Specific Blood Work Questions:

[John O'Connor]

Nelson (or others), can you clarify questions I have regarding blood work? FYI, I'm in the process of applying to Physician Assistant graduate programs, so I'm fairly well educated in basic chemistry, physiology, etc.


1) Is SHBG approximation using Total & Free Testosterone adequate, or is it important to have SHBG as a seperate test?


2) Quest has Estradial Ultrasensitive, but I'm noticing other labs seem to only have Estradiol Sensitive. Does it matter which "sensitive" version I get?


3) Is CBC without differential OK, or do I need with differential? If so, why?


Background: I was diagnosed with hashimoto's thyroiditis in 2006, which is well managed with 50 mcg of levothyroxine. I finally got diagnosed for Low-T in November, 2015. My doctor is a 2nd Year Family Medicine MD and I'm his first TRT patient. He is working with me, but initially just followed basic clinical guidelines. I'm now asking him to run your recommended full blood work.
November #s prior to TRT:
Total T, 341 ng/dL. Morning (I also had an afternoon test = 204)
FSH 16.8 (1.5 - 12.4)
LH 8.2 (1.7 - 8.6)
HGB 16.4 (14.0 - 18.0)
HCT 47.2% (41 - 54%)
PSA 0.6
So he diagnosed me with Primary Hypogonadism. I have a left testicular vericocele since age 18 (now 47), which explains this. Last month I met with Dr. Kat Peterson N.D (& female bodybuilder - Physique - Junior Nationals). She reviewed my symptoms & limited blood work and suspects my DHEA-S will be low.


TRT history:
Started Cypionate 50mg/week on (12/9/15). Total T on Day 8 = 350 (1/12/16). Felt good, had 3-4 morning erections/week, but noticed drop in vitality prior to next injection.


So (1/21/16) bumped up to 80mg/week and Total T on day 4/Peak (2/22/16) = 915, PSA = 0.6, RBC = 6.05 (4.3 - 6.0), HGB = 17.7 (14.0 - 18.0), HCT = 50.8% (41-54%). Should I be concerned about slightly high RBC?

Rechecked total T on (3/3/16) day 8/Trough = 653. Felt great, noticeable increase in strength at gym, but morning erections stopped, slight decrease in desire, but otherwise good sexual function. I'm guessing I was aromatazing the extra T. I also had Vitamin D checked on (3/3/16) and it was low, 19 ng/mL (30-100). So he prescribed 50,000 iu / once per week.


I also started a new drug in January (Namenda - generic = memantine) for ADHD (off-label), the drug inhibits NMDA receptor binding, and has been shown to lower FSH & LH production. Luckily I checked those levels prior to starting the drug. The drug is improving my ADHD symptoms 100%. I've literally never felt sharper mentally. I've had to completely stop Adderall & decrease caffeine to 50mg/day from 200mg per day as I'm literally wide awake on Namenda.


Do to the impacts of Namenda, and not having baseline #s for estradiol, SHBG, DHEA-S & Free T, I agreed to retest baseline numbers. So I've stopped TRT. My last injection was 60mg on (3/17/16). My blood draw is scheduled for (4/13/16). I'm guessing this will be enough time to let my LH & FSH levels normalize. Any thoughts on this?


Back to above questions - He has entered bloodwork, but missed some of the details in your list. I will ask him to correct those, but wanted to verify the SHBG & Estradiol Sensitive/Ultrasensitive & CBC with or without differential issue before messaging him.


Here are the labs he ordered thus far for (4/13/16) blood draw:
Estradiol (he did not specify sensitive - so I will have him correct this.)
Free T
Total T
DHEA-S
Comprehensive metabolic panel
CBC without differential (will ask for differential if you recommend)
TSH 3rd generation w/ reflex to free T4
T4 free
T3 free
PSA
FSH
LH
- SHBG not ordered, but I will request this based on your advice.
- I'll also ask for recheck of Vitamin D.


Please let me know your thoughts, and as always thank you so much for everything you are doing to help so many people in this community. I'm hoping if/when I become a PA, I can pass the knowledge forward to others.


All the best!
~John O'Connor

 

[Vince Carter]

Sensitive and Ultra Sensitive are interchangeable terms between Quest and LabCorp, what's important is the methodology of the test...you want LC/MS/MS.
SHBG is a test of itself that is important to have. INjectiing once per week is old news and why you feel a lesser state of being on days 6/7/8, most any of us on a modern regimen do no less that E3.5D. You'd be wise to move that direction and 80mg week is pretty low for TRT where a base starting dose is typically 100mg, so 50mg E3.5D.
Increased RBC is a side of T replacement managed through blood donations or therapeutic phlebotomy, same with Hematocrit/Hemoglobin.
I just glanced over a few things in your post.

