Help! Getting Nowhere with Endocrinologist

Pharma TRT
1

To give you some background, in 2006 I rapidly put on weight (around 40kg) and developed some gyno. I saw an Endo at the time and he did some tests that didn’t find anything conclusive put scanned my liver and said I had sub-clinical NAFLD and recommended some lifestyle changes. I accepted things and got on with my life, lost some weight but fluctuated over the next few years.

Roll forward to 2014 and I was diagnosed with a brain tumour (left parasagittal meningioma) which was surgically removed in April 2014. It had been growing for some time and structural lesions of this nature compress the brain tissue.

In late 2013, early 14 I lost 25kg in body weight through training but after surgery I couldn’t train because I wasn’t allowed to raise ICP and I put it all back on despite religiously looking after my diet. I then developed an infection requiring more surgery and lots of antibiotics (1 week of IV Methicillin, Cefotaxime, Flucloxacilin, followed by 4 weeks of oral Fluclox and Rifampicin) and had to have further surgery in January 2015 to insert a prosthesis where the infected bone flap was removed. I trained as much as I could throughout this time.

I was on Dexamethasone prior to surgery for a short while and 500 mg twice a day Keppra (Levetiracetam) for six months.

In Feb 2015 I started training again: HIIT, compound and Oly lifting, met con. I struggled to lose weight, any at all in fact but my strength was consistently increasing. It made no sense to me, so I started to restrict my calorie intake (getting down to 1,800 a day) but that did nothing.

Libido dropped off a cliff so I went to my Dr and asked him to test my T which came back low and was referred to an Endo in light of this and inability to lose weight. The Endo wasn’t overly concerned stating “investigations showed a normal male hormone profile with a normal LH of 2.2 and normal FAI of 64 (>35 is normal reference range). His TT is low but this is simply because SHBG is low and of no consequence or clinical significance”.

He then focussed on Thyroid as a possible line in to my issues as there is a strong family history of Thyroid disease and TSH was raised at the time.

I have seen him a few times but the last time he basically dismissed it as something that was not Endocrine related as my TSH had normalised (although I would say still high at 2.7) and despite the fact that he could see how hard I am training from the CK tests her ordered.

He also stated that there was nothing to indicate a deficiency in the Pituitary/Testicular axis. Despite the fact that FSH was at the lower end of the range and Prolactin slightly above the range, LH was normal again and slightly increased (details below). It’s also fair to say I don’t have any Pituitary Adenoma issues as I have had around 20 MRI brain scans in the last 2 years.

I am now totally stumped but I know something is not right and I want to go back to my GP but he’s useless and always asks me what I think he should do…so I want to tell him exactly what to do!

My first approach was going to be to ask for the following tests that I found in another thread:

Metabolic panel with lipids
CBC
Free Testosterone
Total Testosterone
DHEA-S
PSA
Estradiol
Homocysteine
hs-CRP
TSH
Total T4
Free T4
Total T3
Free T3
Reverse T3
Thyroglobulin Antibodies
Thyroid Peroxidase
Cortisol
LH
FSH
DHT
SHBG
IGF-1
Prolactin
Progesterone
Pregnenolone
Vit B12
Vit D, 25-OH Total
Vit D, 25-OH D3
Ferritin
Iron, Total Binding Capacity
Iron, Binding Capacity
Magnesium, RBC

I’ll have to do a lot of research because I don’t really understand the significance of some of these at the moment and I highly doubt my GP will.

Result of blood tests I have had in the past 6 months

03/07/15
Test: Result (Reference Range)
Cortisol (Blood): 437 nmol/L ()
Free T4: 13 pmol/L (10.0 - 22.0)
TSH: 5.1 mu/L (0.3 - 5.5)
LH: 2.2 ui/L (1.0 - 10.0)
FSH: 3.2 ui/L (1.0 - 12.0)
Testosterone: 6.4 nmol/L (9.0 - 29.0)
SHBG: 10 nmol/L (17.0 - 56.0)
FAI: 64.0 (> 35.0)

28/08/15
Test: Result (Reference Range)
Free T4: 14 pmol/L (10.0 - 22.0)
TSH: 3.8 mu/L (0.3 - 5.5)
TPO: <33.4 iu/mL (Inconclusive below 60.0 - 100.0)

02/10/15
Test: Result (Reference Range)
Cholesterol: 4.9 mmol/L (< 5.0)
Triglycerides: 1.7 mmol/L (< 2.0)
HDL: 1.2 mmol/L (> 1.2)
Non HDLC: 3.7 ()
LDL: 2.9 mmol/L (< 3.0)
TChol/HDL Ratio: 4.1 ()
Free T4: 14 pmol/L (10.0 - 22.0)
TSH: 2.7 mu/L (0.3 - 5.5)

