HRT needed? Mid-low T, low Free T, bottom half Bioavailable T

[rd27]

Hi all

Based on the excellent stickies and some feedback in another thread, I went and got full labs. They are below, and I'm wondering what folks thoughts are in terms of HRT and/or supplements.

My Doctor's comments are "normal/unremarkable (FSH just 0.1 < reference range...Creatinine just 0.04 < reference range, resulting in elevated BUN/Creatinine ratio)". But advice I am seeing on places like LEF state I want to be in the upper third of the T ranges, which would be double what I have for free and for bioavailable. My FSH being below reference worries me also. Also, my free has been low for a while and even below the reference range.

My below-ref Creatinine sticks out a bit also. Since I have been most-vegetarian I associate that mostly with my diet. I suppose I could look at hitting the gym or swimming to increase my upper body muscle mass as well (my legs do all the work for running and biking :).


Background on me....

Age 43, Weight 166, Height 5'10", BMI (from tanita scale) 16%

I have realized my energy levels have been generally low for a while (though I get a good amount of exercise and feel fit). I also feel my excitement for life in general feels low (including libido). I tested with low T levels in the past a couple years ago, tried AndroGel for a couple months but didn't stick with it because the Cyalis seemed to be working fine :/.

I do feel athletically I am ok, certainly when compared to the couch potato I was ten years go. I don't "train" or spend much gym time, but I do run, mountain bike, and occasional whitewater kayak 2-4 times a week. I do trail, mountain bike, and adventure races and actually podium fairly often in my age group on the trail runs (which still surprises me each time :).

My diet since early 2009 is mostly vegetarian and fish, with occasional meat when dining out. Note I went in for my first T test near the end of the same year I went most-vegetarian so I do wonder about my diet. If I need to add more meat for my health I am willing to do so.


Thoughts?

Thanks,
d


Lab results (updated 11/9)...

Date	Testoterone Serum	Testoterone Serum Range	Testosterone Free (Direct)	Testosterone, % Free & Weakly Bound	Testosterone, Free & Weakly Bound	Estradiol	Estradio, Sensitive	SHBG, Serum	FSH	LH	DHT	Creatinine, Serum	TSH	T3, Free	ACTH	T4	T4, Free	IGF-1	Prolactin	Cortisol - AM	PSA Serum	DHEA	Vitamin D	Zinc, Serum	Protein Total Serum	Total Cholesterol	HDL	LDL Cholesterol	Triglycerides	VLDL Cholesterol	TC/HDL	Hemoglobin	Glucose	BP-systolic	BP-diastolic	Pulse	Body Fat (15-21)	BMI	Weight
			6.8-21.5 pg/ml	9.0-46.0	40.0-250.0	7.6-42.6	3-70 pg/mL	16.5-55.9	1.5-12.4	1.7-8.6	none?	0.76-1.27	0.45-4.5	2.0-4.4 pg/ml	7.2-63.3 pg/ml	4.5-12.0 ug/dl	0.82-1.77 ng/dl	64-210 ng/ml	4.0-15.2	6.2-19.4	0-4 ng/ml		32-100 ng/ml	70-150 ug/dl	6.0-8.5	100-199 mg/dl	>39 mg/dl	0-99 mg/dl	0-149 mg/dl	5-40 mg/dl
11/9/12							7							3.2	18.7	4.5	1.05	140
10/9/12	525	348-1197	10.1	16.6	87.1	19.6		44.9	1.4	2.6	59	0.72	0.989						8	15	0.7	?	45.5	80 (56-134)		172	59	94	93	19				116	67
8/3/11	541	249-836	7.8										0.808										58.7	116 (70-150)	6.4	128	50	70	41	8
10/4/10												0.79	0.464										43.5		6.9
4/2/10	453	280-800	5.8
12/20/09 (on androgel)	510	280-800	8.6																		0.9		-			186	55	110	104	21
10/15/09	388	241-827	9.4

Supplements: My current vitamin supplements are multi, fish oil, and some extras to end up with the following daily totals. Not including food and many others are not listed of course.

