Pre TRT Labs... Looking For Advice

[pjmurphy]

I recently had bloodwork done and have an appointment to see my PCP about starting TRT.

Symptoms

Sexual

- Low libido. When my wife attempts to initiate sex, I usually would prefer to go to sleep. Sleep is a higher priority than sex. Sex feels more like a chore and something I have to do to keep my wife satisfied.

- Never able to go more than one round

Cognitive

- Constant mental haze. Difficulty focusing on a task. Significant difficulty concentrating. I have tried mindfulness mediation, to build up my ability to focus without much success.

Physical

- My hair has thinned dramatically since high school.

Demographic Facts and Lifestyle

- 39 year old caucasian male

- 5'11" 184 lbs, ~21% body (guessing, based on looking in the mirror)

- Until 3 months ago, I was lifting weights 4-5 times per week. The past month or so, I have been focusing on cardio by running 3 - 4 days/week in preparation for my annual Air Force PT Test. When I was lifting, I made some minor gains, but nothing significant. I was stuggling ot put on any miscle at all and was never ale to lift beyond a beginner's level of strength, despite effective programming and coaching. When I was lifting heavy, it would take everything out of my and completely drain me. I didn't feel like I could effectively recover from heavy lifting sessions.

- I have been eating a keto style diet for about 2 months now

- No tobacco or illegal drug use. Very minor alcohol use.

- Diagnosed with high blood pressure ~6 years ago. On a low dose angiotensin receptor blocker to keep it under control.

- I do not currently use any sports supplements (did use whey protein, creatine monohydrate, beta allenine, and a pre-workout in the past) and have never used steroids.

-Currently take: 3000 mg Omega 3, 5000 iu Vit D3, 30 mg Zinc, 2 mg Copper, men's multi vitamin.

- Work a 8AM-5:30PM white collar job in executive management. somewhat high stress, but I think I handle the stress well.

Labwork
At my last annual wellness visit, I told my PCP that I suspected I might have low T and asked him to run a bunch of labs based on the labwork recommendations here. Attached are the results. I did forget to ask him to retest Vit D. I had low Vit D in May, so I have been supplementing for the past 3 months and will ask him to order a Vit D test to see what my current level is.

I got a call back from my PCPs office last week letting my know that based on my blood-work I have low free T and that he would be willing to start me on TRT injections or topicals. I have scheduled an appointment this Wednesday to meet with him about options and potential side-effects before making a decision.

I would love any feedback on my labs. Summary of the main points (full labs attached):

Test

Result

Ref Range

Thyroid Stimulating Hormone (TSH)	1.430 uIU/mL	0.358-3.740 uIU/mL
Prostate Specific Antigen	0.89 ng/mL	0.0-4.0 ng/mL
Dehydroepiandrosterone (DHEA)	130 ng/dL	31-701 ng/dL
Total Testosterone	378 ng/dL	264-916 ng/dL
Luteinizing Hormone	4.8 mIU/mL	1.2-10.6 mIU/mL

Progesterone Level	0.6 ng/mL	<0.200 - 1.97
Estradiol (E2) Level	23.7 pg/mL	<11 - 52.5 pg/mL
Free Testosterone (Direct)	7.8 pg/mL	8.7-25.1 pg/mL

By the way, I know my lipids look crazy high. My PCP wants me to retest my lipids because my triglycerides look completely out of whack. He thinks there might have been a problem with the blood draw or something because it is a giant spike compared to a year ago. He suggested I retest in about 3 weeks.

Are there any questions I should ask my PCP when I see him Wednesday? What kind of protocol would be a good starting point?

Has anyone here had success getting prescribed a quality protocol going through their PCP? I have considered going through Defy, but if I can go through my PCP then my insurance will cover a lot more of the therapy, which would be financially advantageous. But I am concerned that my PCP does not have as much TRT specific experience as a practitioner I would work with through Defy.

Thanks in advance for any help.

 

[MarkM]

Hi PJ,

Welcome to the forum!

Without question you could benenfit from a proper TRT protocol but your PCP did not run the proper tests to be able to determine a proper protocol. This is not unusual for a PCP, which is a shame, and should cause concern for you when a PCP does not run the proper tests.

First of all, I see no test for SHBG (Sex Hormone Binding Globulin) which is one of the most critical factors, if not the most important factor, in determining what type of protocol we on TRT should be on.

