Starting TRT - Do I need an AI?

[Crowbar62]

I got my blood work back from the lab today.

32 years old. - Lift four times per week, just stated again two months ago after eight year break. Used to lift constantly.

Total Testosterone : 78
Free Testosterone: 10.7

Dr wants me to inject 1ML Test C per week. He is also willing to prescribe HCG although he did not discuss the dosage of the HCG over the phone. I assume he will when I go in for my actual visit next week.

My concern is that I am currently around 29% BF and I'm worried about conversion to Estrogen.

Should I be worried about this? Should I ask for Arimidex , and would he even prescribe it?

I do not know if he tested my estrogen levels when he tested my Testosterone. Should I ask him to do so?

I want to do this correctly, so thank you for your assistance.

Some more info:

Have lost 53lbs since Jan and plan to keep going until I am down around 14% BF. I have no plans to stop lifting, I love it.

Dr was hesitant to start a TRT plan suggesting that my T levels will greatly increase as my weight decreases.

I am also going to ask my Dr to change his 1ML per week to a 3.5 day injection schedule.

Any tips/advice/questions other than my question about needing an AI is appreciated.

Thank you!

[kelkel]

Hi Crowbar!

First, did you find out what is causing your T to be so low? Very doubtful it's idiopathic at your age. If no, then you really need to get more blood work to determine if there's something suppressing your endogenous production. So many things can effect T levels. If you start TRT without finding the root cause then you're simply putting a band aid on the actual problem. If you have more blood work you can put up, please do. Looking for LH, FSH, thyroid panel, cortisol, prolactin, etc.

Then lets talk more about your specific questions.

[Crowbar62]

Thanks for the reply kelkel

I did not find out what is causing my low T. I've gone through TRT before, I stopped after about five months simply because I felt no difference at all and all my symptoms were still present. Probably not the smartest course of action, but it's what I did.

I did not find this forum until after my first visit, so I was not educated enough to ask for specifics when it came to the blood work. I left that up to my Dr.

He did test Prolactin: 10.8 (Showing a Range of 4.0-15.2)

The only other things he tested were: Total T, Free T, Platelet Count, Liver Panel, PSA, TSH and Vitamin D.

I do feel very much like he is a "band aid doctor".

From your reply I feel that it would be prudent to ask him for a complete lab work like the one from the sticky before I proceed.

Please correct me if I am wrong.

Thank you!

[kelkel]

That's exactly what you need to do. Get the full blood work. If your doc disagrees then you need to move to another doctor, one who understands hormones. You may consider using the A4M Doctor Finder (google it) and search by zip code. I would hate to be enter into a commitment such as TRT with knowing that it was the right thing to do at the time. It would drive me nuts.

So many things can cause low T:

Hypothyroidism
Cortisol
Prolactin
Pathologies
Varicoceles, etc.

It's why full BW is so important. Take the time and do this correctly. If your first run with TRT did not work out properly, my guess is it was due to a poorly conceived protocol by your doctor and inadequate follow up titrations. Know that it can also take up to a year for some (not the majority) to really feel the benefits of hormone replacement.

[Crowbar62]

I just wanted to give an update. I am seeing my Dr this afternoon and I will be asking him to run the full blood work from the amazing sticky that kelkel put together. I'm assuming he will agree to run the test, there is really no reason for him to say no. I would assume he will schedule the blood work for Monday morning since I will need to be fasted for some of the test. I don't know how long it takes to get the results back but I will post them when I do.

kelkel, thank you again for your knowledge and help, and I look forward to seeing your thoughts once I can provide the full blood panel/work.

[kelkel]

Glad to help Crowbar. I hope things work out for you!
Update this thread when you can please.

[Crowbar62]

Dr visit was a horrible waste of time and money. He would not order the lab work with the quip "You only need three things on this list tested and if we tested all of them it would cost you over $1,000". He also followed up with a referral to an endocrinologist that has a three month wait time. For the record I don't care if the blood work cost me $1,000. I just want to treat/correct the symptoms.

I'm planning on visiting a new doctor next week. I've been told by some friends that the doctor I am considering is a more "liberal" doctor and is much more likely to run the test and prescribe more "cutting edge medications and treatments".

I'll see if I have better luck.

Anyone ever go directly to the lab to get their blood work done?