15/10/15
Test: Result (Reference Range)
Sodium: 140 mmol/L (133 - 146)
Potassium: 3.8 mmol/L (3.5 - 5.3)
Urea: 5.7 mmol/L (2.5 - 7.8)
Creatinine: 107 umol/L (59 - 104)
Glucose: 7.4 mmol/L (3.3 - 7.9)
Creatine Kinase: 1821 U/L (40 - 320)
Free T4: 16…1 pmol/L (11.0 - 26.0)
TSH: 2.85 uU/mL (0.3 - 4.5)
LH: 4.0 iu/L (1.0 - 8.0)
FSH: 3.5 iu/L (2.0 - 12.0)
Prolactin: 377 mu/L (40 - 360)
IGF-1: 27.0 nmol/L (10.0 - 32.5)
Vitamin D: 30.75 nmol/L (50.0 - 200.0)
SHBG: 7.9 nmol/L (14.0 - 48.0)
Testosterone: 11.2 nmol/L (8.0 - 29.0)
FAI: 141.8 (14.8 - 95.0)
Free Testosterone: 9.7 pg/mL (4.0 - 30.0)
Cortisol (urine): 209 nmol/24hr (99.0 - 378)

I don’t think it is a coincidence that I have struggled to shed the timber since having brain surgery given that a tangerine sized mass was removed that had compressed brain tissue - the scans I had before show a fairly smashed up Cingulate Gyrus and the Corpus Callosum depressed.

I am wondering if Insulin Resistance could be an issue due to low SHBG. Or diabetes is a potential complication of brain surgery also.

Any help is appreciated!

2

Your are on the right track!

Free T4: 16…1 pmol/L (11.0 - 26.0)
So this time T4 is finally near mid-range.
Can you identify that you might have been getting more iodine prior to that lab work?
Is there iodine+selenium in your vitamins and for how long?

SHBG is made in the liver.
With your history, it is odd that AST/ALT are not tested.

Have you read these stickies:

  • advice for new guys
  • things that damage your hormones
  • thyroid basics

Please check oral body temperatures as per the thyroid basics sticky.
Note references to temperature, fT3, rT3, stress, adrenal fatigue and Wilson’s book in that sticky.

Do you get cold easily?
Are you in UK and you consume dairy products?
Do you use iodized salt?

You should take 5,000iu Vit-D3, take 25,000iu/day for first 5 days.

A1C would shed more light on insulin resistance issue.

You could easily have adrenal fatigue with your history and that can block some of your fT3 and can make one hypo even with ideal levels of other thyroid hormones.

Thyroid:
TSH should be closer to 1.0
fT3, fT4, T3, T4 should be mid range or a bit higher.
The reference ranges are rather misleading.

Starvation diets, infections, chronic inflammation, stress can increase rT3.

Endos and urologists are rather bad at male hormone health.

Please see this thread: https://tnation.T-Nation.com/free_online_forum/sports_training_performance_bodybuilding_trt/stupid_things_that_docs_do_and_say

How is digestion after all of those antibiotics?
Have you used a good probiotic after the runs of antibiotics?

We sometimes see low SHBG that is unexplained and not really a rare thing.
SHBG levels are decreased by androgens, administration of anabolic steroids,[20] polycystic ovary syndrome, hypothyroidism, obesity, Cushing’s syndrome, and acromegaly. Low SHBG levels increase the probability of Type 2 Diabetes.[21]

Note hypothyroidism.

ref Sex hormone-binding globulin - Wikipedia

3

Thanks KSman - I did read the stickies but in order they appeared, so missed the “advice for new guys” before posting. I will invest in a thermometer and start taking me temp readings - will provide them once I have taken a few. I have tried to answer your questions in order and provided info I have missed.

In terms of additional Iodine, I was not supplementing or had changed my diet/supps in anyway. The only theory I have to go on is that I had a MRI scan in mid-Sep with contrast medium but I am not sure of the type (Gadolinium, I think) or the Iodine content, or dose.

For vit D, would a trip to the electric beach (tanning shop) for some artificial sun help at all?

Do not typical get cold or feel the cold easily. I think the opposite in fact (I constantly turn down the thermostat for my wife to go and turn it up).

I am in the UK, I consume a moderate amount of diary - semi-skimmed pasteurised milk, cheese and yoghurt.

