# Fatigue & Low Testosterone: Reproductive Endocrinology or Endocrinology & Metabolism?



## CaptainThunderpants (May 21, 2014)

Hi,

36 year old male; have sensed fatigue and low energy, especially in the afternoons, all my life. I've had a sleep study recently; everything was fine, and I'm careful to get adequate sleep. I had an extensive cardiology workoup in high school. In college, I also complained of fatigue, and the doctor on duty referrred me to an endocrinologist, but my main doctor (now deceased) changed that to a referral to a diabetic nutritionist who advised me to eat bagels for breakfast (!). I also requested a Glucose Tolerance Test also back in 1998 and did poorly. *BASED ON THAT INFORMATION, *I have usually followed a low-carbohydrate diet (and gained some fat over the years): I get my A1C tested (through Walmart) and have also owned a glucometer since 2001 and check myself regularly: even when I feel tired, my *sugar is generally normal*.

I have been getting into weightlifting (mostly just reading so far, sadly), and had a testosterone check in late February through LabCorp. Results were as follows:

Testosterone, Total, LC/MS 303.6 ng/dL Low ( 248 - 1197 ng/dL reference range)

Free Testosterone(Direct) 9.4 pg/dL ( 8.7 - 25.1 pg/dL reference range)

I have had "thyroid panels" done before, and I had a normal testosterone (5xx?) about 10 years ago. I'm looking for a *through and extensive workup on my endocrine system *to understand why I have fatigue and low energy, and what the cause of my low testosterone is. I don't really have a primary care physician: I seldom get sick, and have moved long distance several times. * Should I look for a "Reproductive Endocrinology" person or "Endocrinology & Metabolism?" Or maybe urology, but I really don't just want a quick fix with testosterone supplements.*

PS: I've poked around at various thyroid-related Web sites and have some ideas of what questions to ask, but I'd at least like to start by picking the correct specialty. My concern is that a "metabolism" guy will say "you are not a candidate for Metformin at this time; goodbye", but a "reproductive" guy will say "you are not having difficulty impregnating your wife, and you don't even have a wife, so goodbye".


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## Pamzilla13 (Sep 9, 2013)

Look for a doctor who specializes natural hormone replacement. They cover thyroid and sex hormones. I don't know your location, but you can google it. Personally, I found that general doctors are triage doctors. They only refer to a specialists. So, I usually skip them and go straight to a specialist, but you may have to go to more than one doctor to find a "good" one that is thorough. Good luck.


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## CaptainThunderpants (May 21, 2014)

Pamzilla13 said:


> Personally, I found that general doctors are triage doctors. They only refer to a specialists. So, I usually skip them and go straight to a specialist


And endocrinologists are specialist, hence my question of what sort of endocrinologist.


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## joplin1975 (Jul 21, 2011)

When were the latest thyroid labs run and could you, just for giggles, post those results? I couldn't imagine a RE would be the right fit for you, since most of them deal with assisting women get pregnant and maintain those pregnancies. If your thyroid panels look good, a urologist is the most logical step for dealing with the testosterone issue (which mimics thyroid issues -- my husband has low t and I deal with hypothyroid but our symptoms are nearly identical). And, trust me, there is no "quick fix" with testosterone supplements. He and I have both dealt with many dosage changes, blood work, medication changes, etc. It's a different process, but similar. The big key with testosterone supplements is ruling out testicular cancer first and only a urologist is really qualified to do that.

That all said, since the thyroid is sort of the master gland, I'd start there, get some labs done (to include TSH, free t4, free t4, TPO and TSI) and then decide on what kind of specialist from there. Right now, there's simply not enough information.


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## CaptainThunderpants (May 21, 2014)

Hey Janis,

When were the latest thyroid labs run and could you, just for giggles, post those results? 1998 or maybe 2004 and I definitely don't have the 2004 versions; I could probably dig up the 1998 stuff but it was a) probably just the standard thyroid panel that people say isn't very good and b) was not seriously abnormal. But my symptoms etc were such that one physician did write an endo referral when I was about 20.

