Hypo, Thank you for the valuable information.
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Not at all, my pleasure.
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One thing that I am never able to do in medicine is to treat or even interpret blood results without taking good history and performing efficient clinical examination and then come up with clinical problem for which the blood tests are only a guide to the full picture of the problem.
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I do not know your position but this is very good medical practice!
Poor/lazy medicine relies on pathology and advances in science alone when in fact we have hundreds of years of symptomatology. The human body should never be ignored/underestimated, as the answers can often be found via clinical presentation.
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Treating the blood test and not the clinical problem can take us to a dark road.
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I concur (within reason).
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the information I provided was a very simplified honest guidance to Raven. He is clearly not in the medical field and doesn't know about the art of practicing internal medicine.
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True.
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SHBG doesn't go up and down randomly, there are disease states in which this occurs, furthermore it binds both testosterone and estrogen (although more tightly to testosterone). SHBG binds also t4, if it was high in Ravens case his TSH would not be normal.
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It does not go up randomly as you say, but it can and very often does increase with age, can increase due to medication and can often appear high with know known discernable cause and can go up in cases of testosterone replacement in hypogonadal men (thought the latter is not relevant in this situation).
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for eg, if (hypothetically) one is sexually active and fertile, I don't care how low his testosterone is as long as this level is asymptomatic and is not an introduction to a future problem.
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You should, this is incorrect!
There are a myriad of symptoms make up a testosterone deficient male. Libido is only one of those symptoms and I have known of many men, myself included who was sexually active whilst still suffering from testosterone deficiency.
Long term untreated testosterone deficiency for me resulted in osteoporosis in my spine.
Long term testosterone deficiency is strongly associated with a significant statistically increase in (CVD) cardio vascular disease, diabetes (1 in 3 men with type 2 diabetes have hypogonadism), osteoporosis, strokes, Alzheimer’s, obesity etc.
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Gynecomastia ALONE, if caused by abnormal oestrogen/androgen ration will not require any medical treatment and, if surgery is done, is extremely unlikely to recur because the remaining glandular tissue is minimal.
IF GYNECOMASTIA IS PART OF A WIDER SPECTRUM OF CLINICAL PROBLEM and the hormonal ratio is abnormal, then a cause and a treatment would be required.
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No, I’m afraid this is simply not true, I wish it were.
Re-growth is not so rare, I have known many men whose gynecomastia has re-developed because of low testosterone/poor androgen to estrogen balance. There has been dozens through this very website in the space of a year of so.
Almost all surgeons wish to operate only when the patient has had normal pathology come back, all ask the patient to signs waivers- most are aware that gynecomastia can and does return in states where a hormone imbalance remains. A surgeon on this very website has presented cases of re-growth and explained that it is almost impossible to remove all glandular mass. Glandular mass that hormones can still act upon if an imbalance remains.
In the UK health care system, patients are treated first for the hormone problem, and then have to wait around six months or so, so that hormones on treatment are stable.
Maybe we are at crossed purposes here and there is a misunderstanding?
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HARISSON'S text book of medicine, 16th edition,page 2193 has an algorithm that recommends checking hormones ONLY IF there is clinical evidence of androgen deficiency (tender/very large/ rapidly enlarging breasts, small testes....)
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Well I am sorry to report that this is not very good practice!!!!!!
Testosterone deficiency can occur for numerous reasons; one is testicular failure, in which case the clinical picture is usually evidenced by small testicles as measured by an orchidometer or calipers.
However testosterone deficiency can be caused by numerous factors in which testicular size does not reveal a problem.
High prolactin, as seen in cases of prolactinomas, metabolic hypogonadism and post pubertal hypogonadotropic hypogonadism are all examples of causes of testosterone deficiency where testicular size is unlikely to alert the examining doctor to any problem.
The text book you are referring to is at odds with the (AACE) American Association of Clinical Endocrinologists and their guidelines that relate to testosterone deficiency.
From my own point of view, I concur with many European endocrinologists on this matter.
Gynecomastia warrants endocrine testing in all sufferers.
10% of all gynecomastia sufferers have hypogonadism, 25% of all gynecomastia sufferers have some underlying causative condition which causes their gynecoamstia.
These conditions can often be found via pathology.
Furthermore rarer but life threatening conditions such as testicular cancer (16% of all testicular cancer sufferers have gynecomastia), liver cancer, breast cancer, Hemochromatosis (1 in every 250 people of European decent has this iron overload condition that can kill, it is the most common genetic condition in the world), alpha 1 antitrypsin deficiency can be found etc.
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SHBG does not go up and down randomly, there are disease states in which this occurs and they would most likely present clinically, furthermore it binds both testosterone and oestrogen and affect the level of both (although more testosterone).
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Yes I know. But high SHBG binds with less affinity to estradiol as you know which is why it is often an issue in those in whom it is high.
I am aware of the binding affinities of SHBG, a test for SHBG is always relevant when only a serum testosterone test can be undertaken.
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SHBG binds T4 as well and if it was high, Raven's TSH would have been abnormal and this is not the case.
I was not aware that SHBG did bind to TSH, however it is poor medicine to assume that SHBG is ok because TSH could be affected by a poor conversion of T4 to T3, or by secondary hyperthyroidism (unresponsive pituitary).
SHBG should be tested in its own right unless a free testosterone test is undertaken.
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Having said all the above I feel that a better endocrine screen (one that I would do to my patients) would include hCG, total and free testos and oestrogen, SHBG and oest:testos ratio and as you said at 8:00 am.
HCG, yes I agree because it is a tumor maker, free testosterone tests are not always readily available (the UK for instance). There are some poor commercial free testosterone tests that need to be avoided (for methodological reasons). A testosterone to estradiol ratio is something that is usefull and often not considered.
Your pathology panel is very good.
To men that you suspect as being hypogonadal or having thyroid problems I think you should add cortisol, as adrenal fatigue is something that can be a factor. For men you have confirmed as being hypogonadal, you may wish to add IGF-1, as a growth hormone problems can occasionally be a complicating factor.
For men that present with gynecomastia who have used products containing finasteride such as propecia a dihydrotestosterone test should be given.
Topic: My Endo results here... Question? (Read 6911 times)
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