Hypo-
There is no way that you aren't a doctor. Either that, or a professor.
I’m not a doctor, I am a lay person who has hypogonadism and has had gynecomastia.
I have been reading your posts for a while and you have got my mind spinning. I am especially intrigued with what you say about hormone ratios. Is it safe to say that all gyne is caused by permenent of even a temporary hormone imbalance?
At its core gynecomastia IS caused by a hormonal imbalance, for many people this imbalance is a temporary one during puberty. For a significant minority of men the imbalance is permanent or semi permanent.
The question of what the cause (aetiology) of the imbalance is, is sometimes found, when the cause is not found it is referred to as idiopathic. Idiopathic does not mean there is no cause, just that the cause is unknown
According to Glen D Braunstein (studying endocrinologist) and Ismail and Barth (studying biochemists) the relative statistical likelihoods/causes of gynecomastia as given in their respective studies (Brunsteing- Gynecomastia 1993), (Ismail and Barth The Endocrinology of Gynecomastia) are;
Idiopathic 25%
Puberty 25%
Drugs 10-20%
Cirrhosis/liver disease or malnutrition 8%
Primary hypogonadism 8%
Testicular tumor 3%
Secondary Hypogonadism 2%
Hyperthyroidism 2%
Renal disease 1%
Other 6%
So causes unknown relatively account for as many cases as puberty. Drugs as a cause includes prescribed and those self medicated and includes those abusing steroids as well as those on known associated drugs such as digitalis.
Cirrhosis/liver disease is often more of a concern and relative cause in men over 50, but liver disease can rarely be an underlying cause in younger men.
Hypogonadism is a significant cause of gynecomastia and accounts for 10% of all those who have gynecomastia or relatively thereabouts. Other includes all the conditions which have been known to cause gynecomastia in less than 1% of cases such as breast cancer.
The above figures mean that 50% of gynecomastaia cases are caused either by puberty or unknown origin. It also means that;
As many as 50% of cases have an underlying cause which could be found, some of which are serious and require diagnosis.
Of course these statements are only true if the figures presented by the aforementioned doctors are correct/near the mark. At the moment there aren’t any credible studies that conflict with these figures, so in the absence of further study/information it is all we have and so it is what I go off until I am presented with something of similar or greater credibility to the contrary.
It is my personal belief that hypogonadism is under diagnosed and that many of those who are told they do not have a hormone problem and have their gynecomastia labeled idiopathic do in fact have a hormone problem, often hypogoandism.
It is my belief that part of the problem in diagnosing hypogonadism and other hormone conditions and over labeling of gynecomastia patients as being idiopathic comes down to;
Too much emphasis being placed on strict biochemical parameters/definitions that fail to adequately take into account hormone ratios, the inherent problems in defining normal ranges and the lack of attention paid to symptomatology.
Even when considering hypogonadism under the status quo arrangement and reliance on strict criteria that fails to identify many men with hypogonadism;
The conclusion in the latest American Association of Clinical Endocrinologists guidelines on hypogonadism state and I quote verbatim;
The evaluation, recognition, and treatment of hypogonadism the male patient are often dismissed by the patient and overlooked by the physician.
So the national guidelines for the US and all the endocrinologists that comprised their thoughts agree, are in accordance that hypogonadism is “often overlooked by the physician”. If the condition is often overlooked by the physicians in the US, is it any wonder then that hypogonadism is under diagnosed and with it the cause for gynecomastia in some men?
Given that the US is ahead of most of the world in studdying this condition and preparing such detailed guidelines where does that put the rest of the world if not further behind than the US?
Given that such strict definitions/criteria that is placed on hypogonadsm is also placed on the diagnosis and treatment of other hormone conditions such as thyroid and growth hormone conditions, is it any wonder that many websites can be found across the world bemoaning the same inherent problems with strict diagnostic criteria?
I have always wondered how a guy like me, who can pack on muscle with no problem could have suffered from moobs.
There are many potential causes and I cannot comment on your individual case.
What I can say is that many men face a temporary hormonal imbalance during puberty where for a period of time the androgen to estrogen balance is in favour of estrogens. Given the right endocrine environment the physiology for breast development is the same in men as it is in women.
If a mans androgen to estrogen balance favours estrogens for too long a period of time then the breast tissue becomes fibrous and less likely to respond to positive changes in the androgen to estrogen balance and the endocrine environment.