I couldn't imagine a RE would be the right fit for you, since most of them deal with assisting women get pregnant and maintain those pregnancies.

Thanks; that is probably the answer I was looking for. I was afraid that a "metabolic" type would just kick me out for being nondiabetic.

urologist is the most logical step for dealing with the testosterone issue (which mimics thyroid issues -- my husband has low t and I deal with hypothyroid but our symptoms are nearly identical)

Thanks; but I suspect that the testosterone is a recent development and possibly secondary to an underlying hormonal thing which has been going on much longer. My libido was way different even a year and a half before this recent test.

That all said, since the thyroid is sort of the master gland, I'd start there, get some labs done (to include TSH, free t4, free t4, TPO and TSI) and then decide on what kind of specialist from there. Right now, there's simply not enough information.

I agree it's kind of vague at this point. I do feel the need for a thorough endocrinology workup, and since I don't have a primary care physician (and thus will have to wait months to see one), I was hoping to just start there.


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## joplin1975 (Jul 21, 2011)

You'll probably have to wait longer for a endo appointment than a primary care doc. And, most endos won't see you without recent blood work. Heck, I had whacked out numbers and they seriously were suspicious about cancer (which turned out to be correct) but it still took me a month and a half (WITH those labs and test results) to get in to see an endo.


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## CaptainThunderpants (May 21, 2014)

Yeah; that's probably true; I'll make some calls. And by the time the appointment actually happens, I may have moved to another state. Oh well; time to make some calls.

PS: Really sorry to hear about the cancer.


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## visc (Feb 22, 2014)

I'm the same way! Ever work out or exercise in the past? I don't I just sat :/

You become what you do! I've been learning about stress and biology.






and videos by Robert Sapolsky

21 year old male... I'm a wimp lol


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## bigfoot (May 13, 2011)

Welcome from another guy! I'll toss this out first as a preface: take everything with a grain of salt and beware of some specialists (heck, all docs, really). I've been on testosterone therapy for years, and recently had a urologist flat-out tell me, "Oh, people don't really need testosterone." I'm sorry... WHAT?! Not only that, but most endocrinologists are more into diabetes than thyroid or testosterone. There are good ones out there, but it will probably require some searching.

Check out a couple of good books, one is called "The Testosterone Syndrome" by Dr. Shippen, the other is called "Low Testosterone by the Numbers" by Lee Myers. No connection to those authors, but the info is kinda eye-opening. Not having enough testosterone on board opens you up to many further health risks. I honestly think the scare factor of testosterone treatment = prostate cancer is waaay overblown. Not only that, but our processed foods, chemicals, environment, and so forth have caused something on order of a ~25% decline in testosterone levels among healthy men over the last few decades.

A total testosterone of 300 is low, but doesn't tell the whole story. You need to find out "why" your testosterone is low to begin with. It could be from injury, other medical issues, excess estradiol or out of whack hormones (thyroid for example), etc. You definitely want to answer those questions up front before heading down the road of hormone replacement therapy (aka HRT) / testosterone replacement therapy (aka TRT). Once you begin hormone therapy, it's generally for life. And it's really hard to rewind things after the fact and go looking for answers. Trust me on this one!

FYI, a total testosterone, free testosterone, SHBG, and E2 Estradiol labs should be run to give a more complete picture. And watch out for those who say your labs are "normal" because they fall in-range. That doesn't mean optimized for you. We run into the same issues with docs interpreting thyroid labs. We are all our own individual cases, and treating each person the same isn't going to get the same results.

If treatment is the route you wind up going (and low testosterone can absolutely cause nasty fatigue, amongst other things), know that there are lots of versions. There are daily patches (skin irritation), daily gels (messy but can work), injections (once a week is likely best), and also aromatase inhibitors (aka "AI") that will stop your testosterone from becoming estrogen, thus rendering it basically useless. Pro's and con's to each treatment, and a good doc will be familiar with all of this. Not only that, but they can consider supplementing with HCG to keep your testicles in some sort of working order, which is important if you plan on having kids.

