not really stressed
ive used zma, trib, ai, w vaired results
i eat very very healthy, and am 5'11 175lbs 11% bf
sleep is good
the labs also tested for like 30 different infections, and all came back fine
can anyone tell me what the normal test levels are for a 19 year old?
Your levels are normal but for a 85 yr. old man. You need to do more testing to find out what is doing this. Your Cortisol levels were not to high but dam good your morning levels should be the highest in the early morning.
There are a lot of things that can make your levels go down a fatty liver or a low graid infection. Here is a cut & paste of the tests and why that Dr. John dose get them if you find a problem and fix it your levels will go back up.
Phil
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 their experience and expertise. Of note,
there are several other tests which should be included to complete
the true comprehensive Anti-Aging Medicine workup (i.e.
homocysteine, fasting insulin, comprehensive thyroid study, etc.),
as 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)
• DHT
• Estradiol (specify the Extraction Method, or "sensitive" assay for
males)
• LH
• FSH
• Prolactin
• Cortisol
• Thyroid Panel
• CBC
• Comprehensive Metabolic Panel
• Lipid Profile
• PSA (if over 40)
• IGF-1 (if HGH therapy is being considered)
FOLLOW-UP LABS
Two weeks after initiating a transdermal, or five weeks after the
first IM injection:
• Total Testosterone
• Bioavailable Testosterone
• Free Testosterone (if Bioavailable T is still unavailable)
• Estradiol (specify the Extraction Method, or "sensitive" assay for
males)
• DHT (especially if patient is using a transdermal delivery system)
• FSH (3rd Generation—ultrasensitive assay this time)
• CBC
• Comprehensive Metabolic Panel
• Lipid Profile
• PSA (for more senior patients)
• IGF-1 (if GH Therapy has been initiated already)
INDIVIDUAL ASSAYS EXPLAINED
TOTAL TESTOSTERONE
This is the assay your patients will most focus on. It's also the
one physicians who do not understand TRT will use to 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), in favor of:
BIOAVAILABLE TESTOSTERONE
Where we actually 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
approximates the sum of the Free Testosterone plus that which is
loosely bound to carrier proteins, 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 well correlated.
DHT
This assay is especially important 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
indicate cause for ED symptoms.
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. Next,
elevated estrogen can, in and of itself, explain hypogonadal
symptoms. If E is elevated, controlling serum concentrations
(usually with an aromatase inhibitor, which prevents conversion of T
into E) may suffice in clearing the symptoms of hypogonadism. And
finally, rechecking it 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 the testosterone supplementation.
I don't waste time and money drawing estrone and estriol. E2 is the
player of interest here. Unless you specify a `sensitive' assay for
male patients, the lab will run the Rapid Estradiol for fertility
studies in females, which is useless for our purpose here. Quest
Diagnostics calls this their Estradiol by Extraction Method.
Some practitioners believe that it is only the T/E ratio which is
significant, and therefore, as long as E "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 prostate and colon
cancer.
LH
As everyone knows, it is LH which stimulates the Leydig cells of the
testes to produce testosterone. A caveat, however: LH has a half-
life of only about 30 minutes. When you combine this fact with the
absolute pulsatile nature of its pituitary release, care must be
taken to not place too much weight upon a single draw. A luxury
would be to acquire serial draws, say, twenty minutes apart.
However, such would be both inconvenient and probably prohibitively
expensive for the patient. The most important reason to assay the
gonadotrophins is to differentiate between primary and secondary
(hypogonadotrophic) hypogonadism.
FSH
The eight hour half-life of this hormone makes it a better marker
for gonadotrophin production. It is also 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.
Of note, I run FSH (but not LH) on the follow-up labs, the new third
generation ("sensitive") assay, to determine the magnitude of HPTA
suppression secondary to androgen therapy. It also provides valuable
information for those patients undergoing TRT who are interested in
the state of their fertility.
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 an MRI of the sella turcica.
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 (hypogonadotrophic)
hypogonadism. I try controlling elevated cortisol with
Phosphatidylserine, 300mg QD, with good results. It is just as
important to watch for depressed cortisol levels, as well. The assay
of choice for that condition is a 24-hour urine.
THYROID PANEL
I have, for my own convenience, omitted the specifics of the
obligatory thyroid function panel you certainly will want to run.
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 a cause for the fatigue which brought the
patient into your office. You also want to establish baseline H&H,
for those rare cases where polycythemia becomes a problem (and we
are reminded smokers 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 a 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
plenty of water while fasting for the test).
Lipid Panel
This is drawn to provide your bragging rights when you drop the CHOL
30 points, 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 would then be choosing to damage the health and
well-being of the patient.
HDL does frequently drop a bit, but that is believed to be due to
increased REVERSE cholesterol transport; so much of the plaque is,
after being scavenged from the lining of the CV system by HDL, now
being chewed up by the liver. 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.
PSA
For all patients over 40. Even though prostate CA is rare in men
under the age of fifty, we don't want it happening on our watch, do
we? At this time, rises in PSA above 0.75 are a contraindication to
TRT (until follow-up by a Urologist). You may find that, at the
initiation of TRT in older men, when serum androgen levels are
accelerating, PSA may, too. This is especially true when transdermal
delivery systems are employed, because they more greatly elevate
DHT. Once T levels have stabilized, PSA drops back down to roughly
baseline. You won't really see gross elevations in PSA secondary to
TRT administration in younger patients. 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 from testosterone supplementation, and vice
versa. Let's grab a baseline now, before that happens.
THINGS TO LOOK OUT FOR:
CO-MORBIDITIES. Currently, only breast and active prostate cancer
are absolute contraindications for TRT. Patients with serious
cardiac, hepatic or renal disease must be monitored carefully due to
possible edema secondary to sodium retention. Also, TRT may
potentiate sleep apnea in some chronic pulmonary disease patients,
although studies have also shown it can actually ameliorate the
symptoms of sleep apnea.
DRUG INTERACTIONS. TRT decreases insulin or oral diabetic medication
requirements in diabetic patients. It also increases clearance of
propranolol, and decreases clearance of oxyphenbutazone in those
receiving such medications. TRT may increase coagulation times as
well.
