Lab Results and Second Opinion

Pharma TRT
1

Hey fellas, new member here, looking for some help regarding bloodwork and TRT.
Just some background: 35yo male, 5’7", 155lbs. Married, 2 kids.
I regularly go to the gym and eat healthy, but the last couple years I just haven’t been feeling myself. Low energy, little motivation, no urge for sex, and problems gaining muscle mass.

I was getting a yearly physical with my primary and told her my symptoms and was sent to get blood work done. She first started telling me it’s probably something with my thyroid but I asked if they can test my T levels and such, and she agreed since my insurance covered it.
Results came back as:
Total T: 320 (264-916)
Free T %: 1.8 (1.5-3.2)
Free T,S: 58 (52-280)
SHBG: 42.2 (16.5-55.9)

I went for a follow up and she said everything is in range and i’m perfectly healthy.
I told her that my T is definitely on the low side and she insisted it’s nothing to worry about.
Now, i’ve done some reading prior and knew my T levels are definitely on the low side.

I’ve asked for a referral to an urologist and will be following up with one. My concern is that since all my test results were in range, the urologist will have the same opinion as my primary.

If I tell the urologist I would like to try TRT, are my blood results enough to warrant it?
Will my symptons be enough for him to prescribe me something?

Any input appreciated. Thanks!

2

That is a reasonable expectation. I doubt insurance will cover treatment.

It is within range, so she’s correct about that. I suppose she isn’t worried since she is not your wife. However, 35y/o, low energy, motivation, no libido, that’s not healthy. Did she have any explanations for, or possible solutions to, your symptoms?

Not likely, but it’s possible. Worth a shot. Your level of 320 is not good, especially for your age. You should have a complete hormone work-up and may need a TRT specialist going forward.

3

Primary care doctors always look at numbers being in range because they are scared of doing hormone replacement.
urologists used to treat this based on symptoms alone before doing any blood work.
I am a medical professional with a lot of years experience in TRT. based on symptoms, age and that number we would have treated you.

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4

Everything may be in the normal range, but for an old man in his 80’s with diabetes. This is NOT normal for a 35 year old man who should have high testosterone. Insurance companies are sometimes installing roadblocks (<300) so they can deny claims.

Also many healthcare providers are hesitate to initiate men on testosterone replacement therapy
due to the belief that these treatments increase the risk of cardiovascular events.

I don’t get how a doc can consider low energy, low motivation, no urge for sex at 35 and problems gaining muscle mass is healthy. Your heart needs adequate testosterone to remain strong.

Your doc is scared, that much is clear. You can get TRT, just probably not through insurance. It’s better this way, your doc more than likely doesn’t know how to prescribe TRT or manage side effects.

Testosterone Threshold for Increased Cardiovascular Risk in Middle-Aged and Elderly Men: A Locally Weighted Regression Analysis.

The locally weighted regression showed that total testosterone levels of 440 and 480 ng/dL were associated with increased Framingham CVD risk and an increased probability of increased hsCRP, respectively. Men with sexual dysfunction (poor sexual performance, decreased morning erection, and loss of libido) had significantly greater CVD risk.

The guidelines are evolving all the time, it’s even stated men at 345 ng/dL can be prescribed TRT, also if there is a medical benefit, TRT can be prescribed.

By the way a normal Free T percentage is between 2-3 percent. You are below normal. If Free T labs are the direct immunoassay, its worthless.

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5

I would be concerned about those levels at the age of 37. Particularly the SHBG, it’s only going to go up with age and that will drive the Free t even lower. You don’t have much lower to go!

Agree with one of the prior comments that PCPs are notoriously difficult to get to prescribe TRT Mostly because they just don’t know how to do it. They aren’t taught this stuff in medical school. What little they know is driven by the pharmaceutical companies that want to sell their expensive proprietary drugs, which is mostly gels and more lately Nibido.

You are wise to seek second counsel from a Urologist rather than an Endocrinologist. Endos tend to be even more conservative than PCPs. From what I’ve read, urologists seem to be a little more open minded.

Bottom line, is you may have to go to one of the on-line TRT companies. They tend to be very liberal to whom they prescribe TRT. Problem with them is price. It would be great if you could get a Urologist to prescribe the TRT and have your PCP do medication management.