Since I'm on a roll here and you mentioned low-carb... look into "Paleo". Less of a diet and more of a lifestyle and nutrition. The emphasis is on meats, healthy fats, veggies, few carbs, no grains, little dairy, little sugar, etc. Short answer is that much of the research we've been fed (pun intended) over the last few years is a lot of BS. Eggs aren't necessarily bad for you, nor is fat and meats. Items marked "low fat" or "fat free" (gross) or "sugar free" (still have sugar alcohols) in the grocery aren't really good for you after all.

Docs should be turning over a lot of stones looking for answers here. Testosterone could be part of it, as could other issues.


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## CaptainThunderpants (May 21, 2014)

visc: I have always wanted to be more physically fit (hard to find the time/energy when you're fatigued!), but I have been at least going for very long walks (often 12 km) with varying degrees of running / jogging for the past 1.5 years. It was kind of wasteful since I was at low intensity, and it helped my fitness a little, but wasn't a major help to fatigue. I'm slowly getting into barbell training (which was actually the impetus for ordering the test, though I really wasn't expecting to find it low). I think it really helps with doctors if you can talk about what you're doing to fix your problems. If you've already worked on your diet, sleep, alcohol, tobacco, and also exercise, you can kind of tell them "this is what I've done to try to solve the problem: now I need your help".

Major changes after getting the result: no more canned foods: frozen veggies are actually more convenient, since you can create your very own melange, rather than having to cook in whole-can increments, and they're fresher and don't have the nasty BPA).

As far a sitting, I stacked 8"x8"x16" grey blocks (aka cinder blocks) and put my computer desks on them. It has definitely been an adjustment, but I'm glad I did. They're really cheap (I got mine at Lowe's). In addition to "sitting is the new smoking", your balls can hang naturally and regulate their temperature, rather than being squeezed between your pants and your body weight.

[hr]

Thanks Bigfoot. Today I went to a wellness-oriented family practice DO who is interested in getting to the root cause I'm optimistic: I think he's going to be better than an endocrinologist: I think that being respectful, concerned with optimizing quality of life rather than only treating severe disease, and not being wedded to dogmatic protocols is more important than the esoteric knowledge of a specialist (he mentioned that there are good endos, but they are usually only focused on diabetes). Some of this is going to be trial and error related to what works for me personally anyway. I have decided (especially after some advice on T-Nation's endocrinology section) that testosterone is likely the symptom (and probably a recent one at that: I felt considerably different in some ways 1.5 years ago, but fatigue has been an issue since grade school. The low T is useful mostly because it gets the doctor's attention to take me seriously (especially as a new patient). I'm *extremely* reluctant to go on TRT at this point.

I found him because a female colleague of his is listed as a Natural Thyroid practitioner: I have no idea whether thyroid is my actual problem, but it turned out to be a great way to find a good doctor who won't just say "your labs are normal: try a antidepressant".


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## bigfoot (May 13, 2011)

CaptainThunderpants said:


> I have decided (especially after some advice on T-Nation's endocrinology section) that testosterone is likely the symptom (and probably a recent one at that: I felt considerably different in some ways 1.5 years ago, but fatigue has been an issue since grade school. The low T is useful mostly because it gets the doctor's attention to take me seriously (especially as a new patient). I'm *extremely* reluctant to go on TRT at this point.
> 
> I found him because a female colleague of his is listed as a Natural Thyroid practitioner: I have no idea whether thyroid is my actual problem, but it turned out to be a great way to find a good doctor who won't just say "your labs are normal: try a antidepressant".


T-Nation was going to be my next recommendation -- glad to hear you are over there, too! I think you are absolutely right to look for answers first. DO's can be great docs, sometimes more of an "outside the box" thinker.

Thyroid and testosterone are very closely linked, who knows, it could be sub-optimal thyroid or something autoimmune related giving your testosterone side of things trouble. Hard to say at this point.

Sounds like you have tried a lot of good approaches and changes yourself, that is awesome. Do keep us posted on how things progress! :anim_32:


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## CaptainThunderpants (May 21, 2014)

I like my new doctor. He's willing to do more testing later, but wanted to not go too deep on the "initial screening" after my appointment. I have a followup Monday: I definitely want to get more stuff like E2 done. But here's where things stand now. He did lightly touch my thyroid gland before the blood draw: palpating the gland can affect results which apparently can affect the results[1], but it seemed like a very quick and light touch. I took my usual multivitamin the day of the test also: I stopped taking it a few days ago now.

