Would appreciate some advice on my latest bloods. For the past 6 months or so I’ve been on testosterone replacement therapy and been struggling to dial in a dose that works for me. All in all been feeling awful which I suspect is partly due to my thyroid struggling. I think I had a thyroid issue before starting my TRT but I feel my thyroid is getting worse due to the addition of TRT hormones putting a strain on the system.
I feel one of the reasons I’m not having great success with TRT is the underlying thyroid issue... I think I need to address the thyroid problem otherwise I’m not going to see any benefits with my TRT.
If you look at the thyroid bloods over time to me it looks like there’s definitely an issue with FT4>FT3 conversion.
I might be wrong but the way I see it is that my TSH is slowly increasing telling me to increase FT4 which it is doing. But even with higher FT4, FT3 is slowly dropping. And with a FT3 ratio being on the low side would point towards FT4>FT3 conversion issues.
* Medichecks explanation of low FT3 Ratio - “The rT3 ratio measures the level of reverse T3 in relation to free T3 in your blood. A low ratio indicates that the balance is favouring rT3, potentially leaving you with insufficient levels of active thyroid hormones in your cells. Some practitioners believe that a low ratio will lead to symptoms of hypothyroidism even when thyroid hormones are at normal levels.“
————-
Aug 2016
TSH: = 2.48 mU/L
FT3: = 5.02 pmol/L
FT4: = 16.49 pmol/L
Dec 2017
TSH: = 3.07 mU/L
FT4: = 16.50 pmol/L
SE Thyroid Peroxidase Ab Con: = 9.4U/ml (Ref Range: <35.00U/ml)
Jan 2018
TSH: = 4.20 mU/L
FT3: = 5.91 pmol/L
FT4: = 13.50 pmol/L
RT3: = 15.00ng/dl (Ref Range: 10.00-24.00 ng/dl)
July 2018
TSH: = 2.37 mU/L
FT3: = 5.45 pmol/L
FT4: = 15.80 pmol/L
Aug 2018
TSH: = 3.43 mU/L
FT3: = 4.95 pmol/L
FT4: = 17.60 pmol/L
————-
Jan 2018 =
SE Thyroid Peroxidase Ab Con:
Dec 2017 = 9.4U/ml (Ref Range: <35.00U/ml)
Ref Ranges:
TSH: (Ref Range: 0.27-4.20 mU/L)
FT3: (Ref Range: 3.10-6.80 pmol/L)
FT4: (Ref Range: 12.00-22.00 pmol/L)
RT3: (Ref Range: 10.00-24.00 ng/dl)
* The elevated TSH in Jan 2018 was because I did iodine replenishment in December 2017. That why TSH was elevated and FT4 suppressed in the Jan 2018 blood test results.
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I was wondering if I might benefit from a trial of thyroid meds? I will be self medicating most likely and have access to both T3 and T4.
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Flatdanny
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Oh, that's a horrible way to type out results, I'm afraid. We need to see the three together, at any given date. So, when you separate them into TSH, FT4 and FT3 like that, we have to search through and try and remember what goes with what date.
Let's take Jan 2018, for example:
TSH 4.2
FT4 13.50 pmol/L (12.00-22.00)
FT3 5.91 pmol/L (3.10-6.80)
Now, I have no idea what 'iodine replenishment' is, nor why anyone would want to do it, but your TSH is raised, there, because your FT4 is very low, bottom of the range. But, your FT3 is well over mid-range. So, your FT3 is fine, and absolutely no sign of a conversion problem.
August 2018
TSH 3.48
FT4 17.6
FT3 4.95
There, your TSH is saying you're hypo, but your FT4 and FT3 are mid-range. Which is euthyroid. So, whilst your TSH is being peculiar, your Frees are usually ok, and don't show a conversion problem, or hypothyroidism.
That is not to say that they are good for you. But, a doctor would look at them and say, go away and leave me in peace! It could be that you have hormone resistance, or just need a higher level for whatever reason. But, I think any thyroid hormone replacement will have to be on a self-treatment basis.
