39 YO Considering T-Replacement

[quote]CactusBeats wrote:
Finally saw the doc today after nearly three months of waiting. She’s open-minded and listens but the appt was short for all I wanted to ask. She ordered a variety of lab tests. Should be ready to post them early next week. I recently became hypothyroid on a test in March (5.7 on 1.0-5.0).

She is willing to Rx T injections, but for the moment I will have to drive to get them weekly at some “local” clinic. Probably a 35 mile round-trip for that. I think I can convince her to teach me & let me do them at home, with time. One can only hope. I mean, diabetics are allowed to do it, so what gives? She does not Rx hCG but knows a colleague who does and will work with him. That’s a plus, but can imagine only more driving for injections. Not to mention that once a week for either T or hCG is anything but ideal. Unfortunately she does not Rx anastrozole. She mentioned something about “the load on the body” like it was hard on the body. I hadn’t read that before. It sounds like she is just willing to accept E2 wherever it goes and if its too high she’ll just drop the T dose. I am ready to order a research chemical (AI), anastrozole. It makes me feel kind of bad because I want an honest open-relationship with her. I figured maybe I can even wait 6 weeks until the next lab test to start the AI, and then ask what she’s going to do about the increased E2 on the lab report. Or maybe just go rogue & self treat 1mg/week. I know it takes some time to bring E2 back down so its tempting to start the AI with the T. I am willing to continue to see her at this point. Doctor shopping is no fun at all, but there are maybe six or seven others in my area.

For so many guys it seems like the only, the best, & the most economical course is to self-treat. You just have to find a doc to order your labs then. Today raised more questions than answers.

Will post lab results next week.[/quote]

If your test is low, don’t rely on a dr. to get you your test. buy it online. Try some Testosterone cream. If that doesn’t do it, try injections. Many here will go against what im saying, but to have to worry about dr’s visits, blood tests all the time. Thats alot of time away from what you could be doing. Get what you need yourself, and forget about drs.

[quote]CactusBeats wrote:
Finally saw the doc today after nearly three months of waiting. She’s open-minded and listens but the appt was short for all I wanted to ask. She ordered a variety of lab tests. Should be ready to post them early next week. I recently became hypothyroid on a test in March (5.7 on 1.0-5.0).

She is willing to Rx T injections, but for the moment I will have to drive to get them weekly at some “local” clinic. Probably a 35 mile round-trip for that. I think I can convince her to teach me & let me do them at home, with time. One can only hope. I mean, diabetics are allowed to do it, so what gives? She does not Rx hCG but knows a colleague who does and will work with him. That’s a plus, but can imagine only more driving for injections. Not to mention that once a week for either T or hCG is anything but ideal. Unfortunately she does not Rx anastrozole. She mentioned something about “the load on the body” like it was hard on the body. I hadn’t read that before. It sounds like she is just willing to accept E2 wherever it goes and if its too high she’ll just drop the T dose. I am ready to order a research chemical (AI), anastrozole. It makes me feel kind of bad because I want an honest open-relationship with her. I figured maybe I can even wait 6 weeks until the next lab test to start the AI, and then ask what she’s going to do about the increased E2 on the lab report. Or maybe just go rogue & self treat 1mg/week. I know it takes some time to bring E2 back down so its tempting to start the AI with the T. I am willing to continue to see her at this point. Doctor shopping is no fun at all, but there are maybe six or seven others in my area.

For so many guys it seems like the only, the best, & the most economical course is to self-treat. You just have to find a doc to order your labs then. Today raised more questions than answers.

Will post lab results next week.[/quote]

To make weekly trips to get a test injection. Get it yourself. This way you don’t have to worry about drs. tests, weekly hour long drives, forget that, thats a waste of life.

I finally had labs done & saw some doctors. This is more like a first post even though its not.

Age: 40

Height: 5’11"

Weight: 183

Waist: 31.5"

Body Hair: Plenty, but none on back and thinning on ankles.

Facial Hair: Medium thickness & speed of growth.

