Enigma

[Gator8]

My primary doc who is treating me for diabetes, fatigue, fibromyalgia, pain and a whole host of other issues ran a free-t test which came back at 2.8 on a normal lab range of 6.5-28. He prescribed Androgel packets and tested after two weeks. The result with two weeks treatment was 15 for a normal lab range of 7-24. The second test was run by a different lab.

After a month of Androgel, my prescription plan formulary declined Androgel, saying Testim was required instead. I had trouble with itching and some other issues and I had questions about supplementing t vs stimulating the pituitary with hgc. So I consulted an endo I had never visited before.

The endo explained that primary vs secondary should be examined first. That makes sense to me and more tests were run after a few weeks without any t. LH, FSH and free-t were checked a few weeks off-t supplementation. He calls to say all tests are normal and t-gel is not needed and not warranted, not advised. I'm thinking he said 14 but I didn't really hear the numbers.

I don't understand how free-t can be this low before treatment and then be "normal" later without treatment. I am waiting for the lab to mail me my test results for my own eyes to see. My suspicions are aroused after reading here and elsewhere. It would almost be remarkable for my free-t to be "normal" considering 30 years of diabetes for this obese 55 yo and varicocel on each testicle.

Comments?

[marianco]

Originally Posted by Gator8

My primary doc who is treating me for diabetes, fatigue, fibromyalgia, pain and a whole host of other issues ran a free-t test which came back at 2.8 on a normal lab range of 6.5-28. He prescribed Androgel packets and tested after two weeks. The result with two weeks treatment was 15 for a normal lab range of 7-24. The second test was run by a different lab.

After a month of Androgel, my prescription plan formulary declined Androgel, saying Testim was required instead. I had trouble with itching and some other issues and I had questions about supplementing t vs stimulating the pituitary with hgc. So I consulted an endo I had never visited before.

The endo explained that primary vs secondary should be examined first. That makes sense to me and more tests were run after a few weeks without any t. LH, FSH and free-t were checked a few weeks off-t supplementation. He calls to say all tests are normal and t-gel is not needed and not warranted, not advised. I'm thinking he said 14 but I didn't really hear the numbers.

I don't understand how free-t can be this low before treatment and then be "normal" later without treatment. I am waiting for the lab to mail me my test results for my own eyes to see. My suspicions are aroused after reading here and elsewhere. It would almost be remarkable for my free-t to be "normal" considering 30 years of diabetes for this obese 55 yo and varicocel on each testicle.

Comments?

Free Testosterone is not the best way to determine whether or not one has a deficiency of testosterone.

Free Testosterone is not a reliable lab test, for one. It measures a tiny fraction of the total amount of testosterone.

Free Testosterone is not an independent measure. It is highly dependent on the amount of Sex Hormone Binding Globulin and less so on albumin (which tends to be a stable value unless there are large changes in protein intake or loss or dehydration or overhydration)

Sex Hormone Binding Globulin is in turn highly dependent on numerous other hormones. SHBG is raised by thyroid hormone, estrogens, progesterone. SHBG is lowered by testosterone, DHEA, DHT, Growth Hormone and Insulin (e.g. high insulin levels from insulin resistance or diabetes type 2).

Free Testosterone is not representative of testosterone activity. Rather it represents the sum of testosterone, DHT, DHEA, growth hormone, insulin, thyroid hormone, estrogens, progesterone, and other androgens. It is a mess of a measure.

The only use of Free Testosterone is to indicate whether or not there is a problem with these hormones. Since some raise and some lower Free Testosterone, they can also cancel each other out, therefore telling nothing about hormone function.

The best indicator for testosterone activity is total testosterone. Second is bioavailable testosterone. Bioavailable testosterone is actually a calculated value - not a measured one - which is obtained by formula from the total testosterone, albumin and SHBG values.

I think a person should have the right to find out what their lab findings are. This way they can see for themselves what is up.

In an obese person with diabetes, Free testosterone can conceivably be normal. This is because the high insulin levels in diabetes type 2 can be negated by low testosterone from diabetes, and higher estrogen production from abdominal obesity. Abdominal obesity can also cause a relative hypothyroid state via higher estrogen production causing an increased production of thyroid binding globulin. The low thyroid acvity can then reduce SHBG and lower testosterone production, throwing another complicating factor into the mix. Free Testosterone is a useless measure in this circumstance.

