Labs and Opinions on What Next

Pharma / TRT Testosterone Replacement
1

33 yo male who has been feeling low T symptoms for some time. If I had to guess this started in my early 20’s but I was really unaware there was a problem before asking my internist to add test to some blood work. I was 6’5" and around 325 lbs. Been lifting at the gym for about 6 months and while strength doesn’t seem bad I don’t thing I was putting on enough muscle for the effort and I had exercise intolerance. Never an issue with ED but libido is not great. The results came back:

4/11/2012 (non-fasting)
Glucose:102mg/dL
TSH Ultrasensitive: 5.07 uIU/mL [0.49-4.67]
AST: 42 U/L [6-60]
ALT: 88 U/L [9-67]
Antithyroglobulin Ab: 54.7 IU/mL [<116]
Thyroperoxidase Ab: 6.8 IU/mL [<34]
Free T4: 1.32 ng/dL [0.71-1.85]
T3 Total: 119.9 ng/dL [84.6-201.8]
Testosterone: 196 ng/dL [240-950]
Free Testosterone: 7.1 ng/dL [9-30]

Internist puts me on 100mg test IM once a week and I do two injections before wising up. I got the name of an endo off another low t forum and went to see him. He ordered additional tests.

These were obtained after completing a single 200mg IM injection of test, followed by a single 100mg IM injection of test the following week and then no injection of test for 8 days (endo told me to immediately stop test).

Fasting 12 hours taken 05/18/2012
Glucose: 91mg/dL [65-99]
Glucose random: 83 mg/dL [<140]
Hemoglobin A1C: 5.2
TSH: 4.51 mIU/L [0.40-4.50]
Total T4: 7.3 mcg/dL [4.5-12.0]
Free T4: 1.3 ng/dL [0.8-1.8]
Total T3: 132 ng/dL [76-181]
Thyroglobulin Ab <20 [<20]
SHBG: 16 nmol/L [10-50]
Alpha Subunit: <0.3 [Males 0.6 ng/dL or less; hypothyroid subjects 3.7 ng/dL or less]
C-Peptide: 4.75 ng/mL [0.80-3.0]
FSH: <0.7 mIU/mL [1.6-8.0]
LH: <0.2 mIU/mL [1.5-9.3]
Prolactin: 14.6 ng/mL [2.0-18.0]
Total Testosterone: 399 ng/dL [241-827]
E2: 31 pg/mL [<39]

Lipids:

Total Cholesterol: 194 mg/dL [125-200]
HDL: 47 mg/dL [>40]
Triglycerides: 119 mg/dL [<150]
LDL: 123 mg/dL [<130]
CHOL/HDLC Ratio: 4.1 [<5.0]
Non-HDL CHOL: 147 mg/dL

Not going to pay any attention to the internist. Endo says ok you’re insulin resistant and you need to decrease your visceral fat with diet/exercise and I wholeheartedly agree. I’ve lost 10 lbs since. Thyroid is not crazy but he started me on synthroid. His plan for increasing test was 10 days of clomid to make sure LH/FSH respond (those numbers above were suppressed) and then assuming they respond as expected put me on an AI.

This then sparked debate on another forum about the evils of AIs and more specifically arthralgias (I’m a dentist and that would not be good). Now I know I must lose weight and exercise and I’m doing that diligently. At the end of my clomid cycle my options are:

  1. Stay on clomid and kill libido (from what I’ve read). No great research on long term use and effects. Some literature following patients for 3 years.
  2. Go on an AI with the potential joint issues (which seem to usually effect wrists and thumb) potentially causing my professional downfall and making me homeless. I’ve seen numbers of 2-70% of patients on AIs experiencing joint pain depending on the cohort.
  3. TRT which will shut down the entire axis and necessitate life long replacement and when E2 inevitably creeps up the need for an AI anyway or reduce my test.
  4. Use nothing and lose weight (physiology without boosting test is going against me here) and hope weight loss and less aromatase activity normalizes my test. Endo said he thinks it will help but weight loss will not solve all my low T problems.

Just wanted to know what others think about my options…Is there anything I’m missing? What’s your overall opinion on my condition and where would you go with this? I’m a father of three and my wife’s tubes are tied so no more babies for me anyway.

