Urologist Says Bioavailable T Means Not a Good Candidate for TRT

[highpull]

@crashnet

Do you find for that for your patients symptoms resolve above 15ng/dl on the labcorp test?

That is Quest, they report in pg/mL which would be 150. Yes, I would expect many to most, not all, to be better at 150.

@crashnet

Actually just noticed that labcorp is reporting my free as 26.8 but in pg/ml which now makes me confused.

They use different testing methodology, hence different range levels, with the reference range being 8.7-25.1 pg/mL.

[highpull]

@RichardMB

quote=“RichardMB, post:16, topic:275354”]
Can anyone here, including yourself, make any sense out of what the doctor said about his bioavailable T? If not, then he shouldn’t go back. There’s no reason to go back to someone who says something nonsensical.
[/quote]

Looks as though there may have been some miscommunication. I hate it when that happens…

@KCChuck

I met with the Urologist today and one of the things I asked was why wouldn’t I be a candidate for TRT with low TT, FT, and bioavailable. He asked where I got that idea. I said from your nurse who called me with the blood results and your comments. He replied that she misspoke, and said I appear to be a candidate given the bioavailable T being low.

[EyeDentist]

@systemlord

You don’t have to be a doctor to interpret that these levels are low, a child could unstandstant the implications. This is as simple as 1-3 = 2 and still the doctor misinterpret these labs. It’s not like the OP is in a grey area (325 ng/dL) on his labs, he is clearly low not by my opinion, but based off the guidelines.

I don’t know about you, but I wouldn’t want this doctor treating me because he/she has demistated something is wrong upstairs

Serious question: If you’re right–if these labs represent a slam-dunk, child’s-play case for starting TRT–why didn’t the urologist start it? You surmised that the doctor is literally impaired, which is certainly possible. So in that regard: @KCChuck, did your doctor strike you as impaired in some way–demented, intoxicated, incapacitated with depression, etc? Because if he did, @systemlord and others are right–you shouldn’t see him again.

Let’s assume the answer to the above is ‘no.’ (Because OP surely would have mentioned it before now.) How then to explain his passing up on the slam dunk? A possibility: Docs dread suggesting a course of action they know a pt is averse to, because it risks losing the pt as a ‘customer.’ But that can’t be the reason here, because OP wants to be on TRT. (If anything, the doc’s decision may cost him OP as a pt, so he [the doc] was acting against his own financial interests by doing this.)

Other possibilities…Maybe the doc is afraid of the Feds coming after him for inappropriate prescribing? Obviously that can’t be it–not if this is a “child’s play” case of hypogonadism, as you maintain.

It seems to me we’re left with only one possibility, which is that OP’s is not a slam-dunk/child’s-play case of hypogonadism. That there is something going on–something in OP’s other labs, or his medical history, or his physical exam–that makes this anything but a straightforward case of needing TRT. But you guys–brimming with unearned confidence–can’t see this from your base camp on the slopes of Dunning-Kreuger Mountain.

Most of the frequent posters on this subforum know something about hypogonadism. Trouble is, none of you know enough to be able to appreciate how much you don’t know about it.

[systemlord]

@EyeDentist

So in that regard: @KCChuck, did your doctor strike you as impaired in some way–demented, intoxicated, incapacitated with depression, etc?

It may not be about impairment, but a massive character flaw or perception problem. A lot of doctors are afraid to prescribe TRT because of all the negativity of steroids.

@EyeDentist

Maybe the doc is afraid of the Feds coming after him for inappropriate prescribing?

All he has to do is follow “standard of care” and the docors buttt is covered. Speaking to the OP’s high FSH, something is up with his testicles.

[darbh]

@EyeDentist

note that when people who are not doctors interpret labs online, that is also arguably both unethical and illegal.

@EyeDentist. You have made some very good points.

But, there are several reasons why this forum exists. I believe that a principle one is that it meets a need: many patients are not getting the guidance they feel they need.

The missing or incorrect guidance can be far ranging. In my case, I was given one minute instruction re injection, and that was it. I had to go on the net and this forum to learn about the details: site rotation options, alternatives to using harpoons (21g needles), use of needle clippers and other good sharps procedures - and other many simple things. Most docs just don’t have the time. And some don’t know that much about injection. One of my docs was honest, saying “the nurses handle that.”