[InternalFire]

money speaks magic my man, that's why you have to pay to get something done, sad reality but luck is as rare as it gets with finding right doctor.
I did my bloods privately and it doesnt cost a 1000$, your doc is a waste of time if he's concerned with how much something will cost to their medical institution when you're health is at stake. I did real deep analysis bloods and it cost me just about 200eur, if I wanted all out that's medically possible on the list, max I could have went ~ 400eur, but its no bother, like I said, money speaks magic. Usually same day or few days wait with private labs. Walk in and tell them exactly what you want and they will do it for you, of course, for the money. Like a candy shop. Good luck with your endeavour, I wish you a titanium patience and real fortune solving your issue

[kelkel]

Dr visit was a horrible waste of time and money. He would not order the lab work with the quip "You only need three things on this list tested

Sorry to hear this. What were the three things, in his opinion?

[Proximal]

Dr visit was a horrible waste of time and money. He would not order the lab work with the quip "You only need three things on this list tested and if we tested all of them it would cost you over $1,000". He also followed up with a referral to an endocrinologist that has a three month wait time. For the record I don't care if the blood work cost me $1,000. I just want to treat/correct the symptoms.

I'm planning on visiting a new doctor next week. I've been told by some friends that the doctor I am considering is a more "liberal" doctor and is much more likely to run the test and prescribe more "cutting edge medications and treatments".

I'll see if I have better luck.

Anyone ever go directly to the lab to get their blood work done?

Hey crowbar, just curious (not trying to invade your privacy), are you in the states, and in general, is your medical provider generally very stingy with most everything?

Let's just say I'm semiretired from the medical profession and know what a pain in the butt it is to get around it based upon your provider.

[Crowbar62]

Sorry to hear this. What were the three things, in his opinion?

He ordered a test for Total Test, Free Test, PSA, LH, Prolactin and Cortisol.

[Crowbar62]

My general is a very conservative doctor. For example when I see him for really bad cluster migraines he only prescribes three maxalt. Never knew how stingy that was until I went to a walk in clinic one night and the doctor there gave me a prescription for thirty five.

It's never been too much of an issue, as a rule I don't like to take medication unless I really need it, but in this case the symptoms are causing a quality of life issue and it's frustrating when it feels like your doctor is standing in the way, rather than helping.

[Crowbar62]

Hey crowbar, just curious (not trying to invade your privacy), are you in the states, and in general, is your medical provider generally very stingy with most everything?

Let's just say I'm semiretired from the medical profession and know what a pain in the butt it is to get around it based upon your provider.

Yes, I am in the states. Doctor is very conservative and does not like to prescribe medications that have not been in use for at least ten years. He reminds you of that every time you see him. I understand where he is coming from, but it's frustrating that he wont work with you.

[Proximal]

Just speaking from my experience, I complained for years to my regular provider, who did nothing, so I finally paid big bucks for a consult and an expansive blood test @ a TRT clinic. The TRT clinic picked up the elevated prolactin & then finally my regular health provider stepped up. They dealt with the prolactin problem, but never gave me more than 4mg. test patches.

Point is, the average doc doesn't really think these quality of life issues hold much weight against other more health threatening and potentially costly issues to the provider. Thus, they will leave you be - hello TRT clinics and a multi-million dollar industry.

Perhaps Kelkel will add if there are any other tests that could pick up a larger more health threatening issue in which low T is a symptom of.

Elevated prolactin could indicate a tumor, your doc has that covered.

I personally pay for most of my blood work through a private on-line company. I'm not as careful with costs as I should, usually runs me $250.

[Crowbar62]

Proximal, Thank you for the info. I've actually been looking at private online company's to order my blood work from as well. There are only two labs in my area and it looks like most online sites partner with one of them in particular. I will probably end up going this route once I decide what online company to order the blood work through.

There are also two TRT clinics in my area - not sure if I should give them a try or not, but they are both accepting new patients so maybe I will.

[kelkel]

He ordered a test for Total Test, Free Test, PSA, LH, Prolactin and Cortisol.

But no thyroid panel?

[Crowbar62]

But no thyroid panel?

He said that the thyroid had "nothing to do" with low t. That's why I'm going to find another doctor that specializes in hormones.

In the meantime I'm going to do my own blood work through one of the online clinics.

[kelkel]

He said that the thyroid had "nothing to do" with low t. That's why I'm going to find another doctor that specializes in hormones.

In the meantime I'm going to do my own blood work through one of the online clinics.