So, is that what you want to do? If so, I would suggest that you start on levo only, with 50 mcg levo for six weeks and then retest. Remember, this is not going to be a quick fix, it's going to take time. Then, after six weeks, you see how you feel and see what difference the 50 mcg levo has made to your levels, and increase by 25 mcg if necessary.
During those six weeks, I would advise you get your vit D, vit B12, folate and ferritin tested. If they are low, they could be causing problems.
Have you had your cholesterol tested? Are you taking statins or anything else apart from the testosterone?
Thanks for the reply, really appreciate it. I’m gonna edit my post and make it easier to read . Apologies for the way I’ve done it... I actually have really nice plotted graphs of each test over time which helps interpret the results but I cannot upload more than one picture her for some reason which is annoying.
I have regular bloods done to monitor my TRT so will dig out my latest Cholesterol and vits results and update post.
I’m not on any statins and am taking 10mg of tamoxifen daily along with my testosterone.
The reason I mentioned I was taking iodine at that point in time is because it raises TSH and suppresses FT4. So basically we need to ignore the Jan 2018 results.
I do understand that it’s unlikely most doctors here in the UK will diagnose me with hypothyroidism with these numbers but in many other countries that would not be the case. I think taking into account how people feel rather than focusing on lab ranges is essential in diagnosing thyroid issues. Anyway I am happy to self medicate.
Because we need to know how well you convert exogenous thyroid hormone. You're ok on home-produced stuff, but it might be a different story with levo. Plus, there are so many possibilities for hormone replacement, you've got to start somewhere, and starting with levo will give you information that will guide future choices. Anyway, we need your TSH down to at least one to see clearly how well you convert, and levo will do that. If you start on T3, we'll never know how well you convert.
Yes, I'm fully aware that in other countries you would be diagnosed with a TSH over 3, but the NHS is a bunch of miserly sadists, who like you to suffer until your TSH goes over 10, before they will diagnose. It's obviously not ideal, but we have to manage with what we've got, not worrying about what we should have.
Why are you taking tamoxifen? Have you had some kind of cancer? Are you sure it doesn't interfere with the absorption of your testosterone? Why were you taking iodine?
And, by the way, the rT3 ratio doesn't point to anything at all. It's pseudo-scientific mumbo-jumbo.
‘Because we need to know how well you convert exogenous thyroid hormone. You're ok on home-produced stuff, but it might be a different story with levo. Plus, there are so many possibilities for hormone replacement, you've got to start somewhere, and starting with levo will give you information that will guide future choices. Anyway, we need your TSH down to at least one to see clearly how well you convert, and levo will do that. If you start on T3, we'll never know how well you convert.”
- Makes sense
“Yes, I'm fully aware that in other countries you would be diagnosed with a TSH over 3, but the NHS is a bunch of miserly sadists, who like you to suffer until your TSH goes over 10, before they will diagnose. It's obviously not ideal, but we have to manage with what we've got, not worrying about what we should have.”
- Totally agree. I’m really not complaining about the NHS. I understand they follow certain guidelines and I accept that. And I’m willing to self medicate if need be.
“Why are you taking tamoxifen? Have you had some kind of cancer? Are you sure it doesn't interfere with the absorption of your testosterone? Why were you taking iodine?“
- No I don’t have cancer. Hope I don't anyhow! I am using it to control Oestrogen and to stop breast tissue grow. I was having some issues in that area. No issues with testosterone absorption from what I understand.
“And, by the way, the rT3 ratio doesn't point to anything at all. It's pseudo-scientific mumbo-jumbo. :)”
Your results are hard to read. Your ft3 is in a very nice place so no issues there as are the ft4 figures.
You do drop down heavily with the ft4 in jan this year but that maybe affected by the iodine.
Your tsh is raised so it looks like you have some issue going on and I wonder if it not the supply of thyroid hormone but it’s uptake.
Many people have good levels of t4 and t3 but feel terrible and it can be down to the t3 not being sucked into the cells correctly and this is usually caused by an imbalance in cortisol and dhea.
Low testosterone can be a side effect of a dysfunctional thyroid / adrenal set up.
What was the testosterone level before treatment ?
A trial of t4 is always worth ago initially but start low and don’t gush things.
