got labs back, starting new regimen monday!!!!

[Dr. John Crisler]

Have just registered for this forum and will try to be involved as my life schedule permits (with work and three kids at home)...

Hello to everyone!

Marshall and others:

In general, members should be cautious of taking advice and getting all worked up from other members whom are not medical professionals...they are trying to help with advice, but for some people this just breeds anxiety and is more harmful than beneficial.

Regarding the issues posed...

In my experience, the ultra sensitive E test and regular E test are fairly equivalent unless we start talking about VERY low E levels ( <15), which would be too low anyways. At those VERY low E levels the ultra sensitive test is exactly that - more sensitive (this is evidenced by the fact that the regular E test will not detect anything less than 5.1 - it will read <5.1 ... It is not SENSITIVE enough to detect those low levels). The ultrasensitive test is also more expensive and he's welcome to order it, but IMO is a waste of $ that could be better spent elsewhere. In other words, the regular estradiol test will give us a good idea of if E2 is "low", "acceptable/OK", or "high"... which is really what we're interested in anyways. If your interested in knowing EXACTLY how low (ie: 3 vs 10) or EXACTLY how high (ie: 50 vs 65) then the ultrasensitive test would give you that, but at additional cost...

With regards to the thyroid... high TSH, fatigue, being overweight = basically guaranteed hypothyroidism. Sure we can check additional labs (free T3, free T4, reverse T3) but again this is additional cost to the patient and will likely NOT ultimately change our treatment plan as 99% probability with his TSH level (>6) that his T3/T4 will be off. In addition, as I do with most patients, but don't recall specifically my convo with him, I usually give the option of more thorough testing up front (at more cost, with the understanding that it likely will NOT alter the treatment plan) or to empirically start thyroid treatment and monitor on follow-up accordingly... and most patients , Mr Shell included if I recall, choose to start empiric treatment. We ARE monitoring free T3 and free T4 on his 90 day f/ u labs to make sure the armour dosage is dialed in accurately.

Regarding anastrozole, E is 25 (perfect) with total T 400 (fairly high ratio), has history of high E with early breast/gyno symptoms, has relatively high body fat % (= more aromatase activity). He ABSOLUTELY needs an AI. How much?? Well that's the art of it and to be determined through treatment and follow-up. 0.5 mg twice weekly is a good bet of what he'll need ... Maybe a bit more or a bit less, we'll see on follow-up labs. E will begin to rise as soon as T rises (aromatase enzyme doesn't take any vacations), so should start the AI together when starting the T injections ESPECIALLY in patients with a proven history of high E conversion and the related side effects. His current E level is perfect at 25, but it WILL NOT stay there as his T comes up without an AI especially with his high aromatase activity.

I spent over an hour discussing many issues with this patient, once again, he should be cautious of getting worked up or stressed out by posts from forum members that do not know his entire clinical picture, are not medically trained, and have not had an official (1 HOUR) medical consult with him. Some aspects of HRT are more art than exact science, and this is where CLINICAL experience is crucial. Many people have various differing opinions, but I have quite a bit of experience with these and similar hormonal abnormalities and am well versed in the intricacies and caveats of treatment... forum posts by non-medical members should not be taken as the gospel especially if they will breed uncertainty and anxiety.

Good day all!

Dr Saya

Oh, indeed it does.

Challenging thyroid dysfunction runs rampant across our patient population.

If you do not draw a Free T4 and a Free T3 (free levels to remove the influence of Thyroid Binding Globulin) you do not know what kind of medication to prescribe. That is because you don't know what the real problem is.

If T3 is good with respect to T4, you can probably get away with Synthroid (T4) only. But if the patient is not converting T4 to T3 well, we must use a natural thyroid product, or add in T3 (less often); and all the while addressing the issues which are preventing enzyme D1 from making T3 of T4.

IF Reverse T3 is high, or even high-normal, you can not use either Synthroid or dessicated thyroid, as they both contain T4. The T4 will be acted upon by enzyme D3, and instead convert to Reverse T3.

In the words of my pal Dr. Ronald Rothenberg (the best Anti-Aging Medicine doctor in the world IMPO, and a GREAT guy IMO) "Reverse T3 reverses T3."

