To Hypo and all knowledgeable ones on this site

[brm]

Hello. Sorry to bother you all with my personal case. You may remember: drug induced gyne (Avodart, 5ar inhibitor against hairloss). here is the problem. The blood tests seem to have become illegible!
06/2004: bioavailable testosterone:2.43ng/ml (reference range 0.8-4.3)
DHT: 1.94ng/ml (range 0.3-1.06) Estradiol:16 pg/ml (22-50) Androstanediol glucuronide: 0.5 ng/ml (2.5-23.6)
I had then been on propecia for 5 years. OK, those figures meant that propecia had not impaired my T production (my sex drive was very acceptable) and that dht inhibition was too low with the only 1 mg of finasteride that propecia contained.
Then, to counter the ongoing hair loss, I switched to 2.7 mg of finasteride then 3.5, then back to 2.7. And in 05/2005, we have:
Free T: 11.3pg/ml (12-40)  DHT:1.66 (0.3-1.06)
The level of T collapsed and so has the sex drive. The benefit on dht is quite modest but I regrew some hair.
Then, instead of 2.7 mg of finasteride, I switch to avodart+1mg of finasteride to try an other solution, hopefully less antiandrogenic. 6 months later, the gyne sets in. The lab says (11/2005):
Free test: 9.8pg/ml (12-40) DHT:1.2 ng/ml  Estradiol: 17pg/ml  prolactin: 24.4 ng/ml (range: "must be under 24") SHBG:3.5mg/l (range 0.6-3.6) FSH: 4.9 U/l (1.7-10) LH:5.83 U/l (1.5-15)
The estradiol doesn't seem high enough to have provoked the gyne. But the doc prescribes parlodel 2.5 against prolactin, Arimidex (2pills a week) and andractim. I give up avodart and go back to 2.7 mg finasteride. Then back to the bloodtest 2 months later (01/2006):
DHT:thru the roof (over 3 ng/ml) Free test: 11.3pg/ml (12-40) Estradiol: unchanged (17pg/ml) prolactin: quite unchanged (24ng/ml).
So, what of it all? After two months on arimidex (sait to be a powerful drug), the estradiol didn't budge an inch down and after 2 months on parlodel, neither has the prolactin???... Moreover, the underlying cause of the gyne remains unclear even if I've seen a great improvement in this department and am now a very minor case.
What amI to do? Give up arimidex (as I did andractim) and/or parlodel? Why is the prolactin so definitely high? Will the DHT come back to an acceptable level now that I'm clear of andractim? Is the high SHBG the real culprit?
I am seeing an endo tomorrow. What points should I stir and what hints should I make?

Thank you all and sorry again for such a long and quite rebarbative post. But I need your help.
                                                       

[_Edward_]

Prolactin can induce gyne, as I expect you know, and i expect that is what happened to you. There are a few things you can get to fight prolactin levels, but well they have a couple side effects apparently. Bromocriptine and Dostinex, but they are pretty expensive, but effective, although I don't know quite how safe they are. Do some research on them, might help you out!

[Hypo-is-here]

brm,

You have been on too many medications some of which have opposing actions.  Also there have been far too many meds and changes to dosages in FAR too short a space of time.

In short you’re in a real mess; it is like chaos theory in action!!!

I would be fuming if anyone prescribed medications like that too me as it is totally irresponsible.

I am aware that you might be self medicating, I only say this because it is hard to believe an endocrinologist would be as poor at drug management as this.

But look don't take offence, I want to help either way.

If you are indeed with an endocrinologist and they have been responsible for this management.

Fire them IMMEDIATELY and I will get you someone FAR more competent who can extricate you from this situation.

Now if you are doing this yourself, there is no point me saying don't do X, Y, Z as I don't think you would listen.  So if this is the case at least cull some of the things that are nonsensical and doing you no good.

I am and always have been dead set against finasteride in ALL forms as it has often left men with a form of hypogonadism that is difficult to treat.

http://www.androids.org.uk/stories.html

http://www.propeciasideeffects.com/

Also Dr Eugene Shippen one of the worlds leading hormone experts has reported the great difficulty that is sometimes found trying to treat men who have ended up with hypogonadism via propecia.

