Results of hormone blood test, etc.

[Raider Fan]

Hello doctors.  Im a middle aged male.  I began having consistently painful gynecomastia about 6 weeks ago and my doctor order a mammogram.  It showed that I have bilateral gynecomastia, however, only my left breast is having noticeable symptoms (enlarging, pain).  Following this test, I went back in to have my hormone levels checked.  I was told that all the levels came back within the normal range, except my testosterone was "slightly low".  I didn't receive a breakdown of my free and total T levels.  My doctor recommended having my T levels rechecked, to confirm that they are truly low.  I was told if it continued to be low, he would put me on some kind of testosterone gel. 

My questions:

1.  No definite "cause" has been attributed to my gynecomastia by my doctors, even with my slightly low T.  Could "slightly low" testosterone be causing my recent gynecomastia, or do you think it's unlikely and/or coincidental?  My doctor's nurse said no, but the literature I have read says low "T" can cause gyno.  I just don't know how likely it is.  Low T doesn't seem to go with a sudden onset of persistent gynecomastia, but I'm just trying to rule things in and out. 

2.  The literature lists symptoms such as low sex drive and ED for low T levels.  However, I do not have that, nor do I have symptoms of depression or memory loss.  I do have hot flashes, joint pain, low energy and weight/fat gain, but a lot of middle aged guys have that.  When adding these symptoms to my gynecomastia, I suppose it's not unreasonable to say it could be related to low T, but do you think it's likely? 

3.  Some information I read on low T said patients with slightly low levels of T likely will derive no benefit from replacement therapy, therefore, it is not recommended.  Would you agree with this statement, or do you feel T supplementation is generally the way to go for most men if levels are low? 

4.  Prior to developing my gynecomastia, I had a shot of celestone for an ear infection.  Celestone shows to be a corticosteroid, and corticosteroids are on the list of meds that can cause gynecomastia.  Do you think this cortisone shot could have triggered my gynecomastia?  And, could it have been responsible for slightly lowering my T level a few weeks later? 

Thanks in advance for your time and answers. 

[Raider Fan]

No answers/thoughts on any of these questions? 

[Litlriki]

Clearly, something is up with your hormonal levels. Whether that was caused by the Celestone injection or some other factor is beyond our ability to determine, and it's likely that you'll get more informed opinions from an endocrinologist who can support his or her opinions with laboratory testing. 

That said, it sounds like you've had a recent and thus far brief encounter with gynecomastia, and my recommendation would be to wait at least six months to allow for the condition to resolve with or without hormone management, based on the recommendations of an endocrinologist.  You may need surgery in the end, but rushing to that without determining the cause could leave you with a recurrence unnecessarily. 

Good luck,

Rick Silverman

[Raider Fan]

Clearly, something is up with your hormonal levels. Whether that was caused by the Celestone injection or some other factor is beyond our ability to determine, and it's likely that you'll get more informed opinions from an endocrinologist who can support his or her opinions with laboratory testing.  

That said, it sounds like you've had a recent and thus far brief encounter with gynecomastia, and my recommendation would be to wait at least six months to allow for the condition to resolve with or without hormone management, based on the recommendations of an endocrinologist.  You may need surgery in the end, but rushing to that without determining the cause could leave you with a recurrence unnecessarily.  

Good luck,

Rick Silverman

Thanks, doctor.  Yes, as much pain as I'm experiencing right now, I wouldn't even think of having gynecomastia surgery now.  Even if I didn't know that doctors advise NOT having surgery until the active phase of gyne has ceased, simple common sense should tell people that having surgery would not be in their best interest when their breasts are at the height of feeling inflamed and painful.  Cutting into them at such a time just makes no sense until the condition stabilizes.  My problem is.....at this point, there seems to be no indication of there ever being a let up in the condition.  My whole chest is hurting and I am even feeling discomfort/swelling under my armpits.  I don't know what's going on, but it doesn't sound like everyday gynecomastia.  I haven't heard anyone else describe their gynecomastia in this manner....where pain and swelling are the main complaints.  My left breast feels inflamed and when I simply walk around, it feels like i have a golf ball under my skin.  

I did get my hormone tests back and my total T was 230, which is low.  Unfortunately, my doctor did not measure my free T, and from what I've read, that's the most important one of all.  

My estrogen level was just barely within the normal range.  If it had been 3 points higher, it would have been in the high range.  But my doctor just looked at it as no red flag, since it was technically within the normal range.  I'm not a doctor, but to me, that doesn't make sense to just disregard the finding because it's in the normal range.  

Just as ratios are important in cholesterol lab readings, I think ratios between your estrogen and T are probably important, too.  I've got low T and high-normal estrogen.  To me, THAT'S significant.  My LH and FLH are also within the normal range, but toward the low end.  

Everything I've read suggests these findings should point to ruling out a pituitary tumor.  But my doctor only said all my hormone levels were normal except the T.  He wants to put me on Androgel if my next blood test shows the T to be low.  And that's apparently it.  He says my "slightly low" T is NOT the cause of my gynecomastia.  I don't know why he thinks that, when the literature I've read says it COULD be the cause.