Some men have very reasonable androgen to estrogen balances post puberty but are left with gynecomastia, a remnant of a past period of change and flux in the body. Just as the world is left with Fjords, cliffs and valleys from the ice age caused by an earlier prevailing climate, so too the body can be left with gynecomastia as a permanent reminder of an earlier time.
If a temporary hormone imbalance occurs during puberty and the imbalance is rectified soon enough then gynecomastia is usually not fibrous and more likely to be positively affected by the positive androgen to estrogen ratio. When this happens and the gynecomastia is not fibrous, the gynecomastia goes into a state of atrophy and literally shrinks away.
If an individual is post puberty and they readily put on muscle that is a sign of good response to androgens and is a suggestion of good androgen status. If they have good bone development to go along with good musculature, are hairy, have normal sexual development and exhibit no signs of androgen deficiency then androgen deficiency is of course highly unlikely.
The problem is that androgen deficiency can be difficult to spot/diagnose. It does not always follow a basic pattern and some men have some symptoms without others being present. Hypogonadism can occur post puberty often insidiously, in such cases development is normal and symptoms notoriously vague (that happened to me).
I would think that the natural ability to put on muscle would mean that I have high test levels. Is that neccessarily true?
Not at all, certainly not as you and in fact most doctors would view it.
Androgens, the principle being testosterone are only one part of the puzzle. We have so many synergistic interdependent hormones and behind them with have other organs and behind all of what we are we have genetics.
Most doctors view a man testosterone level in isolation. This is a complete mistake.
Endocrinologists have come to understand that factors like SHBG are very important in contributing to the crucial level of what is termed free or bioavailable testosterone.
A simple blood serum level of testosterone only tells you how much of the stuff is swimming around in the bloodstream. What it doesn’t do is tell you how much of the stuff is able to actually work in the body. For testosterone to be considered free and bioavailable to the body it must access Androgen Receptor (ARs) sites which are located all over the body, in the brain, in the chest arms- pretty much everywhere.
Sex Hormone Binding Globulin (SHBG) is the principle transport protein of testosterone and made in the liver. It binds and makes around 98% of testosterone unavailable to the body. If SHBG increases even small amounts it has a significant impact on how much free/bioavailable testosterone exists that the body can use.
What surprises some people is that it is possible to be testosterone deficient with a very high level of serum testosterone as long as SHBG is high enough.
Likewise if a man has a low level of SHBG they can seemingly have a fairly low level of testosterone, but because of how this greatly affects how much free/bioavailable testosterone there is for the body, such a man may in fact have a high androgen status despite what is seen in the serum testosterone level.
There are other factors relating to androgen status though.
For Androgens to work the principle one being testosterone, they have to access the Androgen receptors (AR’s).
An analogy;
Think of all your AR’s as your water mains. Now there might be a lot of water at the water company and in your street etc, just as a man might have lots of testosterone in the bloodstream. For you to be able to have a drink of water, the water must pass through the water pipes to come through the tap and into your glass.
But what happens if your water pipes are blocked?
You do not have access to the water.
It is not free or bio available. There is plenty of it and it is swimming around prior to the blockage but you cannot access it until the blockage is cleared.
The same thing happens when your AR’s are blocked, you have a lot of testosterone swimming around in the blood but little of it is free or bioavailable to the body.
So ok the anaology is a terrible and poorly chosen due to lack of imagination and expediency, but I think the point is still made.
A body needs androgens to be able to access the ARs and if they don’t/can’t do that then testosterone is redundant or at least some of it is.
If a man has a build up of estrogen in the body (the most potent of which is estradiol and commonly used to a word to replace estrogen) a man’s ARs will be blocked by the estradiol. Estradiol acts against the actions of testosterone in the body in more than one way, but one of those ways is to block the ARs so testosterone cannot work in the body.
When your water pipes get blocked you are denied access to a drink (unless you go elsewhere) until the blockage is cleared, you cannot get a drink of water. When the AR’s are blocked and testosterone cannot access the body, you are denied the actions of androgens. This can mean a lack or less of all the things that androgens do such as supporting correct functioning of muscles, bone,. Libido etc etc.
This is why many men who have elevated estradiol have low levels of free/bioavailable testosterone. It is also one of the reasons why many men who are treated with aromatase inhibitors for high levels of estradiol also have a resulting higher level of free/bioavailable testosterone…..the sink is unplugged!
It is possible to have free testosterone measure (at least in the forward moving US).
