urologist or endocrinologist for HRT?

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    urologist or endocrinologist for HRT?


    In a perfect world I would have the money to go see Matrix and his chosen doctors. This is not a perfect world and I am broke, and thus limited to in network insurance covered practitioners only. All praise HMO bull****.

    anyway on to the important stuff...

    ~20 yrs bilateral varicocele, grade 2 and grade 3.

    ~1 yr ago reduced sex drive, low mental energy and finally taking note that body composition does not change with diet and exercise, despite years in the gym and trying various dietary regimens.

    total testosterone 318 total e2 19 before varicolcelectomy , post surgery tt 309, e2 10 , both tests on the 249-836 scale ng/dL
    surgery was in april. june did 3 weeks of clomid, waited 2 weeks, tested at 523 tt e2 30 (actually felt pretty good for about 2-3 weeks here). all three tests i had bottom 20% fsh and lh.

    went in for annual physical this week, mental fatigue as bad as ever, lifts at the gym going backwards, low sex drive, and short term memory as bad as when i smoked weed 20 years ago. the doctor was not willing to test anything beyond total testosterone, he felt that e2 is not important, nor was fsh and lh....but total test comes back at 303 ng/dL on the 348-1197 scale.


    So I am stuck in network with Kelsey Seybold in Houston. I have a choice of the once a week endocrinologist at the clinic, or I can go to the urologist who did my surgery.

    The urologist is a great guy, I trust him and he is more than willing to listen to me and discuss what I bring...as long as I bring my references. He wants the study name and so on so he can go read it if he wants. He has already said he would be willing to do TRT, but my biggest concern is he admits he does not follow a lot of current research on TRT since he doesn't specialize in it. With him I would think that I have a good chance of working together to find the right solution.

    My other option is the endocrinologist who is at the clinic once a week. He actually has stuff published, The Relationships Between Testosterone, Body Composition, and Insulin Resistance

    Its a study of a woman though with a lot of issues.

    Everything I have read shows him being a diabetes/metabolism specialist, he has 20 years or so since graduation. I know nothing about the guy at all, and I am leery if he would work with me or just tell me how it will be.


    What would you guys do?

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    personally i just went with the urologist. easier to see, convenient, and he didn't mind self injections
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    I didnt know a urologist could prescribe TRT...
    "The only good is knowledge and the only evil is ignorance." - Socrates
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    Sorry to hear you are a victim of the system. I may know a guy in Austin texas that may possible take your insurance. Let me check on it.
    I am not a medical Dr, please keep in mind that this answer is for information purposes only, and is not intended to diagnose, treat or replace sound medical advice from your physician or health care provider.
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    Quote Originally Posted by The Matrix View Post
    Sorry to hear you are a victim of the system. I may know a guy in Austin texas that may possible take your insurance. Let me check on it.
    I am 100% positive he cannot. I am a City of Houston employee and on an insurance plan that only allows me to see practitioners through Kelsey Seybold Clinics in Houston. If I was to be able to see doctors outside of that network I would need to be on an insurance plan that costs 3 times as much. If I was single I would do it, but with a wife and child I have to prioritize differently...I am hopeful though that once my wife returns to work and I am possibly promoted in 2013 I will be able to afford out of pocket, and work with you and the doc in Austin. I really like your approach and your methodology far better than any other I have heard about.
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    Quote Originally Posted by v4lu3s View Post
    I am 100% positive he cannot. I am a City of Houston employee and on an insurance plan that only allows me to see practitioners through Kelsey Seybold Clinics in Houston. If I was to be able to see doctors outside of that network I would need to be on an insurance plan that costs 3 times as much. If I was single I would do it, but with a wife and child I have to prioritize differently...I am hopeful though that once my wife returns to work and I am possibly promoted in 2013 I will be able to afford out of pocket, and work with you and the doc in Austin. I really like your approach and your methodology far better than any other I have heard about.
    I do not have any contacts in houston who would take an HMO. For the complexity of the cases, Dr's will turn HMO away because it is not worth there time to deal with. Sorry but this is the truth when dealing with these types of issues. IF you could find an open minded dr then it would be more feasible to work together. You are not the only one this has happen to unfortunately. As people are starting to see HRT is just a very small piece of the puzzle which has been over looked for so long. As volume picks up then I will make adjustments. I do not mind working individually with people, but it makes it so much easier when there is an Medical professional on board because it saves alot of time and hassle for every one.
    I am not a medical Dr, please keep in mind that this answer is for information purposes only, and is not intended to diagnose, treat or replace sound medical advice from your physician or health care provider.
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    I understand. I did not want to take this plan, but as a municipal employee the current trend is to **** us for pay and benefits. With a family to provide for it makes it worse. What really pisses me off is that HMOs are not more cost effective in reality. They look and sound good to accountants and shareholders, but often lose focus on care and focus on profit.

