Doc wants to put me on HRT .. good idea? (labs)

[rg8230]

Hello,

I am new here and my doctor is considering putting me on HRT (specifically Testosterone replacement). I am a bit nervous as I get the feeling she is more experienced with diabetic pathology than most other areas of endocrinology. I would like to share with you a brief medical history and some recent test results.

I am a 27 year old male - 6'1" 176lb nude. My father was a big man and the men on my mother's side of the family were normal sized with full beards. I can not grow a beard nor any body hair (other than under my arms and around my genitals). I have an identical twin brother and he has similar problems, but he is somewhat larger than I am and can grow a bit more body hair than I. We are both smaller and less "masculine" than our father and those close to us in our family tree. I have noticed my twin developing slightly faster than I in the past few years. I have never used steroids.

I have almost completely lost my libido and for a number of years experienced an inability to perform sexually at times. My erections are nowhere near as firm as they used to be and I only occasionally wake with an erection. This decline happened after a rather famously tragic relationship that really got me twisted about. I am not sure how much of this could be psychological. Around this same time, I also lost my lust for life. I no longer feel engaged and I have trouble concentrating.

This is where I complicate things. I was recently treated for HCV (not fun) and completed therapy successfully two months ago. I must wait a few more months to find out if it worked. This treatment has caused my Thyroid to go a bit crazy. TSH has been all over the place. It is still bouncing around a bit, but has settled some since the cessation of HCV treatment.

I have had gynecomastia for some years and I really do not like it. It has been slowly progressing again for the past year or two. Inferior to my nipples and their surrounding areas, the glands resemble flattened donuts. There is not much glandular tissue directly beneath the nipple, but, as you move further, they begin to become more massive. I have the classic puffy nipple and almost never notice any pain, tenderness, or itchiness (1-4 times per year).

I had a pituitary MRI done 2 weeks ago and my posterior pituitary probably has a very small adenoma while my anterior pituitary seems to be ok. There was a bit of confusion on the anterior pituitary as the image was not idea. They did not rule out the possible of some malformation and did see some small anomalies that need further examination but are likely not serious. My Dr. wants to repeat the test in one year. I am about to get my PSA tested in preparation for TRT.

All of the sex hormone test to follow were taken at 8am EST exactly everytime. The TSH was generally taken in the afternoon (3-4pm) unless it is listed on the same date as the sex hormones then it was drawn at 8 am.

Now for test results:

10/12/2009 (during HCV treatment)

TSH				2.241	0.300-5.000*	uIU/mL

11/5/2009 8am

TESTOSTERONE, -	
TOTAL LC,MS,MS		215	250-1100*	ng/dL
% Free Testosterone	2.11	1.50-2.20*%
Free Testosterone		45.4	35.0-155.0*	pg/mL

12/14/2009

TSH				1.291	0.300-5.000*	uIU/mL

1/27/2010 (HCV treatment finished on 1/23/2010) 8am

Estradiol, Free		0.15	< OR = 0.45-**PG/ML
Estradiol, % Free		1.70	1.25-1.85*%
Estradiol(E2) Level		9	< OR = 29-*	PG/ML
TSH/Thy.Stim.Horm	6.25	0.40-4.50*	mIU/L
LH				2.9	1.5-9.3*	MIU/ML
FSH				1.9	1.6-8.0*	MIU/ML
Prolactin			16.7	2.0-18.0*	NG/ML
TESTOSTERONE, -
TOTAL LC,MS,MS		313	250-1100*	ng/dL
Free Testosterone		48.0	46.0-224.0*	pg/mL	
Testosterone, -
Bioavailable			107.1	110.0-575.0*	ng/dL	
SHBG				25	7-49*		nmol/L	
Albumin			4.9	3.6-5.1*	g/dL	

2/3/2010

TSH				3.153	0.300-5.000*	uIU/mL	

2/24/2010 8am

Cortisol			7.0	4.0-22.0 	MCG/DL
ACTH, PLASMA		11	7-50*		PG/ML
FREE T4			1.0	0.8-1.8*	NG/DL
TSH				4.35	0.40-4.50*	mIU/L
IGF-I				236	126-382*	ng/mL
Growth Hormone		<0.1	<=10.0-**	ng/mL

I have a lot of bloodwork, but most of it is more liver specific though I am not adverse to sharing it. Does it seem like a good idea to pursue TRT? I am very concerned. I do not want to exacerbate my existing gynecomastia. Part of me wants to think that TRT is going to reinvigorate me and help me in great ways. There is also another larger part of me that sees this as a potential disaster in the making. I try to stay as well versed as I can in medicine, but I am no doctor.

