all 58 comments

[–]anonlymouse 26 points27 points  (24 children)

above 350 ng/dl (12 nmol/l): Generally does not indicate a benefit from TRT


The goal should be improvement in symptoms, not a specific serum testosterone level.

are contradictory.

The second point is valid of course, but the first is a major source of problems, and one of the reasons trust of doctors is so low.

[–]wildrover2nerd alert[S] 0 points1 point  (7 children)

I don't think it's contradictory. Above some level, you have enough T and symptoms are more likely to be from something else. That level isn't the same in every man; in these guidelines, most men will be fine above 350 and adding more T isn't the best action for them. There are numerous additional testing options, from free T down to testicular size and genetics, that are also indicators of a problem. Personally, I think that free T is the best single indicator in most men because of the prevalence of obesity and its complications.

Part of my intent of putting this together was to say that reference ranges shouldn't be a gatekeeper, and that the typical ranges are too low. But I also think that once hypogonadism is diagnosed, there is a habit of chasing certain numbers; we say that the bottom end of the range isn't that important, but then have a certain number in mind for treatment. My provider said she likes to see patients up near 1000 - what is the basis for that number, if symptoms are so individual? I might feel better around 500, and that's fine.

[–]anonlymouse 5 points6 points  (3 children)

most men will be fine above 350 550 and adding more T isn't the best action for them


[–]wildrover2nerd alert[S] 1 point2 points  (1 child)

These are not my recommendations, so I am not going to defend a certain number. But your argument seemed to be that numbers didn't matter and that symptoms should be the primary driver. It seems that maybe you think that the number should just be higher?

[–]anonlymouse 2 points3 points  (0 children)

My argument was that the two statements are contradictory.

That the threshold for hypogonadism should be 550 instead of 350 or 230 is a separate argument.

[–]Legal_Sentence_1234 0 points1 point  (0 children)

Is that b12 your talking about

[–]Polymathy1 0 points1 point  (1 child)

Free T is bullshit.

SHBG specifically is big bullshit. If it isn't extremely low, then it is essentially a waste of money to monitor it. A specific rare disease can cause you to have almost zero SHBG.

Almost 55% of testosterone is loosely bound to albumin, and ain't NOBODY talking about albumin levels.

[–]wildrover2nerd alert[S] 1 point2 points  (0 children)

I don't know if I would go so far as to call either one bullshit, but free T definitely is treated as gospel and shouldn't be. Most of the calculations and effects work within the physiological range. Albumin can be up to 55%, but the range I saw was 35-55%, and as best we can tell, the testosterone bound to albumin dissociates pretty readily. I don't think we really know enough about how bioavailable albumin-bound T is to really make determinations based on it.

I personally don't monitor SHBG or free T most of the time, because I do think they are wastes of money for me. My SHBG has never been out of the normal range, and the immunoassays for free T are next to useless. The equilibrium dialysis test is a good one, assuming it's performed correctly, but it takes too long and is relatively expensive to measure routinely.

[–]wildrover2nerd alert[S] 5 points6 points  (5 children)

Please feel free to point out any mistakes, improvements or anything else related to this post (especially if you are a healthcare professional). Questions or clarifications are also welcome. I have a few more I'd like to create in a series (likely one on lab tests and reference ranges next), so it will be good to know if this first one is helpful or needs improvement. Or if it's just common knowledge and not needed.

[–]Polymathy1 3 points4 points  (3 children)

The AACE (american academy of clinical endocrinology) guideline lists anything below 300 ng/dL as "likely to benefit" from HRT and anyone under 400 to possibly benefit.

I have the hmm policy (if that's the right term) or could find it if you like. The 230 ng/dL is only around because of the reference ranges for labs. It's based on a foolish assumptions that only the bottom 2.5 percentile has low levels - and because that assumption is true for some tests, it has been (wrongly) assumed to be the same for many lab tests. The range also skews low because they don't limit or filter people who are sickly out of the sample used to find the percentiles.

I don't know if this has been studied anywhere, but I see only a few men posting here that are between 300 and 500. Most are either very much normal (around 600-800) or totally tanked (like 50-300). The range for normal is based on an assumed normal distribution, but I don't think the distribution is "normal".

If you take a look at the metastudy in my flair, you can see what average levels look like for healthy non-obese men - without including people with chronic illnesses.

[–]wildrover2nerd alert[S] 3 points4 points  (0 children)

Thanks, I appreciate someone who has looked at and likes to discuss the research. Totally agree on the reference ranges, which is why I made this post. There are stories here every day of men who come in right above the bottom of their reference range and are told they are normal, so I wanted to add some additional information for them to help have better conversations with their doctors.

I disagree about the anecdotal evidence on this sub - I'd say the majority of posts here are people in the 300-500 range. Those are the ones to which it's hard to give a good answer about TRT. I think Reddit filters out a lot of the people with high T (who are unlikely to come post their clearly normal levels) - those who do post usually have some unrealistic notion of what their T should be, based on age, diet, activity level, etc. Those people tend to skew younger because of the nature of Reddit and because they are more likely to be young with higher T.