Head Hair: Mostly bald on top & advancing male pattern baldness. Who cares really now because I shave my head & am done with bad hair days forever.

Carry fat mostly around lower abdomen. Probably around 12-15% bodyfat currently. When training I am around 10-11%. Normally I am a gym-rat weight-training with heavy weights & regular aerobic exercise, but now recovering (doing PT) from shoulder & knee surgeries late last winter, still. No exercise induced endorphin rush in almost six months!

Symptoms/health conditions: Low energy/ easily fatigued, depression, terrible short-term memory, avoid social situations, and low libido & ED. Eventually stopped dating because of low-T.

Rx & OTC drugs: Lithium, trazadone, Geodon, Cymbalta (all for Bipolar Type II disorder). I will stop the Cymbalata when I can get a regular/daily solid workout again. Just started Test. Cyp. 50mg IM X2 weekly and Armour thyroid 2 grains (60 mg)/day (Armour now discontinued). Will be starting rhCG (Ovidrel) in three to four weeks (when it arrives mail order - due to high cost domestically). I have liquid anastrozole on hand in case gyno becomes an issue before my next Dr. visit in three months. I took propecia for nine months in 2001-2002. I tried a Nolvadex reset/restart (detailed in an above posting) which yielded no noticeable change in libido or anything T-related. The restart was after my first T lab and before my most recent T lab. That said, along with consideration of the labs I would surmise that I am primary hypo.

Lab Results: (Labs presented in reverse chronological order (most recent is first))

5/15/2012 Labs (Hormonal/Thyroid):

Total Test.: 346 ng/dL [300 - 890]
Bioavailable Test.: 176 ng/dL [131 - 682]
Free Test.: 58 pg/mL [47 - 244]
% Free Test.: 1.7 % [1.6 - 2.9]
SHBG: 35 nmol/L [11 - 80]
Estradiol (E2): 27 pg/mL [0.0 - 56]
FSH: 3.4 mIU/mL [0.7 - 11.1]
LH: 4.9 mIU/mL [0.8 - 7.6]
TSH: 6.34 uIU/mL [0.4 - 5.00] HIGH
T3, Free: 3.4 pg/mL [2.2 - 4.0]
T4, Free: 1.27 ng/dL [0.8 - 1.6]
Thyroid Autoantibodies:
Thyroid Peroxidase AB: 28.5 units/mL [<60]
Thyroglobulin AB: 35.6 units/mL [<60]

03/06/2012 Labs (Lipids, TSH, Complete Metabolic (Fasting)):

Cholesterol: 173 mg/dL [100 - 200]
LDL: 114 mg/dL [<130]
HDL: 49 mg/dL [>39]
Triglyceride: 51 mg/dL [<150]
Non-HDL Cholesterol: 124 mg/dL [<190]
Cholesterol/HDL: 3.5 [<4.5]
TSH: 5.730 mcUnits/mL [0.350-5.000] HIGH
Sodium: 141 [135 - 145] mmol/L
Potassium: 4.1 [3.4 - 5.1] mmol/L
Chloride: 106 [98 - 107] mmol/L
Carbon Dioxide: 30 [21 - 32] mmol/L
Anion Gap: 9 [10 - 20] mmol/L LOW
Glucose: 96 [65 - 99] mg/dL
BUN: 23 [10 ? 20] mg/dL HIGH
Creatinine: 1.3 [0.5 - 1.3] mg/dL
GFR Est. African Amer.: >60 [>59] mL/min./1.73m2
GFR Est. Non-African Amer.: >60 [>59] mL/min./1.73m2
BUN/Creatinine Ratio: 18 [7 - 25]
Calcium: 8.6 [8.4 - 10.2] mg/dL
Bilirubin Total: 0.4 [0.2 - 1.0] mg/dL
GOT/AST: 21 [<38] units/L
GPT/ALT: 51 [<66] units/L
ALK Phosphatase: 64 [50 - 136] units/L
Protein, Total: 7.0 [6.4 - 8.2] g/dL
Albumin: 3.8 [3.4 - 5.0] g/dL
Globulin: 3.2 [2.0 - 4.0] g/dL
A/G Ratio: 1.2 [1.0 - 2.4]

