@Joseph_Lavelle has a great series!
This podcast is excellent!
Anyone who is heading into self medicating for “Low T” - especially low bioactive T with a normal range total T really needs to listen to this before heading down a very poorly thought out pathway!
I listened to this today - all information I knew - but a wonderful presentation, nicely mediated by Joe. But I wish this information was widely a part of practice as men are getting the wrong treatment.
Anyway, hats off to Joe Lavelle. Such a quality member on the forum!
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@DrFraser Wow. Thank you very much. I try very hard to produce a useful podcast but the main goal is to learn. TRT is marketed very well. I meet people out in the world who don’t know about WiseAthletes who tell me TRT is the great thing ever. Maybe so. I say be careful with potentially irreversible decisions.
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I had a consult the hour after I listened to this of a patient who had a Testosterone of 900 while being metabolically unhealthy - and having symptoms the “doctor” thought could be low T - even though he didn’t have low T - so now 4 years on, is on testosterone injections - when what he needed was someone who understood the issues, did things to lower his SHBG … now I’m left with the mess of backing out of this mismanagement. This interview demonstrates the issue at hand nicely. Bottom line is … get an expert to review you before you head down into a somewhat difficult to reverse path - that you may never have needed to head down.
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Reviews, 14 May 2024
Associations of Testosterone and Related Hormones With All-Cause and Cardiovascular Mortality and Incident Cardiovascular Disease in Men: Individual Participant Data Meta-analyses
Conclusion:
Men with low testosterone, high LH, or very low estradiol concentrations had increased all-cause mortality. SHBG concentration was positively associated and DHT concentration was nonlinearly associated with all-cause and CVD mortality.
https://www.acpjournals.org/doi/10.7326/M23-2781
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Sadly, this needed to be bioavailable testosterone - and the association would be meaningful as you can have high total T and low bioavailable due to a high SHBG due to poor metabolic health. It is unfortunate that wasn’t controlled for as then the association would be much stronger.
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What did you do to lower SHBG?
Neo
#7
Perhaps higher SHBG is separately also consistent with longevity phenotypes - in addition to bad issues (when eg driven by poor metabolic health) - so important to disentangle
See some papers in posts below.
I.e. depending how one arrives at above average SHBG it could be either good or bad
Any perspectives?
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@Neo has it right. Context.
SHBG is essentially the only such protein that increases with age. This is the confusion - if you look in isolation - high SHBG is associated with health, but the context is different - it is with a high total testosterone and an adequate Free or Bioactive T.
It is a different animal in an older or metabolically unhealthy individual who has an adequate total testosterone, but they have so much SHBG that their Free or Bioactive T is now below normal limits or very low. Those individuals are not healthy and this is a bad thing - and it is an individual assessment to sort our what is wrong - Cortisol/Melatonin Curve, Stress, Obesity, too much protein, too little exercise, metabolic syndrome? Many of the same things interestingly listed in the situation of a low SHBG - but in a different context.
Just looking at the literature it would be confusing to see why I’d want to lower a SHBG – it is context.
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Also a quick item for folks to understand the Total, SHBG, Free and Bioavailable - you simply need a Total Testosterone, a SHBG and an Albumin - and you can get a Free T and Bioavailable. I see some people paying extra for the last 2 items - but these are calculated.
Use this Calculator.
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adriank
#10
What is the best recommendation for dealing with low testosterone? Can some please share their experiences? For me, as soon as I lower my body mass it will recover. But it is a catch 22. I need some help to increase testosterone.
In general, for most men, I give a trial of enclomiphene (but first make sure I have good data, prolactin, FSH, LH, Free/Total Testosterone, Estradiol). There are some complexities, but it is far better to drive up one’s FSH/LH to then tell your testicles to make more testosterone than to take exogenous testosterone (which then suppresses your testicles and after a couple of years, you’ll for sure need to be on testosterone life long). Most men do well with this approach. Some still require exogenous testosterone, but it is a small %.
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Shady
#12
Clomid is nice for short term augmentation of the access. Not sure I prefer it for long term replacement unless fertility is a concern. Several reasons:
- Clomid elevates SHBG so the overall subjective benefit is consistently less as compared to testosterone.
- Long term risks of elevated desmosterol from impairment of cholesterol synthesis.
- Prolonged after images are a real side effect and can be persistent.
- Long term risk of E2 antagonism in various tissues
- If you want oral and still maintain fertility consider Kyzatrex with or without HCG to maintain gonadotropins and intratesticular T levels which in most will maintain fertility.
With the advent of Kyzatrex I don’t see a huge role for clomid in long term replacement therapy unless a young male preferring to maintain fertility.
Edit: yes I’m familiar with clomid vs enclomiphene. Discussion is essentially the same.
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adriank
#13
i am going to be reading a bit longer before deciding … LOL… hopefully not too long.
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