    I already know more than my pcp, he had no clue that total testosterone alone is not very useful. I am hopeful that the next doc is better.

    I also just learned the urologist is out of the question, he was never in network, due to the surgery I was allowed to see him for 90 days after the changeover. So I will see a Dr. Jeffery Rochen in 3 weeks, and will bring in 3 lab results and some history...and I will be ready to argue with evidence on hand to at least avoid pellets or gels/creams. I would actually prefer the topicals, but I often sweat all day at work, and may have to sweat heavily at work at any time during 24 hr shifts. I know the endo is not likely to address causes, and will focus only on test numbers most likely, but if he will welcome my input and participation I believe this could work for a while....
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    I found exactly what EasyEJL said; urologist is more liberal and apt to push limits. An Endo will test you to death to keep you at the lowest possible limits.
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    ^ I agree. And also with EJL: stick with the urologist. You have a longer relationship with him and clearly more comfortable with the approach. He knows you and your condition better. The endo may be specialized towards that but they really dont wanna push things, too watered down ya know?
    By believing passionately in something that still does not exist, we create it. The nonexistent is whatever we have not sufficiently desired.
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    well right now it looks like I am stuck with the endo. The urologist was covered under my last insurance (it changed may1 at work) and i was allowed to see him for 90 days after the surgery, once that time was up they were refusing to pay for him. the PCP i saw left notes on my charts that i was to see the endocrinologist, so i figure i better give him a chanec first since every doctor i am allowed to see is in one system of clinics so my records are open to every doctor in the system.

    My goal in the first appointment is to see if the guy is going to work with me, or just tell me what to do. If he is just going to tell me what to do i walk out and make an appointment with some other doctor in the system.
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    Dr had no clue on how to proper adminsiter clomid. If it was possible administered right you would not have dropped levels. I have seen this scenerio many times and just need proper alteration and the person was fine. Being on clomid is alot better then being on HRT. You caused down regulation to yout LH making it not respond to clomid. I see this all the times from DR's I have dealt with because they are all old school and not up to date on latest information
    I am not a medical Dr, please keep in mind that this answer is for information purposes only, and is not intended to diagnose, treat or replace sound medical advice from your physician or health care provider.
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    18 days at 25 mg should not cause down regulation should it?

    test 1 pre surgery tt 319, LH 3.6 mIU/mL(1.7-8.6) FSH 3.7(1.5-12.4)
    test 2 post surgery tt 309 lh 2.4 fsh 3.2
    test 3 post clomiphene tt 523 lh 3.2 fsh 3.5

    Before and after the clomiphene I see LH levels that are no better than the bottom 30% of the range and as bad as in the bottom 15% of the range. Averages of the LH tests are at 3.067 mIU/mL and the FSH averaged 3.467 mIU/mL.

    To me it seems the feedback loop is just weak on all sides. I am not smart enough to figure out where in the loop the failure is occurring, I can only guess...if I had high LH and FSH I would point squarely at my balls. but with the low LH and FSH, and the fact that my testosterone levels increased 170% 2 weeks after administration of the clomiphene I lean towards either inadequate pituitary function or stimulation. The fact that testosterone DID increase indicates to me that stimulating the pituitary makes a difference, and the feedback loop is broken on the pituitary input side.
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    Quote Originally Posted by v4lu3s View Post
    18 days at 25 mg should not cause down regulation should it?

    test 1 pre surgery tt 319, LH 3.6 mIU/mL(1.7-8.6) FSH 3.7(1.5-12.4)
    test 2 post surgery tt 309 lh 2.4 fsh 3.2
    test 3 post clomiphene tt 523 lh 3.2 fsh 3.5

    Before and after the clomiphene I see LH levels that are no better than the bottom 30% of the range and as bad as in the bottom 15% of the range. Averages of the LH tests are at 3.067 mIU/mL and the FSH averaged 3.467 mIU/mL.

