Is my doctor being too cautious?

[divismal10]

Hi all,
Hoping to gain some insight with this question as I have plowed through these forums and several others and I’m suffering “paralysis by analysis” so here it goes.

Is my doctor being too cautious?

I’m 42 yrs old and have been on weekly injections for about 9 months. I had my testosterone tested after having part of my thyroid removed with a cancerous growth. I was on thyroid replacement for about 6 months and my energy and recovery were worse than ever. We worked together to get my TSH at about 2.5. I had suspected low T in my late 30’s but had never thought to test it, Even though my primary ran me through a bunch of tests for fatigue and I even did a sleep study for sleep apnea. No other life factors came back as a reason for my fatigue and inability to grow muscle or push through cardiovascular workouts. Testosterone never came up because I wasn’t having any bedroom symptoms. Once I finally begged the thyroid surgeon for a T test, The results of my first test came in at 242 Total Testosterone. I had follow up labs that looked like this :
Albumin: 4.1
T Total: 261
SHBG: 34.5
T Free 50.4
T Bioavailable: 112.9
FSH: 5.0
LH: 3.0
Estradiol: 26.8
Hematocrit: 44.1
Platelets: 305
TSH 3.33

I started T gel the next week but quickly wanted to switch to injections with 2 toddler aged daughters at home.
I did 3 months of 200 mg injections every 2 weeks to lead up to doing my own home injections. When I transitioned to weekly injections we started at 100 mg (.5 ml)a week for the first 3 months. I had my blood work done and here’s what came out:
Albumin: 4.3
T Total: 800
SHBG: 32
T Free 186.6
T Bioavailable: 437.4
Hematocrit: 48.8
TSH 2.65 on 100mg levothyroxine
(Continued to dial this in trying to get down to 2.0)

I felt great! Not only physically but emotionally. It was a fresh start for me after a year of trauma post surgery, plus both of my parents were very ill and I was trying to be a good father to my two children under the age of 3.

After those results my doctor lowered my dose to 80mg a week (.4 ml)and I’m still better but still somewhat symptomatic. A day and a half before my next injection my energy is really low and I’m extra cranky and if I push hard at the gym it takes twice as long to recover. Emotionally I’m not with it either. I also seem to have a tough time the day after my shot and I’ve communicated with my doctor about that but he doesn’t seem to have a response. Days 2-5.5 are fantastic and I’ve put all of my hard training days around that window of time.

We looked at my labs again 3 months later after dropping my dose and here’s what came up.
Albumin: 4.4
T Total: 523
SHBG: 30.6
T Free 113.7
T Bioavailable: 272.4
LH: 0.1
Hematocrit: 45.8
Platelets: 295
TSH 3.27 (on 112mg of levothyroxine)

Is he being too cautious? Are we missing something?
He talked about trying me on Aveed and it scared me when I read up on it.
Thanks for any and all insights

 

[timk]

I was on weekly and felt the same low. I switched to twice weekly and don’t feel the lows I did on once a week. If it makes you feel better I’m only on 60mg a week. More isn’t always better.

 

[Deleted member 16042]

Lowering dose can cause withdrawl symptoms. It may be that you just need to wait things out. I had to reduce dosage multiple times and have been through that repeatedly. Things tend to level off for me after 2-3 months when I am full stable on the lower dose. (edit: OK, I see you've been on 80mg for 3 months... time to reassess dosage and frequency).

80/week is a pretty low dose. And TT in the 500's is not ideal, but I don't know how to interpret your free T range*. Some guys do well on that kind of lower dose, But we each have sort of a cut off point on the lower end of dosage. I personally am on 84mg/week dosed EOD (Currently switching to ED). Below that I don't do well.

*(Can you post ranges with your labs? For me, the Free T reference is using a different scale than I am used to seeing.)

Your observation that your feel down a couple days before next injection and the day after points to needing more frequent injections. T cyp is not utilized immediately as it takes time for your body to cleave the T off thecypionate ester, hence the lag after injection, and it is likely you use and clear enough after several days that your levels drop before next injection. Weekly dosage is notorious for causing this roller coaster effect. I personally would not hesitate to go to E3.5 or E3D or even EOD.

I agree Aveed is undesirable. too long acting to be able to make adjustments in dosage. In the US cypionate seems to be the standard, and internationally enanthate probably more common and similar in half life, but if you read this forum, there's also a trend towards proprionate to help mimic diurnal characteristics, though it means EOD or daily shots. If you are on Cypionate or Enanthate I'd stick with it, and work with increasing dose and frequency, though only one change at a time, wait 6-8 weeks, retest and reassess before other changes. I'd choose more frequent injections to start.

