Hormone tests, Hypo

[kennyb]

Here are my hormone tests.  I'm the guy who said my endo said he couldn't do anything for me and they ran a LHRH test (leut hormone releasing hormone) and it worked fine. 

Test, serum  191 ng/dl    241-827
test free 8.58 ng/dl        5.00-21.00
fsh and lh   
  lh   4.1  miu/ml   1.5 - 9.3

prolactin  5.6 ng/ml      2.1-17.7
estrone,serum  45  pg/ml   12-72

So what does that say?  Need anthing else?

My total test seems low but "free test" seems OK.  everything else is Ok, I guess.

[Hypo-is-here]

If your total testosterone is THAT low then you are likely to have a problem.  I seriously doubt the vallidity of any free testostreoine test thsat suggests otherwise with such a low serum testosterone test. 


Even if you were to consider the free testosterone test as being valid (hard to know without an SHBG test and result) it is still near the bottom of the normal range and you have to remember that the range does not take age into account and is the same range used for 90 year old men as that of 17 year olds.  That means the bottom of the normal range is skewed on the basis of the wide ages and differing androgen levels. 

What is normal for a 90 year old is obviously not going to be normal for a 17 year old. 

In young men androgen levels should be at their highest.  If you are fairly young then you should not have a free tetsosterone near the bottom of the normal range and you certainly should not have a total testosterone of 191ng/dl.

What is your endocrinologists position on these results?
 

 

[kennyb]

He said that "testosterone is a funny thing, maybe you don't need that much".

He didn't really have a view on what to do, other than saying that testosterone replacement would be a drastic step.  Or implying it.  I think that means you can't have kids.

[Hypo-is-here]

What your endocrinologist ahs said is true to a degree, certain testostreone is a funny thing and it is odd just how variable some people's requirements are.  That said I still find it difficult to believe that a total T of 191ng/dl isn't an issue.

Lets run a symptomatic testosterone evaluation by you and see what comes up, if you want to of course?

The following test was created and is used by Malcolm Carruthers M.D, FRCPATH, MRCGP one of the worlds leading specialists in hormonal disorders and testosterone replacement therapy and is something he conducts when he is assessing patients in initial consultations.

Score a 0 for none, 1 for slight, 2 for medium, 3 for severe and 4 for extreme for each question and then add up the total score

1
Fatigue, tiredness or loss of energy
 
2
Depression, low or negative mood

3
Irritability, anger or bad temper

4
Anxiety or nervousness

5
Loss of Memory or concentration

6
Relationship problem with partner

7
Loss of sex drive or libido

8
Erection or problems reaching orgasm

9
Dry skin on face or hands

10
Excessive sweating, day or night

11
Backache, joint pains or stiffness

12
Heavy drinking past or present

13
Loss of fitness

14
Feeling Overstressed

15
The age you feel scoring 0 for 30s, 1 for 40s, 2 for 50s, 3 for 60s and 4 for 70s

If you have had adult mumps, orchitis or other testicular problems, a prostate operation or inflammation, persistent urinary infection or vasectomy add another 4 to your overall score.

You do not have to divulge specifics of the questionnaire if you do not wish as I can work off the overall score.  Let me know how you get on with that.

Also out of interest, can you also tell me what time you had your blood taken at for your pathology?

[kennyb]

I have loss of libido and sometimes feel "stressed".   I don't have "dry" skin, have just as thick (very thick) of a beard as always...

That's about it.  Don't have any others.

I work out alot and am relatively "muscular" and am about 6'2" 240.  I actually get compliments on my physique, which is kind of ironic, having low test and gyno.  I have a broad chest so even though gyno is moderate, I don't think people notice it. 

I'm not sure what to do.  I could maybe get some test androgel and just use it for a week or so at a time just to keep the woman happ(ier).  I'd hate to permanently shut down my own test production.

Also the test was done late afternoon. 

[Hypo-is-here]

So you have loss of libido and gynecomastia and a total testosterone of 191ng/dl.

This is a bridge too far for me.

What state and city are you in?

[kennyb]

I had gyno as a teenager, it hasn't gotten much worse since then.  Maybe a little.

I'm in the mid-west.

What do you mean, it's a bridge too far?  You can't figure it out? 

Neither could the endo.  Don't think anything can be done.  Oh well.  Just one of those things.  Maybe I'll get on some test replacement.