Have had vitamin d tested and looked into the cortisol and dhea levels?
What are your waking temps and blood pressure readings. Do you monitor these?
Thanks for your reply and feedback. Ive edited my original post to try and make it easier to read. Also added latest bloods from Medicheck.
“Your tsh is raised so it looks like you have some issue going on and I wonder if it not the supply of thyroid hormone but it’s uptake.
Many people have good levels of t4 and t3 but feel terrible and it can be down to the t3 not being sucked into the cells correctly and this is usually caused by an imbalance in cortisol and dhea.”
- This is what I was thinking too. Possible T3 uptake issue on the cellular level.
“Low testosterone can be a side effect of a dysfunctional thyroid / adrenal set up.”
- Yes this is what I have read.
“What was the testosterone level before treatment ?”
- I have been monitoring levels for a while.
Total T: Ranged from 11-16 nmol/L
Free T: Ranged from 0.357-0.241 nmol/L
E2: <20 pmol/L
LH: 5.8 iu/L
FSH: 8.8 iu/L
“A trial of t4 is always worth ago initially but start low and don’t gush things.”
- I read your bio and see you’ve self medicated and tried a range of different thyroid meds over time. May I ask why T4 is the preferred starting med?
“Have had vitamin d tested and looked into the cortisol and dhea levels?”
- Yes results are posted above in the attached image. I’ve also tested cortisol via bloods which showed a low 8am Free cortisol result on a number of occasions. I was convinced my exhaustion was due to adrenal issues but recently did a four test cortisol saliva test and my levels looked good throughout the day.
“What are your waking temps and blood pressure readings. Do you monitor these?”
- Yes I monitor blood pressure and have also monitored my temps. Blood pressure is always on the low side 120 over 50. With pulse 60-80.
Waking temps were lowish...
Morning = never above 97.3 (Ranged from 97.1-97.3)
Afternoon = never above 98.3 (Ranged from 98.1-98.3)
What is the range for the Total T. Is it 8-29, which is the typical range for NHS hospitals here. A level of 11 - 16 does not warrant testosterone treatment. IS this self treatment or are you being treated by a doc ? Have you been on antidepressant meds ? If so these will tank the testosterone.
- I read your bio and see you’ve self medicated and tried a range of different thyroid meds over time. May I ask why T4 is the preferred starting med?
T4 is the easiest and most successful thyroid med to take. Many people do really well on it. However, a LARGE minority of patients do need a different approach to thyroid replacement and so T3 or NTH is needed. You cant know which patient you are until you have tried the basic T4 first. Why anyone would want to mess around with multi dosing T3 or having to get NTH on the net when all they needed was some T4 is the reason you must always try this first. If it doesn't work out, then you move over to the more complex solutions.
- Yes results are posted above in the attached image. I’ve also tested cortisol via bloods which showed a low 8am Free cortisol result on a number of occasions. I was convinced my exhaustion was due to adrenal issues but recently did a four test cortisol saliva test and my levels looked good throughout the day.
Low morning cortisol does indicate not enough thyroid has been made in the night. The body responds to this by ramping up adrenal performance in the day and so compensates for lower thyroid output. You can then get the issue of too much cortisol in the system and so you don't uptake the T3 as well. Low and high cortisol give the same result. The DHEA needs to be tested as well to see if this is not being depleted. If it is, it is a sign the body is trying too hard to make cortisol and DHEA is sacrificed as part of this process.
Yes I monitor blood pressure and have also monitored my temps. Blood pressure is always on the low side 120 over 50. With pulse 60-80.
These are good figures.
Waking temps were lowish...
Morning = never above 97.3 (Ranged from 97.1-97.3) = 36.1-36.2 C. This is not terrible. Below 36C is not a good sign. I have always been fine even with a 36.2C temp. Ideal is 36.6C on waking according to Broad Barnes, but all these indicators need to be taken as whole and not really looked at individually.
Afternoon = never above 98.3 (Ranged from 98.1-98.3) = Max 36.8C, which is ok.
All your thyroid results look really good (except the TSH readings and when doing the iodine).