Vitamin C	3,392	mg
Manganese	8	mg
Glucosamine HCI	3,350	mg
Chondroitin	3,075	mg
MSM	300	mg
Vitamin D	2,800	IU
Vitamin K	75	mcg
Vitamin B6	50	mg
Folate (B9, Folic Acid)	600	mcg
Vitamin B12	1,100	mcg
Calcium	1,700	mg
Magneisum	100	mg
Fish Oil Concentrate	4,000	mg
Omega-3 (EPA, DHA, other)	2,300	mg
EPA	2,000	mg
DHA	300	mg
Zinc (as Zinc Oxide)	55	mg
Vitamin E	240	IU
Copper	2	mg

[bass]

your LH and FSH and almost shot! any injuries to your testis in the past, AAS use? your total T is in decent shape however your free is not, your e2 test is the wrong one, you need a sensitive assay to make a better judgment, your thyroid is in great shape. your diet has allot to do with your results, from your starts it doesn't sound like you're eating enough, especially protein, and thats why your creatinine is so low. if i were you i would not jump on HRT yest, it sounds like you're primary, maybe hCG and nolva therapy can help you boost your own natural production. hang tight, others will chime in soon.

[sparverius]

FSH and LH are low which I beleive would mean he's secondary (pituitary not working). If he was primary (testes not working) FSH and LH would normal or high.

Here's a good short description of primary and secondary along with possible causes: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002175/

Note that pituitary tumor is one possible cause of secondary hypogonadism. Have you had any brain injuries? The pituitary can be injured when you have a head injury and malfunction later in your life.

I'd look into the root cause rather than starting TRT now.

[rd27]

Thanks, I was wondering about those levels. I haven't talked to my Doctor directly about them yet, but his one liner on the labs seems to think he thinks things are fine because they are close to reference. Historically he is very willing to let me do more tests or try therapies though, and he will happily send me a specialist if we find good cause.

Are there any good sources that talk about the optimal levels are for FSH and LH. I found the sticky, but it just says “< 9.3” for LH and nothing for FSH.

I never had any serious head or testes injuries. Occasional bump to the head, but nothing serious and certainly nothing that needed medical attention. I do mountain bike a lot, but that is primary/testes and as you pointed out its my secondary/pituitary that seems low. No AAS either

Searching for a "root cause" makes sense for me, what are the right next steps?

Also, should I go ahead and get the right E2 test? I did ask for the sensitive, but i can see in the lab request it asked for 004515 rather than 140244. Since the lab is at the doc's office I unfortunately didn't take the time to check them.

Thanks,
dave

[bass]

FSH and LH are low which I beleive would mean he's secondary (pituitary not working). If he was primary (testes not working) FSH and LH would normal or high.

Here's a good short description of primary and secondary along with possible causes: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002175/

Note that pituitary tumor is one possible cause of secondary hypogonadism. Have you had any brain injuries? The pituitary can be injured when you have a head injury and malfunction later in your life.

I'd look into the root cause rather than starting TRT now.

My apologies, I got that backwards, of course it means secondary.

[kelkel]

Do you have older tests that contain LH/FSH levels? Your doc should be sending you for an MRI to rule in/out pituitary adenomas. If he doesn't bring it up ask why? Know the difference between primary and secondary. It would also be nice to see more thyroid tests as TSH is really a weak indicator of thyroid function. T3, T4, FT3 and FT4 would help along with cortisol.

kel

[rd27]

Thanks for the great followup!

Unfortunately this is the first time I have tested hormones beyond Total T and Free T (thanks to my reading stickies and asking for it beforehand).

I did have Cortisol-AM tested this time - 15(6.2-19.4). It's actually in my table above, but you probably need to scroll right to see it. So it's upper reference range, but not out of reference range (I haven't found anything that suggests an optimal cortisol range).

I can certainly ask for the additional Thyroid blood tests. Especially if I am redoing the E2 to get the sensitive test. For passing on to the doctor, the reason is because we want to check the Thyroid function as a way of testing the Pituitary function, correct? Any particular labcorp test #s I should ask for, or is "TSH, T3, FT3, T4, FT4" enough (don't want a repeat of the wrong E2 test)? Actually, I found an interesting article on using the various Thyroid tests, but can share it because I can't post links yet :/. The title is "5 thyroid patterns that won’t show up on standard lab tests" if anyone is interested.

I also found a good article on diagnosing Pituitary Tumors that also suggests testing ACTH and IGF-1 (can't share link, but folks can search for "UVA School of Medicine Pituitary Tumor: FREQUENTLY ASKED QUESTIONS").

It sounds like my next step should be to ask for these tests then go from there? Mention to my doctor that I am wondering about possible pituitary issues?