I am also wondering if you have ever been assessed for free T3 Free T4 and RT3. Just relying on TSH is not comprehensive Thyroid assessment, and targeting a TSH of 2.5 could be sub par in terms of optimization. The general trend is shooting for less than 2.0, and getting more detailed assessment if higher. Especially with your history of surgery, it may be worth studying this. Start with:

Tired Thyroid
Dr. Westin Childs | Thyroid Supplements, Functional Nutrition & Articles
Dr. Westin Childs (youtube videos)
Stop the Thyroid Madness™ - Hypothyroidism and thyroid mistreatment

 

[divismal10]

I was on weekly and felt the same low. I switched to twice weekly and don’t feel the lows I did on once a week. If it makes you feel better I’m only on 60mg a week. More isn’t always better.

Thank you! Twice a week or EOD was something I was going to try next.

 

[Vince]

I agree with blackhawk, get a complete thyroid panel. TSH, free T4, free T3 and reverse T3. Taking synthetic T4 (levothyroxine) will lower your TSH but I doubt if it's helping your free T3. That's what you need to feel good.

 

[divismal10]

Thank you so much. I’ve suspected the thyroid was a big player in my fatigue and grouchiness. I’ll read these specific links and I see my endocrinologist on Monday. I’ll be asking him to run a full work up as I’ve known the TSH is not always the best indicator.

My only levels for Free t4, T3 and T4 were taken after 1 month on 25 mg of levothyroxine.

Here they are.
9/15/17 - 1 month on 25 mg of levothyroxine.
TSH - 3.08
T3 - 111
T4 - 9.4
T4 free - 1.11
2/20/18 - 75 mg of Levo
TSH - 2.84
T3 - not done
T4 - not done
T4 free - 1.32
7/11/18 - 100 mg Levo and 200mg of test every 2 weeks
TSH - 2.27 (best I’ve felt since all this began
No other testing done
4/12/19 - 112mg levo and 80mg test every week
TSH- 2.39
T4 free - 1.31

 

[madman]

Hi all,
Hoping to gain some insight with this question as I have plowed through these forums and several others and I’m suffering “paralysis by analysis” so here it goes.

Is my doctor being too cautious?

I’m 42 yrs old and have been on weekly injections for about 9 months. I had my testosterone tested after having part of my thyroid removed with a cancerous growth. I was on thyroid replacement for about 6 months and my energy and recovery were worse than ever. We worked together to get my TSH at about 2.5. I had suspected low T in my late 30’s but had never thought to test it, Even though my primary ran me through a bunch of tests for fatigue and I even did a sleep study for sleep apnea. No other life factors came back as a reason for my fatigue and inability to grow muscle or push through cardiovascular workouts. Testosterone never came up because I wasn’t having any bedroom symptoms. Once I finally begged the thyroid surgeon for a T test, The results of my first test came in at 242 Total Testosterone. I had follow up labs that looked like this :
Albumin: 4.1
T Total: 261
SHBG: 34.5
T Free 50.4
T Bioavailable: 112.9
FSH: 5.0
LH: 3.0
Estradiol: 26.8
Hematocrit: 44.1
Platelets: 305
TSH 3.33

I started T gel the next week but quickly wanted to switch to injections with 2 toddler aged daughters at home.
I did 3 months of 200 mg injections every 2 weeks to lead up to doing my own home injections. When I transitioned to weekly injections we started at 100 mg (.5 ml)a week for the first 3 months. I had my blood work done and here’s what came out:
Albumin: 4.3
T Total: 800
SHBG: 32
T Free 186.6
T Bioavailable: 437.4
Hematocrit: 48.8
TSH 2.65 on 100mg levothyroxine
(Continued to dial this in trying to get down to 2.0)

I felt great! Not only physically but emotionally. It was a fresh start for me after a year of trauma post surgery, plus both of my parents were very ill and I was trying to be a good father to my two children under the age of 3.

After those results my doctor lowered my dose to 80mg a week (.4 ml)and I’m still better but still somewhat symptomatic. A day and a half before my next injection my energy is really low and I’m extra cranky and if I push hard at the gym it takes twice as long to recover. Emotionally I’m not with it either. I also seem to have a tough time the day after my shot and I’ve communicated with my doctor about that but he doesn’t seem to have a response. Days 2-5.5 are fantastic and I’ve put all of my hard training days around that window of time.