Definitely run from this guy then. It's amazing to me that a doctor would make this statement. How'd he make it through med school? Take some time and do some reading at Stop the Thyroid Madness™ - Hypothyroidism and thyroid mistreatment as well. Thyroid issues are a major cause of hypogonadism.

A good panel for thyroid would be (at a minimum): TSH, FT3, FT4, RT3 and Antibodies.

[Proximal]

BTW, sorry Kekkel, not trying to step on any toes here, just this reminds me of dealing with this type of cost- effective practice/ red-tape for so long.

Crowbar, should have prefaced my words better, just in case I caused concern. What I meant by blood tests to potentially finding "health- threatening" issues was to suggest that at least if that was determined, then your health provider would/should pick up their pace a bit if you direct your concerns as such. In my case it was a benign pituitary tumor. At least you'll get the benefit/peace of mind that you are being looked after enough to prevent more serious consequences, but still very likely you'll have to pay out of pocket at a clinic for TRT, which will be more liberal in their interpretation of what "normal/acceptable" levels of testosterone are.

Have to tell you, my Endocrinologist is the head of a large dept., they are a professor in a local medical school - Kelkel provides me more solid information than my Endocrinologist and the TRT doc combined. Sorry for the blatant butt- kissing, but you're in good hands here and are headed in the right direction.

[Crowbar62]

I found an online clinic to order the blood work from. I'm not sure how legit they are and am a little nervous using them, so I plan on ordering the Thyroid panel only from them now, and if it goes well I will be ordering everything else from them.

I would ask if anyone knew anything about the website or what sites they have had luck with, but from what I understand that is against forums rules.

I want to thank both of you for the information and advice. I will keep updating as things progress.

[Youthful55guy]

I can personally attest to Discountlabs.com. They have a large number of commonly prescribed hormone tests available through LabCorp. LabCorp has a hunge number of draw stations located throughout the USA, so pretty easy to find one. You simply order the labs on line and pay for them with a credit card. The doc sends you the lab order. You make an appointment with LabCorp (or just walk in). They draw the blood and send it off for testing. You get the results by email within 5 business days. They are very dependable and all done through a highly reputable lab.

[kelkel]

BTW, sorry Kekkel, not trying to step on any toes here, just this reminds me of dealing with this type of cost- effective practice/ red-tape for so long.

You're not! The input is always welcome.

[Crowbar62]

I have my blood work ordered and have setup an appointment at the lab for tomorrow morning. I will fast for 12 hours. Once the results are in, I'll post them up.

[Crowbar62]

Ended up fasting for 14 hours. Blood work was taken at 9:00am. Now I'll just wait for the results and post them when they arrive. Thank you everyone for all the help thus far.

[kelkel]

Be waiting.

[Crowbar62]

Lab Results are in. Below are the results. I really can't wait to see what you opinions and suggestions are based on this info. I'm really looking forward to a next step.

Blood was drawn at 9:00am and I was fasted for 14 hours.

CBC With Differential/Platelet

WBC 9.1 x10E3/uL 3.4 - 10.8

RBC 5.36 x10E6/uL 4.14 - 5.80

Hemoglobin 15.4 g/dL 12.6 - 17.7

Hematocrit 45.2 % 37.5 - 51.0

MCV 84 fL 79 - 97

MCH 28.7 pg 26.6 - 33.0

MCHC 34.1 g/dL 31.5 - 35.7

RDW 14.0 % 12.3 - 15.4

Platelets 359 x10E3/uL 150 - 379

Neutrophils 71 %

Lymphs 19 %

Monocytes 9 %

Eos 1 %

Basos 0 %

Neutrophils (Absolute) 6.4 x10E3/uL 1.4 - 7.0

Lymphs (Absolute) 1.8 x10E3/uL 0.7 - 3.1

Monocytes(Absolute) 0.9 x10E3/uL 0.1 - 0.9

Eos (Absolute) 0.1 x10E3/uL 0.0 - 0.4

Baso (Absolute) 0.0 x10E3/uL 0.0 - 0.2

Immature Granulocytes 0 %

Immature Grans (Abs) 0.0 x10E3/uL 0.0 - 0.1

Comp. Metabolic Panel (14)