 

[John O'Connor]

Thanks Vince! I'm planning to go to the E3.5D routine when I go back on. Again, the Dr, (2nd year resident) was initially hesitant as clinical guidelines suggest every 2 week is norm, & 1/week is a possible alternative, but nothing about more frequent. My 915 level on day 4 peak scared him. But when I explained things, he has come around. Both he and I are learning together & he is willing to learn.

Does anyone have thoughts on the importance of CBC With or Without differential? I just want to be able to justify asking him to change it from CBC Without that he currently has ordered.

Also - what are people thought on adding HCG along with E3.5D TRT regimen? Should I get to healthy baseline on TRT prior to adding HCG? If 50mg E3.5D works, would I reduce that dose when adding HCG? If so, by how much?

 

[ERO]

You don't reduce your T dose when you add HCG. HCG is typically started at 250IU twice a week, injected the same day as your Test. Change nothing for 4-6 weeks and test again.

 

[John O'Connor]

Thanks ERO, so would you recommend I start HCG when I restart cypionate on April 13th, or wait and get baseline TRT set first. I'm planning on switching to E3.5D injections when I restart, but since I'm not 100% sure what dose will be optimal yet, would you advise getting cypionate dose locked down first? Or would starting in combination be preferable?

 

[Vince Carter]

It's best you start them simultaneously as every little change, can, upest the homeostasis you've achieved. If you added HCG at 6 weeks, you'll likely set forth having to adjust and then balance out again. There's no reason to do it later, and there's no reason for inducing organ failure at any point by letting your testes atrophy.

 

[Nelson Vergel]

Nelson (or others), can you clarify questions I have regarding blood work? FYI, I'm in the process of applying to Physician Assistant graduate programs, so I'm fairly well educated in basic chemistry, physiology, etc.

MY ANSWERS IN CAPITALS


1) Is SHBG approximation using Total & Free Testosterone adequate, or is it important to have SHBG as a seperate test?

NO NEED TO HAVE SEPARATE SHBG AT FIRST. IF YOUR FREE T COMES BACK UNDER 2 % OF TOTAL T, THEN IT MAY BE GOOD TO SPEND THE EXTRA MONEY.

2) Quest has Estradial Ultrasensitive, but I'm noticing other labs seem to only have Estradiol Sensitive. Does it matter which "sensitive" version I get?

LABCORP'S SENSITIVE IS PRETTY MUCH THE SAME AS QUEST ULTRASENSITIVE. GO FOR THE CHEAPEST. DISCOUNTEDLABS.COM HAS THE BEST PRICE FOR SENSITIVE ESTRADIOL.


3) Is CBC without differential OK, or do I need with differential? If so, why?

CBC MOSTLY COMES WITH DIFFERENTIAL. LOW COST


Background: I was diagnosed with hashimoto's thyroiditis in 2006, which is well managed with 50 mcg of levothyroxine. I finally got diagnosed for Low-T in November, 2015. My doctor is a 2nd Year Family Medicine MD and I'm his first TRT patient. He is working with me, but initially just followed basic clinical guidelines. I'm now asking him to run your recommended full blood work.

November #s prior to TRT:

Total T, 341 ng/dL. Morning (I also had an afternoon test = 204)
FSH 16.8 (1.5 - 12.4)
LH 8.2 (1.7 - 8.6)
HGB 16.4 (14.0 - 18.0)
HCT 47.2% (41 - 54%)
PSA 0.6



So he diagnosed me with Primary Hypogonadism. I have a left testicular vericocele since age 18 (now 47), which explains this. Last month I met with Dr. Kat Peterson N.D (& female bodybuilder - Physique - Junior Nationals). She reviewed my symptoms & limited blood work and suspects my DHEA-S will be low.


TRT history:
Started Cypionate 50mg/week on (12/9/15). Total T on Day 8 = 350 (1/12/16). Felt good, had 3-4 morning erections/week, but noticed drop in vitality prior to next injection.


So (1/21/16) bumped up to 80mg/week and Total T on day 4/Peak (2/22/16) = 915, PSA = 0.6, RBC = 6.05 (4.3 - 6.0), HGB = 17.7 (14.0 - 18.0), HCT = 50.8% (41-54%). Should I be concerned about slightly high RBC?

