Endocrinology.Com June Reader Mailbox
Topic:Testosterone Replacement Therapy

I would like to know if you could tell me what a normal level for testosterone would be for a man 28 years old. I have had an orcheictomy and am having problems with hormones, I went in for blood tests last week and am waiting the results. what i am most interested in is what is the range, and where would one think that I should be? the dr. that i am seeing suggested that the range is between 194-854 however on the web I saw another artivle that said 404-707? which one is correct? and what should I do if mine is low? should I allow the urologist to treat me, or should I see an endocrinologist?

The normal range for testosterone levels is established by the company producing the assay or the reference laboratory performing the assay. Usually, this will be somewhere from a low of 180 to a high of 1000 mg/dl. the actual range used will be reported by your laboratory. Generally speaking, when I prescribe replacement hormone therapy, I try to make the patient clinically comfortable, that is able to describe a normal libido (sexual interest), able to obtain an errection and pennetration as well as to experience a feeling of well being. This means a careful history by the patient and doctor to make certain needs are met. Some men feel well with a testo level of 300, others do best up in the 700's. It really depends on the individual. If you are comfortable with the expertise of your urologist, then I do not see any reason to change doctors. If you feel your questions are not being answered or your treatment not up to expectations, then perhaps a consultation from another physician would be in order.

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Topic: Hyperparathyroidism

Curuous if surgery is the only viable option for hyperparathyroidism. My understanding is that this condition affects up to 1% of all postmenopausal women. If it is that common why does the removal of the glands seem so rare? Is it worht treating are clinical manifestations sever enough to warrent surgery? Are there therapeutics that reduce the levels of PTH?

The diagnosis of hyperparathyroidism is made by establishing an elevated parathyroid hormone level (PTH) in the face of a normal or elevated serum calcium level. The recommendation to have surgery is based upon many factors: Such as the clinical status of the patient, whether or not symptoms are present. Other factors such as the presence of osteoporosis or renal disease with hypercalciuria (elevated urinary calcium excretion) or kidney stones also helps to influence the recommendation to have surgery. Of course, the main determining factor is the degree of elevation of the serum calcium itself. Usually, when it is 1mg/dl or more above the normal range, surgery is advised. There is no effective medical treatment of hyperparathyroidism. Surgery is the cure. An injectable compound which lowers the PTH level and calcium level is in clinical trials, but still probably several years away.

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Topic: Hypothyroidism

I have been diagnosed w/ hypothyroidism twice and have also been put on a supplement only to be taken off twice. The first time I was treated was when I was about 6 years old. ( I am now 29.) The second time I was 27 or 28. Again I was put on synthroid only to be taken off. Still having trouble w/ fatigue, no appetite, and dizziness, I pretty much got tired of being sick and tired. My Dr. finely sent me to another Dr. and now I am being treated for Chronic Fatigue Syndrome (Which I don't believe in!) and some sort of Autoimmune Thyroid Disorder. I am not understanding this thyroid problem, my question is: Once being considered Hypothyroid shouldn't I be kept on Synthroid? I am still having alot of the same symptoms and my thyroid has tested normal for over a year. Is hypothyroid triggered by diet, or something I could be doing or not doing? Just a little confused!

The diagnosis of hypothyroidism is made by demonstrating an abnormal elevation of the serum TSH (thyroid stimulating hormone) level. Also, most physicians will also obtain a serum T4 (thyroxine) or Free T4 level as an aid to securing the diagnosis. It is possible for an individual to have an inflammation of the thyroid gland which is transient. In this case, the individual would become hypothyroid, but as the gland recovers, the thyroid functions would return to normal. In your case, off of any replacement medication, if your TSH is significantly elevated, then replacement therapy is warranted. I tend to keep individuals with this type of condition on lifelong replacement therapy. If they stop, and the TSH rises again, this just confirms the need for lifelong replacement therapy. If your thyroid has tested normal for over a year without replacement therapy, then you cannot attribute your symptoms to a low thyroid function state.

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Topic: Thyroid Cancer

My daughter had THYROID CANCER in 1984 when she was 15 years old. She was cancer free until this past year (1997-1998). She has had 4 children in the last 7 years.Three years ago (1995) when she was pregnant for her third child her Ob-Gyn advised her to reduced her thyroid medication. Which she did. This past August (1997) she discovered a lump on her neck. She had surgery in February, it was cancerous! They advised her to not take any thyroid harmone replacement for 6 to 8 weeks then, they would do a radiation pill treatment! The problem..........Her BODY decided to designate a portion of tissue behind the original scar of her first surgery to start making thyroid harmone (which activated the cancer growth). This rendered the test inconclusive. In March 1998 she did take the radioactive pill. They want her to get off all meds. (she is only taking thyroid replacement meds.) in Sept. or Oct. and do the procedure again. She had follicular and papillary(?) cancer (combined). Of the six lymp nodes removed three had cancer. My concern..................How serious is this and should she go for another opinion??? THERE IS SOME DISCREPANCY BETWEEN THE SURGERY AND ONCOLOGIST.