So in all honesty I would stop use of that immediately irrespective of anything else.

It lowers DHT and you have to understand that hypogonadism is not just a case of low testosterone as it is defined as low testosterone and or its metabolites and DHT is a metabolite of testosterone.

Finasteride is used as a treatment for prostate cancer to chemically castrate men.

If your DHT is lowered too much you say goodbye to your libido, can have erection difficulties etc.

Lowering DHT with finasteride is in short from an androgen point at least making you less male!!!

If I were you I would take my chances with hairloss rather than risk more gynecomastia, low libido, erection problems and possible hypogoandism.

Now if hairloss is a major worry consider hair treatments that do not contain anti androgens (a few do exist) or a hair transplant.

Back to the point;

You are also in the absurd situation where you have been lowering DHT with finasteride and increasing it with Andractim- which is just madness.

On top of upping and lowering DHT you have also been lowering estradiol and prolactin.

Too much too soon and too much hoping about.

I mean you end up in a position where you think ok there is a libido problem now is it because testosterone is too low, DHT too low, estradiol too low or too high or is it a prolactin problem.

Just crazy.

So bin the finasteride.

Next.

Your estradiol is too low according to most male reference ranges in the pg/ml molecular range.

If estradiol is too low you end up with a dead libido, it can also cause erection problems and you can throw your thyroid out.

You might even be experiencing fatigue and back pain from this med at that level.

So I would kill the arimidex at least until further testing (You should be using a lab like Quest which has a sensitive estradiol test for men- with accompanying correct reference range).

Remembering that this is the advice if you are self medicating as opposed to legit which I have already covered.

I would then get an appointment with a competent reproductive endocrinologist to try and ascertain why that prolactin level is so high.

There is no way around this problem self medicate or not.

A good endo will re-test the HPTA and related hormones, almost certainly taking you off the prolactin med as well- leaving you on no meds.

He would then keep you off meds for a couple of months and then re-test the HPTA and relevant hormones.

If prolactin is high and there is no mistake he/she will book you in for a MRI scan of the pituitary to rule out a prolactinoma.  A benign (non cancerous) tumor of the pituitary that can secrete prolactin.  This is no where near as serious as it sounds.  People with this problem will either get a medication that works or have minor surgery with the pituitary accessed via the nose cavity.

If no prolactinoma exists he may look for other causes of the high prolactin or alter the medication to an alternative that will lower your level.

To an extent my advice is one of all roads lead to Rome in the sense that I really do think you need competent professional help irrespective of whether you have been legit or self medicating thus far.

Once you come out of the back end of all this, the endocrinologist can re-test the HPTA in x number of months time and re-asses your HPTA.  In doing this he could check your testosterone, DHT and estradiol levels to ensure all is well and if something is amiss treat with one drug and see over x months how that works.

If you tell me city and state I'll get you the details for the endo.

You can then choose if you want to follow my advice or not...but in any event you'll have the phone numbers should you decide to go with what I have said.

Hope that helps.

[Hypo-is-here]

Prolactin can induce gyne, as I expect you know, and i expect that is what happened to you. There are a few things you can get to fight prolactin levels, but well they have a couple side effects apparently. Bromocriptine and Dostinex, but they are pretty expensive, but effective, although I don't know quite how safe they are. Do some research on them, might help you out!

No that is a bad idea Edward.

It is important to rule out a problem if prolactin is high with a MRI scan and that is something no one can look up on the internet.

The guy will need a good endocrinologist.

[_Edward_]

I'm usually against self-medication, but some doctors are just idiots, and I guess that I was applying my own experience to this man, which was a mistake of mine for which I apologise, although I do stand by that those two medications are effective at fighting prolactin levels, but I suppose I would not advise using them yourself in your state.

[Hypo-is-here]

Your absolutely correct about the meds Edward and I'm sure you meant well.  It's just brm needs to find out why the prolactin is high and rule out an underlying cause.