I do use Iodize salt also.

I did quiz the Endo about adrenal issue (i.e. fatigue) and he was confident that this wasn’t a problem - although I can’t be sure he really had enough info to go on or even fully checked my test results thoroughly. I was insistent on getting T3 and rT3 but he didn’t order them and when I asked why not he said it wasn’t an issue as T4 was normal and TSH normalised - I said about Wilson’s Syndrome and he got a bit shirty and basically said it wasn’t a thing and had been disproven (probably another one for stupid things Dr’s say)!

I have a friend who is a colonic hydrotherapist who sorted .me out with some great prebiotics after finishing the course of antibiotics.

In terms of additional information I have missed:

Age: 31 yr 10 mths
Height: 189cm
Waist: 96cm (I am aiming for 86-90cm in the near term)
Weight: 120kg (when I felt really great, I was 89kg so roughly 30kg more than ideal)
Describe body and facial hair: zero chest/back hair, coarse hairy lower legs arms (not so much upper), coarse facial hair and able to grow a full beard - shave ever other day.
Describe where you carry fat and how changed: mainly front/stomach and chest, gyno (long-standing),
Health conditions, symptoms - have detailed, but should also add that Maternal Grandmother just diagnosed with Sjogren’s Syndrome (potential genetic link)
Rx and OTC drugs, any hair loss drugs or prostate drugs ever: never taken Rx until those outlined, do not take OTC regularly.
Lab results with ranges: provided
Describe diet: Balanced, have stopped restricting as it just made me feel shitty - I focus on getting decent protein primarily from meat, mainly chicken and fresh fish. I do not restrict carbs and eat moderate amounts of veg.
Describe training: mixture of cardio (rowing, running, elliptical, power mill), mobility and compound/Oly lifts, met con.
Testes ache, ever, with a fever? Occasionally but never had fever. I occasionally get a dull ache in my groin also.
How have morning wood and nocturnal erections changed: No major change, I sometimes think maybe strength has changed. I did notice earlier in the year that ejaculate volume decreased but no longer seems to be an issue.

4

Also, Endo did query Cushing’s but 24hr urine was bang in the middle. Acromegaly is not something considered but reading some of the symptoms, I have noticed a thickening of the skin on my knuckles of the forefinger and index finger on both hands (noticeably coarser than other fingers), I do have a fairly prominent brow, I have acrochordon under my left arm and one more has recently started to develop and was going to query CTS with my Dr as I frequently get pins and needles in my lower arms and the forefinger/index and especially at night which often wakes me.

I also get sporadic (cluster) severe headaches (the reason I went to Dr about tumour) which have continued since surgery and neurologist diagnosed them idiopathic stabbing headaches with cluster headache characteristics…they are not nice. And funnily enough I did get them a lot throughout this summer when I was feeling particularly shitty.

However, acromegaly doesn’t sound feasible considering the number of scans I have had…is it possible that this could be bought on my trauma to the head (such as three rounds of brain surgery)? Or even changes in brain structure or changes in haemodynamics or CSF flow?

5

Just take 5,000iu vit-D3.
Tanning beds are $$$ and have risks of their own.

IGF-1 suggests normal GH levels.

Pins and needles in arms at night can easily be from sleeping postures and problems that a massage therapist could work on. That would take several sessions.

Hormone care in the UK is rather dreadful.

6

Thanks KSman, I’ve taken my temperature over the past two days upon waking and throughout the day

3 Jan 16
Waking 36.0c / 96.8f
11am 36.3c / 97.34f
2pm 36.6c / 97.88f
5pm 36.5c / 97.7f

4 Jan 16
Waking 35.9c / 96.62f
11am 36.3c / 97.34f
2pm 36.3c / 97.34f
5pm 36.5c / 97.7f

It appears my temp is low and moderately stable (1/3 avg excl waking was 97.64f and 1/4 97.46f), so doesn’t appear to indicate any adrenal fatigue given that my last bloods indicated normal FT4 and TSH 20% above the mid-range.

However, if my temp was similar during some of the earlier blood tests, it would have been consistent with Hashimoto’s (or hypo with adrenal fatigue) from what I understand but I was only tested for TPO and not TG.

I will keep taking my temp for when I go back to my Dr.

Any thoughts appreciated. Thanks

7

Thermometer under the tongue?

It is good to see if someone else can hit 98.6F/37C with that thermometer.

Any pain or stiffness in your neck and/or shoulders?

What lab results and range for IFG-1?