A typical healthy person will have Ft4 in the mid range (mid to high teens) and a nice highish FT3 in the 5's. The body has a good supply of T4 and most importantly this is being converted into the important T3.
You have this set up, but you also have the higher TSH. Because you feel not so well, it is worth looking into seeing how some T4 would work out.
BUT i would want to do a bit more digging on lifestyle.
What time do you go to bed and wake up ? Is this a regular thing ?
What age are you and what level of physical activity are you doing ? I am guessing you do a lot of exercise and if so this could be a big reason for your issues.
What is your diet like ? Are you restricting in any way certain foods ?
Any antidepressant usage ?
An FSH of 8.8 is getting up to the top of the range which i think is 12. Any testicle damage in the past ? The FSH is the signal to make more sperm so at the moment you may not be making as much as the body would like. It is a hard one to say exactly and so you would need a sperm test. If you are a big cyclist then this will explain that.
“What is the range for the Total T. Is it 8-29, which is the typical range for NHS hospitals here. A level of 11 - 16 does not warrant testosterone treatment. IS this self treatment or are you being treated by a doc ? Have you been on antidepressant meds ? If so these will tank the testosterone.”
- Ranges vary a little with different labs. 8-31 for total T... Really can’t diognose hypogonadism form just looking at total T. Most docs in the UK are clueless about men’s hormones. I self diognosed my primary hypogonadism and self treated. But I also saw a private specialist who agreed with my diognosis. I now have my prescriptions taken care by my GP. * I take no meds of any kind apart from my Test and Tamoxifen.
T4 is the easiest and most successful thyroid med to take. Many people do really well on it. However, a LARGE minority of patients do need a different approach to thyroid replacement and so T3 or NTH is needed. You cant know which patient you are until you have tried the basic T4 first. Why anyone would want to mess around with multi dosing T3 or having to get NTH on the net when all they needed was some T4 is the reason you must always try this first. If it doesn't work out, then you move over to the more complex solutions.
- Okay makes sense, thanks. Got an appointment with my GP tomorrow and will mention to her I’m considering a trial of Levo and see what she says. I read that you are taking your thyroid meds at night before bed. Are you also taking anything throughout the day?
Low morning cortisol does indicate not enough thyroid has been made in the night. The body responds to this by ramping up adrenal performance in the day and so compensates for lower thyroid output. You can then get the issue of too much cortisol in the system and so you don't uptake the T3 as well. Low and high cortisol give the same result. The DHEA needs to be tested as well to see if this is not being depleted. If it is, it is a sign the body is trying too hard to make cortisol and DHEA is sacrificed as part of this process.
- That’s interesting. The reason I thought I had a low cortisol issue was because of how exhausted I felt. Would wake up after 8-10 hours sleep and take a few hours to get going as I was so tired. Then eat breakfast and go for a walk with dog. Half an hour into dog walk I would feel very sleepy. Thought it might be sugar/insulin issue but tests and monitoring of blood sugar was normal. * Last DHEA-S results were 6.39 (range - 0.44-13.40)
What time do you go to bed and wake up ? Is this a regular thing ?
- I always get to be early and try to be in bed before 10pm. (I’m tired) Get up between 6.30-8.30am.
What age are you and what level of physical activity are you doing ? I am guessing you do a lot of exercise and if so this could be a big reason for your issues.
- I’m 44 slim build. 5’6 and 144lbs... Inwalk the dog 1-2 times a day depending on my energy levels. Try to do some gym sessions when I have the energy, but haven’t done much in the last year. Feel too tired and weak.
What is your diet like ? Are you restricting in any way certain foods ?
- I have a very good diet actually. Always have. Very rarely eat processed foods or junk foods. Hardy eat any sugary foods or drinks. Eat lots of fresh veggies and fruits. 95% of foods are freshly made by me or my lovely wife. I’ve given up meat since Christmas, but eat plenty of fish in its place. Don’t really eat much dairy. No milk.
Any antidepressant usage ?
- No
An FSH of 8.8 is getting up to the top of the range which i think is 12. Any testicle damage in the past ? The FSH is the signal to make more sperm so at the moment you may not be making as much as the body would like. It is a hard one to say exactly and so you would need a sperm test. If you are a big cyclist then this will explain that.