This is one reason why some patients tell you they actually feel WORSE when you add thyroid medication. Another reason may be the added T4 uncovered a previously undiagnosed Adrenal Fatigue. And THAT can get complicated.

Then T3-only ....for a while...is how I go. Since rT3 tends to stay where you leave it (high or low), once it is down, you can then reintroduce natural thyroid.

You have to decrease the influences which sponsor D3, and increase the ones which favor D1. THAT is also where patient lifestyle comes in.

As I teach in my Thyroid Optimization lecture, D1/D3 is an excellent way to assess overall health. It's all in the body's ability to convert T4 to T3.

Finally, running the two thyroid antibody assays can help us deal with a huge cause of thyroid dysfunction, Hashimoto's. I have lowered thyroid antibodies from over 360 to normal range with selenium. Once the immune system attack is quieted, we can then proceed to effectively treat the thyroid issues....and give them back their life.

 

[Gene Devine]

Laboratory methodology is reliant upon statistical analysis. Therefore, the top of "normal range" from one lab is the same for the top of "normal range" at another--no matter what the actual numbers.

To illustrate, guys will try to use laboratories where the top of range is a higher number, thinking they will then get more testosterone. In practice, this does not work, because they just end up at the top of range, again, anyway.

THIS ---> IOW, midrange on one lab is the same as midrange on another. Irrespective of the ranges.

It's a strange concept, but it's just part of getting used to walking on slippery rocks all the time, which is what it is like practicing this field of medicine.

I am always learning from you...always!!!

 

[Dr. John Crisler]

I am always learning from you...always!!!

Well, if we think about it, "normal range" is found, for all laboratories, from the same patient population. So how could they actually be different?

We never can get very far away from common sense, can we?

OOPS! Just had to add another slide to my "TRT: A Recipe for Success" lecture...

 

[JSayaMD]

As most of my patients are cash pay (occasionally insurance coverage), it is sometimes challenging to get ALL pertinent tests up front. As stated, I usually counsel and offer to draw additional labs (free T3, free T4, reverse T3 - agree absolutely have to check FREE levels to assess bioavailable hormone status) or treat presumptively based on the preponderance of evidence and then do full labs (if economically feasible for pt) at first follow-up. Of course, never treating if there is anything concerning or "out of the ordinary" in their clinical picture.

In MOST situations a compounded T4:T3 or armour (or even T3/cytomel) are preferred over pure T4 (synthroid).

With reverse T3 high the WORST thing anyone can do is give pure T4 (synthroid) which will exacerbate the situation. This is why I practically never give synthroid alone, in favor of compounded T4:T3 or armour. Reverse T3 is the "anti-T3" and competes with bioactive free T3 for receptor sites. Best option with high reverse T3 is cytomel or compounded T3 only. Although armour/T4:T3 is still better in this situation than synthroid.

Selenium is interesting...

Dr Saya

 

[Dr. John Crisler]

LabCorp now has their LAN Program (whatever that stands for) that dramatically reduces the cost of their tests for those who must pay cash. Maybe someone can check to see if Quest has a similar program.

For those who self pay, we do need to take this one step at a time sometimes. Using a body temperature chart, at least four days, can help direct subsequent therapy, often without additional laboratory analysis/expense.

It has been said a great Surgeon can do a procedure with nothing but a piece of fishing line and a sharp tin can lid. After eleven years of doing this, all day every day, you can tell the levels of five different hormones just by shaking the patient's hand. LOL

 

[JSayaMD]

Yes, as I mentioned, the importance of practitioner knowledge, experience, and confidence cannot be discounted as this is often far more important than any lab value.

For the surgeon...I wouldn't doubt it, but I would not want to be that surgeon's patient!

Have enjoyed the back-and-forth today, but now HOURS behind on my patient notes... back to work :-(

Dr Saya

 

[Keith Willse]

@ Dr. John, It is the LAP Program.

Lab Corps
LabAccess Partnership (LAP) Program
NOTE: To access the LAP program, patients must pay the discounted fees of the ordered laboratory tests in full at the time of service. Patients with prior unpaid laboratory charges may not be eligible for the program until overdue balances are satisfied.

