Confused Primary or Secondary

[t.w.a]

Hi, i am 24yrs old and have been experiencing the usual symptoms of low testosterone for the past two years;

-little to no libido,
-constant fatigue,
-lack of motivation,
-depression?


Got blood work done a few weeks ago that came back showing very low testosterone. I should mention that i am leaner and more muscular than the average guy my age hence why i never thought to get testosterone checked earlier.

Based on the following blood work my doctor thinks i have primary hypogonadism, however the endocrinologist i was referred to thinks secondary is more likely.

20/12/12
Testosterone 5.4 nmol/L (8-29)
SHBG 32 nmol/L (15-45)
FAI 17 (35-93)
Free testosterone 103 pmol/L (198-619)
TSH 1.84 mU/L (0.5-5)

28/12/12
Testosterone 7 nmol/L (8-29)
Prolactin 179 mIU/L (86-324)
Cortisol AM 562 nmol/L (171-536)
FSH 11 U/L (2-12)
Iron 16 umol/L (5-30)
Transferrin 29 umol/L (25-40)
Saturation 28 % (10-45)
Ferritin 371 ug/L (30-500)

8/01/13
Testosterone 7.5 (10-35nmol/L)
Fress testosterone 153 (225-725pmol/L)
FAI 27.8 (20-160)
SHBG 27 nmol/L (10-50)
FSH 11 (<9)
LH 5 (<8)
TSH 1.67 (0.4-4)
DHEA-S 4.6 (4.3-12.2)
Chol 4.4 (<5.5)
Trig 0.6 (<2)
HDL-C 1.9 (>0.9)
LDL-C 2.2 (<3.4)


9/01/13
Testosterone 6.6 nmol/L (10-35)
TSH 2.06 mU/L (.4-4)
FT4 13 pmol/L (10-20)
FSH 12 (<9)
LH 6 (<8)
Prolactin 120 mU/L (<330)
Cortisol AM 598 nmol/L (150-600)


As i understand it high FSH and LH and below normal free testosterone indicates primary? Am i missing something that my endo has picked up on, she has sent me to get an MRI, BW to check chromosomes, and am waiting on semen analysis and testicular ultrasound results.

Any thoughts or opions would be appreciated, cheers

 

[Megatron28]

Low T combined with high lh and fsh generally indicate primary hypogonadism. Your pituitary is screaming for more T but your testicles are not producing it.

 

[t.w.a]

Low T combined with high lh and fsh generally indicate primary hypogonadism. Your pituitary is screaming for more T but your testicles are not producing it.

well testicular ultrasound just came back fine, so probably npt primary?

seeing the doctor tomorrow before leaving for a 2week holiday after the weekend, any suggestions on any other tests i should get/ask for.

Waiting on MRI, semen analysis, and chromosome check.

Would it be worth trying to convince doctor to check E2

 

[t.w.a]

SUMMARY OF RESULTS so far, still no diagnosis

20/12/12
Testosterone 5.4 nmol/L (8-29)
SHBG 32 nmol/L (15-45)
FAI 17 (35-93)
Free testosterone 103 pmol/L (198-619)
TSH 1.84 mU/L (0.5-5)

28/12/12
Testosterone 7 nmol/L (8-29)
Prolactin 179 mIU/L (86-324)
Cortisol AM 562 nmol/L (171-536)
FSH 11 U/L (2-12)
Iron 16 umol/L (5-30)
Transferrin 29 umol/L (25-40)
Saturation 28 % (10-45)
Ferritin 371 ug/L (30-500)

8/01/13
Testosterone 7.5 (10-35nmol/L)
Fress testosterone 153 (225-725pmol/L)
FAI 27.8 (20-160)
SHBG 27 nmol/L (10-50)
FSH 11 (<9)
LH 5 (<8)
TSH 1.67 (0.4-4)
DHEA-S 4.6 (4.3-12.2)
Chol 4.4 (<5.5)
Trig 0.6 (<2)
HDL-C 1.9 (>0.9)
LDL-C 2.2 (<3.4)


9/01/13
Testosterone 6.6 nmol/L (10-35)
TSH 2.06 mU/L (.4-4)
FT4 13 pmol/L (10-20)
FSH 12 (<9)
LH 6 (<8)
Prolactin 120 mU/L (<330)
Cortisol AM 598 nmol/L (150-600)


Testicular Ultrasound
-No problems

Semen Analysis
-Very fertile, no problems

A subtle 5-mm focus found within anterior pituitary. Conclusion 'Examination demonstrates a subtle space-occupying lesion in the anterior pituitary gland, lying just to the right of midline. This is most likely an adenoma.'