Oh, also, the docs have said (plastic surgeons) that they almost never have regrowth.  So I'm not really worried about it.  But do you think I should be with the low test? 

Also here's a question...can the gyno actually create it's own estrogen?  Maybe it is "supressing" test production.  The HPT axis is suppressed by estrogen levels...maybe if I had lower levels of est, I'd have higher test levels...which would of course cause the then lower levels of estrogen to increase due to aromatization.

[Hypo-is-here]

What do you mean, it's a bridge too far?  You can't figure it out? 

No I do not mean that.  I mean there are three very strong pointers to your gynecomastia being caused by hypogonadism.  You have gynecomastia, lowered libido and a very low total testosterone.

Oh, also, the docs have said (plastic surgeons) that they almost never have regrowth.  So I'm not really worried about it.  But do you think I should be with the low test? 

Rubbish.  Plastic surgeons A) have a vested interest in telling you whatever is required in order to get you to go ahead with surgery and B) they are NOT experts in gynecomastia and it’s development, they are only experts in its removal.

If you think about it would you ever trust a survey to evaluate the price of your house off of someone looking to buy your house, or would you ever trust a an inquiry into the behavior of an organization conducted by the organization in question?

They might sound like odd questions but they are relevant because they are all examples of vested interests where you wouldn’t trust certain events.  Clearly plastic surgeons do not want to tell you that there can be re-development of gynecomastia as that may ensure that you don’t go ahead with surgery and that of course looses them business (not saying all PS’s do this but a lot do, perhaps some do dure to ignorance- again they are only experts in removal). 

Are they going to say things that looses them business?

Nine times out of ten the answer is no.

The fact of the matter is gynecomastia can and does re-develop in men who have underlying and ongoing causes of the condition.  It has very little to do with the quality of the surgeon and far more to do with the cause of the gynecomastia, so boasts of recurrence rates are just not valid.

With 10% of all gynecomastia sufferers having the condition because of hypogonadism and 25% of all gynecomastia sufferers having an underlying causative condition the importance of identifying and treating underlying causes cannot be over stated.  I have known of dozens of men with hypoogonadism who have re-developed gynecomastia.

It is equally true that many men who have underlying causes do not re-develop gynecomastia- but that is dependent as much on luck as anything else because it relates to the vascular changes that can occur that inhibit the endocrine influence on remaining tissue and whether or not the surgeon removes all the glandular mass (which is very difficult to do).

If you want surgery and you want the gynecomastia to be gone permanently then I think you have to correct any underlying hormonal imbalance.

Also here's a question...can the gyno actually create it's own estrogen?  Maybe it is "supressing" test production.  The HPT axis is suppressed by estrogen levels...maybe if I had lower levels of est, I'd have higher test levels...which would of course cause the then lower levels of estrogen to increase due to aromatization.

You have clearly tried to understand part of the mechanism of how these things work and you’re almost right in the detail of what you say.  I don’t think it is a case of gynecomastia creating its own estrogen, rather it is a case that gynecomastia being caused by high estrogen, low androgen levels or a poor androgen to estrogen ratio.  So one of these comes first and the gynecomastia comes second as the result.  If estrogen remains high or in the upper third of the normal range (also dependent on SHBG levels) and the gynecomastia is not the result of a temporary hormonal imbalance, but something more permanent, then your total sex steroid levels are higher.  Given the HPTA cannot adequately differentiate between estradiol and testosterone at the hypothalamic level the negative feedback via down regulation of GnRH and subsequently LH certainly can reduce the level of both free testosterone and total testosterone.  In plain English, yes high estrogen levels can indeed cause lowered testosterone levels.

What is causing your low testosterone levels needs to be further evaluated before any medication is prescribed.  It is very important to ascertain the cause first, trying to do so after treatment is prescribed can be VERY difficult.

You said you live in the Mid-West.   I hope you could make it to;

320 - 322 West Ottawa,  Garden Level
Lansing, Michigan 48933

Because I am recommending that you see Dr John Crisler an expert in the treatment of male hormonal disorders and hypogonadism.

E-mail: drjohn@allthingsmale.com
Office Phone: 517-485-4424
Direct Fax: 815-301-2716

[kennyb]

Well I don't know what to do then.

The doctor...I don't think he's flat out lying to me.  He does excision and gets as much of the gland as he can, or so he says.

