My introduction.....

[idmd]

I once had a 4 year old kid with significant cavities. He was a nice kid but had a hyperactive gag reflex and even with nitrous I couldn't work on him in the chair. Because of his gag we couldn't get x-rays but I could see he had significant cavities between his teeth based on the shadowing I could see.

I recommended to the mother we treat him under IV sedation (MD anesthesiologist comes to my office). Mom smiled and left.

1 week later she called me to tell me how incompetent I was because she went for a second opinion and that dentist (a general dentist) said the child's cavities weren't significant and he fixed everything in 20 mins.

I knew for a fact that this kid has 4 quadrants of difficult dentistry and there is no way anyone could do any treatment on this kid in the chair unsedated. It was very hard to hear someone call me incompetent on the phone when I knew I 100% right. I told her her son's problems could not have been fixed properly in 20 mins and I guaranteed these teeth would become necrotic and abscess.

Almost 1 year to the day my partner saw the kid on emergency and extracted 4 teeth that had been treated by the other dentist.

Point is I was 100% correct in every way yet that bat shit crazy mom is out there still thinking I'm an asshole. No doubt she tells all her friends. She may even be out there on a forum right now. Even though I was right! The only thing I did wrong was tell her something that didn't match her expectations.

Patients are crazy and irrational and agree with the first person who tells them what they want to hear because everyone wants to be their own doctor. I'm sorry it didn't work out for you but that's life....I'm positive you're here because you have an axe to grind and that's fine....but I'm also sure it's not as simple or onesided as you state. I will keep seeing Hulinsky until what he says doesn't make sense. So far he's been thorough, logical and done pretty much what I think is best.
Do have to talk to him about the AI but so far so good...

 

[max247]

Dude I'm a 33 yo Irish, English, German, American born in Arlington Heights Il who practices pediatric dentistry.....I'm not a 50+ year old endocrinologist from Sweden or where ever he's from.

I do like the conspiracy theory but you sound bat shit crazy with this rant.

Not as "bat shit crazy" as pretending to be your own patients, writing long, elaborate histories under different aliases to advertise for your own services.

idmd
toolman
answerman
lou123

And a few of your other names.

Don't advertise for your services on these boards anymore.

 

[idmd]

Not as "bat shit crazy" as pretending to be your own patients, writing long, elaborate histories under different aliases to advertise for your own services.

idmd
toolman
answerman
lou123

And a few of your other names.

Don't advertise for your services on these boards anymore.

Blow me dick head I'm here for my own help psycho! Not sure what kind of crazy we're dealing with here but you're sick and need help.

I'm sure a moderator can check IP addresses and confirm none of those posters come from the same area.

Matter of fact why do I care what you think? Go take your crazy somewhere else and get off MY thread!

 

[idmd]

Just sitting here thinking before I get up and weigh myself.....

I was Lexapro for about a year and have been off for about a year now. I believe it effects dopaminergic activity in the pituitary. Wondering if it's possible this had an effect on LH production? I don't think it was the cause (I went on it for many of the symptoms I have from low T) but I'm wondering if it made it worse?

I'll do my own literature search later but if anyone has any citations handy I'd appreciate it.

 

[MANWHORE]

Patients are crazy and irrational and agree with the first person who tells them what they want to hear because everyone wants to be their own doctor.

If I didn't agree with you on that and another dentist told me
different, I would get a third opinion.. If another dentist told me
what you told me, I would settle at that. As long as you both
didn't know each other ..

Now as far as the "everyone wants to be their own doctor" goes:
There are so many off the wall doctors out there, that it sure
as hell doesn't hurt for patients to start reading up on things
themselves ..

