Treatment options for Hypogonadism

Message from sta-kool: This discussion was split from another thread, so it may not be organized the way it ought to be.

For background on Hypogonadism/Low Testosterone, see this article at the Mayo Clinic

Male hypogonadism
Male hypogonadism - Symptoms and causes - Mayo Clinic

Now, ladies and gentlemen let me introduce to Renholder:

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sta-kool (and others on HRT),

Was your miserable pre-HRT state static or did you experience relief from time to time?

I have been struggling with the same issues as you describe for a few years now, but for me the symptoms are cyclical such that I experience periods where I actually feel normal and have a decent sex drive and strong EQ. Although depressing and preventing a good life quality, libido is not the worst problem for me. Fatigue and having to force myself to perform the most mundane things and not feeling refreshed after 8-9 hours of sleep is the worst. I have been meaning to do some research on the issue and once again try to find a solution, but only today did I feel strong enough to actually go through with it.

If my testosterone was really low, I would not hesitate with starting TRT and conclude that was the problem, but my testosterone is only borderline low and I grow a beard, have a reasonably deep voice and am physically strong. Because of that, I am very afraid to start using TRT if low testosterone is not the real issue. Libido is a complex issue and I know guys who have started on TRT and relieved most of their symptoms, but libido remained low. I`m considering if there could be other hormones that are lacking in my body, such as thyroid, but according to my GP, everything is normal. The next step for me is probably to visit a qualified endocrinologist, although I plan on trying on trying one more round with DHEA, but this time also use Clomiphene if my doctor prescribes it.

I have also considered if some kind of food allergy could be a cause. Sorry if that is off-topic.

Regards.

Renholder:My libido was very low. But I did not care. If you are not thirsty, you do no care about drinking water

. Yes that is exactly how my life was. Plus the mental fog, not being articulate, and not being able to learn anything new.

I did have better days than other.

I was still able to gain a little muscle, have a beard, etc etc. So don’t base too much off of that.

Tell me what you mean by “borderline” exactly. Sounds like you are having full blown symptoms.

Here is the thing:

You can be borderline on the normal lab ranges, but that could be rock bottom for you.

So let’s talk a little about “normal” ranges.

Some guys might be perfectly fine at a borderline number because that is how their bodies work. The test levels they have are normal for them, they are perfectly healthy.

However other guy’s bodies are set up differently and need a higher level of testosterone to feel and be normal.

In summary, some healthy guys are naturally low-normal, some are mid-normal, some are high-normal.

(this is why I suggest healthy guys get tested to get a base line. That way you know what is normal for you.)

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Here’s the normal ranges off my latest lab reports:

Total Testosterone: 348-1197 ng/dL
Free Testostorone: 5-21 ng/dL

An older report I have does a breakdown of total test by age.

AGE 14-15 100-320 ng/dL
AGE 16-19 200-970
AGE 20-39 400-1080
AGE 40-59 350-890
60 and Over 350-720

Now, here’s how it works out for me:

My doc and I are pretty sure that I was a high-normal when my testicles were functioning properly.

It was not until we got my levels into the mid 800s ng/dL did I actually start feeling like my old normal pre-testicular failure self.

Hello sta-kool,

Thank you for your reply.

What you say about people functioning differently with different amounts of testosterone makes a lot of sense and I have been considering that myself with regards to interpretation of the blood work.

I first became aware that I really had a problem a few years back when I quit carpentry and found that even when sleeping 8-10 hours per day, low stress and good diet, I had no improvement in my state. If anything, it got gradually worse to the point where I had to spend a large amount of every day in bed. I also had ZERO sexual desire and almost felt impotent. Zero. Up until then, working long hours in a physical job and sleeping less than ideal could explain my symptoms, but not any longer.

I made a thread here on the forum around that time and I recall how it required tremendous effort just to write that post on my computer. Even after my doctor labeled me completely healthy and told me to stop worry, I kept an eye on my ferritin levels, which were abnormal. They kept rising and got so high that I were sent to a specialist. This required a tremendous effort on my part because every doctor told me I was fine and that I should stop worrying. High ferritin indicates possible hemachromatosis and perfectly explained my symptoms. Prior to visiting the hematologist, I had given blood to Red Cross, which is part of the treatment for HH. The hematologist could see that my ferritin levels had dropped so quickly after only one donation that it was pretty much impossible that I had HH. Other related blood work also negated the diagnosis.