If this is accurately measured (equilibrium dialysis being the gold standard assay) and this number is normal then my testosterone in my body must be ok then right?
No.
Even when free testosterone is measured and found to be within the normal range this still does not mean that all is well (even if it is more likely to be so and a more accurate indicator of androgen status than serum testosterone).
Why?
Well for one there are reasons that relate to the clinical human abstract definitions of what we regard as normal. Our normal range does not differentiate between those who are I their 90s and those who are 18 years old. This is unfortunately true with all normal reference ranges. Of course there are significant differences in hormonal levels typically seen in 90 year old and 18 years olds, just as there are significant differences in every area of physiology and decline with age. The normal range is far too broad, what is normal should naturally equate to what is healthy or optimal for a given age group, but this is not the case because of the way in which the normal range is formulated as a one size fits all model.
The above means that an 18 year old at the bottom but with the normal free testosterone range would actually be off the bottom of any normal range for their age and may not have a sufficient testosterone level.
Ok so what if you have a pretty good free testosterone level does this mean that you have a good androgen status. Very very likey, highly probably,.
But even here it is important for endocrinologists/andorologists etc to not presume that everything must be ok.
If symptoms of androgen deficiency exist and are backed up on a symptomatic testosterone evaluation and indicated by such symptoms via a physical examination other factors should be considered.
A poorly functioning liver could result in a high free level of estradiol due to poor estrogen metabolisation by the livers P450 system and high free estradiol could compromise androgen action.
On an even more fundamental level that of genetics things can and do sometimes go wrong.
It doesn’t matter how high a free testosterone level is if the androgen receptors which would make use of it are incorrectly coded and poorly functioning.
There are those who are genetically male but are unable to physiologically deal with androgens in a normal male manner. Such conditions range from being genetically male but having female or ambiguous genitalia right through to problems of a partial nature where physical presentation is male but the genetic coding means that androgens are not quite correct in the way they are handled/function where androgen deficiency is present irrespective of appearing androgen level.
Klinefelters Syndrome (1 in every 500 male births)
Kallmans Syndrome 1 in every 1500 male births)
Androgen Insensitivity syndrome (AIS)
Partial Androgen insensitivity Syndrome (PAIS)
Alpha Reductase deficiency
So even the above though rare are not as rare as you would think given the Klinefelter statistic alone.
In each and every one of use we have differing levels of CAG receptor repeats.
Depending on our individual genetics numbers here we can be more or less responsive to the actions of androgen.
This is why playing a simple numbers game is fraught with difficulties and why symptoms should come first and foremost and pathology second in the evaluation of androgen status and in fact that of hormonal status generally (many diverse factors also affect other hormones and related conditions).
If a man has no symptoms of androgen deficiency and has all the hallmarks of great androgen status then that is because however simple or complicated the reason/actions are, if someone delved deep enough the reasons would become clear.
Likewise if a man has all the symptoms of androgen deficiency then this is because however simple or complicated the reason/actions are, if someone delved deep enough the reasons would also become clear.
I would think that the natural ability to put on muscle would mean that I have high test levels. Is that neccessarily true? If so, would that mean one of the other hormones you mentioned was at one point too high or low? Could that also have something to do with my inability to keep a low level of body fat?
Putting on muscle is a good sign of androgen action in the present, it is a counter indicator of androgen deficnecy. This does not means that an imbalance has not previously existed in such a fashion to have caused gynecomastia to have developed and remained, neither does it 100% exclude androgen deficiency.
It is also possible to have a good androgen status and a poor estrogen status or high sensitivity to estrogen as seen via gynecomastia.
Testosterone is just one hormone that helps to reduce adipose/visceral fat/weight gain.
Many, many factors and hormones are involved
Thyroxin, growth hormone, insulin are just a few other hormones involved and that is before considering calorie, fat, exercise duration and regularity etc etc
You seem to have mastered the relationship of all of these hormones, and I think hormones are one of the most major reasons why people body types are different
I concur with the latter part of the statement. Hormones along with the genetics that underpin them are heavily (excuse the pun) involved. Of course they are not everything and environment plays a huge factor also (again excuse the pun).
e.g
Wealthy western countries have more fat people than poor eastern counterparts, hence greater numbers of men with pseudogynecomastia due to obesity.
I hope this war and pease effort makes a little sense of some of the complcations involved with these issues.
Topic: can testosterone boost help gyne? (Read 7780 times)
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