The endo thinks weight loss w

2

[quote]idmd wrote:
33 yo male who has been feeling low T symptoms for some time. If I had to guess this started in my early 20’s but I was really unaware there was a problem before asking my internist to add test to some blood work. I was 6’5" and around 325 lbs. Been lifting at the gym for about 6 months and while strength doesn’t seem bad I don’t thing I was putting on enough muscle for the effort and I had exercise intolerance. Never an issue with ED but libido is not great. The results came back:

4/11/2012 (non-fasting)
Glucose:102mg/dL
TSH Ultrasensitive: 5.07 uIU/mL [0.49-4.67]
AST: 42 U/L [6-60]
ALT: 88 U/L [9-67]
Antithyroglobulin Ab: 54.7 IU/mL [<116]
Thyroperoxidase Ab: 6.8 IU/mL [<34]
Free T4: 1.32 ng/dL [0.71-1.85]
T3 Total: 119.9 ng/dL [84.6-201.8]
Testosterone: 196 ng/dL [240-950]
Free Testosterone: 7.1 ng/dL [9-30]

Internist puts me on 100mg test IM once a week and I do two injections before wising up. I got the name of an endo off another low t forum and went to see him. He ordered additional tests.

These were obtained after completing a single 200mg IM injection of test, followed by a single 100mg IM injection of test the following week and then no injection of test for 8 days.

Fasting 12 hours taken 05/18/2012
Glucose: 91mg/dL [65-99]
Glucose random: 83 mg/dL [<140]
Hemoglobin A1C: 5.2
TSH: 4.51 mIU/L [0.40-4.50]
Total T4: 7.3 mcg/dL [4.5-12.0]
Free T4: 1.3 ng/dL [0.8-1.8]
Total T3: 132 ng/dL [76-181]
Thyroglobulin Ab <20 [<20]
SHBG: 16 nmol/L [10-50]
Alpha Subunit: <0.3 [Males 0.6 ng/dL or less; hypothyroid subjects 3.7 ng/dL or less]
C-Peptide: 4.75 ng/mL [0.80-3.0]
FSH: <0.7 mIU/mL [1.6-8.0]
LH: <0.2 mIU/mL [1.5-9.3]
Prolactin: 14.6 ng/mL [2.0-18.0]
Total Testosterone: 399 ng/dL [241-827]
E2: 31 pg/mL [<39]

Lipids:

Total Cholesterol: 194 mg/dL [125-200]
HDL: 47 mg/dL [>40]
Triglycerides: 119 mg/dL [<150]
LDL: 123 mg/dL [<130]
CHOL/HDLC Ratio: 4.1 [<5.0]
Non-HDL CHOL: 147 mg/dL

Not going to pay any attention to the internist. Endo says ok you’re insulin resistant and you need to decrease your visceral fat with diet/exercise and I wholeheartedly agree. I’ve lost 10 lbs since. Thyroid is not crazy but he started me on synthroid. His plan for increasing test was 10 days of clomid to make sure LH/FSH respond (those numbers above were suppressed) and then assuming they respond as expected put me on an AI.

This then sparked debate on another forum about the evils of AIs and more specifically arthralgias (I’m a dentist and that would not be good). Now I’m left with I know I must lose weight and exercise and I’m doing that diligently. At the endo of my clomid cycle my options are:

  1. Stay on clomid and kill libido. No great research on long term effects.
  2. AI with the potential joint issues (which seem to usually effect wrists and thumb) potentially causing my professional downfall and making me homeless.
  3. TRT which will shut down the entire axis and necessitate life long replacement and when E2 inevitably creeps up the need for an AI anyway or reduce my test.
  4. Use nothing and lose weight (physiology without boosting test is going against me here) and hope weight loss and less aromatase activity normalizes my test. Endo said he thinks it will help but weight loss will not solve my problem.

Just wanted to know what others think about my options…Is there anything I’m missing? What’s your overall opinion on my condition and where would you go with this?

The endo thinks weight loss w
[/quote]

Well losing weight is certainly something you should look to do. Surprised your doctor never measured Ft3, only went with Ft4. But you did say you have started on Thyroid meds so hopefully he measures it next time around.

It also sucks that he never tested your LH and FSH before giving you the 2 injections. What made him give you 2 injections then stop? Would have been better not to start with injections and run more tests. I don’t know if your LH and FSH would be suppressed that quickly after 2 weeks, maybe someone else can chime in? Or have you been injecting longer than that? But you could have had low levels of LH and FSH to begin with.