My doc who started my TRT- a genius (literally) and a very good person - in addition to 100mg TEST C a week - prescribed me 1,000 iu of HCG 3x a week. I thought this was too high and asked if we do 300 iu 3 times a week. This put me at TT over 1,300. I found a study that showed that 250 iu 3x a week, alone (without Test injection), put the average person 25% above normal TT levels.

I cut back to half that amount of HCG, 125 iu, then down to 80 iu.

Oh, he told me to be sure to cycle off the HCG periodically, to avoid developing insensitivity. He is a good guy, he just does not have deep knowledge. Few do, and, it would seem, much of the knowledge is missing.

So, patients band together to share what they have learned. Yes, a few are on ego trips, etc., but most are just trying to help or get help in an area where there is significant missing info.

[RichardMB]

Better yet, give me one example where someone gave a medical opinion online and was prosecuted for it.

[KCChuck]

To all who have chimed in and shared their opinion and education around cognitive biases, I say thank you. This has been an enjoyable discussion to watch evolve.

As @anon18050987 points out, the message from the doc to me was relayed inappropriately. It didn’t make sense to me and I know we have clinicians on this forum who are wise and offer perspective, as well as individuals who are well educated and recipients of TRT so I sought input. The input has developed a lively conversation that is warranted in the echo chambers we tend to find ourselves in.

Nothing about my blood work or physical appearance suggests hypogonadism until you look at TT and FT. And with the current training in Urology still focused on TT alone and FT being confounding I can understand the docs slow play attitude. It doesn’t mean I agree, it just means I am empathic to his situation. My test numbers flirt with what I have discovered for many clinicians is not "clinically significant. The bioavailability is another matter and is what pushed this clinician to do something, well that along with my passion around the libido and ED symptoms. The cognitive bias discussion has been fun and educational, “gish gallop” and the shout-out to Kahneman’s book were cool to see and the gish is new knowledge for me (fun stuff) I do believe there is wisdom in the counsel of many and these forums have shown this time after time.

I appreciate so much the stories those of you have shared, they are reassuring. I appreciate the value of treating to a number but, as counseled here, being adamant about sharing how I am feeling. I most likely would’ve accepted a treatment plan with TT in the 450 range and FT in the 50-75 range regardless of how I feel if not for the input here.

As I begin my TRT journey with gel therapy, I will visit often and be thankful that forums like this exist to offer reassurance, check impulsive behavior, and offer education.

Thank you all!

[EyeDentist]

@darbh

I found a study that showed that 250 iu 3x a week, alone (without Test injection), put the average person 25% above normal TT levels.

OK, let’s talk about that. Because it’s one thing to ‘find a study’; it’s another thing entirely to interpret it properly. Note that by ‘interpret’ I don’t mean the bottom-line implication of the study itself–that is often straightforward, as in the study you refer to (not having read it, I’m assuming for the sake of argument your bottom-line impression of the results is accurate). Rather, what I’m talking about is:

1. Evaluating the quality of the study. For example, was there anything about participant recruitment/selection that should give one pause? (This is a huge concern in such studies.) What were the dependent variables, and how accurate are the methods by which they were measured? Were statistics employed appropriately? Are the authors a known quantity; ie, does their lab have a reputation for doing good work, or are they infamously shoddy? Do they have connections to the drug industry? Was the work funded by a grant from a pharma corp? The journal in which the study was published–does it have a good reputation? Is it top-tier (and thus highly selective), or a low-tier journal that will publish almost anything? Does it have a rep for high standards of peer review? (Be honest: Do you even know whether the article was peer-reviewed?)
   There’s a reason journals don’t just publish the Conclusions section of a study–why the bulk of an article is dedicated to Methods and Results. If someone can’t read these sections readily and fluidly, they can’t evaluate the study. And if they can’t evaluate it, they can’t (credibly) use it to make medical decisions on their own behalf–much less to render medical advice to anyone else.