Glucose, Serum 85 mg/dL 65 - 99

BUN 18 mg/dL 6 - 20

Creatinine, Serum 1.34 High mg/dL 0.76 - 1.27

eGFR If NonAfricn Am 70 mL/min/1.73 >59

eGFR If Africn Am 80 mL/min/1.73 >59

BUN/Creatinine Ratio 13 8 - 19

Sodium, Serum 139 mmol/L 134 - 144

Potassium, Serum 4.5 mmol/L 3.5 - 5.2

Chloride, Serum 96 Low mmol/L 97 - 108

Carbon Dioxide, Total 22 mmol/L 18 - 29

Calcium, Serum 10.2 mg/dL 8.7 - 10.2

Protein, Total, Serum 7.7 g/dL 6.0 - 8.5

Albumin, Serum 5.4 g/dL 3.5 - 5.5

Globulin, Total 2.3 g/dL 1.5 - 4.5

A/G Ratio 2.3 1.1 - 2.5

Bilirubin, Total 0.3 mg/dL 0.0 - 1.2

Alkaline Phosphatase, S 135 High IU/L 39 - 117

AST (SGOT) 44 High IU/L 0 - 40

ALT (SGPT) 48 High IU/L 0 - 44

Testosterone,Free and Total

Testosterone , Serum 222 Low ng/dL 348 - 1197
Comment: Adult male reference interval is based on a population of lean males up to 40 years old.

Free Testosterone(Direct) 4.3 Low pg/mL 8.7 - 25.1

Dihydrotestosterone 9.6 Low ng/dL
Reference Range: Adult Male: 30 - 85

FSH and LH

LH 5.7 mIU/mL 1.7 - 8.6

FSH 3.4 mIU/mL 1.5 - 12.4

DHEA-Sulfate 110.1 Low ug/dL 138.5 - 475.2

TSH 2.520 uIU/mL 0.450 - 4.500

Sex Horm Binding Glob, Serum 18.1 nmol/L 16.5 - 55.9

Estradiol, Sensitive 24.2 pg/mL 8.0 - 35.0

Thyroxine (T4) Free, Direct, S
T4,Free(Direct) 1.55 ng/dL 0.82 - 1.77

Thyroid Peroxidase (TPO) Ab 11 IU/mL 0 - 34

Triiodothyronine,Free,Serum 3.3 pg/mL 2.0 - 4.4

Reverse T3, Serum 24.4 High ng/dL 9.2 - 24.1

Prostate Specific Ag, Serum 0.9 ng/mL 0.0 - 4.0

[Crowbar62]

Note on the AST & ALT being high. I've had this tested several times over the past month or so and it is directly related to heavy lifting. The same enzymes that the liver releases for these test are found in muscle tissue that I am breaking down as well. I've only been lifting heavy in the gym for about two months and I still get very bad DOMS for three to six days after lifting heavy. (Heavy for me is for example deadlifts three sets of eight at 525lbs). I can link to many study that back this up, as well as it's the opinion of my general practitioner. Just to be safe we did run a full liver panel and a full hepatitis panel, all negative. The levels keep coming down each time we have them checked so he has decided not to worry about an ultrasound for another month or two, but is still going to check them once per month.

[Crowbar62]

I also wanted to include a some lab results that my Dr ordered in case it helps create a more complete picture for everyone.

These were done on 4/19/16 and I was not fasted (told I did not need to be).

Vitamin B12: 602 (pg/mL) Range 180-914
Vitamin D 25OH 59.8 (ng/mL) Range 30.0-100.0
Prolactin 10.8 (ng/mL) Range 4.0-15.2

[Crowbar62]

If anyone has any observations or input concerning my lab results please feel free to post up.

From the research I've been able to do on my own based on these results I feel like the next step is getting my cortisol tested. Does anyone agree or disagree?

Thank you all!

[Proximal]

Crowbar, glad you got the ball really rolling; sure the resident experts will be adding their input sometime soon.

[kelkel]

No worries with cbc or cmp. It's normal for alt and ast to be elevated from muscular trauma as you stated. They'd need to be 3-5 times the full range to really worry, imho.

Re your thyroid. I don't like your TSH level, as anything over 2 raises an eyebrow. The range used is old. Newer range is .3 - 3.0. That said, other than RT3 being elevated it appears fine. Your RT3 doesn't seem to have had much impact on anything else though, which seems odd to me. Definitely not B12 related though. Maybe try adding in some Selenium and Kelp (iodine) and see if it helps. Can't hurt.