Example: My girl was told she had a hernia from an ultrasound,
but she found out she didn't have one from another doctor who
did a CT Scan .. The doctor who said she had a hernia, told me
there is nothing they do for it. I said "are you sure .. You just leave it"
he said: "you wanna see mine" ready to pull his shirt up. ... Well,
he walked out of the room, and we walked out of the hospital

Here is another: This one happened before the last BTW... My girl had cancer 4 times before this happened, so this one was pretty fucked up..
The doc's office calls my girl and tells her she has Leukemia, just by
looking at some blood-work they got from her.. We moved out of that town
into another one, before anything can be done about the SO CALLED Leukemia so she sees a new OBGYN in the new town for a checkup.. The OBGYN tells her, that she never had Leukemia.. This is an OBGYN who had to be the one
settling her mind.. He was right BTW...

OK, another: Next my girl has brain cancer, goes to a specialist .. Yeah, if he is a specialist for brain cancer, then I am a brain surgeon ... anyway, he tells her she has stage 3 brain cancer, and starts a shitload of Chemotherapy, for a few months ... We move out of that town .. very very shady town, even more than the other ones ... We move 1 1/2hrs up north, and she gets a new doc for her Chemo and everything else. Her new doc who was doing the Chemo tells her, she never had stage 3 but only stage 2 and the Chemo she was getting was WAY too much. The cancer was gone after.. I believe 1 or 2 treatments from this new doc and not much Chemo at all...

These are just a few things I will talk about, but this shit
is so sad. When getting some fucked up info from someone
on the street, that's not too bad, cause one should know to follow
up with a reputable source ...
BUT
When getting some crazy fucked up information from a Doctor
who .. Well, we hope ... should know what he/she is talking about, that's
some pretty damn scary shit.

BTW, she was told by one nurse .. about year and a half ago... that
she was pregnant. Turns out the nurse got 2 names mixed up, and told the girl who was pregnant that she wasn't and my girl who wasn't pregnant that she was LOL .. BUT that's a nurse. It's almost expected of them, to not know what they are talking about..

 

[idmd]

If I didn't agree with you on that and another dentist told me
different, I would get a third opinion.. If another dentist told me
what you told me, I would settle at that. As long as you both
didn't know each other ..

Now as far as the "everyone wants to be their own doctor" goes:
There are so many off the wall doctors out there, that it sure
as hell doesn't hurt for patients to start reading up on things
themselves ..

Example: My girl was told she had a hernia from an ultrasound,
but she found out she didn't have one from another doctor who
did a CT Scan .. The doctor who said she had a hernia, told me
there is nothing they do for it. I said "are you sure .. You just leave it"
he said: "you wanna see mine" ready to pull his shirt up. ... Well,
he walked out of the room, and we walked out of the hospital

Here is another: This one happened before the last BTW... My girl had cancer 4 times before this happened, so this one was pretty fucked up..
The doc's office calls my girl and tells her she has Leukemia, just by
looking at some blood-work they got from her.. We moved out of that town
into another one, before anything can be done about the SO CALLED Leukemia so she sees a new OBGYN in the new town for a checkup.. The OBGYN tells her, that she never had Leukemia.. This is an OBGYN who had to be the one
settling her mind.. He was right BTW...

OK, another: Next my girl has brain cancer, goes to a specialist .. Yeah, if he is a specialist for brain cancer, then I am a brain surgeon ... anyway, he tells her she has stage 3 brain cancer, and starts a shitload of Chemotherapy, for a few months ... We move out of that town .. very very shady town, even more than the other ones ... We move 1 1/2hrs up north, and she gets a new doc for her Chemo and everything else. Her new doc who was doing the Chemo tells her, she never had stage 3 but only stage 2 and the Chemo she was getting was WAY too much. The cancer was gone after.. I believe 1 or 2 treatments from this new doc and not much Chemo at all...

These are just a few things I will talk about, but this shit
is so sad. When getting some fucked up info from someone
on the street, that's not too bad, cause one should know to follow
up with a reputable source ...
BUT
When getting some crazy fucked up information from a Doctor
who .. Well, we hope ... should know what he/she is talking about, that's
some pretty damn scary shit.