Feel free to let the jargon fly and know that I value honesty. Thank you for your time.

 

[CubbieBlue]

What is the treatment for the hepatitis? If this is screwing up your thyroid (temporarily) it may be possible it also screwed up your testosterone (key word, possible). It DID jump up 100 points in a few months...

What type of TRT does your doctor offer?

If you want to be conservative wait 6 months - 1 year and see how much your levels rebound. If you do not feel like waiting that long, TRT may not be a bad option for you.

 

[Michael Scally MD]

What is the treatment for the hepatitis? If this is screwing up your thyroid (temporarily) it may be possible it also screwed up your testosterone (key word, possible). It DID jump up 100 points in a few months...

What type of TRT does your doctor offer?

If you want to be conservative wait 6 months - 1 year and see how much your levels rebound. If you do not feel like waiting that long, TRT may not be a bad option for you.

CubbieBlue, I thought for sure you had already done a search!

 

[Michael Scally MD]

The following is the information found on HCV and hormones. Prior to beginning TRT, I would do a challenge test. Afterwards, one can begin TRT. If the challenge test were positive, HPTA restore can be tried once you are healthier. Of course, this is assuming the thyroid workup is complete - address this first.


Plockinger U, Kruger D, Bergk A, Weich V, Wiedenmann B, Berg T. Hepatitis-C patients have reduced growth hormone (GH) secretion which improves during long-term therapy with pegylated interferon-alpha. Am J Gastroenterol 2007;102(12):2724-31.

OBJECTIVES: In vitro and in vivo data indicate multiple, but contradictory effects of interferon on pituitary hormone secretion. We therefore investigated prospectively basal and stimulated pituitary hormone secretion in 21 patients with chronic hepatitis C virus (HCV) infection before and during antiviral therapy.

METHODS: Twenty-one patients received pegylated interferon-alpha plus either ribavirin or levovirin. Baseline and stimulated growth hormone (GH), cortisol, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL), and thyroid-stimulating hormone (TSH) responses were measured using standard pituitary function tests, before therapy in all and during therapy in 17 out of the 21 patients.

RESULTS: Before therapy 17 patients (81%) had severe GH insufficiency and 9 of these had low insulin-like growth factor-1 (IGF-1) concentrations. Basal and stimulated GH concentrations increased significantly during therapy, reducing the number of patients with severe GH insufficiency to four, but IGF-1 remained low. Basal PRL and TSH concentrations were normal before and during therapy, while thyroid-releasing hormone (TRH)-stimulated concentrations increased significantly during therapy. The adrenocorticotropic hormone (ACTH)/cortisol axis, basal and stimulated gonadotropin, and testosterone concentrations were normal throughout. Neither the HCV RNA level nor transaminases correlated with hormone concentrations before or during therapy.

CONCLUSIONS: GH insufficiency is common in patients with chronic HCV infection. While GH secretion improves during antiviral therapy, IGF-1 remains low, indicating persistent GH resistance of hepatocytes. Whether improvement in GH secretion during treatment is due to a direct drug effect or related to the suppression of viral load could not be differentiated, as most patients demonstrated a positive virologic response.


Durazzo M, Premoli A, Di Bisceglie C, et al. Alterations of seminal and hormonal parameters: An extrahepatic manifestation of HCV infection? World J Gastroenterol 2006;12(19):3073-6.

AIM: To evaluate the possible influences of HCV infection and relative antiviral treatment on seminal parameters and reproductive hormonal serum levels.

