Would appreciate some candid advice before I sit down with my TRT doctor. Anything you guys see in my bloodwork that raises a red flag one way or another? Thanks!
Definitely need TRT. Next time, have E2 tested. Have free T4 and free T3 tested. Maybe IGF-1 and DHEA-S. Take VitD3, 5000IU/day.
I have bloodwork from my primary care doc from Feb 2019 with some of those:
E2 = 40.6 pg/mL vs. ref range of 7.6-42.6
IGF-1 = 222 ng/mL vs. ref range of 83-233
DHEA, Serum = 249 ng/dL vs. ref range of 31-701
DHEA-Sulfate = 191.2 ug/dL vs. 102.6-416.3
Don’t have FT3 / FT4 though.
I also had a CT Calcium Score done Feb 2019 - Agatston Score = Zero
A couple more pieces of info. I am 5’9" and currently around 258. I was 283 back in Nov. 2018 so I have lost about 25 pounds through some lifestyle changes with respect to diet and exercise. I am not currently on any prescription meds. I do take a daily multi-vitamin pack + creatine.
Be careful and do not let your doctor prescribe 200mg every two weeks, studies don’t show favorable results. You need one preferably two 50-60mg injections per week to keep levels in the therapeutic range at all times with as little fluctuations as possible.
Maybe your doctor screwed up on the lab order but I noticed he tested total estrogens which is totally wrong, you need direct estrogen testing.
No thyroid hormones were ever checked, troubling. TSH is a stimulating hormone, not an actual hormone like Free T3 which is the most important as it increases metabolism and body temperatures.
A lot of doctors get thyroid and TRT wrong and don’t fully grasp the basics. I foresee trouble ahead and is more common than you know.
You can tell a lot about the competency of a doctor by the lab tests he orders.
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Someone correct me if I’m wrong but on the estrogen test (if I remember right because pre-med was a long time ago) is meant for women and men should make sure they get the sensitive test. Besides that, every male has their own baseline so the important question is how do you feel? Any bad symptoms? Or feel great but got levels tested and was offered it?
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ECLIA vs LC/MS/MS TESTING FOR E2
The ECLIA test (aka immunoassay or IA) for E2 management is commonly used for those on TRT. It is not an incorrect test or a test for women, but simply one way to check estradiol levels. The other commonly utilized test is the LC/MS/MS method (aka liquid chromatography dual mass spectrometry, sensitive or ultrasensitive). It is the more expensive of the two. There are inherent advantages and disadvantages to each of these two methods. I have been fortunate to be able to speak with professionals who work with both methods. One is a PhD researcher for Pfizer and the other is a medical doctor at Quest. I’ll summarize their comments.
The ECLIA method is the more reliable of the two in terms of consistent results. The equipment is easier to operate thus accuracy is less reliant on the skill of the operator. If the same sample were to be tested twenty times, there would be very little, if any, difference in the results.
The ECLIA method is not as “sensitive” in that it will not pick up E2 levels below 15pg/mL. If your E2 level with this test is 1-14pg/mL, the reported result will be “<15”. Because of this, it is not recommended for menopausal women, men in whom very low levels of E2 are suspected, or children. In other words, if your levels are below 15pg/mL, and it is important to know if the level is 1 or 14pg/mL, you do not want this test. For us, this is likely moot, since if you are experiencing low E2 symptoms and your test comes back at <15, you have your answer. For a woman being treated with anti-estrogen therapy for breast cancer, it may be necessary to know if the E2 level is zero or fourteen because therapeutically, they want zero estrogen.
A disadvantage to IA testing is that it may pick up other steroid metabolites, which in men would be very low levels, but still could alter the result. Another potential disadvantage is that elevated levels of C-reactive protein (CRP) may elevate the result. CRP is elevated in serious infections, cancer, auto-immune diseases, like rheumatoid arthritis and other rheumatoid diseases, cardiovascular disease and morbid obesity. Even birth control pills could increase CRP. A normal CRP level is 0-5 to 10mg/L. In the referenced illnesses, CRP can go over 100, or even over 200mg/L. Unless battling one of these serious conditions, CRP interference is unlikely.
The LC/MS/MS method will pick up lower E2 levels and would be indicated in menopausal women and some men if very low E2 levels are suspected and it is desired to know exactly how low, children and the previously mentioned women on anti-estrogen therapy. It will not be influenced by elevated CRP levels or other steroid metabolites.
While some may believe the ECLIA test is for women, on the contrary, as it pertains to women on anti-estrogen therapy, such as breast cancer patients, the LC/MS/MS is the test for women as CRP levels are a consideration and it is necessary to know if the treatment has achieved an estrogen level of zero.
On the other side of the coin, LC/MS/MS equipment is “temperamental” (as stated by the PhD who operates both) and results are more likely to be inconsistent. Because of this, researchers will often run the same sample multiple times.