BTW, she was told by one nurse .. about year and a half ago... that
she was pregnant. Turns out the nurse got 2 names mixed up, and told the girl who was pregnant that she wasn't and my girl who wasn't pregnant that she was LOL .. BUT that's a nurse. It's almost expected of them, to not know what they are talking about..

Well my point was patient and doctor perceptions of an outcome can be very different. I was just trying to give an example of a situation where a parent felt completely justified in her opinion yet she was 100% wrong. If I had to do it over again I would do it the exact same way. This doesn't have any effect on mom's perception of me. In the end I've recommended that treatment successfully thousands of time with successful outcomes. I think it's reasonable to conclude I'm spot on and it was this one bat shit crazy mom who has the problem - and it's HER problem.

The moral of the the story to my accuser is maybe Dr. H messed up completely....I have no idea but I find him to be a rationale logical person who has made perfect sense and you to have all the qualities of a seriously ill person. There's no conspiracy here! Maybe Dr. H has an alias on these boards? Maybe toolman is Dr. H and his referral was part of a deviant master plan to get more patients? Maybe Dr. H really does LIKE to fuck with people and cause harm because he wakes up every day and has nothing better to do?

But it just doesn't seem all that likely so I'm sorry I'm going to pick the logical rationale sane option over the crazier than a shit house rat option.

 

[MANWHORE]

Well my point was patient and doctor perceptions of an outcome can be very different. I was just trying to give an example of a situation where a parent felt completely justified in her opinion yet she was 100% wrong. If I had to do it over again I would do it the exact same way. This doesn't have any effect on mom's perception of me. In the end I've recommended that treatment successfully thousands of time with successful outcomes. I think it's reasonable to conclude I'm spot on and it was this one bat shit crazy mom who has the problem - and it's HER problem.

The moral of the the story to my accuser is maybe Dr. H messed up completely....I have no idea but I find him to be a rationale logical person who has made perfect sense and you to have all the qualities of a seriously ill person. There's no conspiracy here! Maybe Dr. H has an alias on these boards? Maybe toolman is Dr. H and his referral was part of a deviant master plan to get more patients? Maybe Dr. H really does LIKE to fuck with people and cause harm because he wakes up every day and has nothing better to do?

But it just doesn't seem all that likely so I'm sorry I'm going to pick the logical rationale sane option over the crazier than a shit house rat option.

Yes, I hear ya brother and agree.

I just felt a need to post about our experience with wacko docs

Although, you probably wouldn't make a very good impression
up my way, cause people here don't care about their teeth

They get mad when I do this

LOL Nah, they are OK. I only call them hillbillies cause
this backwards country shit is new to me. .. I just don't
get why every guy who owns some land has to have so many sheep...
Must be a macho thing or something like that .. or is it

 

[Structure]

Just sitting here thinking before I get up and weigh myself.....

I was Lexapro for about a year and have been off for about a year now. I believe it effects dopaminergic activity in the pituitary. Wondering if it's possible this had an effect on LH production? I don't think it was the cause (I went on it for many of the symptoms I have from low T) but I'm wondering if it made it worse?

I'll do my own literature search later but if anyone has any citations handy I'd appreciate it.

Took a quick look around to check this. Came up empty handed. I don't think there's a relationship between escitalopram and hypogonadism, be it mediated through dopamine, LH, or otherwise...

 

[idmd]

Took a quick look around to check this. Came up empty handed. I don't think there's a relationship between escitalopram and hypogonadism, be it mediated through dopamine, LH, or otherwise...

Thanks Structure....I didn't find anything either.

I have been reading more about AI's and while the side-effects are definitely something to consider I'm not all that sure my problem is estradiol-related pituitary suppression. I've read some articles in main-stream journals and it seem like AI's have been used successfully in morbidly obese men but these guys started with a mean total estradiol of 123 pmol/l and total testosterone of 167pmol/l and with AI's at 6 weeks and 6 months mean total estradiol was 57/76 pmol/l and total testosterone was 604/610 pmol/l, respectively.