In that case you should have that looked at and try to determine if you are primary or secondary.

Ever get your cortisol checked?

Don’t be afraid of the clomid test this will give you a good insight if your boys are able to produce or not. You don’t need to go overboard on the dosage either 12.5mg - 25mg will get the job done if you take it for say 4 weeks or longer.

Only use the AI if you need to, and if you do need to use it don’t go overboard. That way you will not have the joint issues if you keep E2 at a good level.

If your boys are able to produce then maybe HCG mono therapy might be an alternative as clomid for long term use is probably not the best way to go.

You never know maybe getting your thyroid optimal may also have a good effect.

Currently in your state you really have not ruled out anything that could be causing the low test. So I would not be relying on TRT just yet until you deem it absolutely necessary.

3

[quote]iroczinoz wrote:

Well losing weight is certainly something you should look to do. Surprised your doctor never measured Ft3, only went with Ft4. But you did say you have started on Thyroid meds so hopefully he measures it next time around.

It also sucks that he never tested your LH and FSH before giving you the 2 injections. What made him give you 2 injections then stop? Would have been better not to start with injections and run more tests. I don’t know if your LH and FSH would be suppressed that quickly after 2 weeks, maybe someone else can chime in? Or have you been injecting longer than that? But you could have had low levels of LH and FSH to begin with.

In that case you should have that looked at and try to determine if you are primary or secondary.

Ever get your cortisol checked?

Don’t be afraid of the clomid test this will give you a good insight if your boys are able to produce or not. You don’t need to go overboard on the dosage either 12.5mg - 25mg will get the job done if you take it for say 4 weeks or longer.

Only use the AI if you need to, and if you do need to use it don’t go overboard. That way you will not have the joint issues if you keep E2 at a good level.

If your boys are able to produce then maybe HCG mono therapy might be an alternative as clomid for long term use is probably not the best way to go.

You never know maybe getting your thyroid optimal may also have a good effect.

Currently in your state you really have not ruled out anything that could be causing the low test. So I would not be relying on TRT just yet until you deem it absolutely necessary.
[/quote]

Endo didn’t give me the test injections my internist did and he clearly has no idea what he’s doing. I had already taken two injections by the time I saw the endo who wanted me to stop immediately. My endo feels my FSH/LH were much too suppressed for the amount of test I took and the amount of time that had passed from my last injection (8 days). He said he’s seeing more of a metabolic syndrome picture. Clomid test is just to see if my pituitary is capable of producing enough LH/FSH an get things restarted. He’s dosing me at 100mg qd for 10 days, then test LH/FSH/Test/E2 and if it was as he suspected then stop clomid and only use an AI and weight loss and reeval in 2 months.

I was surprised he wanted to put me on AI’s when my E2 was 30 and that was after taking exogenous test. I haven’t shared with him my concerns about the AI side-effects but surely I think he’ll understand I spent 25 years of education and $250K to make dentistry my livelihood and feel like crap or not I’m not going to jeopardize that. Hell I’m Irish…I grew up thinking men were supposed to feel this way and it was normal :slight_smile:

4

My guess is that you are most likely hypogonodal as a result of your hyporthyoridism. I’m not sure if Synthroid is a T4 or T3/T4 combo medicine, but check out www.stopthethyroidmadness.com to get more info on that. It is run by a bunch of hypochondriac angry women, but there is good info. Just take it with a grain of salt. Especially helpful if you don’t see an improvement in your symptoms.

Your LH/FSH were almost certainly suppresssed from the shots. But your doc is correct in trying to stimulate them with the SERM. Long term SERM use may or may not be an option–I honestly would prefer hcg instead.

If you aren’t taking too much AI, then joint issues are rarely a problem. 1.0 mg per week should be the most you would need if you aren’t taking exogenous Test (and likely the same even if you are).

Insist for Free T3 tested on next round–that is the hormone most responsible for metabolism.

Agree you should lose weight, but that is hard to do when you have hypothyroidism! This is likely contributing to your “metabolic syndrome”. If you get thyroid under control and make good food choices, your “metabolic syndrome” will hopefully magically disappear.