We looked at my labs again 3 months later after dropping my dose and here’s what came up.
Albumin: 4.4
T Total: 523
SHBG: 30.6
T Free 113.7
T Bioavailable: 272.4
LH: 0.1
Hematocrit: 45.8
Platelets: 295
TSH 3.27 (on 112mg of levothyroxine)

Is he being too cautious? Are we missing something?
He talked about trying me on Aveed and it scared me when I read up on it.
Thanks for any and all insights

You need to find a new doctor.

The main purpose of trt is to provide the patient relief/improvement of low t symptoms and improve ones overall well being.

Your doctor clearly has no idea what he is doing.



You stated "When I transitioned to weekly injections we started at 100 mg (.5 ml)a week for the first 3 months. I had my blood work done and here’s what came out"


Albumin: 4.3
T Total: 800
SHBG: 32
T Free 186.6
T Bioavailable: 437.4
Hematocrit: 48.8
TSH 2.65 on 100mg levothyroxine
(Continued to dial this in trying to get down to 2.0)

You stated "I felt great! Not only physically but emotionally"

Although lab work is critical.....treating symptoms is what truly matters and your doctor is much more concerned about your numbers.

You felt great overall and he decided to lower your dose because of your T levels which are by no means too high and even than although TT is important to know FT is what truly matters as it is the unbound active fraction of testosterone responsible for the positive benefits.

You need to provide reference ranges for your labs and regarding your FT and e2 you most likely had the wrong tests done as the estradiol sensitive assay (LC/MS-MS) is the correct test and regarding FT you most likely had the direct analog assay done instead of equilibrium dialysis or better yet save yourself the money and use the new TruT calculated free testosterone



Try the public free testosterone calculator at tru-t.org









For the calculated FT method all that is needed is TT/SHBG/albumin and if one has not had albumin tested than 4.3 g/dL (mean) is the default as albumin levels would only have a drastic impact on FT levels when the level of albumin in the blood is abnormally low (significant hypoalbuminemia).

If we take your pre-trt labs TT 261 ng/dL, SHBG 34.5 nmol/L and albumin 4.1 g/dL using the Calculate free testosterone with TruT by FPT:


Than your FT would be a dismal 7.89 ng/dL reference range 16-31 ng/dL

Now on your protocol where you felt great overall you stated:

"When I transitioned to weekly injections we started at 100 mg (.5 ml)a week for the first 3 months. I had my blood work done and here’s what came out"

If we take your TT 800 ng/dL, SHBG 32 nmol/L and albumin 4.3 g/dL

Than as you can see your FT would be a healthy 28.07 ng/dL which is near the top end of the reference range 16-31 ng/dL

*Take home point being your TT/FT levels are where they need to be seeing as you clearly stated "I felt great! Not only physically but emotionally"

So what did your doctor do.....hesitate over lab numbers and lowered your dose!



Now on the new protocol 80 mg/week if we take your TT 523 ng/dL, SHBG 30.6 nmol/L and albumin 4.4 g/dL

Your FT is now 17.23 ng/dL reference range 16-31 ng/dL.....although still in range you are on the lower end

Now as you stated this is the situation you are in "After those results my doctor lowered my dose to 80mg a week (.4 ml)and I’m still better but still somewhat symptomatic. A day and a half before my next injection my energy is really low and I’m extra cranky and if I push hard at the gym it takes twice as long to recover. Emotionally I’m not with it either. I also seem to have a tough time the day after my shot and I’ve communicated with my doctor about that but he doesn’t seem to have a response. Days 2-5.5 are fantastic and I’ve put all of my hard training days around that window of time"


Sure seeing as you are only injecting once weekly T levels are going to be peaking early in the week only to be followed by lower levels later in the week before your next injection.

It would be more sensible to split dose and inject twice weekly as T levels will be more stable throughout the week mind you I would say you should be back on 100 mg/week (50 mg every 3.5 days) as oppose to the 80 mg/week.

As others have stated you need to get a complete thyroid panel.

My advice is the main goal of trt should be to attain a healthy FT level which provides the patient relief/improvement of low t symptoms and overall well being while minimizing potential side effects/negative effects on ones overall health markers (full blood work).