My estradiol after two weeks of exogenous test was 31 pmol/l....how much suppression could that really cause? I'm assuming 31 is inflated from baseline due to aromatization of the exogenous test. Most of my reading on AI side-effects suggests it's the extremely low E2 serum levels that cause bone/joint issues and with an inflated E2 of 31 I think I'm a prime candidate for E2 levels that are too low. How much could E2 really be playing here in a person with a baseline total test in the 100's?

Opinions and comments welcomed!

 

[idmd]

Or maybe it is......

Check my math but they started at 123pmol/L ~ 33 pg/mL

Ended at 57pmol/L ~ 15.5 pg/mL


Look about right?

 

[Structure]

Thanks Structure....I didn't find anything either.

I have been reading more about AI's and while the side-effects are definitely something to consider I'm not all that sure my problem is estradiol-related pituitary suppression. I've read some articles in main-stream journals and it seem like AI's have been used successfully in morbidly obese men but these guys started with a mean total estradiol of 123 pmol/l and total testosterone of 167pmol/l and with AI's at 6 weeks and 6 months mean total estradiol was 57/76 pmol/l and total testosterone was 604/610 pmol/l, respectively.

My estradiol after two weeks of exogenous test was 31 pmol/l....how much suppression could that really cause? I'm assuming 31 is inflated from baseline due to aromatization of the exogenous test. Most of my reading on AI side-effects suggests it's the extremely low E2 serum levels that cause bone/joint issues and with an inflated E2 of 31 I think I'm a prime candidate for E2 levels that are too low. How much could E2 really be playing here in a person with a baseline total test in the 100's?

Opinions and comments welcomed!

When you first posted your E2 results, this was my thought also. Your E2 just isn't that high.

If I were you, I'd be more interested in looking at primary and secondary as possibilities at this point.

Are you currently on Clomid monotherapy, or are you still on T? If clomid restores your HPT, then that implies secondary. This would be reinforced by a low LH result. Were you tested for LH before you started T?

If memory serves, you were only tested for LH after you started T, and it was very low.

If you are in fact secondary, a treatment option is HCG. Good news would be: no Clomid, no AI, and you get to keep your testicles and fertility (bonus). Bad news is people often dose HCG many times higher than is appropriate, causing high E2 and gonadotropin receptor desensitization. Of course, you have some say in this...

 

[idmd]

When you first posted your E2 results, this was my thought also. Your E2 just isn't that high.

If I were you, I'd be more interested in looking at primary and secondary as possibilities at this point.

Are you currently on Clomid monotherapy, or are you still on T? If clomid restores your HPT, then that implies secondary. This would be reinforced by a low LH result. Were you tested for LH before you started T?

If memory serves, you were only tested for LH after you started T, and it was very low.

If you are in fact secondary, a treatment option is HCG. Good news would be: no Clomid, no AI, and you get to keep your testicles and fertility (bonus). Bad news is people often dose HCG many times higher than is appropriate, causing high E2 and gonadotropin receptor desensitization. Of course, you have some say in this...

No E2 or LH before starting test so no baseline on those....Clomid was for 10 days which I finished Thursday. Gave blood on Friday and just waiting for results. Currently not taking anything until I talk to Dr. H about lab results.

 

[idmd]

So new labs after 10 days 100mg Clomid and 50mcg Synthroid.

TSH = 4.59 [0.40-4.50]

Dr. feels since this hasn't budged and I notice no difference I should go to 100 mcg

SHBG = 18 [10-50]
FSH = 2.9 [1.6-8.0]
LH = 5.8 [1.5-9.3]

Test Total = 333 [241-827]

E2 = 22 [< 39]

AM Cortisol = 22.8 [4.0-22.0]

He still feels AI is the way to go and stop at first sign of joint issues but he's perfectly willing to discuss other options.

I'm still wondering how much mileage I'll get out of an AI with an E2 of 22? Doesn't a low E2 like 22 suggest aromatization is not my problem?

Still have to get the sleep study so I suppose that will help.

What does that AM cortisol mean?

