Quote:
Originally Posted by Mr. Detail  cvictorg,
That was it. One single test. The test name was TESTOSTERONE,TOTAL,MALES and
I was the one that asked the doctor for the blood test. |
From All Things Male
INITIAL LABWORK
Following a good Medical History, which laboratory assays should be run as part of your initial hypogonadism workup? Following is my list, but certainly other specialists in this area run expanded or attenuated panels, per individual clinical experience and expertise. Of note, additional tests which should be included to complete the true comprehensive Anti-Aging Medicine workup (i.e. inflammatory markers, insulin, good and true comprehensive thyroid study, etc.); this chapter is concerned solely with administering TRT. And as always, the panel is tailored to the individual patient. Here they are:
• Total Testosterone
• Bioavailable Testosterone (AKA “Free and Loosely Bound”)
• Free Testosterone (if Bioavailable T is unavailable)
• SHBG
•
DHT (perhaps)
• Estradiol (specify “sensitive” assay for males)
• LH
• FSH
• Prolactin
• Cortisol
• Thyroid Panel
• CBC
• Comprehensive Metabolic Panel
• Lipid Profile
• PSA (age dependent)
•
IGF-1, IGFBP-3 (if
HGH therapy is being considered)
FOLLOW-UP LABS
Four weeks after initiating or changing dose for transdermal, six weeks for IM injection TRT. The time delay provides for stabilization via HPTA suppression and pharmacokinetics of medication:
• Total Testosterone
• Bioavailable Testosterone
• Free Testosterone (if Bioavailable T is still unavailable)
• Estradiol (specify “sensitive” assay for males)
• LH
• FSH
• CBC
• Comprehensive Metabolic Panel
• Lipid Profile
• PSA (for those over 40 with Family Hx of prostate CA, >45 yo. all others)
•
IGF-1, IGFBP-3 (if
GH Therapy has been initiated already)
INDIVIDUAL ASSAYS EXPLAINED
TOTAL TESTOSTERONE
This is the assay your patients will most focus on, as will clinicians unpracticed in the art. Physicians who do not understand sex hormones will deny patients the testosterone supplementation they want--and need!--when Total T is at low-normal levels. Total T is important for titration of dosing, but its relevance is reduced in older men, by virtue of their increased serum concentrations of SHBG (and therefore lowered Bioavailable Testosterone), in favor of:
BIOAVAILABLE TESTOSTERONE
Where we get the “bang” for the hormonal buck, so to speak. This is the actual amount the body has available for use, as the concentration of hormone available within the capillary beds before the androgen receptor approximates the sum of the Free Testosterone plus that which is loosely bound to other carrier proteins in the blood, primarily albumin. If Bio T is not readily available, Free T may be a second choice substitute, as Bio T and Free T serum concentrations are usually well correlated. Bioavailable Testosterone is the gold standard for serum androgen evaluation.
DHT
This assay may be of value to draw, up-front and at follow-up, if a transdermal testosterone delivery system is preferred by the patient. I’ll explain why later.
DHT level may also help explain cause for ED symptoms. Experience drawing serum
DHT, compared to urinary
DHT and intracellular 5-AR metabolites, may show compartmentalization of same in difficult cases.
Instances where patient subjective report is very positive in the face of stable (or even reduced) Total T levels, status post initiation of
TRT and compared to baseline, may be explained by increases in DHT; we must keep in mind it is three times more androgenic than testosterone. Of note, I do not believe placebo effect exists for
TRT.
I do not consider
DHT an “evil” hormone;
finasteride and drugs of that class are to be avoided.
ESTRADIOL
There are several reasons why this assay is VERY important, and should not be ignored in ANY hypogonadism work-up (or subsequent regimen). First, you definitely need to draw a baseline. There are cases where T is adequate, yet E elevated or merely disproportionate. Elevated estrogen (in absolute value or proportion) can, in and of itself, explain hypogonadal symptomology. If E is elevated, controlling serum concentrations (usually with an aromatase inhibitor, which prevents conversion of T into E; or withdrawal of estrogen mimics such as soy or flax seed) may, in very rare cases, suffice in clearing the symptoms of hypogonadism. And finally, rechecking estradiol after beginning the initial dose of testosterone will give the astute physician valuable information as to how the patient’s individual hormonal system functions, as well as making sure estrogen does not elevate inappropriately secondary to testosterone supplementation. This provides a very rough form of receptor mapping, if you will.