Plus the last thing he needs right now is to throw more meds into the mix.

[brm]

Thank you for your answers.  No, I'm not really self medicating since I need prescriptions to get those meds. But those prescribing docs are GP's, one of which says he's knowledgeable in the endo area. I guess you're right. he mustn't be. But loosing my hair would be worse than anything. That's the problem.
Thank you Hypo for your long reply even if some point is unclear. I may understand that DHT, as a metabolite of T  is necessary for a good libido. But we must not forget that with the 1mg finasteride on its own, I was way above the average DHT value observed in a male of my age, all males most of whose are statistically supposed to have a satisfactory libido. So, can't excess DHT be regarded as a dysfunction as long as it's well over the average?  And we must also remark that some finasteride users report some boost of libido. So?...

[brm]

BTW, Hypo, I'm not sure that you can help me with a good endo in my area: Paris (France).
Thanks anyway.

[Hypo-is-here]

Thank you for your answers.  No, I'm not really self medicating since I need prescriptions to get those meds. But those prescribing docs are GP's, one of which says he's knowledgeable in the endo area. I guess you're right. he mustn't be. But loosing my hair would be worse than anything. That's the problem.
Thank you Hypo for your long reply even if some point is unclear. I may understand that DHT, as a metabolite of T  is necessary for a good libido. But we must not forget that with the 1mg finasteride on its own, I was way above the average DHT value observed in a male of my age, all males most of whose are statistically supposed to have a satisfactory libido. So, can't excess DHT be regarded as a dysfunction as long as it's well over the average?  And we must also remark that some finasteride users report some boost of libido. So?...

A)
I do not know of any hormone condition caused by excess DHT.  In fact the bloods do not always tell the full picture as there maybe a reason for some men to have higher and require a higher level of DHT than others at a genetic/receptor level.  Certainly this is true with testosterone and the same maybe said for DHT.

B)
Given you have not been seeing a reproductive endocrinologist I would call into question the legitimacy of the labs results and think re-testing would be in order.  I also wonder why you are seeing multiple gps?  Surely you should have one gp and see specialists in given fields for given concerns and the gp should collate all the info from the various specialists so that you have one all encompasing record of your health that can be correctly managed.

C)
GPs are VERY rarely experts in this area of medicine and given what is going on with your drug management I think the people in charge of your health care have no idea what they are doing/what is going on.

D)
Finasteride cannot increase libido- this is a factual impossibility as it lowers androgen levels.  Hormones of course are only one part of the equation when it comes to libido so it is possible that individuals could have an increased libido at a given time and that this may coincide with the use of any medication.  But certainly any increase cannot be put down to finasteride- quite the reverse.

E)
I probably could get you a top endocrinologists details in Paris if you wanted to see one, you would just have to give me time in locating one.  Remember I have been getting people endos in the states and canada and I am from the UK.

P.S

The one fundamental here is that you are on far too many meds with too many changes in dosages and you have high prolactin which requires investigation.

Best of luck

[brm]

Thanks again. Good if you can find a reliable reproductive endo in Paris or its suburbs.
I'll report what the endo (not a top one, likely) will say to me tomorrow.
(the reported enhanced libido from some fin users lies upon this reasoning (I won't back up nor deny): "Since the conversion into DHT is blocked, the share of bioavailable T is increased.")

[Hypo-is-here]

Any news on the appointment, how did it go?

[Hypo-is-here]

^bump

[brm]