What is the LAP Program?
The LAP program is a menu of routine clinical tests that are available to uninsured patients at discounted pricers when those patients use LabCorp Patient Service Centers (PSC) for specimen collection.
Who is Eligible for the LAP Program?
The LAP program is available to self-pay patients who are uninsured or whose health care benefits exclude coverage for clinical laboratory testing services.
How can Uninsured Patients Participate?
Patients must present their test request paperwork at a LabCorp PSC for specimen collection. A list of PSCs, including hours of operation and directions, is available by calling toll free 888-LabCorp (522-2677) or by visiting the LabCorp website: www.LabCorp.com.

 

[Gene Devine]

@ Dr. John, It is the LAP Program.

Lab Corps
LabAccess Partnership (LAP) Program
NOTE: To access the LAP program, patients must pay the discounted fees of the ordered laboratory tests in full at the time of service. Patients with prior unpaid laboratory charges may not be eligible for the program until overdue balances are satisfied.

What is the LAP Program?
The LAP program is a menu of routine clinical tests that are available to uninsured patients at discounted pricers when those patients use LabCorp Patient Service Centers (PSC) for specimen collection.
Who is Eligible for the LAP Program?
The LAP program is available to self-pay patients who are uninsured or whose health care benefits exclude coverage for clinical laboratory testing services.
How can Uninsured Patients Participate?
Patients must present their test request paperwork at a LabCorp PSC for specimen collection. A list of PSCs, including hours of operation and directions, is available by calling toll free 888-LabCorp (522-2677) or by visiting the LabCorp website: www.LabCorp.com.

^^^^I had no idea that this program existed and certainly would justify any additional labs needed for correct diagnosis where economics are a weighing factor.

Good stuff fellows!

 

[Keith Willse]

Quest also has a program which is called Quest Cares Uninsured Patient Program.
Quest Cares Uninsured Patient Program
•For appointments or to find other local locations, call 1-800-LABTEST (522-8378) or online at www.questdiagnostics.com/psc.
•Locate the nearest patient Service Center (PSC) in your area at 800-377-8448 or QuestDiagnostics.com/patient.
•Anyone without insurance coverage for laboratory testing is eligible to join the QuestCares Uninsured Patient Program. The program includes approximately 100 of the most popular routine tests to help you save money on the tests doctors order most often. Visit the website for an up-to-date listing of tests available through the program.

 

[Dr. John Crisler]

Yes, as I mentioned, the importance of practitioner knowledge, experience, and confidence cannot be discounted as this is often far more important than any lab value.

For the surgeon...I wouldn't doubt it, but I would not want to be that surgeon's patient!

Have enjoyed the back-and-forth today, but now HOURS behind on my patient notes... back to work :-(

Dr Saya

Yes, I too, Good Doctor.

It's really nice interacting with a colleague on a message board who has a practical knowledge of these subjects, and, more so, is THINKING about it really hard!

 

[JSayaMD]

I like thinking and being stimulated to think, which is why I am now even FURTHER behind on my notes.... have to get cracking before I will have to bring work home, which will get me in hot water with the wife!

Dr Saya

 

[paco]

Many thanks to the good doctors for discussing these issues publicly! This is how patients become better educated and empowered, which leads to more HEALTHY people. Who can argue with that? ; )

 

[Gene Devine]

Many thanks to the good doctors for discussing these issues publicly! This is how patients become better educated and empowered, which leads to more HEALTHY people. Who can argue with that? ; )

^^^^Couldn't agree more Paco; it's one of the bigger reasons we created ExcelMale.com as dialog like this could never happen on a FB Group.

And I even picked up new tag line to boot: "We never can get very far away from common sense, can we"?