Secondly, it appears to me that the wrong E2 test was used. You lab works does not state specifically, but I believe the test your PCP used was the Roche ECLIA methodology test, which is a test used for women. The proper test to measure the E2 levels in men is the Estradiol Sensitive LC/MS/MS assay. This is another red flag.

Your DHEA-s is on the low side so you would probably benefit from supplementing with DHEA. Something to consider. If you are wishing to remain fertile and are concerned about testicular atrophy (shrinking testicles) you may want to consider HCG and discuss that with your PCP. He likely won't understand reasoning's for that if he doesn't understand to test for SHBG and the proper E2 test.

The TSH is what I would consider a little elevated even though in range. You really want the TSH below 1.0 but it by itself tells us nothing about your thyroid other than some of the thyroid hormones might not be optimal. An under performing thyroid can give you low Testosterone symptoms nad make optimizing your TRT protocol more difficult. I would run a full thyroid panel to make sure your thyroid is working as it should. A proper thyroid panel would include: TSH, Free T3, Free T4, Reverse T3, and both Thyroid antibodies (TPOab and TgAB).

Not sure what time of day testing was done but it is always best to have blood drawn when testing for hormones between 8 AM and 10 AM.

Like you said, those Triglycerides are crazy, never seen them that high.

 

[pjmurphy]

Thanks for your feedback Mark!
You are right. I did not notice that the SHBG results were not there. I thought for sure I asked him to run that, but now that I look at my notes, I see that it was not one of the tests I asked for. I'll chalk that up to my mistake, since I was telling the doctor exactly what tests I wanted. I did get it tested on April 5 along with a thyroid panel. Those results were:
SHBG 39.6 nmol/L 16.5-55.9 nmol/L

Total Testosterone 380 ng/dL 264-916 ng/dL

Free Testosterone (Direct) 7.8 pg/mL 8.7-25.1 pg/mL

Estradiol (E2) Level 29.0 pg/mL <11 - 52.5 pg/mL

Thyroxine (T4) 7.5 ug/dL 4.5-12.0 ug/dL

Thyroid Peroxidase Antibodies 9 IU/mL 0-34 IU/mL

Free Triiodothyronine 3.54 pg/mL 2.18-3.98 pg/mL

25-Hydroxy Vitamin D Total 26.6 ng/mL 30.0-100.0 ng/mL

Thyroid Stimulating Hormone (TSH) 1.840 uIU/mL 0.358-3.740 uIU/mL

I don't think this Thyroid panel includes all of the tests you recommend. Is it enough to tell if Thyroid function is something that should be looked at more closely?

I did request the sensitive E2 test, so I was disappointed that it appears they ran the non-sensitive one.

As far as fertility is concerned, I am had a vasectomy several years ago and have no plans to have any more kids. I am not too concerned about testicular atrophy, but would be open to HCG if there are other reasons to consider it.

My most recent labs were drawn at 8:30 am. The thyroid panel and other tests listed above were drawn on April 5th around 3pm.

 

[Sean Mosher]

Only other thing to really look at for thyroid would be RT3 and if it's elevated.
But with that Free T3 number it doesn't appear that you have a conversion problem.

Since fertility isn't a concern for you, you try both with and without hCG.
Some get a tangible benefit and some don't for whatever reason.

 

[MarkM]

In reality, your PCP should know that SHBG is critical in TRT without you having to ask for it but that's not unusual.

To add to Sean's comments, your SHBG is just over the mid range of 36.2 at 39.6. That's a good place to be and if you start TRT it will likely come down a little bit which is okay.

Your Vitamin D is low so you should supplement it and bring it up to around 70.

 

[pjmurphy]

Your Vitamin D is low so you should supplement it and bring it up to around 70.

I have been supplementing with Vit D3 for about 3 months now. I am going to ask my PCP to order another Vit D test to see where I am today.

 

[MarkM]

Good deal! What size supplement are you taking? How many IU's?

 

[pjmurphy]

Good deal! What size supplement are you taking? How many IU's?

Right now I am taking 5000 iu of vit D3 and 90 mcg of K2 every morning.
For the first 45 days or so I was taking 2x that.
Here is the product I am taking: http://a.co/d/33R5VC1

 

[Systemlord]

When my testosterone was low, Vit D was also low. I started TRT and Vit D increase on it's own. I see it from time to time on this forum, low testosterone alongside low Vit D.

Low hormones can play havoc on the male body especially low or high estrogen. Your E2 labs are likely overstating your E2 level and it's actually lower. As far as hormone testing and designing a proper TRT protocol, it isn't taught in medical school, so expect the majority of doctors to be hormone ignorant when it comes to proper testing and designing protocols.