You have provided a lot of information. The most important of which is the histological type of the tumor (papillary/follicular) and the fact that there is cancer in the local lymph node beds. In following and treating this type of patient, it is important to make certain that the original surgery was as complete as possible, that your daughter be on thyroid hormone suppression therapy unless scheduled for a total body I131 scan to determine the presence of residual tumor and need to give additional I131 therapy. It is also most important to keep track of the serum thyroglobulin level, as this can be an even more sensitive indicator of tissue growth than the scan. I think if the scan or thyroglobulin level indicates the continued presence of tumor, then consideration to giving a significant dose of I131 is needed vs. continuing suppression therapy while monitoring the thyroglobulin levels. Today, many endocrinologists would switch a patient off of thyroxine onto Cytomel which has the advantage of shortening the time period of hypothyroidism while waiting to get a body scan. Also, soon, recombinant TSH will be available to use as a preparation so some individuals will not have to go off suppression for 2 months. This type of presentation is fairly common and there is still an excellent long term survival >10 year rate, but in my opinion, she should be in the hands of an experienced endocrinologist to monitor and guide her therapy.

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Topic: Adrenal Tumor

My husband had his left upper lobe (lung) removed last year. Had a C. scan done recently,found his right adrenal mass measuring ,(5.5x3.8) also has some around it. can not find information on this problem, What is his chances for surgery? His surgery for his lung was a success and we are shocked about this new information.Please give me some information pretaining to this .

In consultation with your husband's doctors, I am sure that you have determinied that it is not uncommon for lung metastasis to go to the adrenal gland. If surgery is performed, it will be necessary to have the pathologist perform all special staining to determine as certain as possible the origin of this tumor, adrenal or metastatic. It is also wise to have an endocrinologist test your husband's adrenal function prior to surgery to make certain it is not a functional adrenal tumor such as a pheochromocytoma.

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Topic: Pituitary Microadenoma, Prolactin, Amenorrhea.

Hello. I'm a GP and would like more info from an endocrinologist's point of view on a couple of cases. First case... A thirty-something woman presented with secondary amenorrhea for six months. Her LH, FSH, est, and progesterone were normal, she was not pregnant, and she had no withdrawal bleed with Provera 10mg qd for five days. She returned and I did a PRL level which was high at 128. A head CT was normal and supported a pituitary microadenoma. We have a long lineup for MRI's in Canada, so that was not done. In the fall of 97, she had a complete done by a colleague and had high triglycerides and slightly high glucose, but these were not treated. Her endocrinologist gave her a bromocriptine Rx to be filled, depending on the CT results. What is your approach from this point on with the info that I have given? What do you have to say about possible long-term complications such an DM, osteoporosis, etc? I would be vigilant and prevent/treat these conditions like in any other woman.

Regarding your first case, the literature has some support that a prolactin level of 128 mg/dl may not be indicative of a pure prolactinoma. However, in light of the fact that there is no evidence of a macroadenoma on CT scan, it is safe to assume you are dealing with a microadenoma. I would have the patient use bromocriptine, advancing the dos in BID ot TID increments until the the prolactin level returned to the normal range. In the US, my first choice for therapy would probably be Dostinex (cabergoline) which is better tolerated, more potent and longer acting with 2x/week dosing. If successful, then your patient can expect to experience a resumption of her menstrual cycles. I suspect she did not menstruate secondary to low estrogen level and an inadequate length of administration of progesterone. I would follow the pituitary CT or MRI every six months for the next year while closely monitoring the prolactin levels. By the way, it is always important to examine for the presence of galactorrhea in this kind of patient. I would not expect any long term complications if her menstruation returns to normal when the prolactin is suppressed.

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Topic: 46XY female with amenorrhea

Second case... She presented at 18 with primary amenorrhea, weight loss, and alopecia to a departed colleague of mine. She was diagnosed with 46XY testicular feminization or androgen insensitivity. From old records, she had a shortened, blunt vagina with normal breast development and phenotypically female. The latter I take to mean female external genitalia. She had a bilateral gonadectomy (path indicated testes) at 18 in late 93 due to increased malignancy rates and says that she has been lack-luster since. She complains of reduced energy, motivation, and just not feeling right ever since the surgery. She has been on Premarin 0.9mg qd and her endocrinologist put her on Provera to, according to the patient, enhance certain aspects of physical sexual development. She says that the Provera did nothing. Now, she came with her mother asking about testosterone treatment. I could not find old DHEA-S and testosterone results ordered in January, 94, and I have not done any tests yet. I wonder if and when testosterone replacement is indicated here. I am thinking about the old products as well as the new one called Andriol (testosterone undecanoate) in Canada. Any ideas on tests and treatment? Thanks.