2. Evaluating the study relative to the existing literature on the subject. Studies do not exist in a vacuum, and can’t be read that way either. Rather, studies must be contextualized–read in terms of what we already know about a given topic (ie, the existing literature). Special scrutiny must be given to studies that report results at odds with what is already known. And the only way one can contextualize a study is if s/he is deeply, expertly familiar with the previously-existing literature. If you can’t contextualize a study, you’re flying blind.

Putting it all together: If you didn’t evaluate all these issues re the study before drawing your own conclusions from it, you are–respectfully–kidding yourself if you think you made an informed decision when you overrode your doc and altered your prescribed therapy.

@darbh

So, patients band together to share what they have learned. Yes, a few are on ego trips, etc., but most are just trying to help or get help in an area where there is significant missing info

I have already acknowledged that most posters here are good dudes sincerely trying to help one another. But even good people cannot credibly “share what they have learned” if they have no way of assessing whether they’ve learned anything worth sharing.

[RichardMB]

So instead of going with a doctor who says things that jibe with things I’ve read online, I should’ve gone back to a doctor who said he really didn’t understand free T? No thanks. He earned his poor review, and I was proud to write it. He didn’t even test SHBG. He might know something about other hormones, I can’t say. But when it comes to T, the man was useless.

You and the other guy are just doctor apologists, who think you have the high ground because you’re defending professionals. The fact is some doctors aren’t worth their salt. I found a urologist, who I’m happy with. You saying I should’ve stuck with the clueless doctor is actually disrespectful to my current doctor and the other good doctors out there who actually know what they’re doing…

[darbh]

@EyeDentist

it’s one thing to ‘find a study’; it’s another thing entirely to interpret it properly

@EyeDentist Thanks. I agree with you. I am aware of the study evaluation criteria you laid out, the scientific method in general and epistemology, and have undergrad education in statistics. But, I am certain that I have nowhere close to your education and knowledge.

I have been reflecting on the intersection of logical/scientific analysis and living. Living requires decision making.

The problem is that in many (actually most) cases we have to make decisions in life when uncertainties exist.

That is, we have to make decisions about thing where there are no many-times replicated, multi-center, double-blinded, peer-reviewed studies that have been published in respected journals.

Well, statistics and probability theory facilitates “decision making under conditions of uncertainty.” But, often, we don’t even have enough data to use those tools.

Sample question: Should I marry Betty or Jane? Even if “what you are looking for” was clear in your mind, there are no scientific studies of Jane vs. Betty.

So, at best we are left with making a decision based on our general experience.

My understanding is that much of the practice of medicine is conducted in a somewhat similar manner - based on “clinical experience,” not solid, replicated, multi-center studies. I understand “clinical experience” to be a mass of anecdotal experience which itself has often not been subjected to any formal analysis.

I think these forums are, in part, the sharing of “clinical experience” with a view to “review” by other self-clinicians (people taking an active role in their own treatment, hopefully in consultation with an interested doctor).

Among the many flaws in the process is that the participants are self-selected, which biases the anecdotal evidence we are working with.

And, we, largely untrained, are in truth many times relaying our impressions or interpretations of our experiences, and sometimes those of others!

Yes, that flawed process can and does lead to what later turns out to be incorrect ideas and non-optimum protocols.

However:

My impression is that endocrinology - let alone andrological endocrinology - is a relatively young science. I would be surprised if andrological endocrinology receives much funding.

Until it and associated sciences are adequately funded and the subject is sorted out, and then the relevant doctors educated, we are left with what we have: these forums and a very small number of doctors trying to figure out what to do as best we can.

Hopefully in that process we will bring all the rigor we can… But, in most cases it will not get anywhere close to scientific standards … It can’t in most cases…heck, we are for the most part missing a foundational aspect of scientific work: starting off with controlled conditions.

My 2 cents.

[EyeDentist]

First, thank you for your thoughtful comment.

@darbh

My understanding is that much of the practice of medicine is conducted in a somewhat similar manner - based on “clinical experience,” not solid, replicated, multi-center studies. I understand “clinical experience” to be a mass of anecdotal experience which itself has often not been subjected to any formal analysis.

Indeed. This is the ‘art’ in the ‘art and science of medicine,’ and is an important issue I haven’t broached before now. When it comes to managing health issues, there is simply no substitute for clinical experience–for developing, implementing, and following up on treatment plans, over and over again.