[1] http://onlinelibrary.wiley.com/doi/10.1002/lary.20959/full

DATE/TIME MEAS UNIT REF LAB POSITION WRT REF RANGE

2014-05-29T13:30_EDT OT 97.8 degF 98.6 DoctorOffice
2014-05-29T13:30_EDT BPS 124 mmHg DoctorOffice
2014-05-29T13:30_EDT BPD 70 mmHg DoctorOffice
2014-05-29T13:30_EDT BPP 75 bpm DoctorOffice

2014-05-29T13:30_EDT TSH 4.20 uIU/mL 0.35-4.94 MidAmerica 84% [some say 3.0 is high]
2014-05-29T13:30_EDT FT3 2.9 pg/mL 1.7-3.7 MidAmerica 60%
2014-05-29T13:30_EDT RT3 15 ng/dL 8-25 MidAmerica 41%
2014-05-29T13:30_EDT FT4 1.0 ng/dL 0.7-1.5 MidAmerica 38%
2014-05-29T13:30_EDT TPOAb <10.0 IU/mL 0.0-34.9 MidAmerica
2014-05-29T13:30_EDT TGAb <20.0 IU/mL 0.0-39.9 MidAmerica

2014-05-29T13:30_EDT Cortisol(blood) 13.1 ug/dL MidAmerica

2014-05-29T13:30_EDT TotTestosterone 237 ng/mL 250-1100 MidAmerica -2% [outside reference range]
2014-05-29T13:30_EDT FTestosterone 44.9 pg/mL 35.0-155.0 MidAmerica 8% [also quite low]
2014-05-29T13:30_EDT LH 3.2 mIU/mL MidAmerica 21% [based on Wikipedia range: very low under the circumstances]

2014-05-29T13:30_EDT LYME AB < or = 0.90 index MidAmerica
2014-05-29T13:30_EDT Ferritin 145.9 ng/mL 21.8-274.7 MidAmerica 49%
2014-05-29T13:30_EDT IRON 80 mcg/dL 65-175 MidAmerica 14% [hmm....]

2014-05-29T13:30_EDT WBC 7.4 K/CUMM 3.3-10.5 MidAmerica 57%
2014-05-29T13:30_EDT RBC 4.76 K/CUMM 4.15-5.75 MidAmerica 38%
2014-05-29T13:30_EDT HEMOGLOBIN 15.1 G/DL 12.8-16.9 MidAmerica 56%
2014-05-29T13:30_EDT HEMATOCRIT 44.6 % 38.8-50.2 MidAmerica 51%
2014-05-29T13:30_EDT MCV 93.6 FL 78.0-100.0 MidAmerica 71%
2014-05-29T13:30_EDT MCH 31.7 PG 27.0-34.0 MidAmerica 67%
2014-05-29T13:30_EDT MCHC 33.9 G/DL 32.0-36.0 MidAmerica 47%
2014-05-29T13:30_EDT RDW 13.0 % 11.5-15.0 MidAmerica 43%
2014-05-29T13:30_EDT PLATELET_COUNT 177 K/CUMM 150-450 MidAmerica 9% [interesting]
2014-05-29T13:30_EDT MPV 9.3 FL 7.7-11.2 MidAmerica 46%
2014-05-29T13:30_EDT NEUTROPHIL 58 % MidAmerica
2014-05-29T13:30_EDT LYMPHOCYTES 35 % MidAmerica
2014-05-29T13:30_EDT MONOCYTES 4 % MidAmerica
2014-05-29T13:30_EDT EOSINOPHILS 3 % MidAmerica
2014-05-29T13:30_EDT BASOPHILS 1 % MidAmerica
2014-05-29T13:30_EDT ABS_NEUTROPHILS 4.3 K/CUMM 1.3-6.0 MidAmerica 64%
2014-05-29T13:30_EDT ABS_LYMPHOCYTES 2.6 K/CUMM 1.5-3.5 MidAmerica 55%
2014-05-29T13:30_EDT ABS_MONOCYTES 0.3 K/CUMM 0.0-1.0 MidAmerica 30%
2014-05-29T13:30_EDT ABS_EOSINOPHILS 0.2 K/CUMM 0.0-0.7 MidAmerica 29% [I don't know blood...]
2014-05-29T13:30_EDT ABS_BASOPHILS 0.1 K/CUMM 0.0-0.1 MidAmerica 100% [I don't know blood...]