8

Just bought it a couple of days ago so hoping it is accurate! I had wife try and she got to 37.0c / 98.6f.

My last IGF-1 was done on 10/15. Results were 27.0 nmol/L (lab range 10.0 - 32.5).

Thermo was taken under the tongue.

I do get stiffness in neck and shoulder occasionally but I’d say it’s probably more due to training than anything.

9

In terms of taking 25,000iu/day Vit D, should I be spreading this across the day or take all in one go?

10

You cab take all Vit-D3 at once. Some have 50,000 caps for once a week.

Take Vit-D3, DHEA, fish oil with a meal that has more fats/oils and less fiber. Fiber will tend to reduce absorption of these lipophilic items.

11

KSman, would appreciate some of your wisdom on the below:

Low Basal Body Temperature

Waking temperature taken under tongue was never above 36°C (97°F), of 15 intraday (11am, 2pm, 5pm for 5 days) only rose above 37°C (98.6°F) on one occasion.

Temperature is typically stable so doesn’t indicate adrenal fatigue and issue but would indicate hypothyroid.

P R Health Sci J. 2006 Mar;25(1):23-9. “Supraphysiological cyclic dosing of sustained release T3 in order to reset low basal body temperature.”
The use of sustained release tri-iodothyronine (SR-T3) in clinical practice, has gained popularity in the complementary and alternative medical community with a protocol (WT3) pioneered by Dr. Denis Wilson. The WT3 protocol involves the use of SR-T3 taken orally by the patient every 12 hours according to a cyclic dose schedule determined by patient response. The patient is then weaned once a body temperature of 98.6°F has been maintained for 3 consecutive weeks. The symptoms associated with this protocol have been given the name Wilson’s Temperature Syndrome (WTS).

11 patients who underwent the WT3 protocol for the treatment of CFS. All the patients improved in the five symptoms measured. All patients increased their basal temperature. The recovery time varied from 3 weeks to 12 months.

High Prolactin

When a high blood prolactin concentration interferes with the function of the testicles, the production of testosterone (the main male sex hormone) and sperm decrease. Low testosterone causes decreased energy, sex drive, muscle mass and strength, and blood count. If levels remain low for several years, bone strength may decrease (osteoporosis). High blood prolactin also causes difficulty in getting an erection, as well as breast tenderness and enlargement.

Hyperprolactinemia: This can result from a pituitary adenoma, renal or liver insufficiency, primary hypothyroidism, or some drugs (eg, neuroleptics). Hyperprolactinemia can suppress GnRH secretion through a central dopamine-related mechanism. In addition to hypogonadism, this condition can also manifest as galactorrhea and as gynecomastia in men.

Low FSH

Low levels of FSH are consistent with pituitary or hypothalamic disorders/imbalance.

Primary hypothyroidism: This can lead to hypogonadism through hyperprolactinemia. High thyrotropin-releasing hormone (TRH) level, which stimulates prolactin secretion.

Secondary/tertiary hypogonadism, also known as hypogonadotrophic hypogonadism, shows low testosterone and low, or inappropriately “normal,” LH/FSH levels; causes include:

  • Inherited or developmental disorders of hypothalamus and pituitary (no known familial history)
  • Pituitary or hypothalamic tumours (unlikely due to number of scans)
  • Hyperprolactinemia of any cause (mine is definitely elevated)
  • Malnutrition or excessive exercise (decreased calorie intake and CK shows how hard I am working in the gym)
  • Cranial irradiation (CT scans but I would expect them to be typically low level)
  • Head trauma (mass effect of tumour or just brain surgery)
  • Medical or recreational drugs (e.g. estrogens, GNRH analogs – neither are relevant)

In men with low FSH levels and gynecomastia, serum estradiol measurement is indicated to exclude an estrogen-secreting tumor (testes, adrenals)

Low SHBG

If SHBG concentrations are decreased, more of the total testosterone is available to the tissues but Free T at 9.7 pg/mL is significantly below 2-3% it should be (I think it’s actually 0.3%)

Low SHBG is associated with obesity, probably due to a loss of insulin sensitivity. SHBG is often a flag or warning signal of insulin and blood sugar issues. In other words, SHBG does not cause insulin resistance but does indicate it. Elevated insulin lowers SHBG.

Thyroid hormones act indirectly to increase SHBG production by liver via hepatocyte nuclear factor-4a. A hypothyroid man that goes on thyroid medication will often see his low SHBG rise. Thyroid hormones (triiodothyronine (T3) and thyroxine (T4) increase SHBG accumulation in HepG2 and increase cellular SHBG mRNA levels.