The gyno has been stable for a long time, so I'm not sure it would just start growing again...why isn't it growing now?

I'm not near michigan and I'm moving to Atlanta in a month.  Any near there?

Thanks for your help.

What in your estimation can be done with someone 'hypogonadal'?  Anything? 

Like I said I had tests done on whether my pituitary can send out signals and whether my testes can act on them.  They both work fine.  The themostat is just set kind of low.  don't know why.  What can be done?  Don't drink/smoke/ get plenty of sleep, exercise. 

I may just get the surgery and hope they don't grow back.  I have glands about the size of an oblongated golf ball and some fat. 

And again I had this gyno since adolescense when I had a super high libido.  Well pretty high.  Higher than now!

It may have been caused in part by hypogonadism, but does that mean it grows back even if the gland is almost entirely gone?  I'm hoping no.

[Hypo-is-here]

Well I don't know what to do then.

The doctor...I don't think he's flat out lying to me.  He does excision and gets as much of the gland as he can, or so he says.

I don’t think he is flat out lying either.

The gyno has been stable for a long time, so I'm not sure it would just start growing again...why isn't it growing now?

The fact it is stable now is of course good and this makes it less likely/unlikely to re-develop in the short term.

it is also possible that remaining glandular tissue post operatively might not be acted upon by hormones due to changes in vascularisation and it is also possible that all the glandular tissue is removed an that would make it impossible for re-development of gynecomastia.

However!!!

A)   Androgen status declines with age and your androgen status already looks poor and you have already developed gynecomastia once.  As you age your already poor androgen to estrogen ratio can only get worse and whether stable or not now, unless your hormonal situation is treated you would be in a ripe position for re-development of gynecomastia. 

B)   changes in vascularisation that can prevent hormones acting upon any remaining tissue cannot be gaurenteed and is somewhat down to your luck. 

C)   No surgeon can guarantee complete removal of all the glandular mass (most will not want to attempt to take it all out at any rate as this can cause deformation in the chest) and anything left behind can be acted upon by hormones if you are not lucky in terms of vascular changes that prevent re-growth.


The above points are part of the reason why you would want to treat any underlying hormonal imbalance- because it can help prevent re-development of gynecomastia.

I'm not near michigan and I'm moving to Atlanta in a month.  Any near there?

I would have to look around and get back to you.  The reason I recommended Dr John was that he is famous in this field and personally recommended by many people.

Thanks for your help.

It is nothing that you wouldn’t do yourself.

What in your estimation can be done with someone 'hypogonadal'?  Anything? 

I have hypogonadism, hypogonadal is the state of having hypogonadism and it means to lack androgens, more specifically it usually relates to having too little testosterone.  Most people just call it testosterone deficiency.

It is highly treatable but requires a very specific and experienced doctor in this field because correctly prescribing/treating this condition can at times be awkward.  In cases where men have developed gynecomastia it is important that a treating doctor understands and keeps an eye on things like SHBG and estradiol and treats them if they become elevated.


Here is the point where I tell you why it is important to be treated for low testosterone.

A)   It might if properly treated give you your libido back in time
B)   If left untreated it can result in the development of osteoporosis (the silen killer).  I myself have osteoporosis as a result of long term untreated osteoporosis.  Testosterone helps maintain bone density
C)   Two thirds of men with type 2 diabetes have hypogonadism and hypogonadism is though to indirectly increase the statistical chance of developing type 2 diabetes.
D)   Studies have ably shown that men with low testosterone are more likely to suffer from obesity.  Testosterone actually helps to burn fat and make it easier to keep trim.
E)   Testosterone helps build and maintain muscle mass, a lack of it can result in weakened muscles and again bone problems
F)   A lack of testosterone often means a lowered level of stamina.  TRT can increase stamina.
G)   Low testosterone levels have been shown to cause a statistical increase in the development of Alzheimer’s, Cardio Vascular and arterial  Disease and strokes.
H)   The metabolic syndrome is also linked to low testosterone levels
I)   Erectile dysfunction is also associated with low testosterone levels, TRT means increased vascularisation and N.O levels which can resolve this and prevent it in some situations.
J)   Low testosterone is associated with low mood and depression, TRT can help prevent these effects
K)   Memory problems are associated with low testosterone and TRT can improve mental dexterity including memory.