Even though symptom relief is what truly matters as oppose to just numbers do understand that lab work is critical regarding health markers and hormone levels as there is such a thing as too high or too low when it comes to testosterone levels.

 

[divismal10]

Lowering dose can cause withdrawl symptoms. It may be that you just need to wait things out. I had to reduce dosage multiple times and have been through that repeatedly. Things tend to level off for me after 2-3 months when I am full stable on the lower dose. (edit: OK, I see you've been on 80mg for 3 months... time to reassess dosage and frequency).

80/week is a pretty low dose. And TT in the 500's is not ideal, but I don't know how to interpret your free T range*. Some guys do well on that kind of lower dose, But we each have sort of a cut off point on the lower end of dosage. I personally am on 84mg/week dosed EOD (Currently switching to ED). Below that I don't do well.

*(Can you post ranges with your labs? For me, the Free T reference is using a different scale than I am used to seeing.)

Your observation that your feel down a couple days before next injection and the day after points to needing more frequent injections. T cyp is not utilized immediately as it takes time for your body to cleave the T off thecypionate ester, hence the lag after injection, and it is likely you use and clear enough after several days that your levels drop before next injection. Weekly dosage is notorious for causing this roller coaster effect. I personally would not hesitate to go to E3.5 or E3D or even EOD.

I agree Aveed is undesirable. too long acting to be able to make adjustments in dosage. In the US cypionate seems to be the standard, and internationally enanthate probably more common and similar in half life, but if you read this forum, there's also a trend towards proprionate to help mimic diurnal characteristics, though it means EOD or daily shots. If you are on Cypionate or Enanthate I'd stick with it, and work with increasing dose and frequency, though only one change at a time, wait 6-8 weeks, retest and reassess before other changes. I'd choose more frequent injections to start.

I am also wondering if you have ever been assessed for free T3 Free T4 and RT3. Just relying on TSH is not comprehensive Thyroid assessment, and targeting a TSH of 2.5 could be sub par in terms of optimization. The general trend is shooting for less than 2.0, and getting more detailed assessment if higher. Especially with your history of surgery, it may be worth studying this. Start with:

Tired Thyroid
Dr. Westin Childs | Thyroid Supplements, Functional Nutrition & Articles
Dr. Westin Childs (youtube videos)
Stop the Thyroid Madness™ - Hypothyroidism and thyroid mistreatment

Here are the ranges:

T- test Ranges:
Albumin: 3.5 to 5
T Total: 270 to 1070
SHBG: 17.3 to 65.8
T Free 48.2 to 169.6
T Bioavailable: 113.1 to 397

 

[Systemlord]

You told your doctor you "felt great, not only physically but emotionally" and he lowered your dosage, amazing!

There aren't many doctors that understand how to do TRT effectively and to add to it are operating on narrow guidelines put in place by insurance companies. The standard of care for TRT is almost non-existent so doctors are managing numbers on paper without concern for symptoms or lack thereof.

Your doctor likely lowered you dosage do to the insurance companies directing doctors to keep Total T levels <800, this is a problem and often Free T levels are ignored and the most important because it is the free portion of testosterone circulating the your blood.

What you need is a considerable dosage increase to increase Free T to high normal your doctor may be unwilling to do so. You may need two T injections per week to maintain steady levels or else you'll feel low at the end of the week. You may need to seek private care for your TRT and find a doctor that bases his decisions on symptom relief and not trying to manage numbers on a piece of paper.

 

[divismal10]

Thanks everyone! With the holiday weekend I haven't been able to respond as quickly as I've wanted to and you've all given me a lot to think about. I just happen to be seeing a new Endocrinologist (the one managing my thyroid moved) today so I'm hoping he will centralize my care and take on both my thyroid issue and my TRT management. (fingers crossed). You've given me some great insights to advocate for and I've jumped in on the readings and the calculations and the understanding of my own data. My current TRT doctor is out of a men's helath clinic where I live and he's brought me to the end zone but I'm hoping this next Dr. can bring me over the goal line. I'm going in prepared and hopeful it'll go my way. (What a sad statement to have to make about my health care).

 

[Deleted member 16042]

I'm going in prepared and hopeful it'll go my way. (What a sad statement to have to make about my health care).

Sadly, this is the way it is finding appropriate doctors. If it doesn't go your way or the doctor isn't receptive to your input and willing to be a partner/ally, keep shopping.

 

[at15]

@divismal10
in your laboratory results, im assuming these are not nadir levels? what day is this on?