At this point, I had spent so much time and money with no result, that I simply said, “Screw it, every test indicates that I`m fine”, so I better move on with my life. At this point I was feeling dramatically better than I did when I first became conscious of my symptoms. I wonder if I maybe had a chronic infection or something, which could explain the elevated ferritin and really poor state of being. I was at least feeling better than that.

Eventually, after some time, I had to admit to myself that I really was not feeling like a man of my age (27) should. I had read up on how clomiphene have been successfully used as a substitue for TRT, by stimulating the body`s own production of testosterone. I convinced my GP to let me try it for 3 months and to my surprise she said yes. Testosterone increased significantly and I felt better (placebo?), but my SHBG also increased, such that I don`t know if there really was any effect with regards to free testosterone.

After 3 months, my doctor did not want to write out any more prescriptions because she had read how clomiphene could cause cancer in the ovaries with women and did not want to take any risks, although I could assure her I did not have any ovaries. :)

I then found a doctor in the private sector who I were told took these kind of issues seriously and treated them accordingly. After quitting clomiphene, bloodwork showed that my testosterone had dropped to the levels prior to starting the treatment. He said that with my lifestyle and age, my testosterone levels were too low. We agreed on first trying a natural treatment plan with DHEA and high doses of certain vitamins and minerals, including high doses of fish oil. If that did not help, we could try clomiphene one more time and if that failed, we could use injections. I later read about several guys reporting that fish oil killed their libido, so I decided to drop that. Overall, I think I felt some relief with my libido, but I don`t think it really cured anything. I tried getting in touch with him prior to Christmas, but could not get a hold of him and he`s not yet back from vacation.

I think I want to try a new round of clomiphene in combination with the DHEA and see if that could help me. I really don`t want to start on injections now if I really don`t have to. Further, I`m still not convinced that it is low testosterone that is the cause. Maybe it could be thyroid problems. This current doctor, which is not a endocrinologist btw, did not measure my cortisol levels, which I`ve read could alone explain my symptoms including libido, if they are too high/low.

I have now found an endocrinologist in the private sector, so I`m considering paying him a visit to get a second opinion. While the GP I sought out have been specializing on these issues on his own and working with people having low testosterone, he is not medically trained as a specialist and there was one thing he said that made me a little suspicious regarding his qualifications. I think starting with TRT is a big decision and maybe it is not stupid to get a second opinion before making a decision. Oh, and I know about depression and how the symptoms are similar. Actually, being like this have been depressing, but I`m not really depressed and feel mentally very fine. I just lack the physical part most of the time (not today). :)

Sorry for the length, but when I start writing I have troubles keeping it short.

Regards,

Renholder

Based on your age the doctor will want to check your cholesterol, and your prostate. So prepare for he one glove treatment.

Bloodwork.

I have taken more bloodwork than this, but testosterone always fluctuated between 375-/391 ng/dl prior to clomiphene.

March 2009 August 2010

PS-T3-FREE: 3.8 pmol/l (2.6 - 5.7) ——-PS-T3-FREE: 4.6 pmol/l (2.6 - 5.7)
PS-T4-FREE 12 pmol/l (9 - 24) ——-PS-T4-FREE 14 pmol/l (9 - 24)
PS-TSH 1.22 mU/l (0.35 - 4.70) ——-PS-TSH 2.73 mU/l (0.35 - 4.70)
PS-ANTI-TPO <3 (0 - 15) ——-PS-ANTI-TPO <3 (0 - 15)

CORTISOL 264 nmol/L = 9.57 ug/dL ——-CORTISOL 748 nmol/L = 27.12 ug/dL
TESTOSTERONE 14.9 nmol/L = 429 ng/dL ——-TESTOSTERONE 13.6 nmol/L = 391 ng/dL
ESTRADIOL <0,07 pmol/L = < 0.07 pg/mL ——-ESTRADIOL <0,07 pmol/L = < 0.07 pg/mL
PS-FSH 2 ie/l (1 - 12) ——-PS-FSH 2 ie/l (1 - 12)
PS-LH 2 ie/l (2 - 12) ——-PS-LH 6 ie/l (2 - 12)
PS-SHBG 36 nmol/L (13 - 60) ——-PS-SHBG 17 nmol/L (13 - 60)
PS-PROLACTIN 145 ie/l (0-580)

Sorry about the layout, could not figure out how to space it properly.