E2 is the major player of interest in foundational TRT. Evaluation of the other members of the hormonal class “estrogen” (E1, E3, as well as other estrogen metabolites), via 24 hour urine panel, may help explain gynocomastia or water retention in the face of acceptable E2, indicate relative cancer risk, etc.
Unless you specify a ‘sensitive’ assay for your male patients, the lab will default to the standard estradiol designed for females, which is useless for our purposes here. I have run the standard assay and the sensitive assay concurrently on a number of my patients, and the two results may be as night and day. However, patient symptomology is best described by the sensitive assay. The reason is the bell curve from which the
test is designed sits well within the “normal” range for females; therefore the hormonal concentration range appropriate to adult males falls on a very flat slope of said bell curve. The same holds for Total Estrogens. Laboratory testing is best when small changes in concentrations result in large changes in subsequent reported result.
Some practitioners believe it is only the T/E ratio which is significant, and therefore, as long as E only “appropriately” rises with elevations in T, all is well. However, the absolute concentration of E is of concern, too, especially in light of new information pointing to elevated estrogen as cause, or adjunctively encouraging, several serious disease processes, including numerous cancers, as well as significant potential for induction of sexual dysfunction (no matter the accompanying androgen load). Therefore T/E ratio is only useful for describing the cause of symptoms, not as a treatment goal.
Estrogen is absolutely necessary for our physical health. Of note, same also provides the emotional component of a mature gentleman’s sexual being. This is why estrogens must be evaluated and, when necessary, controlled. The “sweet spot” E concentration depends upon SHBG. Rule of thumb is mid-range for both.
LH
As everyone knows, it is Luteinizing Hormone (LH) which stimulates the Leydig cells of the testes to produce testosterone. A caveat, however: LH has a half-life of only minutes. When you combine this fact with the absolute pulsatile nature of its pituitary release, care must be taken to avoid placing too much weight upon a single draw. A luxury would be to acquire serial draws. However, such would be both inconvenient and probably prohibitively expensive for the patient. Therefore a single LH assay serves only as a proven example of just how much LH the pituitary can produce. The most important reason to assay the gonadotrophins is to differentiate between primary and secondary (hypogonadotropic) hypogonadism. This is especially true when a HPTA-recovery protocol, to “restart” LH production, is desired (the details of which remain beyond the scope of this document) secondary to anabolic steroid or prohormones use, as well as other hormone disrupting influences.
Rapidly attenuated LH can serve as proof a transdermal testosterone preparation is indeed penetrating. This can be quite valuable information in confusing cases, especially when the preferred 24 hour urine panels are not available.
FSH
The hours long half-life and less pulsatile production of Follicle Stimulating Hormone (FSH) makes it a better marker for gonadotropin production, at times, when evaluating HPTA activity. It is less an acute phase reactant to varying serum androgen and estrogen levels than LH. Greatly elevated FSH levels could signal a gonadotrophin-secreting pituitary tumor.
FSH also provides valuable information for those patients undergoing
TRT who are interested in the state of their fertility. Of note, while there are never guarantees where fertility medicine is concerned, I do not believe appropriate
TRT will make a fertile man infertile. Constitutive expression is maintained.
PROLACTIN
A very important hormone, and must not be overlooked on initial work-up. Approaching five percent of hypogonadotrophic hypogonadism is associated with hyperprolactinemia, due to inhibition of hypothalamic release of LHRH. Its serum concentration must be maintained within physiological range (meaning neither too high NOR too low). Greatly elevated hyperprolactinemia, or hyperprolactinemia plus a Total Testosterone less than 150ng/dL, equals a trip to an Endocrinologist for a pituitary MRI.