Defy Medical is an excellent idea.

 

[pjmurphy]

Still keeping Defy as an option.
I have my follow up with my PCP this afternoon, so I am going to see what he offers. I will discuss Defy with him as well. I am wondering if there is anyway he can collaborate with Defy so that I can take advantage of insurance to cover my meds but also get the benefit of the expertise of the medical staff at Defy. Has anyone ever had any luck with anything like that?

Right now, from my research I am thinking a protocol along these lines would make sense:

• Test Cyp, E3.5 Days, subcutaneous injections
• HCG 500 iu E3.5 Days
• DHEA 25 mg Daily
• Pregenelone 30 mg daily maybe?

Obviously, I am just taking a stab at the doses, etc. but I am hoping that my PCP will be open to something along these lines. if not, I may be looking at Defy again.

What is the standard for determining when I should have my levels retested after starting TRT? 2 weeks? 1 month?

 

[Systemlord]

When you start TRT it takes 6 weeks for testosterone blood levels to reach a stable state and it may take longer to notice maximum benefits as gene expression takes place and tissue is repaired, of course if you're just starting TRT the time course to maximum benefits in more than 1 year.

A lot of guys expect immediate results are are disappointed and some even quit TRT thinking it doesn't work for them. The first year you will be making adjustments to your TRT protocol to get dialed in, this dialing process will halt or slow if you're working with an inexperienced doctor.

SHBG allows a protocol to be designed, without it the process of dialing in is already slowed.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3188848/

Effects on sexual interest appear after 3 weeks plateauing at 6 weeks, with no further increments expected beyond. Changes in erections/ejaculations may require up to 6 months. Effects on quality of life manifest within 3–4 weeks, but maximum benefits take longer. Effects on depressive mood become detectable after 3–6 weeks with a maximum after 18–30 weeks. Effects on erythropoiesis are evident at 3 months, peaking at 9–12 months. Prostate-specific antigen and volume rise, marginally, plateauing at 12 months; further increase should be related to aging rather than therapy.

Effects on lipids appear after 4 weeks, maximal after 6–12 months. Insulin sensitivity may improve within few days, but effects on glycemic control become evident only after 3–12 months. Changes in fat mass, lean body mass, and muscle strength occur within 12–16 weeks, stabilize at 6–12 months, but can marginally continue over years. Effects on inflammation occur within 3–12 weeks. Effects on bone are detectable already after 6 months while continuing at least for 3 years.

The time-course of the spectrum of effects of testosterone shows considerable variation, probably related to pharmacodynamics of the testosterone preparation. Genomic and non-genomic effects, androgen receptor polymorphism and intracellular steroid metabolism further contribute to such diversity.

 

[pjmurphy]

Thanks Systemlord.
Thanks in large part to this forum, I am aware of the timeframes to see the effects. I have also read the article you linked to. I am not expecting an overnight miracle (as nice as that would be).

SHBG allows a protocol to be designed, without it the process of dialing in is already slowed.

I do have SHGB results from my April 5 panel of labs, it was just left off of my most recent panel by mistake. I will make sure that all future panels include it. Are you suggesting that I should postpone treatment until I have another full panel done with SHGB?

 

[Jesse-Defy]

Still keeping Defy as an option.
I have my follow up with my PCP this afternoon, so I am going to see what he offers. I will discuss Defy with him as well. I am wondering if there is anyway he can collaborate with Defy so that I can take advantage of insurance to cover my meds but also get the benefit of the expertise of the medical staff at Defy. Has anyone ever had any luck with anything like that?

Right now, from my research I am thinking a protocol along these lines would make sense:

• Test Cyp, E3.5 Days, subcutaneous injections
• HCG 500 iu E3.5 Days
• DHEA 25 mg Daily
• Pregenelone 30 mg daily maybe?

Obviously, I am just taking a stab at the doses, etc. but I am hoping that my PCP will be open to something along these lines. if not, I may be looking at Defy again.

What is the standard for determining when I should have my levels retested after starting TRT? 2 weeks? 1 month?

Absolutely. There's no requirement to order the medications from us. You're welcome to email me at [email protected] and I'd be happy to assist.

 

[Systemlord]

No need to wait if you already have captured the range at which shbg is sitting. It may fluctuate a little, but not drastically, unless of course thyroid function is taking a hit.