    To me it seems the feedback loop is just weak on all sides. I am not smart enough to figure out where in the loop the failure is occurring, I can only guess...if I had high LH and FSH I would point squarely at my balls. but with the low LH and FSH, and the fact that my testosterone levels increased 170% 2 weeks after administration of the clomiphene I lean towards either inadequate pituitary function or stimulation. The fact that testosterone DID increase indicates to me that stimulating the pituitary makes a difference, and the feedback loop is broken on the pituitary input side.
    HAd a person at 25 mgs ED first month held at 600 3 months later dropped to 320. Been on clomid now for over a year at 12.5 mgs m,w,f at 700-800 like clock work. He also had all the bells and whistles properly back filled to provide the optimum hormonal response. Given the hormone is one thing provided the environment for it work to its capacity is a whole other ball game only a few dr's do.
    I am not a medical Dr, please keep in mind that this answer is for information purposes only, and is not intended to diagnose, treat or replace sound medical advice from your physician or health care provider.
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    I understand that clomiphene citrate can lower igf-1 levels. If that is the case it seems that long term use could cause another cascade of issues. In addition to that there is no long term research on using clomiphene in males, only anecdotal evidence, and that really concerns me about being a lab experiment.

    I also am fairly confident that aside from side effect concerns, clomid is not covered by my insurance (not even for labelled use by women), so it would be out of pocket without doctor support.
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    Quote Originally Posted by v4lu3s View Post
    I understand that clomiphene citrate can lower igf-1 levels. If that is the case it seems that long term use could cause another cascade of issues. In addition to that there is no long term research on using clomiphene in males, only anecdotal evidence, and that really concerns me about being a lab experiment.

    I also am fairly confident that aside from side effect concerns, clomid is not covered by my insurance (not even for labelled use by women), so it would be out of pocket without doctor support.
    Clomid is generic and very cheap drug. Properly dosed less then one pill per week.
    I am not a medical Dr, please keep in mind that this answer is for information purposes only, and is not intended to diagnose, treat or replace sound medical advice from your physician or health care provider.
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    Just finished with the endo...overall impression is more positive than negative. He drew more blood, a base metabolic panel, psa, prolactin, free test, t3 and free t4. Better than I expected but not as much as I hoped. He said if prolactin was high I would have a pituitary mri, and see about lowering prolactin levels, if its not high he suggested trt. He said gels/creams are equal in that they have advantages and disadvantage that balance out, but for my career the shots would be better. He is not opposed to self injection at least...I wish overall he cold be even more thorough, but at least he seems willing to talk with me and within the constraints of a managed system he is doing more than I expected.
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    Quote Originally Posted by v4lu3s View Post
    I understand that clomiphene citrate can lower igf-1 levels. If that is the case it seems that long term use could cause another cascade of issues. In addition to that there is no long term research on using clomiphene in males, only anecdotal evidence, and that really concerns me about being a lab experiment.