By the time men are about 50 years-old, many will have some age-related secondary hypogonadism from the aging pituitary being unable to produce enough LH, and some age-related primary hypogonadimsm from aging testes which are not responding to Luteinizing hormone as when younger. This and other complicating factors (such as hypothyroidism and diabetes) is why about half of men 50 years old are hypogonadal and reaching for Viagra.

[Gator8]

I see your points. It's not clear to me why "free testosterone" is the only test first run. Perhaps cost and insurance was a consideration. Is "free testosterone" so non-specific that a measurement of 2.8 for a lab norm of 6.5-28 is useless for making a yes or no decision?

I've had thyroid tests numerous times, always normal except for "reverse T3". What is the significance of high reverse throid other than it's inactive?

[marianco]

Originally Posted by Gator8

I see your points. It's not clear to me why "free testosterone" is the only test first run. Perhaps cost and insurance was a consideration. Is "free testosterone" so non-specific that a measurement of 2.8 for a lab norm of 6.5-28 is useless for making a yes or no decision?

I've had thyroid tests numerous times, always normal except for "reverse T3". What is the significance of high reverse throid other than it's inactive?

Free Testosterone is run under the assumption that it indicates the testosterone that is actually "active" - meaning the testosterone that is not loosely bound to albumin or tightly bound to SHBG.

This is a wrong assumption. Testosterone that is loosely bound to albumin is also active. Testosterone bound to SHBG also has signaling function at SHBG receptors.

The physicians who use Free testosterone also don't realize that many hormones determine free testosterone. Further Free testosterone can be normal while total testosterone can be very low (e.g. 170 ng/dl). The physician who relies on labs rather than history and physical exam will think the person is not hypogonadal, but that person is more commonly hypogonadal. This is a physician who treats the lab rather than treats the person.

The cost of doing Free Testosterone is often higher than doing total testosterone. It is much more difficult to measure free testosterone since it is a smaller value than total testosterone. This is also one reason the measure is unreliable - it is a very small value.

High reverse-T3 indicates that type-3 deiodinase activity is high in comparison to type-2 deiodinase activity. Type-2 deiodinase is the main enzyme that activates T4 to T3. Type-3 deiodinase inactivates T4 by converting it to reverse-T3. Type-1 deiodinase can activate T4 or deactive T4.

Increasing type-2 deiodinase activity or production (to better activate T4 to T3) requires adequate T3 levels, insulin, norepinephrine, and growth hormone/IGF-1. IGF-1 is not only determine by growth hormone but DHEA and other hormones.

The need for T3 to activate type-2 deiodinase is one reason Armour Thyroid (T3, T4 + T2, T1) has an advantage over Levothyroxine (T4) in thyroid replacement therapy.

When a person has adrenal fatigue, the prolonged low glucose levels can lead to prolonged low insulin production. This can then lead to less activation/conversion of T4 to T3 and a hypothyroid state. This is opposed though by the high norepineprine levels that can occur with adrenal fatigue - which increases the activation/conversion of T4 to T3. Which pathway wins depends on the person.

[Gator8]

I obtained my test results. These tests followed pre-treatment the prior night with dexamethasone to evaluate for Cushings. It follws two weeks wash-out time for androgel. I gather the low cortisol is the desired result from dexamethasone.

testosterone, serum 455 (ref 241-827)
LH 2.6 (ref 1.5-9.3)
FSH 3.2 (ref 1.4-18.1)
Prolactin 2.4 (ref 2.1-17.7)
TSH 0.813 (ref 0.350-5.50)
T4 free, (direct), 1.1 (ref 0.61-1.76)
Cortisol 1.3 (ref 3.1-22.4)


The doctor who prescribed androgel treats by careful interview concering symptoms, but he prescribed the free-t test, seemingly missing the mark. The doctor who did the above work-up goes by numbers, not symptoms.

[Gator8]

With these test results, would I benefit from TRT?

[marianco]

Originally Posted by Gator8

My primary doc who is treating me for diabetes, fatigue, fibromyalgia, pain and a whole host of other issues ran a free-t test which came back at 2.8 on a normal lab range of 6.5-28. He prescribed Androgel packets and tested after two weeks. The result with two weeks treatment was 15 for a normal lab range of 7-24. The second test was run by a different lab.

