (2.5-17.4)

Don't know if that changes anything, but I thought I'd correct it. They're still all technically "in range," just all ng/dl and not pg/ml or ng/L.

Yeah, the same unit of measurement "ng/dl" on both FT3 and RT3 kind of throws it deeper into the fire. It would make more sense with the FT3 being 2.9 pg/ml. By chance do you have a Total T3 lab? I can check it against that as well.

 

[Gizmo12]

Yeah, the same unit of measurement "ng/dl" on both FT3 and RT3 kind of throws it deeper into the fire. It would make more sense with the FT3 being 2.9 pg/ml. By chance do you have a Total T3 lab? I can check it against that as well.

You know, since you mentioned it, and since I didn't have a lot of trust in a nursing assistant or receptionist relaying lab info in a patient portal, I just asked for a fax of the labs, and the FT3 is in pg/ml. I understand that's still a problem, but at least not as much of a discrepancy.

Lesson learned: don't rely on portals for bloodwork values. Get the actual labs.

I don't have Total T3.

 

[Vettester Chris]

You know, since you mentioned it, and since I didn't have a lot of trust in a nursing assistant or receptionist relaying lab info in a patient portal, I just asked for a fax of the labs, and the FT3 is in pg/ml. I understand that's still a problem, but at least not as much of a discrepancy.

Lesson learned: don't rely on portals for bloodwork values. Get the actual labs.

I don't have Total T3.

I gathered there had be a mistake on the unit of measurement. It could have been counter-checked with Total T3, but no need since you confirmed what I was looking for with the FT3 lab.

If you get a chance, can you take your temperature throughout the day for 4 or 5 days? Take it 3 hours after you wake up in the morning, then 3 hours after that, then once more 3 hours later. Write down the data and we can do some comparisons to your circadian profile and review any deviations. Hold on to it, this will probably be something you want to repeat when you get on some type of treatment program, as it will help provide some feedback on how your body is adapting and progressing to the therapy.

 

[Gizmo12]

I gathered there had be a mistake on the unit of measurement. It could have been counter-checked with Total T3, but no need since you confirmed what I was looking for with the FT3 lab.

If you get a chance, can you take your temperature throughout the day for 4 or 5 days? Take it 3 hours after you wake up in the morning, then 3 hours after that, then once more 3 hours later. Write down the data and we can do some comparisons to your circadian profile and review any deviations. Hold on to it, this will probably be something you want to repeat when you get on some type of treatment program, as it will help provide some feedback on how your body is adapting and progressing to the therapy.

Thanks, Chris. Belated reply because I've been pursuing more avenues to get some answers. I'm getting more bloodwork done next week--an update free/total test, estradiol, magnesium, LH--and consulting with a new doctor. Also getting an MRI done Thursday to rule out a pituitary adenoma. I will follow your suggestion of a temperature read and update everything when I can.

 

[Vettester Chris]

Excellent!! Thanks for the update!

 

[Gizmo12]

One follow-up: is there any benefit to asking for a GnRH level? Would that help further isolate the issue to the hypothalamus?

 

[Vettester Chris]

Not sure if you're looking at some sort of stimulation test (?) ... I'd personally just make sure no tumors/ adenoma are present with an MRI, then work with your physician on a good treatment program.

 

[Gizmo12]

Well, had bloodwork done Monday in advance of a phone consult next week, and I think I'm more confused than ever.

Test: total is now sitting at 498 ng/dL, or basically double what it was in late May. Free is 9.6, up from 6.1. LH also doubled, from 1.4 to 2.8. Estradiol, which I had never measured before, is 29.2 (ref. range 7.6 to 42.6). Magnesium 1.8 (range 1.6 to 2.6 mg/dL).

I went from old-man numbers to seemingly average for my age in a four-month span. In that time, a few variables were at work:

- I started lifting again (3x/week, heavy weights and low reps) and also added some interval training 2x/week. Had ten weeks of this under my belt prior to Monday's tests.

- Got more protein and a little less junk in the diet.

- Began taking Propecia at .5mg/day for hair loss. Waited to start taking it until after first round of BW so it wouldn't confuse the situation. Now I'm thinking it might be responsible for raising test via blocking the DHT conversion. Is this possible? And if it is, is there a point where it might start to raise estrogen instead?

I still obviously have some adrenal/thyroid issues to address, but now I'm thinking TRT is no longer indicated. Any thoughts welcome.

Edit to note both draws were done at roughly the same time of day, fasted, not having "released" in the 24 hours prior, and at the exact same LabCorp location.

 

[Vettester Chris]

Well, sometimes lifestyle changes can definitely make a difference. As you stated, your LH is up, and that my friend will account for you Test Serum being up. The free & bio available test just follows suit, yours is close to 2%, which is definitely in the "normal" range.

On the Propecia, if the DHT value changed, that wouldn't have any impact on your test serum. DHT is downstream. Again, the jump in LH is the variable that is promoting increased test serum levels. The numbers are still probably a little low for where you might want to be, but it's definitely an improvement in the right direction. Based on what we've discussed on other pituitary functions, e.g., ACTH & TSH, I would still want to keep the pituitary exam option open, but that's just my .02

Keep us posted on the progress with your thyroid and the other areas you are concentrating on ... Also, on that estradiol lab, I know that isn't the Labcorp sensitive .. By chance is that just a standard E2 assay?