Doctor does not see this as a cause for secondary but thinks i should go see the endo for further investigation. He pretty much said that from all the results he can't tell me why my testosterone is so low

Other than seeing my endo again, does anyone have any suggestions on where to go from here

 

[cross88]

Youre primary, high normal to high lh/fsh along with low test. Human Chorionic Gonadotropin (HCG) or clomid restarts generally wont be effective as your lh and fsh are sending out a strong signal to the testes to produce more testosterone but the actual testes are not functioning properly. DEfinitley see an endo or specialist

 

[Megatron28]

Lots of us know which type of hypogonadism we have but we don't know WHY we have it. We did all the same tests you ran but there was no easy explanation. Often you just have to live with the fact that you ruled out things like varicole and pituitary tumors and start treatment. It may just be due to aging or obesity or who knows what else... Good luck.

 

[SolomonGrundy]

for years docs whould comment that I had one testacal smaller than the other, only after finally having to describe my symptoms did anyone check my levels, id always ask does that mean anything and they said probable not.. sure enough one testacal must have suffered trauma . good you looked into it young and not hiding your symptoms

 

[t.w.a]

Saw the endo today and there are no more tests she can do so i've been diagnosed as idiopathic secondary. She wants to put me on Reandron 1000, where you inject every 10-14 weeks. Told her i would get back her as i haven't heard great reviews on it. She seemed very opposed to any sort of treatment plan that involved more regular shots and adding in AIs. Thoughts or review on reandron? is there currently a 'best' protocol that i can suggest to her bearing in mind im in Australia,

cheers guys

 

[SolomonGrundy]

i think they are looking to approve it in the US, the undeconated ester make the release very slow so you get a 1000mg every few months, if blood levels are steady id love to not shoot every week, its a better first step then rubbing gels on every day

 

[IMT staff]

I agree with Mega, I am no doctor but I would place my money on primary. You could always do an HCG stimulations test to find out for sure.

 

[t.w.a]

I agree with Mega, I am no doctor but I would place my money on primary. You could always do an HCG stimulations test to find out for sure.

with all the tests i've done at this point does it really matter what the diagnosis is? secondary or primary due to unknown cause still means testosterone replacement therapy (TRT), no? or does testosterone replacement therapy (TRT) protocol differ between secondary or primary

 

[THE-DET-OAK]

No it really doesn't matter that much. The only thing is if you are primary then HCG would be a waste of time and money.

 

[t.w.a]

Options between doctor and endo are;
-Reandron/Nebido (injections every 10-14 weeks)
-test enanthate, (Primoteston by Bayer) 2x week or every 5 days, plus HCG and/or Aromatase inhibitor (AI) as required
-Testogel 5g

-going to try again to get a serm or hcg trial, but both endo and doc already declined
Doing my research but currently leaning towards the test enanthate and then getting as close to Ksmans protocol as the doctor will allow?


Questions
Am seeing the doctor monday to start treatment, but i want to make sure all issues have been adressed, so my questions;

-If thyroid responds to iodine is that any reason not to start TRT? (can hypotythroid suppress test levels that much)
-Is my low DHEA-s something i need to look into?
-I am getting morning wood fairly often and almost always getting nocturnal errections, ED is not a problem but libido is. Is this indicative of anything?

- Main question, is there any reason not to start medication come next week?

Any input help is much appreciate guys

 

[t.w.a]

Had my first shot of primotestin 250mg (test e). One more shot in 2weeks then bw to see what test, E2 etc. are doing.

However thinking about splitting it to 125mg weekly on the downlo. Just seems like everyone does better on more frequent shots, so i'd rather just start that straight away. And from what i've been reading it seems that high doses of T at less frequent intervals results in a greater aromatization of T into estradiol, something i certainly want to avoid?