The higher the Vitamin D, the lower the SHBG but my Vitamin D is borderline problem zone – so this doesn’t make sense.

Low SHBG and IGFBP-1 were both associated with an increased
prevalence of abnormal glucose tolerance and the metabolic syndrome.

High-Normal IGF-1

Signs and symptoms are seen with excess GH and IGF-1 production that I have:

Headaches

  • Snoring – goes through periods where this can be bad or non-existent
  • Thickening of the skin – on knuckles
  • Acrochordon – skin tags under left arm
  • Trapped nerves – numbness in hands/forearms but could also be Thoracic Obstruction

Cushing’s ruled out because of normal Cortisol (24 hour urine).
Acromegaly unlikely as no pituitary adenomas.

IGFBP-2 or IGFBP-2, to help confirm the GH deficiency?

Next Steps

I am going to make an appointment to see my GP and request the following blood panels. I will get a copy of the results and hopefully that will provide me with some insight and I can decide where I want to go from there.

Metabolic Panel:
Glucose
Calcium
Albumin
Total Protein
Sodium
Potassium
CO2
Chloride
BUN
Creatinine
ALP
ALT
AST
Bilirubin

Complete Blood Count:
White Blood Cell (WBC)
Red Blood Cell (RBC)
Hemoglobin (HB/Hgb))
Hematocrit (HCT)
Mean Cell Volume (MCV)
Mean Cell Hemoglobin (MCH)
Mean Cell Hb Conc (MCHC)
Red Cell Dist Width (RDW)
Platelet count
Mean Platelet Volume

Sex Hormones:
Free Testosterone
Total Testosterone
Progesterone
Estradiol
DHEA-S
Pregnenolone

Pituitary:
Cortisol
LH
FSH
DHT
SHBG
IGF-1
IGFBP-2
IGFBP-3
Prolactin

Thyroid:
TSH
Total T4
Free T4
Total T3
Free T3
Reverse T3
Thyroglobulin Antibodies
Thyroid Peroxidase

Other:
Vit D, 25-OH
Total Vit D, 25-OH D3
Ferritin
Iron, Total Binding Capacity
Iron, Binding Capacity
Magnesium, RBC
CRP
HbA1c

12

I’ve finally got my general practice doctor to a point where he recognises that I have low testosterone. The problem I now have is the way the NHS works in the U.K. and that he’s only able to prescribe Nebido (T Undecanoate) or AndroGel.

I am going to speak to an endo as I still want to maintain fertility and want HCG as part of my protocol.

AndroGel is a non starter for me but what are opinion on T esters? Is Undecanoate favourable or should I push for weekly Enanthate?

@KSman any advise would be appreciated!

13

Nebido or AndroGel are the worse choices for TRT and neither are very effective, you have to push hard for ethanate or life will be difficult.

14

Thanks. Is this your experience? When you say terrible, do you mean in terms of side effects?

Do you have any studies to back this?

15

Studies no, men coming in here complaining about Nebido or AndroGel, all the time. Nebido has a very slow acting ester and most men metabolize testosterone at a faster rate (low SHBG men), so Nebido is far from ideal for most men.

AndroGel is the weakness tropical form of TRT, add to that absorption rates vary wildly from person to person. The majority of men do not absorb enough AndroGel to get in the optimal range, those that do see levels falling month or years later.

You may be able to go private and get sustanon or ethanate.

Update: There are studies out there that show Nebido doesn’t elevate testosterone levels high enough, I can’t provide links do to forum rules.

16

Thanks for the reply. I have looked at my local Clinical Commissioning Group formulary and Sustanon 250 is an available option.

However, I understand that it is very aromatising so should I be asking Clomiphene Citrate? and hCG?

17

Clomid is a short term solution and most men feel terrible on it, eventually you will need TRT.

18

What would a decent protocol look like for Sustanon 250 + hCG?

The formulary recommends Sustanon 250 every 3 weeks. I’m assuming that is because of the decanonate half life.

As my SHBG has always come back low (most recent 13 nmol/L), I will probably rinse through a bit quicker than normal.

Would it be worth throwing an AI in the mix? From what I’ve read, as long as you get the dose right, you shouldn’t need an AI.

19

I would inject smaller doses of Sustanon 250 every 3.5 days given your SHBG level, an AI is needed after you have made a solid attempt to lower estrogen by adjusting your Test dosage and E2 is high enough that it’s causing symptoms.

20

Thanks @systemlord. My most recent E2 was 98pmol/L (lab reference range 41-159)