 

[LW64]

That's not much of a rise in T level after 10 days of clomid at 100 mg/day. Men who are secondary can see their T level double or triple on clomid.

Continue with it at the same dose for a while longer and have labs done again. You might just now be getting to the point where clomid is 'waking up' your HPTA. If not, you may be primary - but I tend to doubt it because of the weight issue which can really put your HPTA to sleep.

I'll take back part of my own previous advice and say a short duration, low dose course of an AI could be beneficial. Men with adiposity issues seem to be very E2 sensitive. Even with E2 well within the normal lab range, you could be so metabolically sensitive to it that in your case an E2 of 22 is too high.

Sleep apnea lab is a good idea.

High am cortisol is a sign of stress and fits in with the pattern of insulin resistance, high BP, etc., - metabolic syndrome.

 

[idmd]

Thanks LW64 I appreciate your thought!

Well that T level is nearly double my baseline. Also, I have been reading a lot about hypothyroid-induced hypogonadism. I'm hopeful when my TSH finally does change in response to my increased Synthroid that will help things along too.

Down 16 lbs so that's going well and has led to less EtOH (would rather spend the calories on nutritious food) which is another positive.

Interestingly my BP has been 130/80 since starting weight loss.

Incase anyone has a similar issue my Insurance won't cover arimidex and CVS wanted $288 for a one month supply. Costco has the generic for $22!

 

[idmd]

Oh and the other thing...I know I have a lot going on but subjectively I don't feel any better even if my numbers seem to have improved. Still tired, irritable, exercise intolerance, no libido although I feel a little clearer in the head.

My last blood test showed a test level around 488ish and I had just started feeling crappy again so my guess is I'm going to have to be at least 600+ to feel good.

 

[Structure]

That's not much of a rise in T level after 10 days of clomid at 100 mg/day. Men who are secondary can see their T level double or triple on clomid.

Continue with it at the same dose for a while longer and have labs done again. You might just now be getting to the point where clomid is 'waking up' your HPTA. If not, you may be primary - but I tend to doubt it because of the weight issue which can really put your HPTA to sleep.

I'll take back part of my own previous advice and say a short duration, low dose course of an AI could be beneficial. Men with adiposity issues seem to be very E2 sensitive. Even with E2 well within the normal lab range, you could be so metabolically sensitive to it that in your case an E2 of 22 is too high.

Sleep apnea lab is a good idea.

High am cortisol is a sign of stress and fits in with the pattern of insulin resistance, high BP, etc., - metabolic syndrome.

I'm going to have to disagree with you here. Here's why:

As we all know, obesity induced hypogonadism happens when adipose tissue creates too much estrogen. The reason why this results in hypogonadism is because the estrogen makes its way from the fat tissue, through the bloodstream, to the pituitary. This is an important point to consider: plasma E2 is what determines the suppression. Thus, if your E2 comes back lowish normal on a blood test, then you are not suppressing your pituitary, regardless of how much extra weight you are carrying around.

If for some reason, one is hypersensitive to estrogen, then it is possible to suppress the pituitary with a lowish normal plasma E2. However, this has nothing to do with obesity induced hypogonadism, and would happen at any weight. It is worth mentioning that this is not a common scenario.

An E2 of 22 is not the source of idmd's problems.

As far as the cortisol reading goes: a single reading of elevated cortisol is not worth much. If you are nervous, it can go up far past this level. Dieting is another way to elevate cortisol. Once, I had an unpleasant blood draw, and I had a cortisol reading of over 80. (The tech kept moving the needle around, and I could feel it scratching up my vein...) Only if your cortisol is consistently elevated (and by a significant margin) would one consider additional pathology...

I agree with you on the point that it's starting to look like primary. However, he will need some more testing to verify this. It's a shame Dr. H didn't have the common sense to check LH / FSH before prescribing medication!

 

[idmd]

Thanks Structure....one point of clarification that I've tried to make a few times but probably got lost in everything else.