Thanks again,
d

PS, I sure would like an "optimal range" for FSH so I can talk to do doctor about being out of that range rather than just being at the bottom of reference.

[kelkel]

Ha! I totally missed the "scrolling right" part! Read this on cortisol: http://www.lef.org/magazine/mag2011/...ortisol_01.htm

Labcorp E2 Sensitive codes: 140244. CPT code 82670. Take these with you EVERY time. They never seem to get used to this test.

Labcorp standard FSH range: 1.5 - 12.4

Ask for a complete thyroid panel and spell out what you want to avoid mistakes. Also visit www.stopthethyroidmadness.com for great info.

I'm pretty well versed in Pituitary adenomas. I own one myself! Check this site: http://pituitary.mgh.harvard.edu/Tra...dalSurgery.htm

I'd still bump your D up to at least 5k per day. It will help to lower your shbg level which will allow more free (useful) T. As we get older it's natural for it to rise. D is arguably one of the best vitamins (actually a hormone) we can take.

kel

[rd27]

Ok, my PCP has approved the additional labs (waiting on the fax now). I will post when I get the results.

He also has suggested an endocrinologist consult, so now its time for me to find a good one in the metro DC area. I've followed up on that in the existing thread "TRT In Northern Virginia" and will be following the "Finding a TRT Physician" sticky advice as well.

PS, I'm sure my PCP would be willing to work with me, but finding someone with existing experience would clearly be preferable.

PPS, I've bumped to 5 grams Vitamin D . Thanks for the tip.

Thanks again for the ongoing help!

d

[rd27]

I got back some additional labs. I've pasted them below and updated my table in my original post. Also, once more data point that I thought I had in my original post, but somehow lost when I started this thread. I did try AndroGel for a couple months two years ago. At the time my main focus was libido/ED, and Cialis plus a new girl friend helped out on that front to the point where I just stopped taking the AndroGel.

In terms of these last tests, I do not see anything shocking, but my T4 is at the bottom the range. Does that further indicate a possible pituitary issue?

I also think I have found an Endo that has potential. He has written some articles and blog posts on HRT including T injection. Unfortunately my appointment with him is not till January.

In the meantime I do have my physical coming tomorrow with my PCP. I'm thinking of maybe asking him to let me try AndroGel again (or maybe Fortesta since its patient savings program makes it way cheaper than me). I don't want to spend two more months without energy/libido. I'm also thinking it will give me more info to take to Endo in January.

Still, since I seem to be secondary is there a downside to trying a gel while I wait to see the Endo?

Thanks!
dave

[Rusty11]

Labcorp E2 Sensitive codes: 140244. CPT code 82670. Take these with you EVERY time. They never seem to get used to this test.

I'd still bump your D up to at least 5k per day. It will help to lower your shbg level which will allow more free (useful) T. kel

Quick Hijack....Kel, thanks for the info. I'm doing the sensitive assay myself because Dr. won't do it. So, this is great to know. Second, I've been taking D3 and knew it was good, but didn't know it would lower my shbg. It was at 40 two months ago and 36 last week. I wasn't sure why it went down. Appreciate it.

Ok,,,,back to the topic. Sorry

[kelkel]

Op, paste those labs over here or provide a link please. Then we can talk more.

Rusty, your welcome.

[rd27]

Oops, meant to include them in that last post. Here they are. They are also in the first line of my original post (you may need to scroll right)..

Estradiol, Sensitive	3-70 pg/mL	7
T3, Free	2.0-4.4 pg/ml	3.2
ACTH	7.2-63.3 pg/ml	18.7
T4	4.5-12.0 ug/dl	4.5
T4, Free	0.82-1.77 ng/dl	1.05
IGF-1	64-210 ng/ml	140

And here are the ones I think are interesting from my last lab work. Once again, the are also in my original post (along with a bunch of others)..

Testosterone Free (Direct)	6.8-21.5 pg/ml	10.1
Testosterone, % Free & Weakly Bound	9.0-46.0	16.6
Testosterone, Free & Weakly Bound	40.0-250.0	87.1
Estradiol	7.6-42.6	19.6
SHBG, Serum	16.5-55.9	44.9
FSH	1.5-12.4	1.4
LH	1.7-8.6	2.6
DHT	none?	59
Creatinine, Serum	0.76-1.27	0.72
TSH	0.45-4.5	0.989
Cortisol - AM	6.2-19.4	15

Thanks!