Hormone level questions

[miscellaneousmedia]

My T is 385 (low/low-normal for a 50-year-old; free T is 60). My E is 13 (low! Not high!). I have had, though, gynecomastia since adolscence. Two docs have done work ups and find it to be ideopathic adolescent gynecomastia. But now I find I have osteoporsis! And again, after much blood work, the osteo is ideopathic, although my T level is making one doc wonder just a little bit about hypogonadism as a cause of the osteoporsis, and he has offered to give me some testosterone gel for the osteoporsis, as an alternative tratment to Boniva and other drugs in that class. He is concerned, though, that the testosterone gel could make my existing gynecomastia problem worse. Could it? Odds? Solutions? Thoughts?

[Hypo-is-here]

I can tell you for a fact that if you have low testosterone that can sometimes result in a low estradiol level (the opposite of what some people find) as testosterone is the fuel that fires estradiol, estradiol being a metabolite of testosterone (estradiol is the most potent estrogen and the one commonly measured and you can take it to be interchangeable for the word estrogen).

It is very common for men with hypogonadism to develop osteoporosis as a result of long term low testosterone.

Your testosterone level is fairly low, but all you have had measured from what you have told me is total testosterone in the blood.

A better picture could and should be elucidated by a more complete assesment of your endocrine system.

You should have

LH
FSH
Free Testosterone if not possible SHBG should be tested.
Estradiol
Prolactin
If possible dihydrotestosterone

The crucial factor is the level of free testosterone that is available for your body, if you cannot obtain such a test an estimate can be obtained by looking at total testosterone and a protein that binds testosterone called SHBG- Calculated Testosterone (CT).

Certainly your situation could very well require treatment.

There are differing forms of treatment for low testosterone which I am sure you will be aware of.  There are the gels, differing types of injections, implanted pellets and tablets.  It is very much a case of different strokes for different folks with something that works for some not working for others and vice versa.

Your gynecomastia is very unlikely to improve as a result of testosterone replacement therapy (TRT) given how long you have had the gynecomastia (it becomes fibrous after a couple of years and less responsive to medications).  So if you want rid of the gynecomastia you will almost certainly require surgery.

The TRT could increase any existing gynecomastia and in fact could see it return post surgery- that is a potential hazard.

What a good endocrinologist would need to do is start you on TRT and monitor your estradiol SHBG and free testosterone and act accordingly to lower SHBG or estradiol if either becomes problematic and therby prevent any issue.  This is easier said than done as obtaining an endocrinologist who is knowledgeable and up to speed on the latest treatment protocols for TRT, hypogonadism and related meds is not easy.

That said I will make it easier for you to get enough information to get where you need to be by pointing you here;

http://health.groups.yahoo.com/group/hypogonadism2/

and here

http://www.andropause.org.uk/newforum/forum_frameset.htm

These support groups can help you learn all you need to know, but it can take a long time to learn enough to help yourself understand such matters and the need of such healthcare- leaving it to the doctors and hoping they will just get it right on your behalf just isn't a viable option in this arena unfortunately.

On a positive note I can tell you that testosterone is one of only two hormones that actually helps to reverse osteoporosis.  Testosterone is an osteoblastic stimulator- osteoblasts are the human bodies bone remodeling team.  They are constantly at work building bone- when we lack testosterone we lack osteoblasts but we do not lack osteoclasts which deconstruct and strip away bone.  For this reason men with low testosterone are highly susceptible to having less bone re-built than that stripped away on a constant basis and resulting osteoporosis.  Testosterone can help redress this balance and improve bone density.

I have osteoporosis as a result of long term low testosterone myself and am currently on TRT.

I hope you found some of this info helpful.

[miscellaneousmedia]

Hi, thanks for the info and sorry for my delay in replying; I've been out of the country. Anyway, my other labs are this: Free T (60); Estradoil (13); LH (4.4); FH (4.4); Prolactin (5.4) and DHEA 252. I'm getting a second opinion in three weeks, the fact that everything is ideopathic, the gyne, the osteo is just plain puzzling to me and I am suspicious that there is a connection. Taking the TRT and worsening the gyne is a concern. Is there some way a doctor can lessen that risk. How does one get gyne, anyway, if the E has been low and the T normal and slowly sloping into low/normal? Besides prostate cancer and gyne, are there other risks to TRT?

[Hypo-is-here]

Hi, thanks for the info and sorry for my delay in replying; I've been out of the country.

No problem.