Your LH is great, which indicates thyroid, prolactin and probably cortisol aren't an issue, even though cortisol can effect you both at the hypothalamus and gonadal levels. Lovely. All this leads me to a possible testicular issue. Have you considered an Ultrasound or palpation (pick a young, hot female doctor if possible) of your testicals to check for possible issues, varicoceles, etc?

ps: solid Vit D level.

[Youthful55guy]

Concur with kelkel. Low TT and abysmal FT in combination with normal LH & FSH and normal SHBG indicates secondary testicular issues. Have you ever had a testicular injury? Also want to be checked for varicoceles per kelkel's recommendation. I'm surprised E2 isn't lower.

Given the above, especially your very low FT, you will probably feel a lot better with TRT, assuming it's done properly. Your original post indicated your doc wanted to start with 1 mL (assuming that's 200 mg/mL) per week and inject on a weekly basis along with an undetermined amount of HCG .

My personal advice is to start off with much smaller and more frequent dosing. Consider 0.2 mL every 3 days or MWF with 200 IU HCG on the same schedule. On a weekly basis, about 40% less than your doc recommended, but the more frequent dosing will give you a much smoother ride with less E2 conversion and hematocrit side-effects. Retest after 3-4 weeks and adjust from there.

The great thing about smaller and more frequent dosing is that the smaller volume can easily be injected with an insulin syringe. I use a 28G 1/2 inch needle. Much less pain than the harpoons that most docs stick you with when you use those larger volumes.

[Crowbar62]

Thank you for the replies kelkel and youthful.

I have never had an injury to my testicals that I can remember. However for the last six years I have had a stinging/burning pain on my left testicle that never goes away. You can also feel some tissue around the back and top of it that is not present on the right testicle. I've gone to a urologist for this and they did do a ultrasound. They found a epididymal cyst. The urologist told me that it should not be causing any pain though. When I asked about the tissue I could feel he just said that it was inflamed, probably from bounding up and down too much and instructed me to take some anti-biotics and to make sure they don't shake or vibrate for a couple of weeks. He also suggested ice on and off to help. I looked up varicocele and I honestly feel like this is what I have and that my urologist somehow missed it. I will ask for another ultra sound to check for a varicocele very soon. From what I understand the epididymal cyst cannot cause low T issues, is this correct in your opinion?

A few follow up questions have.

Now that you have seen my lab results do you think including HCG with my test c would be of benefit? I do not want to loose fertility, and if it's possible to correct the issue and come off of TRT I think this would help as well?

Should I be concerned that my DHT is so low? 9.6ng/dL out of a range of 30-85 looks like a big deal.

DHEA was also low, would I see any benefit from a DHEA supplement to go along with my TRT?

If I do end up having a varicocele, and have it treated would it be a bad idea for me to start back up on TRT and continue until it is treated?

Thank you all for your feedback and all of the information. I feel like I should be paying you guys, not my doctor.

[kelkel]

Correct, the cyst should not cause T issues.
Unless I've misread something you have not started TRT yet. If correct you should be investigating the possibility of a varicocele first and if one is located, correct it. Then see how much your T rises. You would not want to implement TRT at this point whatsoever so the HCG question is moot at this time. Your DHT and DHEA are low because your test is low. It's that simple. It's your cholesterol pathways. Once your T rises (hopefully naturally) those levels will rise.

If TRT is implemented down the road then it's always a good idea to help out your chol pathways that would then be shut down. Adding preg and dhea (micronized) is highly recommended, imho.

[Crowbar62]

Thank you for the reply kelkel. I was planning on starting the TRT while investigating the varicocele - I'll heed your advice and hold off until I have it checked out. Thank you for confirming that DHT and DHEA follow testosterone . I'll get that ultrasound completed as quickly as I can. It can be difficult where I live to get anything done quickly in the medical field.

[kelkel]

Be patient and do things the right way. It'll pay off in the long run. Update this thread when you can please.

[Proximal]

Hey Crowbar, sorry everything has been so dragged out in finding a diagnosis. Here's looking to an great end-result!

[Crowbar62]

Hey Crowbar, sorry everything has been so dragged out in finding a diagnosis. Here's looking to an great end-result!

Oh no problem, I'm getting tons better info here than from my doctors and the end result is all I care about. I would love to start treating the symptoms now because dealing with this is getting depressing but I would rather correct the issue than be on TRT for life if possible. Hope to get good news from the doctors soon!