Like I said I had tests done on whether my pituitary can send out signals and whether my testes can act on them.  They both work fine.  The themostat is just set kind of low.  don't know why.  What can be done?  Don't drink/smoke/ get plenty of sleep, exercise. 

Further endocrine assessment with someone experienced in such matters.  I honestly think a visit to Dr John would be more than helpful- despite the distance involved. 

I may just get the surgery and hope they don't grow back.  I have glands about the size of an oblongated golf ball and some fat. 

And again I had this gyno since adolescense when I had a super high libido.  Well pretty high.  Higher than now!

It may have been caused in part by hypogonadism, but does that mean it grows back even if the gland is almost entirely gone?  I'm hoping no.

You could just do that, but that would be ignoring the other factors involved in hypogonadism, your libido and the possibility or re-growth (although I must say that is not likely in the short term give its stable nature).

Your call ultimately.


If I seem eager for full endocrine evaluation and treatment where required it is because I know first hand the problems that come from leaving this untreated.

[kennyb]

Well I may go back to my original endo.  Actually it's another endo now I was seeing in his office...a younger guy, maybe he'll be more up on things.

I was set to get some more tests but I just felt like it wasn't doing any good so I skipped it. 

He may put me on test replacement.  I know you have to watch estrogen due to aromatization, etc.  It's probably very tricky.  I have thought that maybe I could do test replacement a week at a time and then two or three weeks off...maybe that way my test will be supplemented but not replaced.  I don't know if my HPT would eventually shut down over time with this though.  I don't really want that to happen...to be completely dependent on test replacement.

[Hypo-is-here]

Well I may go back to my original endo.  Actually it's another endo now I was seeing in his office...a younger guy, maybe he'll be more up on things.

Seriously this is something you need to get expert experienced advice/diagnosis and treatment on.  I would not leave this to chance by giving some endo a chance.  If I were in your shoes I would get myself to Dr John…honestly.

I was set to get some more tests but I just felt like it wasn't doing any good so I skipped it.

If you didn’t feel like you were getting anywhere that is understandable.

He may put me on test replacement. 

That would be a HUGE screw-up.  You need to find the cause of the problems before tresatment is prescribed.  If you get a crap endo who just throws you on treatment this can come back to bite you on the ass if things aren’t working well.  It can turn out that the cause of the problem has important ramifications in terms of what treatment works.  If treatment is not working, it can be VERY difficult and can necessitate coming off TRT in some cases and that at a latter date can cause real problems.

This again is another important reason why you need an expert with experience in this area.

I know you have to watch estrogen due to aromatization, etc.  It's probably very tricky. 

It depends on the individual, the form of TRT etc.

I have thought that maybe I could do test replacement a week at a time and then two or three weeks off..maybe that way my test will be supplemented but not replaced.  I don't know if my HPT would eventually shut down over time with this though.  I don't really want that to happen...to be completely dependent on test replacement.

First of all the HPTA will shut-down or at least be suppressed within the space of a few days to a week.  Second of all, cycles have no benefit whatsoever in TRT terms.  Cycles are used in the vast doses seen in steroid abuse- not in testosterone replacement.  In fact a cycle as you mentioned would not stop the shut-down/suppression of the HPTA and in fact would lead to a poorer androgen to estraogen ratio and be worse for symptoms, libido and gyncomastia re-development.

Being dependent on TRT is not a big deal at all if it is well prescribed and works.  It is not difficult medicine to take.  Also you might not need TRT exactly.  For instance if the cause of your problem was metabolic or hypogonadotropic (hypothalamic or pituitary related) you could be treated with HCG, which would improve your own testosterone production.  This is another reason why it is important to ascertain the cause of deficiency.


If you are to avoid a lot of wasted time, effort, money and mistakes that could make matters worse you need the best help you can get.

[kennyb]

Well thanks for your help.

But that's my original question.  What could be wrong with me that can be "fixed"?  It's not metabolic, I don't have diabetes, don't drink, eat right, get good exercise and sleep. 

What is HCG?  I'd like something to kick start the testes for a while.

The thing about cycles is that if you take some testosterone for a week or so you get the benefit...then when you come off your own HPTA is not so suppressed that you have no test.  But that's kind of why I was just thinking I'd leave well enough alone.

I'll email that doctor John.  Not sure what he can say.  He might not want to give free advice over the internet.