@darbh

I think these forums are, in part, the sharing of “clinical experience” with a view to “review” by other self-clinicians (people taking an active role in their own treatment, hopefully in consultation with an interested doctor)

Sort of, except that each of you has only treated one pt–yourselves. Let’s say there are 20 posters on the forum. That’s 20 pts’ worth of experience. For someone like the OP’s urologist, 20 pts is a morning. So while I can’t say there’s no utility in the pooling of experiences that goes on in a TRT forum, I hope you will agree that the wisdom accrued thereby can’t come close to matching that of a physician.

@darbh

My impression is that endocrinology - let alone andrological endocrinology - is a relatively young science.

I do not share this impression. I would say that what is relatively young is the current high level of public awareness re the existence of TRT. (I am old enough to remember the first Big Pharma ad campaign intended to ‘increase awareness of low T’–in other words, to create a market for their product.)

@darbh

Until it and associated sciences are adequately funded and the subject is sorted out, and then the relevant doctors educated, we are left with what we have: these forums and a very small number of doctors trying to figure out what to do as best we can.

I would say this is a mischaracterization of the science, the purpose of which is to allow men to rationalize and justify ignoring their doctors as they seek simple, easy solutions to what are multifactorial, daunting problems.

Edited to clarify a point

[KCChuck]

Hello friends,
I thought I might come back and update my journey for the many well-wishers on this lively thread.

It’s been a hot minute since Sept '21 and the journey continues. After a considerable amount of pleasant disagreement with the treating urologist, I finally got him to admit he didn’t believe I actually needed TRT but he was willing to Rx it. I told him that was unacceptable for both of us. He shouldn’t feel compelled to provide the medical treatment he didn’t think was necessary and I shouldn’t be expected to accept less than what should be the best for me. He agreed and admitted that though he is a urologist he specializes in big surgeries and that is his focal point, so this area, is not clinically practiced or desired. I asked why he chose to see me then. He admitted he was next in rotation for new patients. Nonetheless, when I asked if he would refer me to another dooc in his practice who I now knew did TRT, he did. The new doc didn’t blink an eye and started me on injections of 100mg/wk. Got my 8-week bloodwork back and TT = 509 and FT= 145. Everything else is WNL. I feel better than I have in years. Some may say that TT could be pushed but I like the FT number and am super happy with how I feel. My workouts are off the hook and recovery is commensurate with effort now. My joints don’t ache all the time anymore. My wife says I’m acting like I’m in high school and probably should learn some self-control at 56 I am kicking myself or not being more aggressive in finding treatment 7 years ago when my TT was first in the 300-330 range.

So to my earlier quote that TRT isn’t a magic bullet and to which

@highpull

You know what? It might be. Usually, it is

Yeah, for me I think I can say it was as close as you can get to one.Thanks for the motivation @highpull

Though many times these forums can be an echo chamber for people wanting to have their choices rationalized, for me, it provided encouragement and motivation to advocate for myself. I know the journey isn’t over but I felt the need to express my gratitude to all who contribute to this forum and especially to @highpull @EyeDentist @anon18050987 @swoops39 and @studhammer (dude, you gave me a realistic idea of what you experience in a couple of sentences and that motivated me more than you can know).

For those of us seeking treatment inside the system (not a cash pay clinic), the biggest lesson I learned was to make sure you and your doc are communicating upfront about not only your desires but theirs. Docs can feel like they “have” to do something and that only causes everyone to suffer. It takes an inordinately stupid amount of time to find someone not in a clinic, and I tapped a lot of resources (from pharmD’s to drug reps) to find this guy. In the end I’m on a better path.

Thanks to all and best wishes!

[highpull]

@KCChuck

I feel better than I have in years.

Congratulations, glad it is working out for you.

Don’t be too hard on the cash clinics…

[studhammer]

@KCChuck

My wife says I’m acting like I’m in high school and probably should learn some self-control at 56

TeLl her to get used to it. I sometimes feel like I’m going thru a second puberty. But I will tell you that life with me isn’t boring anymore. I am way more spontaneous and happier and vibrant.

Depending on your wife’s age, she may need HRT as well. My wife is on pellets and oral progesterone and she has completely changed! Now we’re both acting like teenagers again.