    I also am fairly confident that aside from side effect concerns, clomid is not covered by my insurance (not even for labelled use by women), so it would be out of pocket without doctor support.
    Clomid generic $27 for 10. I do not think its really going to bust the bank...Keeping with in forum rule..Where there is will there is a way. People read too much from people who are uneducated and mis informed, just because you have lower Igf-1 levels does not mean low GH out put. I can not tell you how many people have low normal igf-1 and have excellent GH out put over 24 hours via urine. As T goes up you will be able to utilize GH much more effectively. Look at the GH and T deficiency symptoms they are identical !!
    I am not a medical Dr, please keep in mind that this answer is for information purposes only, and is not intended to diagnose, treat or replace sound medical advice from your physician or health care provider.
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    As much as the Clomid alternative sounds great, it is not an option without medical oversight. That limits me a lot as I cannot in any way afford the cash outlay needed to find a doctor willing to go that route. As it is an extra $20 out of my monthly budget puts me close to the edge. I would love to take on a 3rd job to pay for more, but honestly the 70-120 hours a week I am at work already is enough load. Perhaps in the future i will have some luck with the current medical care I have access to, or will have the ability to pay cash for my care, but not right now.
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    Quote Originally Posted by v4lu3s View Post
    As much as the Clomid alternative sounds great, it is not an option without medical oversight. That limits me a lot as I cannot in any way afford the cash outlay needed to find a doctor willing to go that route. As it is an extra $20 out of my monthly budget puts me close to the edge. I would love to take on a 3rd job to pay for more, but honestly the 70-120 hours a week I am at work already is enough load. Perhaps in the future i will have some luck with the current medical care I have access to, or will have the ability to pay cash for my care, but not right now.
    With out health there is no wealth, you do what you have to do to get by I understand...
    I am not a medical Dr, please keep in mind that this answer is for information purposes only, and is not intended to diagnose, treat or replace sound medical advice from your physician or health care provider.
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    Quote Originally Posted by v4lu3s View Post
    Just finished with the endo...overall impression is more positive than negative. He drew more blood, a base metabolic panel, psa, prolactin, free test, t3 and free t4. Better than I expected but not as much as I hoped. He said if prolactin was high I would have a pituitary mri, and see about lowering prolactin levels, if its not high he suggested trt. He said gels/creams are equal in that they have advantages and disadvantage that balance out, but for my career the shots would be better. He is not opposed to self injection at least...I wish overall he cold be even more thorough, but at least he seems willing to talk with me and within the constraints of a managed system he is doing more than I expected.
    This sounds a lot like what my endo did. My prolactin did come back in the "normal range" but it was high normal. I am having an mri next week. He did start me on injections yesterday, 200mg bi weekly, however I'm going to split that up into 2 weekly shots of 50mg. After speaking to him and reading some of Matrix's advice on what I should be checking, he seems willing to take the time to dial me in and continue to check bloodwork. My endo uses the gel himself and suggested it for me but he was receptive when I told him i didn't want o go that route. Good luck.
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    Matrix, more than anything I want to go a different route, but financially no other route is viable. $27 may not break the bank but many months it can cause me to dip into the bank account that I have for emergencies(plus it helps that i have secondary insurance that will reimburse for the $200 or so a year it would take for average TRT). I have to sacrifice my health to a degree to take care of my family, and I will always make that choice that way. Hopefully this situation is temporary as future earnings will be large enough to seek other options. It doesn't help that it looks as if my career choice enhances my risk of cancer far greater than the normal populace and on top of that immuno-suppression is normal in my field due to stress, ptsd and altered sleep patterns.

    BTW I referred a guy to you from the gym, hopefully he will be able to get with you as he just started TRT and is very against it, but wants to feel normal again very badly.


    Jarhead...it almost sounds like you have a similar endo. I should know my labs today or tomorrow. Of course my visit with him was barely 20 minutes, but I will see how things pan out as we go. We did discuss tracking estrogen, and he said he does that in some patients, but typically unless they have symptoms that indicate a need for more testing he won't just dive in like that, which I can understand to a degree since he has constraints placed on him by accountants and time. We did discuss gel, but due to my career he agreed it was not suitable, though honestly I feel it may be a better choice as far as mimicking the natural ebb and flow of hormones.
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    got some numbers back...

    glucose 88 65-99 mg/dL
    bun 19 6-20
    creatinine 0.88 0.76-1.27
    bun/creatinine 22 8-19 (see what happens when you workout out the day before and that day?)
    sodium 142 134-144 mmol/L
    potassium 3.7 3.5-5.2
    chloride 102 97-108
    calcium 9.0 8.7-10.2 mg/dL

    prolactin 8.8 4.0-15.2 ng/mL
    PSA 0.3 0.0-4.0 pg/mL
    free test 6.8 8.7-25.1 pg/mL
    TSH 2.140 0.45-4.5 uIU/mL
    t4 free 1.21 0.82-1.77 ng/dL

    note at the bottom reads all looks fine other than low test, make appointment with injection nurse for every 2 weeks then see me in 3 months, no mri needed.