I wouldn’t worry about getting insurance coverage because TRT is not all that expensive. In fact, I’ve never even tried to submit to my insurance. I pay out of pocket. Here’s a breakdown of my costs, which amounts to less that a Starbuck’s coffee per day:

PRIMARY HORMONES (all prescribed) = ~$907/year = $2.48/day

Testosterone Cypionate -Pizer branded Depo-Testosterone 200mg/mL - Local Pharmacy $63.36/10 mL. At prescribed dose of 0.2 mL E3D = 50 doses/vial = 150 days of treatment = $0.4224/day = $154.18/year

HCG - Merck branded PREGNYL - Local Pharmacy $127.01/10,000 IU = $0.012514/IU. At 1050 IU/week (current dose 2X more than prescribed) = $13.34/week = $693.47/year

Syringes (for testosterone) - 122 (28G 1/2 inch) 1 cc insulin syringes/year. Currently use Easy Touch brand from EasyTouch 28 Gauge 1/2 Inch Insulin Syringes - 100 Count. $14.45/100 = $0.14 each = 122 X $0.14 = $17.08 /year

Syringes (for HCG) - 156 (31G 5/16 inch) 0.5 cc insulin syringes/year. Currently use Easy Touch brand from 31G .5cc 5/16" Insulin Syringes from EasyTouch. $13.99/100 = $0.14 each 156 X $0.14 = $21.84 /year

Doctor Visit (copay) = 1/year at $20 = $20.00 /year

Labs = $0 (no copy)

6

How is your sleep and stress level?

7

Sleep really isn’t bad, I get a minimum of 6-7 hours a night and I always feel rested when getting up. Stress isn’t bad either TBH. I manage my time between work, home, and the gym pretty well. I also don’t work weekends.

Thanks for all the great replies. After reading all this i’m going to be very hopeful the Urologist will be more reasonable than my PCP, but that doesn’t mean insurance will cooperate. If it comes to it, I don’t mind paying out of pocket seeing that costs are THAT high.
I live in NY though, so if I end up not being covered by insurance, getting bloods in the future will always be a PIA. Living in NY also means I won’t be able to use any online TRT companies if i’m not mistaken.

8

Hey so a bit of a follow up since I last posted.
I went to my urologist and was prescribed 100mg Test Cyp, weekly subq injections.
I don’t know if it was the testosterone or just something in my head, but I can say I for sure felt better the days after my first injection. Since then I have been sleeping better, feeling more rested when I get up, and just feel better overall.
I also have a feeling my natural test production has been shutting down because I have been feeling a bit lethargic the last few days, even after my last injection.

Now, I just got blood results after 5 weeks of injections. Blood was drawn exactly 7 days after my last 100mg injection.
Results were:
Total T: 450 (264-916 ng/dl) (342 before injections)
Free T didn’t register for some reason so I will have to ask the doc for those.
SHBG: 35.6 (16.5-55.9 nmol/l) (48.5 before)
Estradiol: 8.5 (7.6-42.6) (5.0 before)

I have a follow up with the doc this week to discuss the results. What do you guys think? Does anything looking alarming? Should I continue the same protocol or see if I can get the dose increased? I feel like my total T could be a bit higher, but again that was 7 days after my last injection so I’m not too sure how to read into that. Thanks.

9

Total T of 450 seems a bit low. Might want to go to twice a week injections. Estradiol is also pretty low.

10

Agree with the prior post that I would recommend splitting the dose up into at least 2 injections per week. I much prefer every 3 day dosing because the interval between injections is always constant, In this case 0.2 mL of a 200 mg/mL T soultion every 3 days would equate to 93 mg per week and i think you will feel better, even with a slightly lower dose. Also, your nadir T level will be higher, probably closer to 600 ng/dL.

I think there is also room for increasing the weekly amount. I would consider bumping it up to 0.25 mL E3D, which equates to 117 mg/week.

11

I had very similar numbers and my doctor said the same as yours. I talked her into referring me to an endocrinologist who then at first also said that I am in range. However, I was not happy about that and discussed age adjusted ranges, showed him graphs of the decrease in serum t levels of the population throughout the past 40 years, complained about how the endocrine society just recently lowered the range again and so forth… He was listening and suggested to try clomid. I am now on t gel, and my next goal is to get him to switch me to injections. It was all covered by insurance so far. It is more the physicians looking at the ranges than it is the insurance companies I believe. Just tell him that you would like to be mid range to see how this will affect your symptoms, call it a trial, and if it doesnt help then you stop treatment.

12

Agree!!

A lot of guys get caught up on making sure it’s covered by insurance. I equate this to cutting off your nose to spite your face. TRT is a dirt cheep medication if you go with the injectables and forget the proprietary gels and creams, or worse overpriced pellets.