 

[Dr. John Crisler]

Quest also has a program which is called Quest Cares Uninsured Patient Program.
Quest Cares Uninsured Patient Program
•For appointments or to find other local locations, call 1-800-LABTEST (522-8378) or online at www.questdiagnostics.com/psc.
•Locate the nearest patient Service Center (PSC) in your area at 800-377-8448 or QuestDiagnostics.com/patient.
•Anyone without insurance coverage for laboratory testing is eligible to join the QuestCares Uninsured Patient Program. The program includes approximately 100 of the most popular routine tests to help you save money on the tests doctors order most often. Visit the website for an up-to-date listing of tests available through the program.

Thank you, Keith.

 

[Gene Devine]

Can't tell you all enough how great this thread has become!

This is precisely why we created this forum and to see an epic thread like this so early in our development makes me very proud to be a part of this community.

Thank you all very much fellows!!!

GD

 

[JSayaMD]

I missed this post previously, but interesting...

Laboratory methodology is reliant upon statistical analysis. Therefore, the top of "normal range" from one lab is the same for the top of "normal range" at another--no matter what the actual numbers.

This would make the discrepancy between the Quest and LabCorp results even MORE alarming as the Quest range for those patients was 241 - 827 ng/dL (with their actual readings being 2000-2400) while LabCorp range is 348 - 1197 ng/dL (with their actual readings being 900-1200. So Quest readings >double upper limit, while LabCorp readings in upper normal range. Keep in mind - SAME patient, SAME time... this has happened on 3 separate occasions for me with Quest, so I tend to have more faith in LabCorp readings in general.

To illustrate, guys will try to use laboratories where the top of range is a higher number, thinking they will then get more testosterone. In practice, this does not work, because they just end up at the top of range, again, anyway.

IOW, midrange on one lab is the same as midrange on another. Irrespective of the ranges.

Yes, true...as the lab reference range is just a statistical derivation of that specific lab's patient population with "reference range" normally encompassing the middle 95% of lab values (chopping off the top 2.5% and bottom 2.5%). The "scale" (careful not to read as units) is different depending on the range (ie: a 10 point change in T level in a more narrow range (Quest) is a larger PERCENT change than a 10 point change in a broader range (LabCorp).

It's a strange concept, but it's just part of getting used to walking on slippery rocks all the time, which is what it is like practicing this field of medicine.

Not really strange if one understands statistics, but certainly difficult to grasp if they do not. Another example of where the standard E2 assays and the "Sensitive" E2 assays are different and cannot be compared...they both report different reference ranges. For example, the LabCorp "Sensitive" estradiol reports a reference range of 3-70 pg/ml, while the LabCorp standard estradiol assay reports a reference range of 7.6 - 42.6 pg/ml. If based on same patient population, this demonstrates my previous point... a "sensitive" assay will be better at giving a precise measurement of VERY LOW or VERY HIGH values (as evidenced by the fact that the sensitive assay "reference range" for middle 95th percentile is broader 3-70 vs 7.6 - 42.6). If anything, this shows that the standard assay would UNDERESTIMATE, in some cases when E levels on high end of range, E levels as I stated before, NOT OVERESTIMATE and lead to overuse of AI.

From these two reference ranges (both calculated as middle 95th percentile of all values), one can infer that a patient with a reading of low end on standard assay (7.6) may have an actual E level closer to 3 as seen on sensitive assay (ranges 3-70 vs 7.6 - 42.6)...this is the patient at the 2.5% spot on BOTH ranges.

Conversely, a reading of 42.6 on standard assay is roughly equivalent to a reading of 70 on sensitive assay (ranges 3-70 vs 7.6 - 42.6). For LabCorp's sensitive estradiol assay, they even state "estradiol results obtained with different assay methods cannot be used interchangeably (even when presented in same units of measurement)".

Thus, take home point...do NOT compare results from one assay to another (not apples and apples), and STICK with whichever assay you use consistently to monitor serial trends. As long as you understand, as you do but other practitioners may not, that you need to pay more attention to WHERE a value falls WITHIN its designated range than the actual number itself, then you will get all of the info you need regardless of assay methodology.

We can never get too far away from statistical facts, can we...

Dr Saya

 

[Dr. John Crisler]

I missed this post previously, but interesting...