Lab 11/28/2011:

Total Testosterone: 376.4 [280 - 1100]

Lab 05/10/2011:

TSH: 2.711 mcUnits/mL [0.350-5.000]

Diet: I’m very aware of body fat & weight and eat high protein, moderate fat, low carb diet with whole grains, lactose, green vegetables, & sparse fruits as only carbs. I eat plenty of fish (wild-caught & farmed), along with poultry and once (no more than twice) per week red meat. I eat whole foods & prepare meals & avoid most processed foods (excepting cheese). I take a daily multivitamin, B-complex, 4000IU vitamin D, 50mg zinc, fish oil 720mg EFA/Omega 3’s, 1000mg vitamin C. I have experimented with 25mg DHEA in the past with almost no result on low T symptoms.

Describe Training: Right now my training consists of knee & shoulder physical therapy exercises using three & five pound dumbbells for injured left arm. I was curling 45-60 pound dumbbells before surgery. I had a SLAP tear caused by impingement of the clavicle. Arthroscopic surgery removed bone spurs & performed a biceps tenodesis (reattach the long-head biceps tendon to bicep groove on humerous). Arthroscopic knee surgery to correct Hoffa’s Syndrome (enlarged & frayed fat pad in left knee) causing patello-femoral pain whenever I would try running. The jury is out on both surgeries yet, but my progress is slow & steady. I currently walk 30 min per day along with the PT knee & shoulder exercises.

My usual exercise routine is three days in the gym (up to two hours each day, because I really love what lifting heavy weights does mentally first, & physically second) and the fourth day is running/biking (a four day program that I repeat). Two gym days - upper body and one gym day - legs/abs. I live to be physical, workout, & especially body-build. I have had no problem building & keeping muscle despite low T levels. This might be due to muscle-memory as I weight-trained heavily from age 12-18. As an adolescent & 20-something I surmise that I had very high testosterone levels (easily build muscle, very high sex drive & almost annoyingly high if it can be said, great performance, never an issue with ED or libido). I was (in high school) and still am accused of juicing because of muscle mass.

Testes ache ever with fever? Not aware of having a fever but for about the last seven years my right testicle would ache very uncomfortably, sporadically for no apparent reason and usually last a few days. I always chalked it up to potential slight torsion that I myself would try to correct by coughing & repositioning. In 2010 it even landed me in the ER twice because of the pain. Had an ultrasound done on it & no cause was found for this pain. Referred to urologist, but never followed up on it. My symptoms of low T coincide with the past seven years during these same episodes of pain.

Morning wood/nocturnal erections: Practically non-existent for last seven years. Had my first strong morning wood the morning after my first injection, but nothing since then. I’ve only had three shots so far.

My first Dr. appt for low T treatment was on May 15 and my most recent labs were on the same day. I gave my doctor some material from this website on the suggested protocol of treatment and asked if it was possible. My doctor read the material and responded with a letter stating that she was not the right doctor for me considering the hCG, AI, and home injections, all of which she was uncomfortable with. Unfortunately, she billed the appt for the following three reasons; 1.ED, 2. Thyroid function/needed treatment, and 3. libido. If you mention either ED or libido in regard to testosterone therapy to my insurance company, coverage is automatically denied. I am appealing her stated reasons (codes) for the appt considering I gave her printed materials stating my primary reasons (energy, depression, social withdrawal, etc.) but am not hopeful (she’s with a large hospital conglomerate that is very inflexible) as we only discussed ED and libido in regard to symptoms. I allowed her to do the diagnosing rather than me trying to prove I have low T by stating all my symptoms. Most of my questions were in regard to testing & treatment, not how she would code the appt. Ultimately, this is my fault because when I asked if they took my insurance for what they were seeing me for and they said “Yes,” I made the assumption that the professionals would know how to code the appt properly in order for the claim to be accepted. Obviously, that was a terrible assumption. $300 for nothing you could say, or at least almost. The labs were paid for & accomplished.