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## CaptainThunderpants (May 21, 2014)

PS: Absent any other counsel, I'm probably going to go on Iodoral soon.

PPS: Also posted in the Lab tests section:

http://thyroidboards.com/forums/topic/10688-first-round-of-testing-for-fatigue-low-testosterone/


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## bigfoot (May 13, 2011)

Your TSH, FT4, FT3, and Total Testosterone jump out at me right off the bat. Body temp is a little low, which can be typical with someone who is hypo or thyroid not functioning fully. TSH is not exactly optimum (should be less than 3.0, and really in all likelihood, closer to 1.0 or less), and FT3 & FT4 could possibly use a slight boost. The TPO Ab and Thyroglobulin Ab's are low, which is good. The argument can be made that folks should have absolutely zero in terms of those antibody values, but most labs have a cutoff as yours does. Either way, thankfully yours are not skyrocketing into the hundreds or thousands area. Interestingly, your Reverse T3 (RT3) looks good, as does your Cortisol and Ferritin. It will be interesting to see an E2 Estradiol reading if they run it, as well as if they do anything like a Lipid Panel. FYI -- triglycerides are typically high in folks with thyroid problems.

I quickly Google'd what "Iodoral" is, sounds like an Iodine supplement. I don't know if the doc recommended this or not, or if you're taking it upon yourself, but I'll throw it out there that many with thyroid problems steer clear of excess iodine. Especially folks with autoimmune components / antibodies, it can potentially flare things up. Not sure where you fall in all of that.

Based on what I see, my $0.02 FWIW is that you are hypothyroid a bit. And definitely something is up with the testosterone. The question then becomes, is this poor thyroid function leading to the low testosterone? Or is the low testosterone (or possibly high E2) keeping you from optimum thyroid levels? Or something else entirely? Estrogen does have a knack for blocking active thyroid hormone; when my E2 is elevated, my TSH get worse. Testosterone and thyroid kind of play off of one another -- the HPA axis and HPG axis.

Good to hear you found a doc willing to listen, definitely keep us updated and good luck with the upcoming appt!


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## CaptainThunderpants (May 21, 2014)

I posted some tests from the 1990's on the lab result thead. The conclusions are 1) my thyroid response has decreased by about 80% since age 18 and 2) my paltelet counts were low during other times when I suffered from fatigue.

My triglycerides were 100 mg/dL back in November when I had a worse diet and more stress (when I was 18, they were actually flagged low: 34 mg/dL).

Monday was one of the worst days of my life. It was a complete Jekyll & Hyde. The guy who bragged about his persistence said "yeah, your T is really low and you probably should get on something". I said that I was not ready to do that without knowing the root cause. He kind of agreed and suggested I see an endocrinologist, though he didn't recommend anyone in particular. I asked about platelets and also showed him the old numbers, and he gave a little speech with the conclusion that he basically only cares about the reference range, not the position within the reference range, and that maybe the platelets were "normal for you". He also said that insurance companies really care about reference ranges.

After leaving the office, I remembered my initial question and have a voice mail confirming that I should see the *Endocrinology & Metabolism* type.

So here's my new plan:
0) Do not supplement iodine: it's risky enough that I'd like medical supervision, and the doctor recommended not doing so if I was planning on having additional testing.

1) Put medical issues out of my mind completely until my financial situation changes (this is likely in the next couple of months). I'm nowhere near my deductible, and a specialist would be at least 2 visits and probably a higher rate than allowed for a primary care visit.