22nd November (after using 25 mg clomiphene daily for 1 month)

Estradiol 0,10 (0,04-0,18)

FSH 3 (1-12)

LH 9 (2-12)

Testosterone 17,6 pmol/l or 507 ng/dl

SHBG 31 (13-60)

Now, I have never measured free testosterone directly at a lab, so assuming I could use the calculator at testim, it would read like this:

March 2009 - Free testosterone = 8.39 ng/dl

August 2010 - Free testosterone = 11.0 ng/dl

November 2010 (after one month of clomiphene) - Free testosterone = 11.1 ng/dl —> If my math skills are correct, serum testosterone increased by over 30%, but due to increased SHBG, free testosterone is pretty much unchanged.

October 2011 (last measurement and having been off clomiphene for a while) = Free testosterone = 9.77 ng/dl

Renholder: Yes I thought it was work burn out too. Extreme fatigue, never rested, no energy.

I have never heard of the clomiphene and DHEA protocol you have tried.

HOWEVER, I do know about a successful protocol using human chorionic gonadotropin (hcg) by itself (no testosterone)

The HCG stimulates your testicles back towards normal function. It too is an injection, but it is subcutaneous (with an small insulin needle)

It works for those who have secondary hypogonadism. If you have secondary hypogonadism, your original bloodwork would have shown low T, low LH and low FSH.

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Mayo Clinic for definition:

Male hypogonadism - Symptoms and causes - Mayo Clinic

Primary. This type of hypogonadism — also known as primary testicular failure — originates from a problem in the testicles.

Secondary. This type of hypogonadism indicates a problem in the hypothalamus or the pituitary gland — parts of the brain that signal the testicles to produce testosterone. The hypothalamus produces gonadotropin-releasing hormone, which signals the pituitary gland to make follicle-stimulating hormone (FSH) and luteinizing hormone. Luteinizing hormone then signals the testes to produce testosterone.

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For what it is worth, I was diagnosed with Primary Hypogonadism. So HCG only would not work for me.

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I just came across a very long forum post going over the HCG protocol. I don’t know anything about this forum, however the summary the poster gives is quite accurate Evidently the guy is a patient of Dr, Schippen, the endo who wrote that book I recommended. Will post the first section here:

A Primer on HCG and Dr. Shippen's HCG Protocol
http://www.momb u.com/medicine/ … wn-2307457.html

Human Chorionic Gonadotrophin (HCG) is a hormone found in men and women. Women secrete large amounts of HCG during pregnancy and men secretelarge amounts during puberty.

HCG is administered as a form of TRT. HCG is an alternative to standard TRT in men with low LH and FSH (i.e., secondary hypogonadism). To determine if you are a candidate for HCG you must have a blood test showing low T, LH and FSH. This blood test cannot be taken while you’re on standard TRT because standard TRT shuts down LH and FSH production and thereby distorts the test results. Alternatively, a Clomid Stimulation Test can also demonstrate secondary hypogonadism (see separate posting on this topic).

Rather than shutting down your body’s natural T production system (like standard TRT does), HCG stimulates it back towards normal function. Your body produces it’s own T. I believe that HCG is vastly superior to standard forms of TRT for the following reasons:

1. Better mimics the body’s own natural physiologic rhythm of T production.

2. Easier to maintain normal T levels when administered properly.

3. More physiologic T levels minimize excess estradiol production (i.e., reduces aromatization).

4. Maintains normal size of testicles (in contrast, standard TRT shrinks the testicles).

5. Stimulates sperm production (thereby increasing/restoring fertility). In contrast, standard TRT reduces, if not eliminates, sperm productionthereby making you infertile.

6. Restores normal function to testicles - the benefits of normal testicular function are not fully known. In his book "Saw Palmetto:Nature’s Prostate Healer", Ray Sahelian, M.D. says that the testicles
and the prostate exchange enzymes. I don’t know what purpose these enzymes serve, but I’d rather have them working than not working.

7. Restarts the pituitary/hypothalamus axis (see Medline article 4044781). My HCG dosage is very small (currently 480 IU per week). This means that my body is responding to HCG by producing more LH and FSH on
the "off days." Some have claimed that HCG can restart your system completely so that you can get off the shots and your body will maintain on it’s own. While, I’ve yet to hear of someone for whom this has actually happened, my HCG dosage has steadily declined over 3 years from 1000 IU to 480 IU per week. Also, I feel good about the fact that my pituitary/hypothalamus axis is being stimulated to return towards normal
function.