My second appt was completely the opposite of the first. Actually, I hit the jackpot. My new doctor is 100% on-board with home injections, has Rx’d me 100mg/week T in two divided doses, 250IU hCG MWF, and starting an AI after my second appt, if necessary. I even bought some vitamin B-12 to use periodically (SC) with the hCG, although I’ve never had my B-12 levels tested. I’ve had my first three 50mg T injections so far, and hopefully will start the hCG in around three weeks or so. Even though I pay may own insurance I am also paying 100% of the cost (visits, meds & future labs) for low-T with this new doc because he’s not covered by my insurance. I see it as money well-spent though because he’s likely the only physician in my area who will even consider this protocol. His office visits are reasonably priced unlike some other well-known docs in this field. It’s nice to be treated as an adult as far as my treatment is concerned.

The stickies here answered a lot of my questions so thank you guys for those. I am posting my case mostly in case of future issues/questions, but I do have some questions now regarding thyroid. A little background first.

In September 2009 I started taking Lithium which dramatically altered my life for the better, being bipolar (since age 9). At age 37, I finally found the right meds (listed above) which I am still on. One side-effect of lithium in 10% of people who take it is hypothyroidism. It has something to do with speeding up the metabolism of the thyroid which then loses some of its needed iodide (replaced by lithium). I recently began supplementation of potassium iodide to see if this makes any difference. I already have been eating lots of fish which are supposed to be a good source of iodide I have heard. All of that aside, my TSH has been on the uptick since at least May 2011. I get a TSH reading once a year because of the Lithium. May 2011: TSH: 2.711, March 2012: TSH: 5.730, and May 2012: TSH: 6.34. Keep in mind my symptoms of low T far pre-date my starting lithium (at least four years prior to 2009) when my thyroid was functioning normally. My shrink has been testing my TSH yearly since 2009 and hasn’t raised a red flag until March 2012. I am going to get TSH numbers prior to May 2011 when I see her in two weeks. I am not convinced that the recent elevated TSH has had much additional significant impact on my T levels.

Now the first doc Rx’d me levothyroxine (Synthroid) 50mcg which made me feel like I was being poisoned after one or two days. I couldn’t sleep, became anxious, depressed, and even paranoid while on it for five days. I am not kidding when I say if the choice was suicide or life on Synthroid I would choose the former after not very long. I quit the Synthroid and she Rx’d Armour Thyroid 60mg (2 grain) which I recently started after a week away from the Synthroid. For the first two days on Armour I felt better. The third day depression, fatigue, anxiety all crept back in and now I have also stopped the Armour. The Armour was better in that at least I could sleep while on it. Even though I was very easily fatigued before both thyroid meds, that fatigue is better than having all the additional sides, plus fatigue, experienced while taking these thyroid meds.

My intolerance for the thyroid meds along with climbing TSH numbers prompted me to try stopping the lithium which likely is causing the elevated TSH. After five days I found that quitting was easier said than done. My quality of life deteriorates quickly without the lithium so I begrudgingly went back on it. I will discuss options with shrink in two weeks, and my shrink knows NOTHING about thyroid medications, not that the MD’s do either.

The first TRT doc thinks I need thyroid replacement due to my high TSH, but my new doc doesn’t think I need a thyroid med yet. He cites my normal labs for T3, Free & T4, Free, and normal thyroid antibodies. He says T3,Free & T4,Free are much more important indicators than TSH.

My theory & questions: What I probably need next is a reverse T3 test (for more insight into thyroid issues) and also an 8am cortisol to check for adrenal fatigue as that could also be causing my fatigue. Does anyone else here concur with this? Do I really need thyroid treatment with these numbers or not? I already have two doctors who disagree on this. Continuing on thyroid replacement will cause my own thyroid to shut down completely after some time I am assuming. How difficult is it to re-boot a shutdown thyroid if need be? If anyone can help on this I would be grateful.