Sorry hypo.  I was busy these past days. Well, I can not assess the appointment I had with the endo. After 5 mns spent in her office, I thought it was one more useless consultation. The girl didn't know propecia, nor chibroproscar, nor avodart, nor arimidex. She had to refer to her drug directory for each. She didn't even know that antiandrogenic medications were prescribed against hairloss. But she seemed to weigh it all out after all and told me about the same as you did: too many drugs thrown in. She took me off arimidex, off parlodel (against prolactin) and worried mainly about the quite high prolactin level. She said though that domperidone (which I take for gastric matters) favored prolactinemia. She asked me to wait for some time before having some fresh bloodtest for prolactin and estradiol (though estradiol appeared untouched in spite of the 2 months on arimidex). So, I'll wait a fortnight until getting the job done then back to her. Then, according to the result, she said that some pituitary MRI might be needed.One thing left me a little perplex. I told her about my concerns with andractim. Having taken some for 2 months in november to help "cure" my gyno, I'm experiencing some hair shedding now, though I couldn't relate the two for sure. She  positively said that andractim was a safe drug, unable to have any serious systemic effect.  Unto which I replied that the DHT test had revealed some huge increase which was harmful for my hair. She seems to believe that the action of andractim against gynecomastia is effective and hormonally focussed upon the  chest where it's applied. I find it very difficult to believe this even if i would be very glad to. She backed up her assessment by the fact that andractim is prescribed to adolescents whose sexual development is not hindered nor disturbed in any way. Yes, but how could a 14 year old  boy suffer from a serious case of alopecia. The example doesn't seem very convincing to me. What d you think? BTW, are exogenous hormones, like DHT, as potent or harmful (accordingly) as endogenous ones?

[Hypo-is-here]

Sorry hypo.  I was busy these past days. Well, I can not assess the appointment I had with the endo. After 5 mns spent in her office, I thought it was one more useless consultation. The girl didn't know propecia, nor chibroproscar, nor avodart, nor arimidex. She had to refer to her drug directory for each. She didn't even know that antiandrogenic medications were prescribed against hairloss.

Endocrinologists are not all the same they specialize in many differing areas and it maybe that this endocrinologist specializes in something other than reproductive endocrinology.  Having said that, as long as the endocrinologist concerned is compassionate and willing to help (something an individual either has or doesn’t have irrespective of their chosen walk of life) then there is the chance that they can take the necessary basic and rational endocrine steps that will allow for a good outcome.  Of course it would be helpful if she were aware of these things at the outset, but the bottom line is if she treats you effectively such details in the end will prove irrelevant.  

But she seemed to weigh it all out after all and told me about the same as you did: too many drugs thrown in. She took me off arimidex, off parlodel (against prolactin) and worried mainly about the quite high prolactin level.

Well it’s good if the layman’s advice tallies with that of the consulting endocrinologist.

She said though that domperidone (which I take for gastric matters) favored prolactinemia.

And she may just have hit the nail on the head.  See below.

http://www.canadadrugsonline.com/Domperidone/domperidone-side-effects.html

In cases where medications cause particular unwanted side effects it maybe possible to discontinue that medication and have an alternative prescribed that does not have the same problems.  Of course it can be swings and roundabouts as an alternative medication may have its own differing and troublesome side effects.  Nevertheless this is certainly worth looking into.  

She asked me to wait for some time before having some fresh bloodtest for prolactin and estradiol (though estradiol appeared untouched in spite of the 2 months on arimidex). So, I'll wait a fortnight until getting the job done then back to her. Then, according to the result, she said that some pituitary MRI might be needed.

Quite odd.

Given the medications you were on I would have thought a re-assessment would be in two to three months time.  I am not sure the effects on all those medications will be gone in the space of time that has been mentioned.  I suspect (but it is only a suspicion) that the medication that you have mentione and your endocrinologist has raised is the cause of all your problems.


I am slightly surprised that she didn’t take you off that medication now and reassess the prolatin level as this would have told her whether or not an MRI is required.

Still I am sure she is just going about matters in a slightly different way.  

One thing left me a little perplex. I told her about my concerns with andractim. Having taken some for 2 months in november to help "cure" my gyno, I'm experiencing some hair shedding now, though I couldn't relate the two for sure. She  positively said that andractim was a safe drug, unable to have any serious systemic effect.  Unto which I replied that the DHT test had revealed some huge increase which was harmful for my hair. She seems to believe that the action of andractim against gynecomastia is effective and hormonally focussed upon the  chest where it's applied. I find it very difficult to believe this even if i would be very glad to.