The only disadvantage of HCG is that [many] doctors are unaware of this excellent alternative.

<MORE AT LINK>

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Neither did I before a guy I know introduced it to me and I had done quit some research before that. As I understand it, clomiphene is not FDA approved for treating males and that is probably why it is a little known protocol even in the US. Actually, the current GP I`m with had not heard of it either.

Clomiphene Citrate Effects on Testosterone/Estrogen Ratio in Male Hypogonadism

J Sex Med 2005;2:716–721.

ABSTRACT

Aim. Symptomatic late-onset hypogonadism is associated not only with a decline in serum testosterone, but also with a rise in serum estradiol. These endocrine changes negatively affect libido, sexual function, mood, behavior, lean body mass, and bone density. Currently, the most common treatment is exogenous testostosterone therapy. This treatment can be associated with skin irritation, gynecomastia, nipple tenderness, testicular atrophy, and decline in sperm counts. In this study we investigated the efficacy of clomiphene citrate in the treatment of hypogonadism with the objectives of raising endogenous serum testosterone (T) and improving the testosterone/estrogen (T/E) ratio.

Methods. Our cohort consisted of 36 Caucasian men with hypogonadism defined as serum testosterone level less than 300 ng/dL. Each patient was treated with a daily dose of 25 mg clomiphene citrate and followed prospectively. Analysis of baseline and follow-up serum levels of testosterone and estradiol levels were performed.

Results. The mean age was 39 years, and the mean pretreatment testosterone and estrogen levels were 247.6 ± 39.8 ng/dL and 32.3 ± 10.9, respectively. By the first follow-up visit (4–6 weeks), the mean testosterone level rose to 610.0 ± 178.6 ng/dL (P < 0.00001). Moreover, the T/E ratio improved from 8.7 to 14.2 (P < 0.001). There were no side effects reported by the patients.

Conclusions. Low dose clomiphene citrate is effective in elevating serum testosterone levels and improving the testosterone/estadiol ratio in men with hypogonadism. This therapy represents an alternative to testosterone therapy by stimulating the endogenous androgen production pathway.

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BJU Int. 2011 Nov 1. doi: 10.1111/j.1464-410X.2011.10702.x. [Epub ahead of print]
Outcomes of clomiphene citrate treatment in young hypogonadal men.

Katz DJ, Nabulsi O, Tal R, Mulhall JP.
Source

Male Sexual and Reproductive Medicine Programme, Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.

Abstract

Study Type - Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Hypogonadism is a prevalent problem, increasing in frequency as men age. It is most commonly treated by testosterone supplementation therapy but in younger patients this can lead to testicular atrophy with subsequent exogenous testosterone dependency and may impair spermatogenesis. Clomiphene citrate (CC) may be used as an alternative treatment in these patients with hypogonadism when maintenance of fertility is desired. This study shows that CC is a safe and efficacious drug to use as an alternative to exogenous testosterone. Not only have we validated previous findings of other papers but have proven our findings over a much longer period (mean duration of treatment 19 months). This prospective study is the largest to date assessing both the objective hormone response to CC therapy as well as the subjective response based on a validated questionnaire.
OBJECTIVE:

•  To prospectively assess the andrological outcomes of long-term clomiphene citrate (CC) treatment in hypogonadal men.
PATIENTS AND METHODS:

•   We prospectively evaluated 86 men with hypogonadism (HG) as confirmed by two consecutive early morning testosterone measurements <300 ng/dL. •  The cohort included all men with HG presenting to our clinic between 2002 and 2006 who, after an informed discussion, elected to have CC therapy. CC was commenced at 25 mg every other day and titrated to 50 mg every other day. The target testosterone level was 550 ± 50 ng/dL. •  Testosterone (free and total), sex hormone binding globulin, oestradiol, luteinizing hormone and follicle stimulating hormone were measured at baseline and during treatment on all patients. Once the desired testosterone level was achieved, testosterone/gonadotropin levels were measured twice per year. •  To assess subjective response to treatment, the androgen deficiency in aging males (ADAM) questionnaire was administered before treatment and during follow-up.
RESULTS:

•  Patients’ mean (standard deviation [sd]; range) age was 29 (3; 22-37) years. Infertility was the most common reason (64%) for seeking treatment. The mean (sd) duration of CC treatment was 19 (14) months. •  At the last evaluation, 70% of men were using 25 mg CC every other day, and the remainder were using 50 mg every other day. •  All mean testosterone and gonadotropin measurements significantly increased during treatment. •  Subjectively, there was an improvement in all questions (except loss of height) on the ADAM questionnaire. More than half the patients had an improvement in at least three symptoms. •  There were no major side effects recorded and the presence of a varicocele did not have an impact on the response to CC.
CONCLUSION:

•  Long-term follow-up of CC treatment for HG shows that it appears to be an effective and safe alternative to testosterone supplementation in men wishing to preserve their fertility.
© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.

A short read on how clomiphene works:

How Clomid Works in Men - Male Health

Thanks for that link. Very interesting, I learn something new every day.

Now note that the HCG guy above mentions a "A clomid stimulation test":

"Alternatively, a Clomid Stimulation Test can also demonstrate secondary hypogonadism"

Here is his post on that:

A Clomid Stimulation Test

http://www.momb u.com/medicine/ … f-8-989103.html

A Clomid stimulation test is a standard protocol that has been used by endocrinologists for years to test whether a man’s hypogonadism is primary or secondary. If the test is successful (i.e., if your T rises
significantly), that means that all of the organs in the feedback loop (the testicles, pituitary and hypothalamus) are healthy and functional, but for some unknown reason the system has gone dormant.

A successful test result also means that you are a good candidate for HCG or Clomid, which in contrast to standard TRT, stimulate your body to produce its own.

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So it does sound like you may be a good candidate for the HCG only protocol.

HCG might be something your doc would be more comfortable proceeding with?

ON EDIT for other readers: Clomid = clomiphene citrate

Sorry sed26, hope you don’t mind me and Renholder talking about this here.

If so I could use my “secret mod powers” to split it off into another thread.

Thank you very much for that link, sta-kool. I have only briefly heard about HCG, but this looks very extensive and relevant to me.

Feel free to split it for me. I actually considered starting a thread about clomiphene treatment as an alternative to TRT since it is not a very known protocol even in the US it seems.

Sta-kool, with the amount of T you’re taking, do you ever worry about testicle shrinkage?

No, I don’t care about that at all.

Why?

Because it is a trade off. Testicular shrinkage versus poor health and poor quality of life.

I’d rather be clear headed, feeling good, staying healthy, interested in life, and full of energy.

Does that make sense?

Now that being said:

- If you are on HRT and you decide to father a child, your doc will give you HCG to wake the boys up so they produce sperm
- The more modern HRT combines both testosterone and low dosage HCG.

The thinking behind this Test + Low Dosage HCG protocol is that your testicles produce other things than sperm. They communicate with the prostate for example, and some think that there are LH receptors in the brain

It is based off this article:

Low-Dose Human Chorionic Gonadotropin Maintains Intratesticular Testosterone in Normal Men with Testosterone-Induced Gonadotropin Suppression
The Journal of Clinical Endocrinology & Metabolism 90(5):2595–2602
Printed in U.S.A. Copyright © 2005 by The Endocrine Society
doi: 10.1210/jc.2004-0802

The article is a free download so I am attaching it.

My doc and I are doing a trial of this. I take the HCG every other day, subQ with an insulin needle. For what it is worth mentally I feel more self confident, so I think there is something to the brain-testicle connection. It is true that balls have gotten a little bigger, enough that wife had commented on it.

Thanks for the link. I had no idea a PDF would download into iBooks. I’ll skim thru it as soon as install this garbage disposal so the wifey can get her spurs out of my ribs. Lol

One quick question. When you say “balls have gotten bigger,” are saying the HCG have enlarged them or stopped them from shrinking. I’m 45 so kids aren’t really my priority at this point in my life, but still I am slightly put off by the prospect of diminishing nuts. I say slightly because I fully understand your stance about the trade off…but it’s still something to think about. You know?

Basically they are getting bigger from the shrunken state, so I am getting back to my previous size. Does that make sense?

Really though my reason for working with my doc on the low dose Hcg is reading stories of guys on that protocol who were having success with it on another forum.

I’ve read a little on HCG but not enough to know all the benefits. You should start another thread with your experiences with this issue. I don’t think I’m the only one hungry for knowledge in this area.