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My Endo results here... Question?

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Offline hypo

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Re: My Endo results here... Question?
« Reply #15 on: July 02, 2005, 03:34:26 PM »
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.

Re: My Endo results here... Question?
« Reply #16 on: July 03, 2005, 03:13:50 AM »
Hypo, thank you again for the very deep information you provided.
This discussion could go for ever, so I would rather stop here.
speaking of the UK health system, I trained in Liverpool Medical school and praciced Medicine in the northwest of 5 years after that and I am a member of the royal college of physicians of london, but I am not an endocrinologist.

I was first seen regarding my gyne by the Prof. of breast surgery in the Royal Liverpool, who did not do any blood tests for me and offered me surgery only (I was in my second yr at the time with very little knowledge).
They messed up my chest good style and as a result i had further 3 surgeries to correct things.

It is the british rather than other schools that stresses  the principles I provided above.
In general, there are hundreds of  approaches to any clinical problem depending where you seek the information.

the testosterone deficiency example I gave above was hypothetical and I clearly said "ASYMPTOMATIC" and "NOT INTODUCTION TO A FUTURE PROBLEM".

A man with liver cirrhosis would have small testicles and hypogonadism. What is the cause of gyne here, cirrhosis??? high oestogen???? low testosterone????? abnormal SHBG???!!! or alcohol???? or spironolactone for his ascites?????? or cimetidine that he is taking for his G.I bleed.!!!!!!
this is the problem with treating blood results and not the case.

SHBG binds T4 not TSH. TSH is a very sensitive marker of the true thyroid function, (but I still check free T4 and T3 in  case I miss subclinical hypothyroid which is in fact a misnomer as its not really subclinical).

Anyway, the areas we are talking about are grey and there is not enough evidence to prove any of us right or wrong, so we could agree and disagree and be both wrong. We need respectable trials before we say who should be given what...Logic only, although sounds impressive, proved failure in many aspects of medicine especially endocrine and there are hundreds of exampls for this.

" it would indeed be rash for a mere pathologist to venture forth on the uncharted see of endocrines,strewn as it is with the wricks of shattered hypotheses, where even the most wary mariner may easily lose his way as he seeks to steer his bark amid the glandular temptations whos siren voices have proved the downfall of many who have gone before"    WILLIM BOYD

thank you again
one can never prepare to win a war, but one can prepare not to be defeated.

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Offline hypo

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Re: My Endo results here... Question?
« Reply #17 on: July 03, 2005, 04:07:11 AM »
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Hypo, thank you again for the very deep information you provided.  
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No problem.

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This discussion could go for ever, so I would rather stop here.
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True and understandable.

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I was first seen regarding my gyne by the Prof. of breast surgery in the Royal Liverpool, who did not do any blood tests for me and offered me surgery only (I was in my second yr at the time with very little knowledge).
They messed up my chest good style and as a result i had further 3 surgeries to correct things.
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I'm very sorry to hear that.

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the testosterone deficiency example I gave above was hypothetical and I clearly said "ASYMPTOMATIC" and "NOT INTODUCTION TO A FUTURE PROBLEM".
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I think we may have a difference of opinion on this.

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A man with liver cirrhosis would have small testicles and hypogonadism. What is the cause of gyne here, cirrhosis high oestogen? low testosterone?? abnormal SHBG!!! or alcohol? or spironolactone for his ascites or cimetidine that he is taking for his G.I bleed.!!!!!!
this is the problem with treating blood results and not the case.
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This is a good example of the multifactoral nature of many conditions and reasons for not simply treating blood results (again within reason).

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SHBG binds T4 not TSH. TSH is a very sensitive marker of the true thyroid function, (but I still check free T4 and T3 in  case I miss subclinical hypothyroid which is in fact a misnomer as its not really subclinical).
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You have given me information that I was previously unaware of, thank you.  I will read more on this.

I explained myself badly, I was thinking one things and wrote something else (an action slip).  What I meant to say was that even if SHBG binds to T4 it would not necessarily be seen via the negative feedback on TSH as a poor conversion of T4 to T3 would mean limited TSH feedback.

Sorry for not explaining myself properly.