[Crowbar62]

Had my doctors appointment with the new doctor yesterday. I think things are moving in the right direction now. I'll share what he said and let you guys share your opinions. I welcome all your thoughts as I want to do this correctly and be as informed as possible.

First he noted that I had a thyroid problem. This is the elevated RT3. He said that because my TSH/T3/T4 were pretty much okay that I had neither hypo or hyper thyroidism but that the high RT3 causes the same symptoms and side effects as hypothyroidism. He said the cause was most likely an iodine issue and ordered blood work to check my iodine levels. I told him that I had already ordered some kelp for this and he said I could start taking it after my blood work. So kelkel was right on the money about the kelp (iodine).

When it came to my low T he somewhat differs from kelkel's opinion of it being a testicular problem. He did entertain the idea of a varicocele but said that he highly doubted that it was the cause. His line of reasoning was that if I had a varicocele on one testicle that in most cases the other testicle will over-compensate. However I did read online that a varicocele on one testicle could effect both, so I'm not sure what to believe. It's pretty much a non factor because he did order an ultrasound anyways just to check so that I would know and be able to make a decision on treatment if one was found.

He also said that if it was a testicular issue that my LH and FSH would be high, and not simply sitting at normal ranges. He said they would both be higher because my body would be trying to send a stronger "signal" to my testicles to produce more testosterone .

He believes it is either a pituitary problem, or an estrogen problem.

For the pituitary problem he went over a list of common issues that can cause this such as a benign tumor, etc. He ordered a prolactin and cortisol test so that he could see what was going on there. He also ordered the full blood work that I had done before and posted above because in order for my insurance to cover any treatment they need two separate early morning lab results that show low T levels.

As for the possible estrogen issue... I'll try to explain as best I can, I was pretty much lost on this topic and most of it went over my head. He said that it's possible for your body to "hyper convert" testosterone to a form of estrogen that does not show up on a estradiol test and has none of the side effects of the usual high estrogen such as gynecomastia . He said that it's not clear why this happens in some men and that there is no current way to test for this. All of this sounded like hog wash to me, but you guys may know more.

I am going to see him again in two weeks when he gets the results of my blood work back.

His proposed treatment depends on the lab results, but he had a pretty good idea of what he wanted to do next.

He wants to start me on HCG only. His reasoning is that HCG acts like LH and signals the testicles to make more testosterone. After four weeks he would check my hormone levels again and see if my T levels have gone up. If they do go up, we know it's a pituitary problem since my testicles responded to the signal to make more T.

If my T levels do not go up while on the HCG, he wants to keep me on the HCG for four more weeks and add Nolvadex . Again we would recheck after four weeks and see where my T levels are. He wants to do this to see if it's that mystery hyper conversion to estrogen that's not estrogen bs that I tried to explain above. Is this really even a thing?

Overall I am happy that he wants to find the cause of my low T and not just treat the issue. If we can't correct the cause and have to do hormone therapy, he wants to try to get my T levels around the 700 mark. He wants to achieve this by using a combination of HCG, Nolvadex, and clomid only. He does not want to inject T unless we have to do so to get my levels to the 700's and he said we may very well have to do so. So he is not against injecting testosterone at all, he just wants to see if HCG/Nolvadex/Clomid can do the job first.

So what do you guys think. Is this doctor going down the right path, or should I run like hell to another hormone doctor?

Also, when checking for cortisol he did so by blood sample. I've seen a lot of info online that suggest that checking cortisol via blood work is not accurate and that it should be tested via a five sample saliva kit. What are your opinions or experiences with this?

[kelkel]

Had my doctors appointment with the new doctor yesterday. I think things are moving in the right direction now. I'll share what he said and let you guys share your opinions. I welcome all your thoughts as I want to do this correctly and be as informed as possible.

First he noted that I had a thyroid problem. This is the elevated RT3. He said that because my TSH/T3/T4 were pretty much okay that I had neither hypo or hyper thyroidism but that the high RT3 causes the same symptoms and side effects as hypothyroidism. He said the cause was most likely an iodine issue and ordered blood work to check my iodine levels. I told him that I had already ordered some kelp for this and he said I could start taking it after my blood work. So kelkel was right on the money about the kelp (iodine).