Not really strange if one understands statistics, but certainly difficult to grasp if they do not. Another example of where the standard E2 assays and the "Sensitive" E2 assays are different and cannot be compared...they both report different reference ranges. For example, the LabCorp "Sensitive" estradiol reports a reference range of 3-70 pg/ml, while the LabCorp standard estradiol assay reports a reference range of 7.6 - 42.6 pg/ml. If based on same patient population, this demonstrates my previous point... a "sensitive" assay will be better at giving a precise measurement of VERY LOW or VERY HIGH values (as evidenced by the fact that the sensitive assay "reference range" for middle 95th percentile is broader 3-70 vs 7.6 - 42.6). If anything, this shows that the standard assay would UNDERESTIMATE, in some cases when E levels on high end of range, E levels as I stated before, NOT OVERESTIMATE and lead to overuse of AI.

From these two reference ranges (both calculated as middle 95th percentile of all values), one can infer that a patient with a reading of low end on standard assay (7.6) may have an actual E level closer to 3 as seen on sensitive assay (ranges 3-70 vs 7.6 - 42.6)...this is the patient at the 2.5% spot on BOTH ranges.

Conversely, a reading of 42.6 on standard assay is roughly equivalent to a reading of 70 on sensitive assay (ranges 3-70 vs 7.6 - 42.6). For LabCorp's sensitive estradiol assay, they even state "estradiol results obtained with different assay methods cannot be used interchangeably (even when presented in same units of measurement)".

Thus, take home point...do NOT compare results from one assay to another (not apples and apples), and STICK with whichever assay you use consistently to monitor serial trends. As long as you understand, as you do but other practitioners may not, that you need to pay more attention to WHERE a value falls WITHIN its designated range than the actual number itself, then you will get all of the info you need regardless of assay methodology.

We can never get too far away from statistical facts, can we...

Dr Saya

I am afraid that is not true. Standard Estradiol is almost always much higher--sometimes much higher--than the sensitive assays. I have about 1,000 lab printouts to prove this, where they ran both types of assays.

You can reason and figure all you want, but those are the actual laboratory printouts. Start ordering the Sensitive assay, and you will see exactly what I mean. You just haven't run enough of them yet.

In fact, I presented a LabCorp printout demonstrating this phenomenon to Mr. William Falloon (in his kitchen LOL) a couple weeks ago, to convince him to change the Life Extension Foundation "Male Panel" to switch to the Sensitive assay. We'll see.

Sometimes the standard Estradiol is even above its range, with sensitive at half way point. For those who treat based purely upon labs, this means they are indeed administering an AI when they clearly should not (unless, of course, the gent has elevated E symptoms, such as with a lower SHBG).

As I have said, there are very good reasons why that paragraph appears in a Quest Diagnostics printout, when a practitioner has mistakenly ordered the Standard E2 for an adult male: the experts at the lab have figured this out to be true.

By the way, when you write in all bold, it prevent highliting to designate a particular passage.

 

[Dr. John Crisler]

By the way, every lab shanks an assay now and again. You can't draw a comparison between labs, or lab ranges, based on n=1.

And if your patient was on a T gel, it is also possible surface contamination occurred at one of the draw sites. Look at Free T to ascertain. It will be through the roof.

 

[JSayaMD]

Not on gels, on cyp. Three separate occasions where I took the pain to draw at same time through Quest and LabCorp, same result EACH time for different patients (and poorer customer support when staff reached out to them to discuss...just personal experience).

Statistics are statistics, unless as stated above, lab/human error is entered into the equation at which point all is out the window.

Symptoms will ALWAYS take precedence regardless of what assay one may use (even if they are those practitioners who mistakingly fail to even monitor E levels).

Standard assay, as long as you evaluate WHERE in range and are a little more weary of very high or very low numbers, does a great job for a general classification of E levels ( low/normal /high). With economic/cost of care considerations it may make more sense to only order the sensitive (more expensive) E2 test when "things don't add up (symptoms don't correlate with numbers)" or in cases of questionable very high or very low readings on the standard assay. This seems the more practical and prudent utilization of a more specialized/expensive test and is the way I utilize it.

Dr Saya

 

[JSayaMD]

BTW didn't realize it kept entire post in bold lol... In case anyone forgot their glasses today