Once you buy into the concept of frequent injections too, injection discomfort also go out the window. With the small volumes you use, you can drop down to a 28G insulin syringe, which is about the same a misquote bite.

Regarding cost, I don’t even bother submitting it to my insurance company. I buy branded Pfizer Depo-Testosterone from our local pharmacy for $63.36/10 mL. At the prescribed dose of 0.2 mL E3D, that works out to $154.18/year, or $0.42 per day. I spend a lot more than that on supplements!

HCG is a bit more expensive, but even that’s not too bad. I buy Merck branded PREGNYL - Local Pharmacy $127.01/10,000 IU = $0.012514/IU. Most guys can get by on 500 IU per week, so that works out to $330/year = $6.35/week = $0.91/day.

Syringes are almost free in comparison to the hormones:

Syringes (for testosterone) - 122 (28G 1/2 inch) 1 cc insulin syringes/year. Currently use Easy Touch brand from EasyTouch 28 Gauge 1/2 Inch Insulin Syringes - 100 Count. $14.45/100 = $0.14 each = 122 X $0.14 = $17.08 /year

Syringes (for HCG) - 156 (31G 5/16 inch) 0.5 cc insulin syringes/year. Currently use Easy Touch brand from 31G .5cc 5/16" Insulin Syringes from EasyTouch. $13.99/100 = $0.14 each 156 X $0.14 = $21.84 /year

13

Difficult to say, but you are probably around 750-900 a day or two post injection. If I am you, I’d go to 140mg a week. If you’re concerned about being “level”, you could go to twice weekly, or even more frequently, injections. I think I would still go up, if you didn’t want to go to 70mgx2, you could try 60mgx2.

I believe that is a reasonable option as well.

14

Alright so I will be asking the doc if it’s okay to do 120mg a week. I don’t see him having an issue with this, but regardless what he says I will probably increase it and ride it out until my next bloods.

I currently inject Thursdays, if I split it into two injections I should do 60mg Monday and 60mg Thursday? Time of day doesn’t really matter as long as i’m getting the correct weekly dose right?

15

I would agree with 140’ish a week or whatever you feel comfortable with. I’d try to make it at least 2 injections per week.

You might also try IM at some point just to see if you’re one of the ones that get higher levels that way.

16

The issue I see with a 2 day split is that the interval is not equal between the two injections. It probably will not make a difference in how you feel, but it will make a difference in the labs. You will need to pick a particular day of the week for your labs in order to compare one lab to another. On an every 3 day protocol, you can pick any injection day to have the lab draw because the interval between injections is always the same.

Time of day does not make a difference, but it should be consistent within a few hours, again so that labs are comparable.

17

Many people that do twice a week do every 3.5 days. So Monday morning and Thursday evening. With this protocol probably best to get blood drawn Monday morning before you pin.

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18

I doubt it would matter very much, or at all, but I have patients who will freak out if they forget a morning injection or didn’t call in their refills in time and are a day late. If you really want to treat this like insulin injections, go every 3.5 days and take one in the morning, and the other in the evening, 3.5 days later. Pick days that will work around your schedule when you can get to the lab. For example, a Monday morning/Thursday evening schedule would ideally put you at the lab Monday am before your injection or Thursday afternoon.

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19

With a dose of 120-140mg a week, should I have to worry about having an AI on hand?
I have not been getting any sides of high estrogen so far.
My E2 before TRT was 5.0, and 8.5 (7.6-42.6) with my most recent bloods, which were drawn 7 days after my shot.

20

Most guys are way over paranoid of E2. I do not recommend using an AI unless you are WAY out of range and have the correct labs to demonstrate it. AIs are extremely difficult to dose for men and a lot of guy crash their E2, which has many of the same symptoms as low T. In particular, E2 is needed for a proper erection response.

In my dose-response experiment, my E2 (LC/MS lab method at LabCorp) was in the range of 9-63 with a normal range of 8-35. As you can see, E2 fluctuates a lot so a single test does not indicate an E2 problem. In fact, this fluctuation occurred throughout the range of the experiment. At 180mg for example, my E2 was 9.1 but at 88mg it was 22.4. E2 was all over the map!

I personally use the cut off of about 50-70 pg/mL for E2 when I start to be concerned, but only after 3 consecutive samples showing that problem persists over several weeks. This has not yet happened.

If it makes you feel better to have an AI on hand, go ahead an purchase some, but I caution not to use it without rationally thinking through the consequences of having low E2.