When it came to my low T he somewhat differs from kelkel's opinion of it being a testicular problem. He did entertain the idea of a varicocele but said that he highly doubted that it was the cause. His line of reasoning was that if I had a varicocele on one testicle that in most cases the other testicle will over-compensate. However I did read online that a varicocele on one testicle could effect both, so I'm not sure what to believe. It's pretty much a non factor because he did order an ultrasound anyways just to check so that I would know and be able to make a decision on treatment if one was found.

He also said that if it was a testicular issue that my LH and FSH would be high, and not simply sitting at normal ranges. He said they would both be higher because my body would be trying to send a stronger "signal" to my testicles to produce more testosterone .

Ok, what he's saying about one testical taking over is not a statistical fact. It may occur or it may not. Let's wait for the ultrasound and be sure about it. Having a varicocele does not automatically indicate an excessively high LH value. Varicoceles exert degrees of testicular suppression based on the varicocele itself. It's not an all or nothing scenario. People can have degrees of both primary and secondary hypogonadism. It's not always one or the other.

He believes it is either a pituitary problem, or an estrogen problem.

For the pituitary problem he went over a list of common issues that can cause this such as a benign tumor, etc. He ordered a prolactin and cortisol test so that he could see what was going on there. He also ordered the full blood work that I had done before and posted above because in order for my insurance to cover any treatment they need two separate early morning lab results that show low T level

Doubtful it's pituitary related due to the LH level you presently have. Elevated prolactin would suppress it and your's is not. Unless amazingly your LH runs even higher naturally, which I doubt. Good to check cortisol as it can interfere both at the hypothalamic and gonadal level. Again though, I'm not seeing this.

As for the possible estrogen issue... I'll try to explain as best I can, I was pretty much lost on this topic and most of it went over my head. He said that it's possible for your body to "hyper convert" testosterone to a form of estrogen that does not show up on a estradiol test and has none of the side effects of the usual high estrogen such as gynecomastia . He said that it's not clear why this happens in some men and that there is no current way to test for this. All of this sounded like hog wash to me, but you guys may know more.

He'd need to show me the study to back that up. He's probably referring to intra-testicular estrogen. It's nothing to worry about in your case and it's not the cause of your issue.

I am going to see him again in two weeks when he gets the results of my blood work back.

His proposed treatment depends on the lab results, but he had a pretty good idea of what he wanted to do next.

He wants to start me on HCG only. His reasoning is that HCG acts like LH and signals the testicles to make more testosterone. After four weeks he would check my hormone levels again and see if my T levels have gone up. If they do go up, we know it's a pituitary problem since my testicles responded to the signal to make more T.

If my T levels do not go up while on the HCG, he wants to keep me on the HCG for four more weeks and add Nolvadex . Again we would recheck after four weeks and see where my T levels are. He wants to do this to see if it's that mystery hyper conversion to estrogen that's not estrogen bs that I tried to explain above. Is this really even a thing

Four weeks? Absolutely unnecessary, imho. All you need is about 3 days or so to see if an HCG stimulation test will work, not a month. Long term HCG is suppressive to LH function as your hypothalamus / pituitary sense that it does not need to produce it any further and slows down it's own production. Make sense? Like injecting testosterone, your endogenous production then is slowly shut down.

Adding Nolva while on HCG. Think about my above comment and relate it to this. Nolva is a SERM that stimulates LH production at the Pituitary Level. HCG is suppressive of that. Combining them is counter-productive. WTF.

Overall I am happy that he wants to find the cause of my low T and not just treat the issue. If we can't correct the cause and have to do hormone therapy, he wants to try to get my T levels around the 700 mark. He wants to achieve this by using a combination of HCG, Nolvadex, and clomid only. He does not want to inject T unless we have to do so to get my levels to the 700's and he said we may very well have to do so. So he is not against injecting testosterone at all, he just wants to see if HCG/Nolvadex/Clomid can do the job first.

Again, you don't run SERMS with HCG. Not prudent and medical science backs this up. Clomid is fine by itself but I don't feel your problem is pituitary related. Lets wait for the results of your ultrasound. If and when the time comes for therapy, worry about your free T level, not total T. Free is what works for you.

So what do you guys think. Is this doctor going down the right path, or should I run like hell to another hormone doctor?

Also, when checking for cortisol he did so by blood sample. I've seen a lot of info online that suggest that checking cortisol via blood work is not accurate and that it should be tested via a five sample saliva kit. What are your opinions or experiences with this?

​Your doc is trying hard. I'll give him credit for that. He's just off a bit, imho. Be direct with him when it comes to what you want to try. It's your body.