I feel like I need to go to an endocrinologist and I feel like I need to have an MRI of my brain to rule out the pituitary tumor.  I also would like some more blood work to look at other hormone levels which have not been checked.  My cortisol level has not been checked, and I would like to have my liver and kidney functioning looked at.  

I really don't understand why, if estogen is too high and T is too low, the typical treatment is simply to put a man on T gel.  I know it's important to supplement the T if it's low, but it would also make sense to try to lower the estrogen.  No one ever seems to go that route.  Everything I read, they just focus on increasing the T.  And much of the time, it doesn't seem to benefit the person.  So if there's no noticeable benefit from it, why use it?  Especially when the side effects can be exceptionally bad (shrinking testes, stops sperm production).  

I know there are medications for lowering estrogen, the main one being Tamoxifen.  But other powerful meds for this are Letrozole and Anastrozole.  You don't see these mentioned much, and I really don't understand why.  I know a lot of doctors simply don't know about them.  If meds are used in ways which are not in the PDR, they seem to freak out.  When I brought up Tamoxifen to my doctor when I first thought I gynecomastia, you would have thought I told him I was a space alien.  He just looked at me like I was crazy for even suggesting such a thing, when the literature is full of using Tamoxifen to ward off early gynecomastia.  

Can you take medicines to increase T and lower estrogen at the same time?  In other words, would it be ok to take Tamoxifen and/or Letrozole while also using the Androgel?  I just never see this.....it's only the T gel that doctors use.  They don't seem concerned about lowering estrogen.  

To me, it would make sense to address both problems.  Lowering the estrogen should definitely take care of the gynecomastia.  But most doctors only focus on the T gel.  And ironically, the T gel can CAUSE gynecomastia.  Great.....    It's one big puzzle that no one seems to know the answers to.  It's amazing to think that in this day and age, medicine just doesn't seem to know much about hormone-related disorders.  We really don't know what the optimal T level should be for men across a variety of age ranges.  We really don't know what giving T long term will do to the body.  It's disconcerting when even the doctors are pretty much guessing, too.  

I really wish I could get a handle on what all is going on with me.  It's stressful to feel sick, and not knowing why or for how long I'm going to feel bad makes it even more stressful. Everything moves at a snail's pace and it's hard when you are in pain and want answers RIGHT NOW!  Waiting for blood tests, getting referred to new doctors, getting more tests under THAT doctor, and waiting for those results....it's just a never-ending process.  

[Litlriki]

I'm not an endocrinologist, but I would agree with your doctor's approach: manipulate one variable at a time to correct the problem.  If your problem is low testosterone, then you need to increase that level.  That should correct the "ratio" and it's the ratio that's the problem with gynecomastia.  If that doesn't bring your testosterone levels back to normal, then something else may be required. 

Drugs like tamoxifen (which can also cause gynecomastia) also have side effects.  If you can manage the problem with one drug, why add others, which only increase the potential for additional side effects?

As for additional studies (MRI, etc.) I'm not able to comment based on your history.

Rick Silverman

[Raider Fan]

If your problem is low testosterone, then you need to increase that level.  That should correct the "ratio" and it's the ratio that's the problem with gynecomastia.  If that doesn't bring your testosterone levels back to normal, then something else may be required.

Curiously, my doctor said he DOESN'T think my low T was responsible for my gynecomastia.  The reason he's concerned with the low T is mainly because of other health problems it can apparently cause.  His nurse specifically mentioned osteoporosis to me, but the literature mentions a variety of other things, like heart problems, depression, arthritis, Alzheimer-like signs, low libido and impotence.  As far as I know, the only low T symptoms I have are hot flashes, arthritis and weight gain (especially around the middle), but I think a lot of "normal" T men have these things.  So who knows?

The thing that's frustrating to me is that my doctor doesn't seem to want to find the CAUSE of my low T the way I do.  He dismisses my high-normal estrogen blood level.  He also said he would refer me to an endocrinologist if I really wanted to go to one, but he thought I would be "wasting my money".  I don't think he thinks an endocrinologist would be able to do anything more than he's able to do.  And he may be completely right about that.  From what I've heard, all endo's do is mainly a lot of blood tests....the SAME tests my doctor has already done.  And treatment simply depends on the results of those blood tests.  There's nothing "magical" about it.  Any doctor should be able to follow accepted protocol.  As much as I know about it, I feel like I could even interpret the results and choose treatments. 

After my last T test came back low (230), he wanted me to have another T test. So I did and it came back around 430....which is not low.  That's an average of 330 for the two tests.  Now he wants me to have another T test in a week or two. 

My concern now is.....WHY was my T so low the first time it was checked, and what is someone supposed to do if they are only low on T "sometimes"?  I guess that's what my doctor is trying to determine. 

From everything I've read, if a man has low T but no symptoms, the prevailing opinion is NOT to treat it with TRT.  Even when men are treated with TRT, it often seems to not do a whole lot.  Coupled with the side effects, it's kind of a scary medicine to take....especially if there's not a clear need for it.  And the "clear need" goes back to what I said before.  No one seems to know about hormone levels, even in this day and age.  There's not even agreement between doctors of when low T should be treated and when it shouldn't. 

In the meantime, my left breast continues to feel like it has a grass burr inside it, and no one seems to know what to do about it.   

Thanks for your comments and your time, doc!