Dealing with Doctors

Pharma / TRT Testosterone Replacement
1

First of all, let me say I don’t have much of a clue on this topic. Don’t be afraid to dumb it down…

I requested a blood panel for my first followup after starting TRT based on TCs advice:

"…make sure you get tests done in exactly the way specified below. (For instance, if you don’t ask for a " sensitive assay " estradiol test for males, they’re going to measure your estradiol the same as if you were a ballerina from the Bolshoi ballet suffering from menstruation problems.)

Ask for this lab work:

  • Testosterone, total
  • Testosterone, bioavailable
  • Testosterone, free
  • Estradiol (sensitive assay)
  • Steroid Hormone Binding Globulin
  • Follicle Stimulating Hormone (FSH)
  • Luteinizing Hormone (LH)
  • Dihydrotestosterone (DHT)
  • Complete Blood Count (CBC)
  • Prostate Specific Antigen (PSA)
  • Blood Chemistry Panel
  • Metabolic Panel

These tests will give a fairly good baseline reading of where you stand so that when you have follow-up blood testing done three to six months later, you can see…"

I get this back from the VA doc:

"Thank you for your message. Based on evidence based medicine, the recommendation for TRT monitoring is a history & physical examination, a total testosterone level, hematocrit, Prostate Specific Antigen, Bone density scan and a digital rectal exam, all of which I will happy to order and perform.

Please send me any scientific evidence backing you justification for the following labs:
• Testosterone, bioavailable
• Testosterone, free
• Estradiol (sensitive assay for males)
• Steroid Hormone Binding Globulin
• Follicle Stimulating Hormone (FSH)
• Luteinizing Hormone (LH)
• Dihydrotestosterone (DHT)

Additionally, what is the difference between a blood chemistry panel and metabolic panel?"

I think he’s being a smart ass with the last one. Is he pointing out the fact that I don’t know what I’m talking about? I looked it up- the blood panel does not include protein and liver tests. So what? The reason I asked for all these test is the first time a diff doc allowed some of these and a nurse took it upon herself to not include the FSH or LH or both because I’m male!

Since this is not a baseline test, are some of these not needed now?

How do I respond to the doc? I have a full plate right now and don’t have the time or know-how to get that info, and again, I think he’s messing with me. What’s he gonna do with just total T?

2

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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3

Unfortunately, the VA will be difficult.

4

This is government-funded health care at its best, suck it up or get TRT somewhere else.

5

Do you want him to prescribe your TRT? If so, get over your butthurt and do things his way.

Can you blame him? You came at him with a laundry list of labs–all gibberish to you–that were ‘prescribed’ by some internet rando. He’s your doctor, not your lab bitch.

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6

I am a Veteran and use the VA. You are crazy if you think all of those labs will be covered by the VA or think the VA is going to treat you in a similar manner to a cash pay clinic.