I think you are both coming to this from very different perspectives.  She has said that Andractim is a safe drug.  This much is true- unless you have certain specific conditions that I wont go into or are at a particular age which could adversely affect bone growth, but yes she is correct.  She goes further and say “unable to have any serious systemic effect”, the operative word there from her perspective I would imagine is “serious”.

I would very much doubt that hair loss would represent a serious situation to her, obviously it does to you.

In terms of the actions of Andrcatim and in fact any androgen applied locally via a gel;

They work locally via the site of application and they also work systemically via the endocrine system.  It is quite wrong and ridiculous to try and state otherwise.  

I apply Androgel every day.  It is a testosterone replacement therapy.  Now if I place this testosterone on my shoulders or on my legs- it will still elevate my total testosterone level in the blood and my free testosterone level used by the androgen receptors across my body, so that is a systemic effect.  However if I place the gel on my chest (the pharmaceutical manufacturers specifically state not to do this) where there is glandular tissue and where there are local estrogen receptors that could result in gynecomastia, as the result of the localized actions of testosterone.  Likewise if I was daft enough to place the Androgel on my scrotum, an area packed with alpha 5 reductase tissue, then a high percentage of the testosterone would be converted into DHT.  Again we are talking about a systemic and localized action.  Interestingly there is a cream that many hypogonadal men are on that is applied to the scrotum because of this exact localized effect.

With Andractim the same as with Androgel or Testim etc you have a hormone and you have a carbomer/patented hormonal delivery system.  You have systemic and localized effects.

In you put Andractim on your chest it has a localized effect on the Estrogen receptors and glandular tissue in the chest and it also has a systemic effect in that it absolutely increases DHT in the blood and effects DHT via the androgen receptors elsewhere in the body.

Which is why many men on Andractim have reported;

Hairloss
Fatigue
Increased libido
Increased number and strength of erections

She backed up her assessment by the fact that andractim is prescribed to adolescents whose sexual development is not hindered nor disturbed in any way. Yes, but how could a 14 year old  boy suffer from a serious case of alopecia. The example doesn't seem very convincing to me. What d you think? BTW, are exogenous hormones, like DHT, as potent or harmful (accordingly) as endogenous ones?

[/quote]

That is an inappropriate example.  Young men who are given DHT presumably have alpha 5 reductase deficiency (some may have differing androgen related issues) and are deficient in DHT to start with; therefore replacement of this hormone to adequate levels is not the same as use of this hormone in men that do not have this deficiency.

Her example is like saying, I have had a chocolate liqueur and that contains alcohol and I am not drunk ergo drinking alcohol does not cause drunkenness.  

It is all about levels/quantity.

Water is toxic in certain quantities but we do not say water is toxic do we.

Andractim in the boys she has mentioned would be about hormone replacement, not raising the hormone to supraphysilogical levels.

I have labored that point.

But also Andractim is DHT is dihydrotestosterone and dihydrotestosterone cannot cause male pattern baldness on its own.

Hormones obviously have an effect on hair loss, as can be seen by the lack of hair loss in women (obviously the conditions name says it all MALE pattern baldness).  But an individual can have very high DHT and still no hairloss whatsoever.  This is because there is a recessive gene involved in this condition and you need to have the recessive gene in combination with high DHT for the DHT to be the source of hairloss.

Many of the boys she is referring to would not have the recessive gene and therefore not experience the condition even if DHT levels were high enough (but like I said they wouldn’t be).

Added to that, hairloss is something that is often the product of time.  If boys were on DHT treatment how many of them would have noticeable hairloss within the time frame that they were studied.

So every which way you can see what is being said is wrong.

Last of course is the fact that hairloss simply wouldn’t really be checked in DHT treatment of young boys anyway, it simply would not be a concern to the treating endocrinologists at the time and highly unlikely to be reported.

I hope that helps.


P.S

Despite some incorrect statements and some missing knowledge, I think your endo has took the right steps for the most part and I think you may be close to getting to the cause of your gynecomastia.

[brm]

Thank you hypo. This is not very comforting as to the looming big shed of hair. As to domperidone, the daily dose has been cut by half by my othorinolaryngologist. It's a fist step. i ha d been on it for 2 years.