I obtained my test results. These tests followed pre-treatment the prior night with dexamethasone to evaluate for Cushings. It follws two weeks wash-out time for androgel. I gather the low cortisol is the desired result from dexamethasone.

testosterone, serum 455 (ref 241-827)
LH 2.6 (ref 1.5-9.3)
FSH 3.2 (ref 1.4-18.1)
Prolactin 2.4 (ref 2.1-17.7)
TSH 0.813 (ref 0.350-5.50)
T4 free, (direct), 1.1 (ref 0.61-1.76)
Cortisol 1.3 (ref 3.1-22.4)

The doctor who prescribed androgel treats by careful interview concering symptoms, but he prescribed the free-t test, seemingly missing the mark. The doctor who did the above work-up goes by numbers, not symptoms.

With these test results, would I benefit from TRT?

It would be difficult to say that a man with a testosterone over 400 ng/dl is hypogonadal. Sexual dysfunction would more commonly have other hormonal causes such as adrenal fatigue, hypothyroidism, diabetes, excess estradiol, etc.

Testosterone optimization (e.g. raising blood levels over 650 ng/dl, while trying to avoid supraphysiologic levels), may be helpful in some cases to reduce diabetes or insulin resistance, to improve a person's tolerance to pain, to improve energy (e.g. via improving thyroid hormone production - though in some men, thyroid hormone production is reduced and fatigue worsens instead). Testosterone, in general, is also an anti-inflammatory hormone (reducing the levels of inflammatory cytokines - immune system chemical messengers). It can help reduce hypertension (though in some men it can increase blood pressure - if not enough of the other hormones are made - such as DHEA, Estradiol, Progesterone, Thyroid hormone). Testosterone may also help reduce abdominal fat (though excess DHT may increase abdominal fat), help reduce the damage from stroke or heart attack, etc.

The primary problem is in getting a physician to prescribe TRT for these indications. An anti-aging physician may - but it varies. Many of the big-name anti-aging doctors will target around 550-650 ng/dl, others may go higher. It depends on the physician's philosophy on the matter.

[Gator8]

[quote][It would be difficult to say that a man with a testosterone over 400 ng/dl is hypogonadal. Sexual dysfunction would more commonly have other hormonal causes such as adrenal fatigue, hypothyroidism, diabetes, excess estradiol, etc./QUOTE]

I guess considering all of my risk factors, I'm pretty lucky to be fairly free of sexual dysfunction. The month trial of Androgel improved function rather than restore absence. More important changes were in pain levels, energy and cognition. Unexpectedly and perhaps unrelated, my insuln needs went up not down. My question when I visited the Endo was not if I should supplement testosterone but rather wouldn't this better be treated by medication that stimulated the pituitary in a more normal control loop rather than treatment that consequently suppressed the testes. The answer back was "no treatment was indicated".

How immediate does Androgel or Testim suppress endogenous testosterone production? If one is in the mid-four hundreds for serum testosterone and then adds one of these gels, would this gel temporarily produce supraphysiologic levels of testosterone that are not sustained with further application? Would improvements in energy, pain and cognition continue with continued treatment or were these temporary from temporary excess levels?

[pmgamer18]

[quote=Gator8]

[It would be difficult to say that a man with a testosterone over 400 ng/dl is hypogonadal. Sexual dysfunction would more commonly have other hormonal causes such as adrenal fatigue, hypothyroidism, diabetes, excess estradiol, etc./QUOTE]

I guess considering all of my risk factors, I'm pretty lucky to be fairly free of sexual dysfunction. The month trial of Androgel improved function rather than restore absence. More important changes were in pain levels, energy and cognition. Unexpectedly and perhaps unrelated, my insuln needs went up not down. My question when I visited the Endo was not if I should supplement testosterone but rather wouldn't this better be treated by medication that stimulated the pituitary in a more normal control loop rather than treatment that consequently suppressed the testes. The answer back was "no treatment was indicated".

How immediate does Androgel or Testim suppress endogenous testosterone production? If one is in the mid-four hundreds for serum testosterone and then adds one of these gels, would this gel temporarily produce supraphysiologic levels of testosterone that are not sustained with further application? Would improvements in energy, pain and cognition continue with continued treatment or were these temporary from temporary excess levels?

If I were you I would get my Estradiol tested if high this can be why your Free T was low and getting it down will bring your 400 total T up some 200 to 300 points. You would need to take Arimidex .5mgs every other day to get this down. Here is a good link.
http://www.medibolics.com/ArimidexBo...stosterone.htm
And this one is better.
http://jcem.endojournals.org/cgi/content/full/89/3/1174
Also like Dr. Marianco says get everything tested.