METHODS: Ten male patients with HCV-related chronic hepatitis and 16 healthy male volunteers were studied. In all subjects seminal parameters (nemaspermic concentration, progressive motility, morphology) and hormonal levels were determined. Seminal parameters and inhibin B, follicle-stimulating hormone, luteinizing hormone, total and free testosterone, estradiol, prolactine in patients were measured after six and twelve months of antiviral combined (interferon+ribavirin) treatment.

RESULTS: Patients before treatment showed a significantly lower nemaspermic motility and morphology as well as lower inhibin B and free testosterone levels than controls. Inhibin B levels in cases were improved six and 12 mo after treatment in five responders (161.9+/-52.8 pg/mL versus 101.7+/-47.0 pg/mL and 143.4+/-46.1 pg/mL versus 95.4+/-55.6 pg/mL, respectively). Hormonal pattern of patients did not significantly change after treatment, with the exception of estradiol levels with an initial reduction and an overall subsequent increment (19.7+/-6.4 pg/mL versus 13.6+/-5.0 pg/mL versus 17.3+/-5.7 pg/mL). However in 1-year responders a significant increment of free testosterone (14.2+/-2.54 pg/mL versus 17.1+/-2.58 pg/mL) occurred. An impairment of nemaspermic morphology occurred, while other seminal parameters did not change significantly during antiviral treatment.

CONCLUSION: Patients with HCV infection show worse spermatic parameters than controls, suggesting a possible negative influence of virus on spermatogenesis, with further mild impairment during antiviral treatment. However therapy could improve the spermatic function, as suggested by the increased inhibin B levels and improved hormonal pattern in responders. Further studies are needed to confirm these preliminary intriguing results.

 

[Chong Li]

TRT is not permanent. try it out for 3 months or so. im sure your doc will be testing you often so all is well if thats the case.

TRT should not make gyno worse as long as you control the estrogen (with meds if needed). talk to your doc about controlling estrogen.

ive had a couple gyno procedures myself to get rid of it. i never had that much gland, it was just naturally puffy skin. get the surgery. its worth it. dont pay more than 3k for it. lots of rip off guys out there.

im 27 too.

 

[rg8230]

Thank you everyone for your replies. I feel much better after hearing from you all.

Cubbie, Dr. Scally was correct. I was taking pegylated interferon alfa (120mcg per week) as well as ribavirin (1000mg per day) for 48 weeks and I had genotype 1 (the one more common to North America).

I have been considering the gyno surgery for a while, but I am not sure I can afford it at the moment.

My doctor contacted me today and told me my PSA was normal. I have not recieved the results yet. She wants to start me on Androgel 2.5g per day. I am waiting for insurance to authorize it and I have an appointment with her on thursday. I feel ill prepared and am considering delaying the treatment until I feel more reassured.

I assume challenge test refers to a clomid challenge test. I will get my doctor to try this out.

Thanks again for the advice. I appreciate it much.

 

[rg8230]

Because of my gynecomastia should I talk to my doctor about a potential aromatase inhibitor or is that likely not necessary unless problems develop?

Is 2.5g Androgel an adequate dose? The prescribing information on their sites states that one should start at 5g and titrate up if need be. The prescribing information also states the contents as "testosterone gel". Is it truly just testosterone and not some kind of acid salt?

 

[chemman]

She wants to start me on Androgel 2.5g per day.

Run far far away my friend. You will probably be worse off on this dose. I don't think your doctor knows what she is doing and I would not accept this treatment plan if I were you.

 

[rg8230]

I get the same feeling chen. Would 2.5g be ineffective or detrimental? I am slightly confused by your last comment. Thanks.

 

[CubbieBlue]

I get the same feeling chen. Would 2.5g be ineffective or detrimental? I am slightly confused by your last comment. Thanks.

Both. For the majority of people on these boards 5 g doesn't do the trick. 5 g is one packet of gel per day. For most posters, that gets their levels anywhere from 250-400. For the majority of those seeking TRT, those are pretty damn close to the levels they had originally. So not only does it not do anything, but it REALLY shuts them down so now they can't even naturally produce the their baseline levels.

Now an important caveat: the vast majority of people on TRT do not come to these message boards for help. They do just fine on one packet of androgel per day. Some may even do fine on half a packet per day.