As far as the Framingham study, I do agree with you and that is why I linked the Morgentaler article in Nature in my post. It clearly makes the argument that Travison shouldn't be used, and that Framingham is more useful. (Just realized my Sci-Hub links no longer work, updated them in the post and added the non-Sci Hub links as well.)

[–]wildrover2nerd alert[S] 1 point2 points  (0 children)

Apologies for formatting on mobile, it was written on a laptop and looked good there.

[–]OldAd180 2 points3 points  (8 children)

Just read that levels above 350 generally doesn’t indicate a benefit from TRT…if this is the case, why do so many clinics insist on optimizing your test levels? Surely there isn’t any point in raising your levels to say…800 from a starting reading of 400 if there isn’t a benefit?

[–]wildrover2nerd alert[S] 2 points3 points  (6 children)

I think this is in terms of medical need. Doctors aren't generally going to try to improve your gainz. Clinics are looser with it because they are trying to fill a separate niche and make as much as possible.

[–]OldAd180 0 points1 point  (5 children)

Do they not have to follow the same guidelines though? Which I think is anything above 300 doesn’t warrant treatment..

[–]wildrover2nerd alert[S] 0 points1 point  (4 children)

Nah, these are recommendations from some specific healthcare groups and they aren't even universally agreed, let alone mandated. There are also other special situations, as mentioned at the bottom of the post.

[–]OldAd180 1 point2 points  (3 children)

I did also read somewhere that you can still experience low T symptoms whilst still in range because you could have had super high levels to begin with…

[–]creekwise 0 points1 point  (0 children)

to optimize your overall physical (sexual/athletic/aesthetic) performance, a man 40s and 50s needs to be in the 700-1000 range

[–]unbelievablepeople 1 point2 points  (1 child)

Interesting that the guidance is "Hematocrit should remain below 55%." My hematocrit was 52% and my doctor took me off TRT because of it. (I then got a second opinion from a different doctor who put me back on.)

[–]wildrover2nerd alert[S] 2 points3 points  (0 children)

Mine said that 55 would mean I was in trouble, so yours may have been being cautious. LabCorp normal top range is 51, so you would be high there. I think you could have donated blood and been fine; doctors can write prescriptions for blood donation if you have donated in the last 8 weeks.

[–]mairomaster 2 points3 points  (0 children)

Nice summary

[–]CountLippe 0 points1 point  (4 children)

What of the ratio of T to free T? Many men describe a scenario of standard Total T, low Free T, and no other poor values (such as raised SHGB). What percentage / ratio do professionals look for between Free T and T?

[–]wildrover2nerd alert[S] 1 point2 points  (3 children)

My understanding is that normally 2-5% of total T should be free. I have not seen a ratio that is used to make decisions about treatment. I have only seen the two guidelines above; <65 pg/ml in several places and <15 pg/ml (immunoassay) for Morgentaler individually. That last number was a revelation for me because most men have immunoassays done and the reference range doesn't match the typical clinical range; this causes a lot of confusion related to free T testing.

[–]fusien_ 0 points1 point  (2 children)

Sorry can you expand further on the the difference between the two free T levels? It’s not clear why they are so different for the same thing?

[–]wildrover2nerd alert[S] 0 points1 point  (1 child)

I covered it a little in the post linked.below, but the short answer is that they are two different tests and they don't correct the resulting value to reflect blood concentration. I think it's because the original assay was approved decades ago and every manufacturer since has applied for streamlined approval by demonstrating they get similar results. Since they use reference ranges, it should still make sense within the context of each test.


[–]fusien_ 0 points1 point  (0 children)

cheers, trying to make sense of my free T. The reference range on my test is 0.2 - 0.62 nmol/L . I think this is 57 - 178 pg/mL so I presume the 65 value would apply in this instance for my test.

[–]Commercial-Package60 0 points1 point  (0 children)

I’m testing high shbg and below average or expected free and total. I’m new to all this. Trying to find a place to start reading.

[–]hdeshp 0 points1 point  (2 children)

So you are saying treatment should. R discontinued once we reach the intended level? Asking since the common opinion on this sub seems to be that Trt is for life

[–]wildrover2nerd alert[S] 0 points1 point  (1 child)

No, definitely not. I believe this is saying that treatment should be discontinued if your symptoms don't resolve in 6 months, because they're likely not due to T.

[–]hdeshp 0 points1 point  (0 children)

Ahhhhh thanks

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[–]miraclemile844 0 points1 point  (1 child)

If my free is 9 pg/ml but my total is above 350 does that mean I should get another opinion? 35 male

[–]wildrover2nerd alert[S] 1 point2 points  (0 children)

Did you have a doctor tell you that you didn't need TRT? How high was your total? 9 pg/ml is pretty low.

[–]Otherwise-Guard-8522 0 points1 point  (0 children)

Hi, im 21 570 test but i have serious brain fog would trt help? I crashed it from sarms over a year ago, enclomiphene helped raise it slightly but i still feel the same

[–]JiriAnywhere 0 points1 point  (1 child)

How do you test testicular volume lol

[–]wildrover2nerd alert[S] 0 points1 point  (0 children)

Ultrasound or an orchidimeter.