 

[lakers0812]

I'm not an expert on testosterone replacement therapy (TRT) protocol but I'm pretty sure that the reason you want to do weekly injections instead of 1 every two weeks is because of the half life of test. You'll experience more highs and lows if you do the injection every 2 weeks. I dont think you will have to worry about aromatization too much with 125mg/week. Do you have an ai?

 

[IMT staff]

I'm not an expert on testosterone replacement therapy (TRT) protocol but I'm pretty sure that the reason you want to do weekly injections instead of 1 every two weeks is because of the half life of test. You'll experience more highs and lows if you do the injection every 2 weeks. I dont think you will have to worry about aromatization too much with 125mg/week. Do you have an ai?

You are correct. Anyone that gets 2x a month injections needs to find a new doctor. it makes me shake my head when I see these post's, they should stick with us and they wouldn't have to worry about stuff like this.

 

[t.w.a]

i will get an Aromatase inhibitor (AI) if my bloodwork shows a big increase in E2.
Yes luckily for me one of the members here as graciously emailed me showing how to correctly split the dosage. I had the shot done on monday (250mg) is it recommended to wait 2weeks before i start doing the weekly dose or could i just jump straight in this coming monday with 125mg?

At least this doc is willing to monitor E2 levels, and prepared to give dosages every 10 days. My previous 2 doctors AND an endo all flatly refused that E2 was of any significance, and told me there was absolutely no benefit in more regular injections, i needed to stop overthinking and do as they say and follow the prescription protocol

 

[IMT staff]

Im not blaming you, its not your fault, it is the physicians fault. With that being said, I can not recommend ever that you do not do what your doctor says, as I am not a doctor, but I can tell you that you really should find a new one. You really are just wasting your time there.

What about Human Chorionic Gonadotropin (HCG)?

Did they rule out thyroid problems?

Testosterone enanthate has a half life of 7 days, maybe even 6 honestly. It is very important to dose esterfied testosterone according to the half-life. There are numerous reasons for this.

I know these things because I have seen this scenario play out a million times.

 

[t.w.a]

Im not blaming you, its not your fault, it is the physicians fault. With that being said, I can not recommend ever that you do not do what your doctor says, as I am not a doctor, but I can tell you that you really should find a new one. You really are just wasting your time there.
Yeah no worries mate. I get what you guys are saying but it seems that here in australia testosterone replacement therapy (TRT) is still behind the times in comparison to the US. And like i said i have already seen 2 doctors and an endo, all of which were considerably less knowledgeable than this guy. At the moment i don;t think i have any other choice but to stick with him. I will however me applying what i've learnt and what you guys suggest to me, in order to feel the best that i can. At the end of the day i think alot of guys are self injecting and finding out on their own what the ideal doasage and frequency is etc.

What about Human Chorionic Gonadotropin (HCG)?
Unfortunatly he does not seem to keen on Human Chorionic Gonadotropin (HCG) for someone who is not looking to conceive. I however will be looking to get some Human Chorionic Gonadotropin (HCG) from somewher if he is not willing to prescribe it at my next appointment. My boys have already shrunk as a result of low test over these past few years, i think may dissapear now that i;ve started testosterone replacement therapy (TRT) haha. My testicular volume is 10cc, the average is around 20-25cc. Luckily this hasn;t impacted fertility
Did they rule out thyroid problems?
Yes, at this point i am sceduled just to back for a MRI in 8-12 months to see if that 5mm space in the pituitary gets any bigger. I did regonise that my TSH is a touch high and ft4 a bit low, and have started supplementing iodine as body temp was a bit low. I've already seen a increase in waking temperature which is a good sign, but overall i don't think hypothyrodism is an issue

Testosterone enanthate has a half life of 7 days, maybe even 6 honestly. It is very important to dose esterfied testosterone according to the half-life. There are numerous reasons for this.

I know these things because I have seen this scenario play out a million times.
I am going to start by self injecting on a weekly basis, from there i can go to a 5day schedule etc. if need be

appreciate the help you guys are giving me, im sure everything will fall into place over the next few months

 

[Brizza60]

When my endo first put me on testosterone replacement therapy (TRT) it was 200mg once every 2 weeks and the ups/downs were horrible,So i just asked him to do weekly injections of 100mg instead and was feeling so much better with less of a roller coaster effect. I would suggest just asking your doc to split your dose and request weekly injections.