- Yes my FSH and LH are high normal and that combined with, very low E2, low normal total T, below range Free T, undecended testicles as a child with testicular damage when they operated lead to the primary hypogonadism diagnosis. Also been trying for a baby for like 10 years. (Going through IVF now)
————
* I read your old post about joint pain. Not sure if your got that sorted but wondered if you ever looked at your E2 levels. It’s very common to have joint pain with low E2. Ive suffered all my life with joint pain. I have scleroderma and have some joint pain with that. But only recently found out I have been living with very low E2. As soon as my E2 increased on my TRT my joints got 100% better (;
Ok so with you are a typical slim and fit looking male, but really you feel like crap.
I've been there.
I do wonder if the issue is not with testosterone but the thyroid. Only a trial will help you, but the testosterone does complicate things. I am just not sure whether you do have a testosterone issue. Your results look better than mine and i am sure i don't have a testosterone issue.
The key to understanding if it is testosterone or thyroid is to see how you feel on the hormones to replace what you are possibly deficient in.
You are taking testosterone, so have you improved ? Is it making life better for you?
Would the issue be more about a low oestrogen level then ? This is the same in a male as low testosterone i think. I am not that clued up on male oestrogen and testosterone because it has never been an issue for me.
We have some stuff in common as i had an undescended testicle and so really i have only one proper working testicle because i am assuming the other one is not really working that well. My FSH is typically 12. My testosterone level is around 15-21.
In january this year i did the medichecks male profile and i was a touch shocked by my lower testosterone compared to a few years ago and higher SHBG.
With reference to my joint pain, i think the issue was down to slightly to high a dose of T4. This summer i have reduced down and now take 112.5mcg T4 per day (at bedtime and no i don't take any more T4 in the day). I have improved overall again by doing this. I still have aches and pains, but i work physically so i am thinking this is down to my work and just getting older. But at 47 nearly i am certainly fitter and healthier than many years ago when i wasn't treating my thyroid.
I do mean to get some more blood tests, but i am busy and feeling fine so it is a push to make myself go and do the tests.
I know for sure the thyroid level affects testosterone. Whether the lower T4 level has improved my testosterone results i cant say until i get those bloods done, but i do have results from starting thyroid and then seeing the new testosterone results. This was over 10 years ago, but testosterone went up a fair bit. I think from 13 to 17 nmol/l.
The only other thing i use for my health is progesterone. This has been the main factor in restoring full health. Thyroid only did so much, but when i got on to the progesterone every thing clicked into place. My TSH went from being suppressed for years on any type of thyroid treatment to bottom of the range at 0.3. That is a big increase really and it shows me that the progesterone was creating a better cortisol/DHEA balance and so the uptake of T3 was improved. My testosterone also jumped from 17 to 21. This was 3 years ago however.
The progesterone usage may have been a factor in the joint pain as well, but since the summer i have again found lowering the progesterone to be very helpful in the summer and increasing in the winter time. So in the summer i was using 3mg every other day and now i am back on 4.5mg per day. I think in the winter i need more as cortisol production drops when the sun light drops off.
Good luck with the IVF. We did 3 rounds and luckily it worked on the final round. So we have a lively 4 1/2 y/o daughter
“I do wonder if the issue is not with testosterone but the thyroid. Only a trial will help you, but the testosterone does complicate things. I am just not sure whether you do have a testosterone issue. Your results look better than mine and i am sure i don't have a testosterone issue.”
- Persoanlly I’m pretty sure I have an issue with low testosterone. It’s very clear to me looking at my bloods, symptoms and testicular damage when I was a child. Apart from total testosterone there are a number of other bloods that need to be checked do get a clear picture of hormone levels. Total t is not an accurate measurement because it’s free T/bioavailable T that important. Even though my total T was low normal in the range my free T and E2 were very low. E2 was low because testosterone was low. I was blubbing watching silly stuff on TV which was out or character. Anyway I agree only a trial of thyroid meds will really tell me if there’s an underlying thyroid issue. And if there is it will explain why I’m still feeling crap even though I’m on TRT.
