Few years ago I’ve noticed symptoms of low T, so I went to my physican. He checked my total testosterone and it was bellow lower range. I checked it again with FSH and LH. Then, I did more detailed blood tests and MRI, potential causes were excluded and I was diagnosed with secondary hypogonadism. Doc presribed me clomid, but despite of good spike of total testosterone I haven’t noticed improvement in my symptoms. My doc told me that it could be psychological factors causing my symptoms, but I should still get this med. Recently I read on excelmale.com that this is common situation, when clomid works only “on paper”, and the alterative is going on TRT. Whats your opinion on that?
Yes, this does seem to happen sometimes, and those folks sometimes do better on TRT.
I’d also look into a sleep study to rule out obstructive sleep apnea.
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Thanks for your reply. I’ve also done polysomnography, and the results were ok, however quality of my sleep is poor, I often wake up at night and can’t fall asleep again, although I pay attention to sleep hygiene.
BTW, what’s your opion on checking SHBG - is it reliable marker worth checking? Dr Austin Saya wrote on excelmale.com that clomid often tends to elevate SHBG and too much of it can be a cause, why clomid does not work even when it elevates total testosterone. My concern is how to distinguish which is the cause of my symptoms, low T, or depression?
SHBG is sometimes worth checking in the setting of obesity. I don’t think checking it now would change much in terms of management with respect to your Clomid.
The latter question is a difficult one to answer, given the tendency for symptoms of both issues to have some placebo response to treatment.
Yesterday I’ve listened your podcasts about testosterone, and I would like to ask about one more thing. If someone has low T symptoms, you check his testosterone - how low must it be to decide to do another testosterone measurement? Let’s assume that there is no problem with sleep, and the measurement was at 8-10am.
Reference ranges often vary by lab. If you’re suspicious, it doesn’t hurt to recheck.
So you mean, everthing above normal lab range isn’t indication for further blood check? My lately lab range where 164-754ng/dl, so having for example about 250ng/dl would be ok, despite of having symptoms of low T? I found some data from this video https://youtu.be/3MDRQ5WAIyk?t=477 but I don’t know is it a reliable source.
I’m a little confused, becasue if normal range is so wide, and for example if someone who had about 800ng/dl, and then for some reason his testosterone dropped to 300-400ng/dl with having hypogonadal symptoms should be treated despite beeing in lab ranges?
No, I’m saying there isn’t clear agreement on what the bottom end of the range should be. In other words, there is no specific cutoff that perfectly differentiates “normal” from “abnormal”. So there isn’t a clear answer here – the decision making is complex and needs to be made in context of the broader clinical picture (presenting symptoms and other context).
If someone had a level of 800 and suddenly appeared to “drop” to 300, I’d be suspicious of lab error (or catching a level at some other point during the circadian cycle) before anything else.
Refs:
AACE Hypogonadism Guidelines, Endocr Pract. 2002;8(No. 6)
Arver S, Lehtihet M. Current Guidelines for the Diagnosis of Testosterone Deficiency. Front Horm Res. 2009;37:5-20.
Lunenfeld B., et al. Recommendations on the diagnosis, treatment and monitoring of hypogonadism in men. Aging Male. 2015 Mar;18(1):5-15.
Dandona, P et al. A Practical Guide to Male Hypogonadism in the Primary Care Setting. International Journal of Clinical Practice 64.6 (2010): 682–696.
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“f someone had a level of 800 and suddenly appeared to “drop” to 300, I’d be suspicious of lab error (or catching a level at some other point during the circadian cycle) before anything else.”
I’ve meant a case, when that dropped level would be repeated in the next lab checking. I had pituitary macroadenoma (acromegaly) diagnosed 6 years ago, then had succsesfull surgery, felt much better after, my testosterone increased from 200 to 350 after surgery, but I never regained to my oldversion of myself in terms of hypogonadal symptoms like fatigue, depression, mood swings, poor libido, poor sleep quality, lack of motivation. My acromegaly is controlled by Octreotide 30mg, I have IGF-1 in normal ranges, other homornes are ok, and fortunately, I haven’t developed any complications due to my disease.
Sorry that I haven’t mention that before asking my previous questions. I have some friends visiting this forum and I didn’t want to be recognized.
Yes, this is a much more complex situation given the history of surgery for pituitary tumor. It’s also impossible to be 100% certain that your symptoms are entirely attributable to testosterone levels, as you’ll notice that they are all quite non-specific in nature. With the complexity of this situation, discussion of a trial of TRT would be one you’d have to have with your endocrinologist.
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