You are quite correct in testing for T3 as well.  On a thyroid panel, it can also be worth testing for thyroid antibodies.  Also 24 urine tests for T4 and T3 can sometimes reveal those with thyroid problems that are not seen via blood tests.

You are quite right regarding your comments on subclinical hypothyroidism.

Despite areas of disagreement your thinking as far as the importance of symptoms and what should and should not be tested for is better than many endocrinologists I have spoken with.

P.S

Apologies to Raven for this separate side discussion.



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Offline Raven

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Re: My Endo results here... Question?
« Reply #18 on: July 03, 2005, 07:09:42 AM »
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How do you feel in yourself?

Do you ever suffer from any of the symptoms below?

Fatigue/lethargy
Poor concentration/action slips
Poor memory
Low libido
Erection difficulties
Excess sweating
Depression
Panic attacks/nervousness

If you do not and you feel very health your SHBG level is probably ok along with your free testosterone level.

In which case you may just consider lowering the estradiol level a little.




No worries about highjacking my thread.
I just want to know a little more about my results.
So here goes:

I feel good...
And I do not have any of the symptoms you listed above.
Although I tend to sweat a little here and there when outside working in the sun etc, but I certainly wouldn't say excessive.

I weigh 200lbs and stand at 5'11"
I have a bit of fat around my lower abdomen, but thats it. No fat anywhere else (aside from gyne)

I'm not an athletic person, but not a lazyass neither.
I walk about 30-45 minutes a day.
Always active in the sense of always runing around doing things.. Not a couch potato is what I mean.


So how would someone lower their estradiol level a little?



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Offline hypo

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Re: My Endo results here... Question?
« Reply #19 on: July 03, 2005, 08:16:22 AM »
Zinc supplementation might help.

Zinc acts as an anti aromatize, lowering the conversion of testosterone to estradiol in many men particularly those who are deficient.

And

The National Health and Nutritional Surveys-NHANES I, II and III- performed over the last thirty years have consistently shown deficient intake in large segments of US society.

60mg of zinc a day with copper trace may help.

Another option would be DIM or to give it its full name diindolylmethane.

Dim is not a drug, it is a phytonutrient (plant nutrient) which aids a healthy estrogen metabolization and is quite effective (more so than zinc) at lowering estradiol.

It is perfectly safe and is actually the same as the end product derived from cruciferous vegetables like cauliflower and broccoli.

The reason DIM is preferable to vegetables for many people, is because you would have to consume an awful lot of vegetables daily instead of taking the supplement and however well intentioned most people cannot do that.

It is proven to lower estradiol, it is used by many men with hypogonadism to control their estrogen and it may be something that would help you.

Whatever supplement you wish to use, do so following advice and consultation with your doctor.

If you are considering the latter of the two supplements, it may be an idea to book an appointment with your doctor and take a print out from the link below and see if he is happy about its use (best to use it with his agreement and knowledge).

http://www.atdonline.org/pdf/DIMandCancer.pdf#search='what%20does%20dim%20indolplex%20do?'

I hope that helps.

P.S

Other than your somewhat raised estradiol level you sound very healthy- lucky you :D



 





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Offline Raven

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Re: My Endo results here... Question?
« Reply #20 on: July 03, 2005, 02:09:12 PM »
Thanks for your input, I will do some additional research on this prior to making any next steps.
Thanks again,

ps, what would the normal Estradiol level in an adult male be?    in pmol/L ?

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Offline JTZ

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Re: My Endo results here... Question?
« Reply #21 on: July 04, 2005, 11:36:00 AM »
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Do you ever suffer from any of the symptoms below?

Fatigue/lethargy
Poor concentration/action slips
Poor memory
Low libido
Erection difficulties
Excess sweating
Depression
Panic attacks/nervousness

If you do not and you feel very health your SHBG level is probably ok along with your free testosterone level.



Wow, I have all of those symptoms.  :-/

What is SHBG?

If you have gyno, along with the symptoms above, is there a listing of hormones that should definitely be checked in an endocrine work-up; or is it pretty much standardized?

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Offline hypo

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Re: My Endo results here... Question?
« Reply #22 on: July 08, 2005, 04:18:49 PM »
If you let me know where you live JTZ I will try and give you a list of contact details for endocrinologists in your area that have an interest in reproductive endocrinology (the field that best covers gynecomastia).





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