It is not clear if FDA approval is significant, but this appears on Quest’s lab reports: This test was developed, and its analytical performance characteristics have been determined by Quest Diagnostics Nichols Institute San Juan Capistrano. It has not been cleared or approved by FDA. This assay has been validated pursuant to the CLIA regulations and is used for clinical purposes. This statement is on LabCorp’s results: This test was developed and its performance characteristics determined by LabCorp. It has not been cleared by the Food and Drug Administration.
It is unlikely that any difference in the same sample run through both methods will be clinically significant. Estradiol must be evaluated, and it should be checked initially and ongoing after starting TRT. It obviously makes sense to use the same method throughout. Most important are previous history and symptoms related to low or high E2. Those are correlated with before and after lab results. Any estradiol management should not be utilized without symptoms confirmed by lab results.
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I recently received what I believe to be an error in my sensitive E2 lab value, normally when I score in the low 400’s (406), estrogen is very close to 30, however this time it was 56 and had zero high E2 symptoms, if anything E2 felt a little low. If I had actually been in the 50’s, I surely would have experienced high E2 symptoms as I always do.
Neither E2 tests are perfect, if you can afford it run both.
So I have my appointment scheduled for next Friday with the TRT doc. I have a bunch of questions for him. Here is what I have so far:
- Curious why didn’t you test E2, FT3, FT4, IGF-1 and DHEA-S ?
- Do you know what is causing my low testosterone?
- Can low T be obesity related? If I were to lose another 40 lbs, on top of the 25 pounds I have already lost, do you think my Testosterone levels would improve?
- Can my low T be attributable to a thyroid condition (eg. Hashimoto’s). Shouldn’t we rule out a thyroid condition before going on a TRT plan? My wife has Hashimoto’s and it was not observable via TSH, FT3, FT4, and Reverse T3 tests. Only a thyroid antibodies panel picked it up.
- It appears I have low testosterone (both TT and Free), while having estrogens at top end of the range (4/9/19 blood test) and E2 at high end (2/25/19 blood test). Is my body converting too much Testosterone into estrogen? Would an aromatase inhibitor make sense here?
Anything else I am missing ?
Thank you for the heads up on Vit D3 5,000. I went back and check a few years worth of blood tests and I am consistently low. Just started taking 5,000 iu today 
Because he doesn’t specialize in TRT, some doctors don’t dig deep enough. He may be the opposite of a perfectionists.
It’s multifactorial, lifestyle, diet, environment, genes all play a part. Time is money and resources are not unlimited, healthcare costs are rising out of control. You’re 39 years old, don’t expect optimal testosterone at age 39 living in a polluted, toxic environment filled with harmful chemicals that is seeing men’s testosterone levels on the decline worldwide for the past several decades.
In 2040 we will be unable the have children the old fashion way, no more sperm the way things are going.
Maybe a little, but you’ll never reach the optimal ranges like you had in your 20’s, your 11 years away from 50 when men are expected to have sexual problems.
This is not usually the case, again even if it was (extreme long shot) optimal testosterone at 39 years old is a not happening.
Your are missing estrogen testing, no experienced doctor relies on Total Estrogens. If by some miracle it is accurate, it usually means excess body fat is to blame. Lose the visceral fat and estrogen should decrease, however you may need an AI for a short duration to gain control of the situation. We are not talking about 1mg, we are talking about .125 1-2x per week available through compounding pharmacies.
Wanted to give you guys a quick update. I got another set of bloodwork through Defy. My consult is scheduled with Dr. Saya for 7/29. Since my initial post in early April, I continue to work out like a mad man. I am doing cardio on a peloton bike 5-7x week, 45 min / day and lifting 3-4x a week. Today my weight is down around 246-247. It was 258 in early April and 283 in November 2018. That being said, my weight loss seemed to have hit a brick wall. For the last month I have been doing cardio every day and weight hasn’t budged… my bodyfat % is 27.5% so I have plenty more fat to lose…
I had a bunch of thyroid tests in my bloodwork so I am wondering if anyone has insights if I have a thyroid issue? Also, my fasted glucose is borderline high and my diet is very carb light. So, I feel like I have some kind of insulin sensitivity issue. I wonder if I should be taking Metformin.
Any observations would be greatly appreciated.
I do not like your TSH one bit, 3.0 is problematic, Free T3 is sub-optimal and needs to be at least mid-range. TRT will not be life changing at these Free T3 levels. CBC labs are all on the lower end, iron status is an unknown, but MCV and MCHC are on the lower end.
TRT could cause iron deficiency down the road, keep an eye on iron status.
Yes it does:
“Overall, our study suggests that what is best for men’s health is to keep testosterone levels balanced and within a normal range,” says Loeb, who suggests that men with testosterone levels below 350 nanograms per deciliter and symptoms should seek medical advice about whether they should consider testosterone therapy.
Testosterone Therapy Does Not Raise Risk of Aggressive Prostate Cancer, Study Suggests