“You are taking testosterone, so have you improved ? Is it making life better for you?”
- From where I was, yes definitely improved. Though not anywhere near as much as I hoped for. Joints improved 100% which is mostly because my E2 has risen. Feel a lot more motivated than I did before. Still got lots of negative sides Which is why I think there’s an underlying thyroid issue. Im hoping once thyroid improves I’ll see improvements with TRT.
“Would the issue be more about a low oestrogen level then ? This is the same in a male as low testosterone i think. I am not that clued up on male oestrogen and testosterone because it has never been an issue for me.”
- Yes low E2 is a massive factor. Low or high E2 an really make you feel awful. But E2 and testosterone goes hand in hand.
“We have some stuff in common as i had an undescended testicle and so really i have only one proper working testicle because i am assuming the other one is not really working that well. My FSH is typically 12. My testosterone level is around 15-21.
In january this year i did the medichecks male profile and i was a touch shocked by my lower testosterone compared to a few years ago and higher SHBG.
I do mean to get some more blood tests, but i am busy and feeling fine so it is a push to make myself go and do the tests.“
- It does seem to be a common issue. (undescended testicle) Your FSH is high and even with total testosterone of 12-21 if you have high SHBG you might have low free testosterone. Might be worth testing your free testosterone. Though if you’re feeling fine it might not be worth bothering for now.
“I know for sure the thyroid level affects testosterone. Whether the lower T4 level has improved my testosterone results i cant say until i get those bloods done, but i do have results from starting thyroid and then seeing the new testosterone results. This was over 10 years ago, but testosterone went up a fair bit. I think from 13 to 17 nmol/l.”
- Yes thyroid definitely affects testosterone... so it would make sense that your testosterone results improved when you sorted your thyroid.
“The only other thing i use for my health is progesterone. This has been the main factor in restoring full health. Thyroid only did so much, but when i got on to the progesterone every thing clicked into place. My TSH went from being suppressed for years on any type of thyroid treatment to bottom of the range at 0.3. That is a big increase really and it shows me that the progesterone was creating a better cortisol/DHEA balance and so the uptake of T3 was improved. My testosterone also jumped from 17 to 21. This was 3 years ago however.
The progesterone usage may have been a factor in the joint pain as well, but since the summer i have again found lowering the progesterone to be very helpful in the summer and increasing in the winter time. So in the summer i was using 3mg every other day and now i am back on 4.5mg per day. I think in the winter i need more as cortisol production drops when the sun light drops off.”
- It’s interesting about how progesterone has helped you. It’s one thing I have not checked and was wondering about. I did take pregnenolone for a short time but maybe not long enough to see any benefits. Are you using progesterone cream? I think I read progesterone lowers E2 which might be one of the reasons you had some joint pains.
“Good luck with the IVF. We did 3 rounds and luckily it worked on the final round. So we have a lively 4 1/2 y/o daughter“
- Thanks man, appreciate it! Glad it worked out for you. Our first round did not work out, so fingers crossed the last round would out. (Only two NHS rounds in Wales)
No I use ProgestE which is in vitamin e oil. It delivers a 3mg drop and a bottle lasts over 2 years. It’s about £35 from an online shop in Sheffield.
It was developed by ray peat. I would have a look at the ray peat forum as they have a lot of advise on hormones and diet Xmas maybe able to give you some new leads on what is happening.
I was taking 6mg per day for 2 years then this year I realised I needed to lower it down a touch. This helped the joint pain but I still have pain in the elbows and just think this is part of getting old.
No I didn’t because getting blood tests is so time consuming and costly.
I prefer to trial stuff over the years and keep going with something if it shows positive effects. Thyroid and progesterone were very positive for example. Dhea and pregnenalone never really made a positive difference in the longer term.
That’s interesting about the DHEA and pregnenalone working for you but the progesterone helped. I will order some and do a test for a Month or so and see how I feel.
I’m struggling to get hold of the Progest E online. Any chance you could PM me where you get yours online? I can get the creams but would rather try the oil.
I’m on Nebido and also have hypothyroidism and my thyroid readings have barely changed but it does worry me. Last reading was 2.3 for TSH. Glad I found this post.
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