5

Thank you everyone for the replies. I will ask my endo about free T3 and see what he says. I’ve been on synthroid for 5 days now and clomid for 5 days and I don’t feel any different although I’ve been dealing with a whopper of an URI the past 2 days so that is definitely knocking my energy level down.

More opinions are welcome and I keep this post up-to-date.

6

[quote]idmd wrote:
Thank you everyone for the replies. I will ask my endo about free T3 and see what he says. I’ve been on synthroid for 5 days now and clomid for 5 days and I don’t feel any different although I’ve been dealing with a whopper of an URI the past 2 days so that is definitely knocking my energy level down.
More opinions are welcome and I keep this post up-to-date.

[/quote]

Synthroid takes a while for it to build up. Usually you will get retested after about 6 weeks any sooner probably not worth it.

What dosage did he start you on?

7

50mcg per day.

8

[quote]idmd wrote:
50mcg per day.[/quote]

That is good.

9

Some more labs. This was after 10 days on Clomid 100mg QD.

TSH = 4.59 [0.40-4.50] Previous lab prior to starting Synthroid was 4.51

This has not changed on 50 mcg QD so doc would like me to take 100 mcg QD.

FSH = 2.9 [1.6-8.0] Previous lab was result was <0.7 - this was not baseline and was taken 8 days after stopping 100mg test/week.

LH = 5.8 [1.5-9.3] Previous lab was <0.2 - this was not baseline and was taken 8 days after stopping 100mg test/week.

Total Test = 333 [241-827] Baseline was 196. Previous lab was 399 - this was not baseline and was taken 8 days after stopping 100mg test/week.

E2 = 22 [<39] Previous E2 was 31 which I assume was artificially elevated due to aromatization of the exogenous test.

A.M. Cortisol = 22.8 [4.0-22.0]

We’re proceeding based on the idea that I have secondary hypogonadism… anyone else seeing hints of primary based on my low E2 levels and modest increase in LH/Test after 10 days of Clomid?

He wants to start a low dose AI but I don’t think that’s going to get us very far. What is everyone’s thoughts? Anyway this all being driven by hypothyroidism?

10

You really need to get a handle on your thyroid first. Is snythroid a T3 only med, or T4/T3? You do not seem to be utilizing it properly in your body.

your T response to higher LH is not promising. I would conitnue current treatment and retest again in a few weeks–if LH is still good and Total T is not, then that indicates primary hypgonadal instead of secondary.

I see no need to start an AI, especially since oyu are already taking the SERM.

11

[quote]VTBalla34 wrote:
You really need to get a handle on your thyroid first. Is snythroid a T3 only med, or T4/T3? You do not seem to be utilizing it properly in your body.

your T response to higher LH is not promising. I would conitnue current treatment and retest again in a few weeks–if LH is still good and Total T is not, then that indicates primary hypgonadal instead of secondary.

I see no need to start an AI, especially since oyu are already taking the SERM.[/quote]

SERM has been discontinued after the initial 10 days. It was only being used to test LH/test response. I agree…I just don’t see E2 playing a large role and that has me wondering about thyroid. I have a very strong family history of Hashimoto’s and while I’m Ab negative…I guess we will see if 100mcg does anything. If not (and I’m not a thyroid expert by any means) but we’ve only tested TSH, Total T4, Total T3 but no free Ts or reverse T3.

Synthroid is T4 only.

12

ummm so what is your doctor planning to do about your shitty T levels now that he has pulled you off the SERM?

Some people (probably only a minority) do not do well on T4 only and need T3 medicines (they don’t convert T4 to T3 properly). read up on that on www.stopthethyroidmadness.com to see if it is applicable for you. Monitor symptoms.

13

[quote]VTBalla34 wrote:
ummm so what is your doctor planning to do about your shitty T levels now that he has pulled you off the SERM?

Some people (probably only a minority) do not do well on T4 only and need T3 medicines (they don’t convert T4 to T3 properly). read up on that on www.stopthethyroidmadness.com to see if it is applicable for you. Monitor symptoms.[/quote]

I think he’s currently still operating under the idea that my issue is increased aromatization…even though my E2 has never been elevated. I will speak to him about this since it doesn’t make sense to me.

I agree I need to tackle the thyroid issue first, see how it effects everything including the possible use of Armour or Cytomel if Synthroid isn’t effective, let my LH and test go back to baseline with the only change being thyroid meds and reassess.