Saw the "Reproductive Endo" @ Mass General today- moer puzzled than ever!
- 04-24-2007, 10:23 PM
Saw the "Reproductive Endo" @ Mass General today- moer puzzled than ever!
This is a bit long, so please bear with me. See the update at the bottom as well
After a lengthy wait I finally got to see the specialist in reproductive endocrinology today. She is an active researcher, well published and a professor at Harvard Medical School.
After the usual review of medical history, test results and the like we spent a full hour together. The only tests she was initially interested in were T, T free, LH/FSH, SHBG, Prolactin and Estradiol. More came into play later.
I was totally blunt about my medical history which is short, but includes 1 1/4 yr of Paxil (dropped due to perceived weight gain) followed 4 weeks of Welbutrin. After 2 weeks on W/B a crane wasn't going to get me up, so I soon dropped it. She was very interested in my family history, weight gain in the last 2-5 yrs and general state of being.
After she explained the whole HPTA process in detail she confirmed that my T at 185 is indeed low as are FSH/LH (each around 2) and suggested 2 possible contributing factors, neither of which I even remotely saw coming and which I remain skeptical of.
The first is my tendency to be a bit anxious and at times uncomfortable in my own skin. For example, although I am financially secure I get rather uneasy if there is one month where the credit card isn't paid in full. I also can on occasion spend entirely too much time thinking about stupid things, like how many relationships my wife of over 10 yrs was in before we met or how much I'll need to retire. My intellectual side will consistently tell the stupid emotional side to STFU, but the little thoughts sometimes still remain.
She repeatedly pointed out that anxiety issues can dampen the HPTA and suggested of all things yoga or counseling to help calmness. Okay........Um, sure......
The second point was "insulin resistance" as a worsening vicious cycle which lowers T, then makes insulin worse, which in turn lowers T and down it spirals. Didn't see this coming, either. I am 43, 6' tall, 218lbs and in decent shape. I lift or do some cardio (don't like cardio, but I force myself) a good 4-5 days per week and generally eat very well. I've gained about 20 lbs around the middle in the last 2-3 yrs roughly corresponding to when I used Paxil. That's when she asked me about blood sugar, Cholesterol and the like.
At 215 +/- lbs and in what I thought was decent shape for a 43 yr old, she postulated that the extra 20lbs was suppressing the HPTA in a downward cycle. 20lbs?? What about guys who are 100lbs overweight and still get rock hard? "Everyone is different and you may be predisposed" was the reply. What am I to do? I already eat well and exercise. "Reduce carbs, lose the 20lbs and level out at 190-195 lbs" was the reply. Much of her response was based on my low SHBG level of 11 (8-40+ scale).
I asked about estrogen levels, since I was at 32 or so. "No worries there". Will I need TRT? "Maybe, but let's try a multi-draw glucose tolerance test and the other suggestions first".
I then asked if they use hcg or clomid, etc. "No, we'll only use hcg if you want to remain fertile. Your testicles won't shrink that much". This seems to fly in the face of what I've seen here.
Wht was really puzzlng were indirect comments that while 185 is low, she wouldn't see much wrong at levels I'd think way too low, like 400. I should have followed up more, but given the limited time wasn't able to talk forever. She did say that given my still fairly high libido she believes lower T is a symptom of other issues as noted above.
The bottom line: I am more confused than ever. Occasional anxiety and an extra 20 lbs or less as the cause of a precipitous decline in erectile quantity and quality, not to mention sub basment T levels? Huh??
As always, I welcome scrutiny and comments. Maybe this note and my experiences will help others here as well.
***UPDATE*** Now I know why this Dr is so big on Insulin as a factor. Here is a link to a published study by her:
News - Insulin Resistance Tied to Low Testosterone in Men: Presented at ENDO
- 04-24-2007, 11:25 PM
That is confusing. If you are already working out 4 or 5 days a week and eating right.....what does she suggest you do to lose 20 pounds?
Also...why no mention of thyroid and or adrenal testing? Those seem a lot more likely to explain the weight gain than testosterone.
- 04-24-2007, 11:38 PM
Bingo! This is why I remain puzzled (more)
I mentioned I'd had other tests, including thyroid (OK) and a slightly elevated 24hr urine cortisol test. We didn't spend too much time on that.
I intend to still see Dr John or Dr Shippen, but never really thought that a visit to a Harvard prof would go like it did. Nice, caring and obviously brilliant women, though.
I'll check the thyroid again. Also, here is another study linking Low T to insulin
Came across this one as well. Skip to the end and you'll see the connection. Here is a link and a quote:
Increasing Insulin Resistance Is Associated with a Decrease in Leydig Cell Testosterone Secretion in Men -- Pitteloud et al. 90 (5): 2636 -- Journal of Clinical Endocrinology & Metabolism
"Regardless of the mechanism by which insulin resistance is associated with decreased T production, it has important clinical implications. In men with low T levels, consideration should be given to screening for insulin resistance using fasting insulin levels or HOMA-IR. Indeed, some investigators believe that an alteration in the sex hormone milieu is such a key component to the metabolic syndrome that the more appropriate name should be the glucose-insulin-lipid-hypertension-T-estrogen, or GILHT-E, syndrome (61).
During the hyperinsulinemic milieu of the glucose clamp, we demonstrated an increase in serum T levels, consistent with previous human studies (22) and in vitro data (17, 18, 19, 20), suggesting that high levels of insulin can overcome insulin resistance in the testis. Although the increase in T levels during the clamp was greatest in the obese men, T levels also tended to increase in the lean subjects; the failure of these changes to reach statistical significance is probably the result of the small sample size and limited statistical power. Plasma glucose levels were maintained in the normal range during the clamp, thus excluding a role for changes in glucose in mediating the increase in T levels (62).
In summary, this study demonstrates that the low T levels associated with insulin resistance result in part from an alteration in Leydig cell function, the molecular mechanism for which is still unclear. Interventional studies are clearly needed to assess the potential role of insulin-sensitizing agents in increasing T production in insulin-resistant men."
Everybody got this? Wow.......
May be tough nut to crack.
Keep on talking to your profesor, she may be the right person.
Is there ANYONE out there with lower SHBG? - MESO-Rx
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