Now I know some of you will say I am on TRT prematurely due to elevated TSH, but as I said my low T symptoms far predate my recently elevated TSH numbers. There is no history/precedent of hypothyroidism in my family. I have been tested for thyroid issues periodically since age 9 because of my struggle with unrelenting depression and the doctor involved has always reported a normal TSH. Only after starting lithium three years ago has my TSH recently become elevated, which is a known side-effect of lithium. Oh, and I already know about stopthethyroidmadness.com. I also for a six-month period of time in 2006 was off all psych meds which for me is all prescription meds, and my low-T symptoms remained the same.

I’m studying the FDN approach to low test. You would need to do labs showing cortisol, DHEA, Estrogens, Test, Progesterone, melatonin, liver and gut function, parasites and food sensitivities. Possible mineral analysis as well.

Then you can workout what is causing the low test. Could it be that high stress is causing progesterone steal which lowered your DHEA? If you have low DHEA, you wont produce enough test.

You are training for too long, 45-60 minutes max is better. Excess exercise causes excess cortisol production or adrenal dysfunction.

Is it possible that you are too low carb, or low calorie? That can mess with cortisol as well.

Trazodone reduces sex drive. Not sure why, but its a side effect.

Cymbalta reduces sex drive.

This is a great article on a recover bipolar 2 suffer from forbes mag: How I Overcame Bipolar II (And Saved My Own Life)

I’m setting up my labs through PrivateLabsMD for my second appointment. We’ve already established that I am primary hypogonadal so I’m wondering if there is any sense in being tested for LH & FSH again. [EDIT]: Upon further research I see the answer is “No.” [END EDIT] I am paying out-of-pocket for labs, Dr. visits, & meds so I want to only pay for the essential tests. I think I need follow-ups on thyroid (experiencing major fatigue still) and the necessity for thyroid replacement is still an open question. I was thinking of doing the hormone panel for males (instead of the more common & cheaper hormone panel for females) since it includes some thyroid tests & Free T. Also would like to know if I should add only Free T3 or both Free T3 and Free T4 to TSH, TSI, T3, & T4. [EDIT]: Upon further research I see that both Free tests & Reverse T3 are indicated. [END EDIT] Last time I had elevated TSH (6.34) but both my T3 and T4 were in the normal range which led one doc to recommend thyroid replacement and my current doc saying that it wasn’t necessary.

I may also do an 8am cortisol to test for adrenal fatigue since I haven’t done that one yet.

I am currently using 50mg T IM Mon & Thurs along with 250IU hCG M,W,F. About seven to nine weeks into therapy I went through a “sweet spot” where things felt very good. Unfortunately, I’ve regressed back to low sex drive, low energy, and back into somewhat of a mental fog. My upcoming Sept 20th appt will be about sixteen weeks into therapy (longer than recommended, I know), but at least I have leveled off, albeit in a less than ideal place. I’ll probably be looking into adding an AI pending lab results.

[EDIT]: I pretty much answered the above questions here by re-checking the sticky’s. If anyone has anything to add that’s fine too. In addition I’ve never had DHEA-S, Vitamin D, Iron, or Ferritin checked yet either. How important are these? I take 4000 IU Vit D and do get some sun. I’m already at $353 for labs with thyroid and cortisol checks, but if I had this stuff tested at my PCP clinic I’d easily be over $1000 already.

Can anyone tell me if I should bother spending money to test for Free Testosterone on my first set of labs after starting TRT? I can only guess, but subjective experience tells me my total T may still be a little low and give at least a 50/50 chance that I’ll be increasing my weekly T dose and maybe adding an AI. I was thinking that maybe it would be OK to skip testing Free T this time and for sure do it next time after initial adjustments are made. Basically, is it important to test for free T everytime? Can we determine adjustments based on total T without free T?

I’ve never had a prolactin test and was thinking if I could get away without testing free T this time, I might be better off spending $ on prolactin.