CORTISOL
True Anti-Aging medicine must be well-familiarized with the ins and outs of this hormone, the only one our bodies cannot live without. Elevated levels can cause secondary (hypogonadotropic) hypogonadism. I try controlling elevated cortisol with Phosphatidylserine, 300mg QD, with good results. It is just as important to watch for depressed or inappropriate cortisol production, AKA Adrenal Fatigue, as well. The assay of choice for that condition is a 24-hour urine, via summation of cortisone and adrenal metabolite production.
THYROID PANEL
I have, for my own convenience, omitted the specifics of the obligatory thyroid function panel you certainly will want to run. Besides the fact thyroid is intimately associated with every function of the body, hormonal and otherwise, (even subclinical) hypothyroidism mimics hypogonadism in several of its effects.
CBC
This is just good medicine. Ruling out anemia is important, of course, as it may be cause for the fatigue which drove the patient into your office. You also want to establish baseline H/H, for the small portion of cases where polycythemia becomes a problem (and we are reminded smokers and sleep apnea sufferers are at increased risk for polycythemia). Above 18.0/55.0
TRT is withheld, and therapeutic phlebotomy recommended.
CMP
Again, just good medicine. Baseline for sodium (which may elevate initially secondary to androgen supplementation) is important. We also want to see LFT’s, as elevations in same secondary to androgen supplementation are listed as a possible side effect in the product literature--although I have yet to see this actually happen. I like the BUN/creatinine ratio as marker for hormonal hemo-concentration, and also it gives me a hint of how compliant the patient will be (because I always tell them to make sure to drink their normal “plenty of water” while fasting for the test). Of note, many of my patients consume prodigious amounts of protein each day, due to muscle building interests or specialty dieting, and this is remembered while reading BUN concentration.
Lipid Panel
This is drawn to provide your bragging rights when you drop the CHOL significantly, thanks to your own good administration of TRT. You should expect to see lowered TRIG and LDL’s, too. Be advised, this will not happen if you choose to elevate their androgens above the top of “normal” range, i.e. providing what amounts to an anabolic steroid cycle. Of course, this would no longer constitute TRT, as the practitioner is then choosing to damage the health and well-being of the patient.
HDL does frequently drop a bit, is believed due to increased REVERSE cholesterol transport. Androgens also elevate hepatic lipase, and this may have an effect. The important thing to keep in mind is that
TRT inhibits foam cell formation. For these reasons I provide my
TRT patients a free 10-12 point bump in HDL evaluation.
PSA
For all patients over 45, and over 40 if Family History of prostate cancer. Even though prostate CA is rare in men under the age of fifty, we don’t want it happening on our watch. At this time, accelerations in PSA above 0.75 are a contraindication to
TRT (until follow-up by an Urologist). You may find, at the initiation of
TRT in older men, when serum androgen levels are rapidly rising, PSA may, too. This is especially true when transdermal delivery systems are employed, because they more elevate DHT. Once T levels have stabilized PSA drops back down to roughly baseline. New
TRT patients need to be cautioned, and reminded, to abstain from sexual relations prior to the draw, as they may now be enjoying greatly elevated amounts of same.
I get a PSA up front on my over 40 patients, at the one month follow-up in my more senior patients, and every six months after that. DRE (Digital Rectal Exam) is recommended twice per year as well, although the American Academy of Clinical Endocrinologists backs “every six to twelve months” in their 2002 Guidelines for treating hypogonadotrophic patients with TRT.
IGF-1
For those who are considering the addition of
GH to their Anti-Aging regimen. IGF-1 will rise somewhat from testosterone supplementation, and vice versa. Let’s grab a baseline now, before that happens. Current thinking is to also assay IGFBP-3.
Copyright 2009 John Crisler, DO. This article may, in its entirety or in part, be reprinted and republished without permission, provided full credit is given to its author, with copyright notice and
All Things Male - Center for Men's Health clearly displayed as source. Written permission from Dr. Crisler is required for all other uses.
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