Anyway, my other labs are this: Free T (60); Estradoil (13); LH (4.4); FH (4.4); Prolactin (5.4) and DHEA 252.

I would need your reference ranges as well as results.

I'm getting a second opinion in three weeks, the fact that everything is ideopathic, the gyne, the osteo is just plain puzzling to me and I am suspicious that there is a connection.

Idiopathic just means that the cause is unknown, nothing more.  There is nothing at all puzzling about developing gynecomastia and osteoporosis if you have had low testosterone.  Gynecomastia readily develops when the testosterone to estrogen balance/ratio favors estrogen and that doesn’t require high estrogen- just a relatively poor free testosterone to estrogen ratio at some point.  Osteoporosis on the other hand develops quite easily when there is a long term lack of testosterone.

Taking the TRT and worsening the gyne is a concern. Is there some way a doctor can lessen that risk.

Oh yes, they have to know their onions and not many do.  In plain English they have to be very knowledgeable and progressive when it comes to treating male hormones and not be some old conservative fool or general endocrinologist who is used to dealing with diabetes all day.

The endocrine system is a symphony of hormones; the hormones require balance and are synergistic.  An endocrinologist who knows this ensures that if TRT increases estrogen too much that medications are on hand to reduce estrogen and keep the testosterone to estrogen ratio positive so that the patient feels well and benefits most from treatment and does not develop gynecomastia.  This balancing act can be very simple or difficult, depending upon the individual- some people do not require anything other than the right dose and type of TRT, other people need differing additional medication.      

How does one get gyne, anyway, if the E has been low and the T normal and slowly sloping into low/normal?

Well first of all, all we have is a snapshot of how your hormones have been at the point at which you had the blood drawn.  We do not known what your hormone levels were at the time the gynecomastia developed.  If it was a considerable time ago they could have been quite different and you could have had high estrogen and the same low testosterone, which would have been a perfect environment for the development of gynecomastia.  Even if your hormones were exactly the same as they are now, there are still many other complicating factors that affect the androgen to estrogen ratio and your susceptibility when it comes to developing gynecomastia.  What I can tell you is that if your testosterone is/has been low then that is a bad starting point and something that can certainly help make you far more susceptible when it comes to developing the condition.

Besides prostate cancer and gyne, are there other risks to TRT?

There is absolutely no link/connection between the development of prostate cancer and TRT.  Any doctor that is saying that there is any connection is talking/ basing their statements on outdated research from many, many years ago which has since been shown to be flawed and invalidated.  This is not just my thoughts but the thoughts of all endocrine societies in the western world.

TRT is only a problem and contraindicated in those that ALREADY have prostate cancer.  This is because when an individual already has prostate cancer; androgens can speed up the progress of the disease.

So making it clear, andorgens/TRT can increase prostate cancer if you already have it, but it does NOT in any way increase the likelihood of developing prostate cancer to begin with.

Prior to instigation of TRT, men with low testosterone should have Prostate Specific Antigen and Digital Rectal Exams to ensure that no prostate disease exists.

Patients on TRT should be monitored at regular intervals to ensure all is well.  Ironically such testing which includes PSA and DRE exams ensures that should a man on TRT develop prostate cancer, it is far more likely to be found at an earlier and more treatable stage than in men not on such treatment.

[Bradley07]

I'm calling tomorrow to schedule a consultation. Do you think I'll be required to have my hormones checked? I just don't have any reason to believe that there's a problem with my hormones. I have a mild case of gyne but I have normal hair growth, testicles, I don't have a *raging* sex drive but I've never had a problem performing either.  Soooo, do you think I'll have to go through all those hormonal tests? I really hope we can skip it because I don't think it's necessary. Do they always do those tests or only if they have reasons to suspect the gyne is caused by hormones? Thanks.

[Hypo-is-here]

It is my personal opinion that all men who have gynecomastia and particularly those considering surgery should have their hormones checked as a precautionary measure.

Many hormone specialists/endocrinologists routinely do this, whilst and equally high number of gps or endocrinologist don't.

[Bradley07]

well, i'd really prefer to just leave my hormones alone. people start giving you testosterone and prescriptions and then your testicles shrink or your hair falls out or something. i have a normal penis/testicles, a full head of hair, etc. I just want to get some surgery and have this crap excised/sucked out/whatever.

[Bradley07]

and just as an fyi, i didn't write "thingy", LOL...the board automatically changed the word to that. I guess it doesn't like the P-word, LOL.