Dr. H did not Rx the test without getting my baseline LH first. My internist did this and Dr. H was not too happy about it. He had me stop immediately and then ordered labs 8 days after my last injection.

While not perfect it was Dr. H opinion that my LH/FSH was far too suppressed 8 days after my last test (and after a total of only 200mg test ever) suggesting secondary. However it was still not clear so he wanted the 10 day Clomid. Honestly I did hope for a more robust response. After Clomid now we factor in a less than great response to Clomid and in the background normal to low E2 levels hinting at primary.

Is it possible I'm both? Some issue with LH/FSH suppression (highly sensitive to E2) and nads that are underproducing test.

How about good old hypothyroidism? It effects every tissue in the body and there's good lit out there looking at hypothyroid induced hypogonadism with documentation of it affecting both the hypothalamus-pituitary and gonads directly.

 

[idmd]

Alright.....a cup of coffee and the drive to work to think about everything. I think I see a mixed primary/secondary hypogonadism.

Pro secondary hypogonadism results:
1. Low initial LH/FSH and even though we would expect it to be suppressed from exogenous test my doc and some on here feel it was too suppressed given the dose of test and time since last injection.
2. Obesity has definitely been shown to cause secondary hypogonadism.
3. Positive response to Clomid.
4. Hypothyroidism has been shown to cause secondary hypogonadism.

Pro primary hypogonadism results:
1. At no time has my E2 been high and now it's low normal. High serum E2 is the mechanism by which obesity causes secondary hypogonadism and that doesn't seem to be the case with me.
2. Less than robust response to Clomid. LH went up but the response of my testicles was not overwhelming.

Results open to interpretation:
1. Was the rise in LH/FSH proportional or what one would expect from 10 days of 100mg/d clomid?
2. Is my testosterone level due to the clomid proportional to what one would expect based on my elevated LH level while on clomid?
3. How well does Clomid block E2 at that pituitary? Is it wrong to think clomid for 10 days would completely block estrogen receptors suppression at the pituitary and that my testosterone level of 333 represents the absolute best my testicles can produce? Is it correct to assume this represents the maximum potential of my complete unsuppressed (or nearly complete) HTPG axis?
4. How is hypothyroidism playing a role here? 50mcg has done absolutely nothing for me. Will a higher dose stimulate both my hypothalamus-pituitary and testes?

More questions than answers but the AI will be interesting. I suppose if we see a robust increase in testosterone we could consider some form of E2 hypersensitivity. If however it does absolutely nothing or it's a very modest response then we can rule out E2 playing any important part in this.

As always....comments, opinions, corrections in my misguided thinking welcome!

 

[idmd]

I'm going to add one more section:

Things not consistent with hypogonadism:
1. I find it strange that I have never had any ED or fertility issues. As I've said before libido is definitely low (even non-existent at my current level of 333) but once I force myself to get interested there has never been a problem.....even while on SSRIs. Also I have a 2, 4 and 6 year old. When my wife and I decided to have the 6 year old we made the decision, had sex one time and two weeks later she was pregnant. For the 4 year old we had sex one time unprotected and I zigged when I should have zagged and she was pregnant. The 2 year old we were living with my in laws waiting for my house to close so sex was difficult but we had sex one time in that month and she was pregnant.
2. I'm obese but still a fairly muscular/strong person and always have been. I may not make as much progress at the gym as I feel I should but you could never look at my arms and say they aren't significantly muscular. I'm not quite Paul Sr. size but not too far off.
3. I've felt this way for at least 10 years and probably longer. I went from 6'5" 190 lb athletic VERY HORNY teenager to an obese sedentary almost asexual person over 3 or 4 years - a 100 lbs weight gain on a diet that was not great but not that bad. I can't tell you if the sedentary lifestyle was a cause or a symptom. The more I think about it I think it was a symptom as I remember trying to exercise and I just had severe exercise intolerance during exercise and it took an extended period of time after exercise to recover.

I don't me to belabor this just trying to summarize all the findings in one place to see if someone sees a pattern. I appreciate any help.