    looks like the standard path is injections every 2 weeks by a nurse in the clinic at $60 office copay plus cost of medications...i already called and asked about self administration since that will cost for less than the $1600 a year plus cost of meds...
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    Quote Originally Posted by v4lu3s View Post
    looks like the standard path is injections every 2 weeks by a nurse in the clinic at $60 office copay plus cost of medications...i already called and asked about self administration since that will cost for less than the $1600 a year plus cost of meds...
    $25 every 90 days for me for 13 1ml vials, so just about $100 a year
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    I wish I had that kind of cost. I convinced them that I could not afford office visits (I can't even come close). If the mail order pharmacy allows it I can get close to $100 year but I suspect they won't dispense that much at once.
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    Quote Originally Posted by v4lu3s View Post
    I wish I had that kind of cost. I convinced them that I could not afford office visits (I can't even come close). If the mail order pharmacy allows it I can get close to $100 year but I suspect they won't dispense that much at once.
    Bend over bro and ask them how far..You got just got screwed !!
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    Appointment is set for lesson in self injection, prescription for multi use 10ml vial of test enanthate 200mg/ml is in the mail, and I will pick up syringes at the pharmacy this week. All that is left is seeing how much the mail order pharmacy will dispense/charge compared to the pharmacy.
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    Quote Originally Posted by v4lu3s View Post
    Appointment is set for lesson in self injection, prescription for multi use 10ml vial of test enanthate 200mg/ml is in the mail, and I will pick up syringes at the pharmacy this week. All that is left is seeing how much the mail order pharmacy will dispense/charge compared to the pharmacy.
    figure about $150-200 per bottle if its going through some compounding pharmacy.
    Costcos $69..
    I am not a medical Dr, please keep in mind that this answer is for information purposes only, and is not intended to diagnose, treat or replace sound medical advice from your physician or health care provider.
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    $88.50 at the local pharmacy for 10ml. insurance covers nothing.
    $33.33 per 10ml vial at the mail order pharmacy through Cigna...but they require a 90 day supply be ordered. so i am hoping that a single vial being 20 weeks will work out for that.

    costco near me lists at 142.28 a vial
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    looks like the Cigna pharmacy is a crock of ****. They told me they would ONLY release 30 days of medication at a time, meaning they were not going to fill the prescription as written. they then quoted me an insurance assisted price of $87.85 per 10ml vial. I asked for cash price and they said $67.21. GO figure, not only are insurance companies a bunch of *******s they are also trying to make money by charging more than what a drug is worth!
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    Quote Originally Posted by v4lu3s View Post
    looks like the Cigna pharmacy is a crock of ****. They told me they would ONLY release 30 days of medication at a time, meaning they were not going to fill the prescription as written. they then quoted me an insurance assisted price of $87.85 per 10ml vial. I asked for cash price and they said $67.21. GO figure, not only are insurance companies a bunch of *******s they are also trying to make money by charging more than what a drug is worth!
    The insurance nows are giving 1 ml and charging 33 bucks per bottle. So they are turning a $85 into $330. Anything to make a quick buck. If you have escript or express script now certain pharmacies are not excepting it.
    I am not a medical Dr, please keep in mind that this answer is for information purposes only, and is not intended to diagnose, treat or replace sound medical advice from your physician or health care provider.
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    Hello brother,

    I also work for HFD and have KelseyCare (Cigna). You and I have just about the same story, only I'm at the initial stage of receiving low testosterone news from my labs. I was just looking over the endocrinologists in the Kelsey system when I ran across this thread. How is Dr. Rochen working out? Did you find a cheaper way to order the meds? This information could save me a lot of time and aggravation.

    PM me if possible.

    Thanks.

    (...and we'll forgo names and other references for anonymity)
  

  
 

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