[Hypo-is-here]

well, i'd really prefer to just leave my hormones alone. people start giving you testosterone and prescriptions and then your testicles shrink or your hair falls out or something. i have a normal penis/testicles, a full head of hair, etc. I just want to get some surgery and have this crap excised/sucked out/whatever.

That is all well and good, however if your hormones are a problem as they are for a significant minority of men and the gynecomastia re-develops then you will know why.

Ignorance is not the way to go- knowledge is power.  Have your hormones checked to be prudent as a precaution and ensure that if you do have an operation that it has less chance of returning.

That is my opinion for what it is worth- but do as you wish as is your prerogative, either way...all the best.

[Bradley07]

but i think if there were a problem w/ my hormonal levels then i would have other symptoms. i do not.

[Hypo-is-here]

I had pretty much no symptoms for 13 years other than gynecomastiaand ended up with osteoporosis due to low testosterone.

These things are not nearly so obvious as some doctors/people seem to think.

Symptoms of course are likely, but they do not always follow as a matter of course.

Gynecomastia and hypogonadism are associated conditions and 10% of all gynecomastia sufferers have hypogonadism.  25% of all gynecomastia sufferers have some underlying causative condition.

If you feel confident that it is not worth bothering with then that is upto you.....either way I hope you can get rid of or live with the gyne.

[Bradley07]

thanks for your advice/support. however, i REALLY don't think i have a hormone problem. i just read some info on hypogonadism, etc. and it talked about poor sexual performance and lack of body hair, beard growth, etc. i don't have any sexual problems, i have a very large "member" and have been told so by my sexual partners so it's not "in my head". also, i have plenty of body hair and beard growth isn't a problem. i shave in the morning and by the end of the day i need to shave again! soooo, i personally don't think it's a hormonal thing but I'll talk to the doc about it during my consultation on Sept 25. Thanks for the tips!

[Bradley07]

if i do go to a endocrinologist to have my hormone levels checked, would my insurance cover those tests? i know it may vary depending on the provider, but i'm speaking in general. Thanks!

[Hypo-is-here]

I would expect so, but you would have to check that this is the case with your provider/people in the US who can properly answer this question (I am from the UK).

[Hypo-is-here]

I missed this post so just to clear a few things up.

thanks for your advice/support. however, i REALLY don't think i have a hormone problem.

Advice- no thanks required..

Because of your lack of symptoms it probably isn't due to a hormone problem- but safe is better than sorry.

I just read some info on hypogonadism, etc. and it talked about poor sexual performance and lack of body hair, beard growth, etc. i don't have any sexual problems, i have a very large "member" and have been told so by my sexual partners so it's not "in my head". also, i have plenty of body hair and beard growth isn't a problem. i shave in the morning and by the end of the day i need to shave again! soooo, i personally don't think it's a hormonal thing but I'll talk to the doc about it during my consultation on Sept 25. Thanks for the tips!

Again, I agree you probably don't have a problem, but it is better to be safe rather than sorry, it is prudent.

Also most sites that explain about hypogonadism fail to properly explain just how diverse the symptoms are or how many people have some symptoms and not others or even no recognisable symptoms at all.  Very few sites explain how symptoms differ depending upon age, severity, time the deficiency began etc.

I know one guy who reported a very high sex drive despite being hypogonadal/untreated.  

I know of many guys who have had no reduction in sexual performance despite being hypogonadal/untreated.

So while libido and performance are often reduced in hypogonadal men untreated, this is not always so.

For many years prior to diagnosis/treatment I had no problems here.

Whilst reduced hair growth is seen in some men, this is not always so as hair growth also relates to other hormones and to a greater extent genetics.  Beard growth is sometimes only affected in men with severe deficiency.

In terms of the size (ahem).  Reduced size is only seen in men who develop hypogonadism prior to puberty.  If hypogonadism or partial androgen deficiency develops post puberty size is not affected.  I developed hypogonadism after chemotherapy post puberty- nothing changed in that department.

Of course everything I have stated relates to hypogonadism.  You need to have your hormones checked to ensure that estrogen is not high as this alone could cause re-development of gynecomastia post surgery.  Equally so could a thyroid disorder.

Again, most likley you don't have any problems whatsoever, I am not scaremongering, I have only said what I have because such practice/hormonal checks should be routine when a man has gynecomastia, particularly if he is considering surgery.

At least that is my belief- I don't want to hear about anyone re-developing post surgery as a result of taking a short-cut.