Regarding your second case, this individual has been raised as a female. Testosterone should not be used. Much larger doses of estrogen need to be given, on the order of 2.5 to 5.0 mg/day along with progesterone, or you may choose to substitute a birth control pill to achieve a fuller feminization. thje testosternoe levels should be on te order of 10 or less if there are no gonads. It is important to make certain this individual recognizes that they are sterile and cannot bear children. But, they should be fully replaced with female hormones so they can be fully developed phenotypically, sexually active and lead a normal lifestyle.

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Topic: Pre-menopausal osteoporosis

I am 36 yrs old and have been diagnosed with ADVANCED osteoporosis. I am premenopausal. I stopped smoking and drinking alcohol 6 years ago. I have two toddlers which provide for an active lifestyle. I have had a number of blood tests including thyroid, parathyroid, calcium, vitamin d. I also have 24 hr urine test for calcium. The test were within normal although the calcium and vitamin D were on the low level. I am currently taking fosamax, calcium and vitamin D. I also have bilateral osteoarthritis of the hips. Have you had experience with such a case? Do you think it requires a visit to an endocrinologist? Any thoughts on what causes this so prematurely?

I think it is important to be under the care of a specilist in the field of osteoporosis, either an endocrinologist or a qualified rheumatologist. You are very young, and it is important to obtain a careful history and proper interpretation of the bone mass studies. Most persons in your age group did not lose bone. Rather, they simply did not accumulate a high peak bone mass. Over 50% of the skeletal bone mass is aquired from the time of puberty until the early 20's. It should be maintained up to around age 40. Beyond that, it may be necessary to make lifestyle committments to exercise, diet and if necessary, medications. Remember, too, we have a strong genetic inheritance involved in determining our peak bone mass. In your case, assuming the information is accurate, then adequate calcium supplementation, regular exercise, normal menstrual cycles and the avoidance of low estrogen states is important. Also, avoidance of tobacco, alcohol and certain other medications is a must. I would use Fosamax (alendronate) to help try and improve by peak bone mass and put me into net positive calcium balance. I would get regular DEXA scans of my bone mass to try and make certain I am achieving some preservation or gains!

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Topic: Hypothyroidism

I saw your e-mail address on the internet, and I have a few general questions. I know you cannot give specific advise, but based on what I have read , I need to know whether or not my situation is very obvious, or whether you suggest that I have it further evaluated. Please read on, and let me know what you think. I am a 30 year old woman in generally excellent health. I spend a lot of time exercising and taking care of myself. The only difference I notice between myself and other active people, is that I am slightly more tired, and require more sleep (an absolute minimum of 8 hours per night). In May, 1998 I was experiencing chest pains, which turned out to be a slight strain due to too many chest excerises. As my doctor was ensuring the health of my heart, she noticed that my heart rate was on the lower range, and decided to check my TCH levels in my blood work. On May 19, my TCH level was 10.5, and all other blood work result were in the normal ranges. My doctor diagnosed me as having hypothyroidism, and prescribed 0.05 mg of Levoxyl, which I began taking on June 3rd. Since taking the medication, I have noticed no difference in my level of energy. I have noticed that my skin is drier, I have loose stools, and am experiencing more facial blemishes. On June 11, I had more blood tested. My TCH level rose to 11.7, my blood type is O negative, the ANA was negative, and the test for autoimmune disease came out at 14. On June 18, as prescribed by my doctor, I doubled my dosage to 0.10 mg. Differences in my body remain as described above. Since it seems to me that it is very coincidental that just as I happened to get my blood tested my thyroid started to increasingly fail to produce its hormones, and that I do not seem to match any of the general at risk groups of people, I have the following questions: O Is it possible by giving my body Levoxyl, now it is requiring more? (Am I making my situation worse?) O Is this a "cut and dry" situation, that I should trust my general practitioner to take the medication as prescribed, or does my description warrant a visit to an Endocrinologist for further evaluation? Any advise that you could give me would be greatly appreciated.

In answer to your questions, on a very sensitive assay for TSH, a level of 10.5 with a normal T4 or Free T4 would be called occult hypothyroidism, not clinically apparent, except by lab testing. If your thyroid condition was stable, then the nitial dose was simply too low. On the otherhand, if you had an evolving process such as an auto-immune thyroiditis, then you may require increasing doses to maintain a normal TSH and T4 until a new steady state is reached. Your symptoms may not improve until your TSH is normalized for a few months. Then again, many persons have symptoms of fatique with normal thyroid functions. Facial blemishes may be a sign of androgen excess or just the dry skin.

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