However, I do not think that doing 2.5 g a day of androgel is going to do you any good. Are you sure you understood him/her correctly? And they are talking about androgel and not some compounded formulation correct?

If he/she is indeed talking about half a packet per day I would call around and find a uro or endo that can manage your trt that you can get referred to.

 

[rg8230]

I am pretty sure she said 2.5g Androgel once daily; however, as with anything, I could be mistaken. I have an appointment with her today at 2 est and I will be asking as many questions as I can. I will also be asking about a clomid challenge test to determine if I am primary or secondary.

I was considering finding someone who is a bit more knowledgeable in the Pittsburgh, PA are, but I am not sure for what I am looking. You said endo or uro. Should I look for any kind of expertise specifically. I realize I want someone who has experience treating hormonal imbalances that are specific to men, but I am a bit clueless as to the terminology or keywords for which I may be looking. I really appreciate the help and wisdom you have shared with me.

 

[CubbieBlue]

I am pretty sure she said 2.5g Androgel once daily; however, as with anything, I could be mistaken. I have an appointment with her today at 2 est and I will be asking as many questions as I can. I will also be asking about a clomid challenge test to determine if I am primary or secondary.

I was considering finding someone who is a bit more knowledgeable in the Pittsburgh, PA are, but I am not sure for what I am looking. You said endo or uro. Should I look for any kind of expertise specifically. I realize I want someone who has experience treating hormonal imbalances that are specific to men, but I am a bit clueless as to the terminology or keywords for which I may be looking. I really appreciate the help and wisdom you have shared with me.

If she is your PCP ask for an endocrinology referral. You can call around and ask how they treat hormone deficiency in young men.

 

[rg8230]

She is the endo to whom I was referred. She kind of scares the hell out of me. When I saw her today she contradicted much of what I have read over the past few weeks or plead ignorance or denied relevance.

I saw her today and was sent home with a 2.5g androgel per day prescription and a blood rx for 6 weeks after beginning treatment (only ordered total t despite protestations). She is moving in July which is good for her because I was so splitsville after this disaster. Now I just need to find a good doc in Pittsburgh. I was considering driving out to reading to be assessed by Dr. O. We shall see.

 

[CubbieBlue]

She is the endo to whom I was referred. She kind of scares the hell out of me. When I saw her today she contradicted much of what I have read over the past few weeks or plead ignorance or denied relevance.

I saw her today and was sent home with a 2.5g androgel per day prescription and a blood rx for 6 weeks after beginning treatment (only ordered total t despite protestations). She is moving in July which is good for her because I was so splitsville after this disaster. Now I just need to find a good doc in Pittsburgh. I was considering driving out to reading to be assessed by Dr. O. We shall see.

If she is moving I wouldn't even bother getting started on her regimen. See who is in your network and call them and see how they treat hypogonadism. Ask your PCP for another referral.

 

[rg8230]

Thankfully I do not need a referral with my insurance. I am considering Susan L. Greenspan. I will call and question her staff tomorrow and see if she is worthwhile unless I find a better prospect.

 

[rg8230]

I have been shopping around my area (Pittsburgh, PA) and I am having extreme difficulties finding a doctor. The one that seemed vaguely promising actually specializes in osteoporosis, but she has published a number of papers on male hypogonadism. She will not have an opening until September.

I have not looked into Urologists yet. Is this a viable option or are they, generally speaking, worthless in this regard.

Thanks for any thoughts you might confer.

 

[CubbieBlue]

I have been shopping around my area (Pittsburgh, PA) and I am having extreme difficulties finding a doctor. The one that seemed vaguely promising actually specializes in osteoporosis, but she has published a number of papers on male hypogonadism. She will not have an opening until September.

I have not looked into Urologists yet. Is this a viable option or are they, generally speaking, worthless in this regard.

Thanks for any thoughts you might confer.

I would stick with the endos.

 

[rg8230]

I have seen a few endos so far and they have all scared the bejesus out of me. They were all happy to run a test or two then give up hope of finding a cause and throw some hormones at me. If I have to take hormones, then so be it, but I am not ready to throw in the towel yet .. tempted but not ready. I am probably just having bad luck; need to stick it out I guess.