2) I have ordered prolactin and estradiol tests online for about the price of anohther useless office visit. Just in case my condition improves spontaneously over the next couple of months, I really need these numbers to understand what's going on. Due to fasting on Monday, I'll probably get the draw done next Monday after my system settls out a bit.

3) When I return to this issue, I'll probably see an endocrinologist, but I'm beginning to think that I may need to go outside the insurance-based system to really get an answer. This isn't a political rant (as many single-payer systems arguably have much worse rationing), and I can't say that I've been completely ignored over the years, but I suspect my problem may be too subtle and borderline for the insurance system to uncover. Or maybe I'll have to do doctor-shopping and get a few tests at multiple doctors. Maybe I'll pull a Tim Ferris and do medical tourism in Argentina.

I hope not to have to go to such extremes, but I only got my T checked by asking about it or by doing it myself.


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## bigfoot (May 13, 2011)

Looks like a good plan to me. I would agree that insurance companies probably like reference ranges and flimsy research they can use to discourage further testing, thus saving money (and passing it along to their shareholders), but ultimately your doctor really has the final say. Is this doc the same one who looked promising and drew labs on 5/29? If so, that's pretty slick of him to now blame the insurance companies, instead of doing his job and justifying why he feels a patient need further testing. But I digress...

As far as endocrinologists go, perhaps it's a blessing in disguise that he didn't recommend anyone. You may not want to deal with who he feels is a "good doctor."

One angle you might want to look into is finding an infectious disease doc, preferably one with an interest in chronic fatigue. They like to look under all sorts of rocks.


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## CaptainThunderpants (May 21, 2014)

Yes, same doctor.

He wasn't completely shifting blame to insurance companies: he seems to truly believe that the Reference Range is infalliable, and in retrospect this was somewhat evident even in the initial visit (he gave a blank look when I said that we wouldn't be happy if a child of ours scored 1 IQ point above the official retardation threshold). He also said that I would be feeling way worse if my free testosterone wasn't low, despite the fact that it's less than half of the midpoint value and only 8% from the lower threshold (which is usually defined at the point where 97.5% of the population is higher). He seens to think that testosterone fully explains my fatigue, and somewhat agrees with my desire to find the root cause, but he thinks that an endocrinologist is better equipped to do that.

Nonetheless, even if he did believe in optimizing health, he's right that this is difficult when insurance is involved.

Although I wanted to get tested for a few viruses, I hadn't thought of an infectious disease specialist: that's a great idea and thanks for the tip!


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## bigfoot (May 13, 2011)

CaptainThunderpants said:


> ...(he gave a blank look when I said that we wouldn't be happy if a child of ours scored 1 IQ point above the official retardation threshold).


Now that is a very easy way to get your point across. Hard for anyone to argue with that. Might have to borrow that one in the future!

I can't take credit for the infectious disease doc idea, as it was suggested to me by my own doc, since I am dealing with many of the same issues as you.

That being said, I can also say that when I was diagnosed with low testosterone a few years back, the day I started treatment was like a breath of fresh air. Much of the fatigue subsided within days. Unfortunately, my docs never asked the "why" question, so I've had to spend the time since then scrambling to learn as much as possible and optimize things.


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## CaptainThunderpants (May 21, 2014)

bigfoot said:


> Now that is a very easy way to get your point across. Hard for anyone to argue with that. Might have to borrow that one in the future!
> 
> I can't take credit for the infectious disease doc idea, as it was suggested to me by my own doc, since I am dealing with many of the same issues as you.
> 
> That being said, I can also say that when I was diagnosed with low testosterone a few years back, the day I started treatment was like a breath of fresh air. Much of the fatigue subsided within days. Unfortunately, my docs never asked the "why" question, so I've had to spend the time since then scrambling to learn as much as possible and optimize things.


Thanks; it is comforting to think that I might see rapid improvement once I actually start the process.

I posted the results for Prolactin & Estradiol in the other thread.


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## dred349 (Oct 27, 2014)

do you have varicocele ?


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## CaptainThunderpants (May 21, 2014)

dred349 said:


> do you have varicocele ?


That's a good suggestion, thanks.


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