NO, IT IS NORMAL. IF IT GETS HEMATOCRIT GETS NEAR 53, GO DONATE BLOOD.

Rechecked total T on (3/3/16) day 8/Trough = 653 (3/3/16). Felt great, noticeable increase in strength at gym, but morning erections stopped, slight decrease in desire, but otherwise good sexual function. I'm guessing I was aromatazing the extra T. I also had Vitamin D checked on (3/3/16) and it was low, 19 ng/mL (30-100). So he prescribed 50,000 iu / once per week.

TOO BAD YOU HAVE NO ESTRADIOL, NO FREE T3, AND MORE LAB TESTS.Blood Tests Needed Before and During Testosterone Replacement Therapy
I also started a new drug in January (Namenda - generic = memantine) for ADHD (off-label), the drug inhibits NMDA receptor binding, and has been shown to lower FSH & LH production. Luckily I checked those levels prior to starting the drug. The drug is improving my ADHD symptoms 100%. I've literally never felt sharper mentally. I've had to completely stop Adderall & decrease caffeine to 50mg/day from 200mg per day as I'm literally wide awake on Namenda.

GOOD TO KNOW, WAS THIS AT THE SAME TIME AS YOUR ERECTIONS STARTED GETTING SOFTER?

Do to the impacts of Namenda, and not having baseline #s for estradiol, SHBG, DHEA-S & Free T, I agreed to retest baseline numbers. So I've stopped TRT. My last injection was 60mg on (3/17/16). My blood draw is scheduled for (4/13/16). I'm guessing this will be enough time to let my LH & FSH levels normalize. Any thoughts on this?

I HAVE NO IDEA WHY YOU WOULD STOP NOW. WHO CARES WHAT YOUR BASELINE WAS? NORMALIZATION OF HPTA TAKES A WHILE, SO YOUR NEXT BLOOD DRAW MAY BE TOO SOON.


Back to above questions - He has entered bloodwork, but missed some of the details in your list. I will ask him to correct those, but wanted to verify the SHBG & Estradiol Sensitive/Ultrasensitive & CBC with or without differential issue before messaging him.


Here are the labs he ordered thus far for (4/13/16) blood draw:
Estradiol (he did not specify sensitive - so I will have him correct this.)
Free T
Total T
DHEA-S
Comprehensive metabolic panel
CBC without differential (will ask for differential if you recommend)
TSH 3rd generation w/ reflex to free T4
T4 free
T3 free
PSA
FSH
LH
- SHBG not ordered, but I will request this based on your advice.
- I'll also ask for recheck of Vitamin D.

GOOD

Please let me know your thoughts, and as always thank you so much for everything you are doing to help so many people in this community. I'm hoping if/when I become a PA, I can pass the knowledge forward to others.

 

[John O'Connor]

Nelson - Thanks for the detailed response.

And to answer your question. I noticed decrease in frequency of morning wood within a few days of going from 50mg/week up to 80mg/week. 80mg dose began on January 21st.

I began titrating onto Namenda January 26th. Week 1: 5mg/day, Week 2 10mg/day, Week 3 15mg/day, Week 4 20mg/day (full dose). I did not notice any benefits from Namenda until February 14th when I started 15mg dose.

As I stated above, the decrease in frequency of morning wood from 3 to 4 days per week, to 1 day per week seemed to be related more with the increase to 80mg dose. Erection quality is still strong (not soft), but desire was not as high as on the 50mg dose. My strength at gym increased 20% upon going to 80mg/week. Jumped from 65-70 pound incline dumbbells straight to 80 pounds. Dumbbell curls went from 35 pound to 40+. Weight also increased from 187 to 192. Now that I'm off TRT, my weight has dropped to 187 again over the last few days. That might also be related to working more and not hitting the gym as much the past 2 weeks. But mentally the Namenda is still working amazing. I'll provide update once my labs are done.

As for, why stop now? It has more to do with Namenda. It is off-label, and a newer drug for ADHD (FDA approved for Lewy Body Dementia to improve working memory). I've struggled with ADHD my entire life, despite IQ measured at 132 as a child. Some of the benefits of Testosterone (vitality & some mental improvements), needed to be ruled out. Also changing to 80mg on 1/21, and then starting Namenda on 1/26 created some questions. Additionally it will be interesting to see where my LH & FSH numbers end up on 4/13, since they were originally high, but Namenda is shown to decrease these. I figure its best to just get baseline numbers on Namenda, since I plan on staying on it the rest of my life.