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Secondary Hypogonadism - Should I get a second opinion?

I have been struggling with weight loss for 10+ years. My new doctor ordered a testosterone test and my results came back "low".  I was referred to an endocrinologist, and I did not have a good rapport with her and did not feel as though she understood the years of effort I have put into trying to keep my weight down.  After tests, she did not recommend testosterone treatment.

Height: 5'7"
Weight: 209lbs
Age: 33

Test 1: 267 ng/dl  (8:57am)
Test 2: 290 ng/dl (10:12am)
Test 3: 333 ng/dl (7:54am)

Other tests related to the pituitary gland (same day as test 3):
FSH: 3.1 mIU/mL

From my research, these numbers can be considered as Secondary Hypogonadism depending on what reference range the lab/doctor use.  If diagnosed, I can be treated with Clomiphene Citrate which would increase testosterone without the typical negative effects of testosterone replacement therapy.

From what I read, I strongly feel as though the treatment would help me, but of course, I am biased and looking for a solution to my weight and low energy problems. To be crystal clear, I know this will not solve everything, I understand I will need to keep working at eating well, and exercising.

What do you think, should I seek a second opinion? Should I try to discuss more with my current endocrinologist even though I don't feel a good rapport?

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Avatar universal
If you stop TRT most men's testicles come back on line.  The problem is that it is a rarity that they will come back to full potential. At best they will return to the production that they did before you went on TRT and usually a little lower as natural production is reduced every year you age. So if you are on TRT for say 2 years, and then go off.  You will most likely return to a natural production MINUS the "normal" reduction of about 1% per year.  So if you are low production now, in 2 years your natural production will be the low level MINUS a little less.  So that is why they generally say it is a one way street.

ANY extrogeneous (means outside drugs) completely suppress your normal production.  This is why they call it REPLACEMENT, they do not,  nor is it really feasible to "supplement"  testosterone or just add a little to bring you up to normal range.  And this is why they say it is "all or nothing".

The reason for this as I understand it is that the single dose of cream/gel/injection is high enough burst, that the pituitary gland senses the high level of Testosterone, and then believes that there is PLENTY of testosterone, so it reduces the LH and FSH to shut your testicles down of production.  And virtually ANY amount of outside testosterone is enough to flip the switch in the Pituitary and shut down testicle production.

Again HCG seems to help maintain testicular size and even some fertility. Some men only feel well with HCG, others not so much.

Banking sperm is probably a good idea regardless if you are young and think you MAY want to have kids in the future.  It is at least an insurance policy just in case you want kids.

Estrogen is extremely important in men.  (just as testosterone is extremely important for women).  Not enough estrogen and men will not build bone.  TO much however and it is not good.  

Some testosterone you take is converted into estrogen.  Most people if they have a problem tend to have too high of estrogen and need to take Arimidex to control it.  That is itself a trial and error experiment.  People with low SHBG have other issues as so little is bound up and every person is so unique, how the testosterone converts to free T and estrogen is never a known.  It all has to be done with trial and error dosages and blood testing along with your symptoms.
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1616953 tn?1443835511
If you do go on HRT have them regularly check estrogen.  When I did injectables it was too high and I needed to take Arimidex to keep it in normal male levels.  If its too low you will be dealing with the same issues as too little testosterone.  Personally (I'm not a doctor) I would not count on ever coming off HRT so there won't be anything much to do about testicular atrophy.  *And I think even if you go off HRT its not likely they return to normal but I might be reading the wrong thing.  My doctor told me its a one way street.  So one thing to ponder might be sperm banking if your still considering fathering any more kids.
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Avatar universal
HCG can keep testicles from atrophy, and even people who have atrophied testicles have stopped taking TRT and the testicles usually recover.

Clomid can work and is certainly worth a try when young.  It can raise SHBG and result in little to no gain in Free Testosterone and therefore little to no improvements in feeling better. But it is always worth a first try.

Remember to get SHBG tested and also estradiol.  Clomid can also raise estradiol (estrogen).  Both SHBG and estradiol bind to or use up testosterone leaving less of the "total T" available as free T to do work.  You can take a drug to lower estradiol.  But it is very sensitive and you should not take it unless you need it. And the only way you know if you need it, is to have estradiol tested!

If you try Clomid, people should start out with a very low dose and SLOWLY work up.  it doesn't have a great success rate, but it seems like those folks who do get success usually do with very low doses.  A common mistake it for a Dr to put a person on too high a dose and frequency and then they have a bad response.

I am not an expert by any means. Just a guy who is reading up on stuff on the internet.  But with your LH and FSH numbers, I'm not sure those are that low. Which would suggest it may be primary rather than secondary low T. That means that your testicles just are not able to produce.  Secondary, means that your pituitary is not kicking out LH and FSH to tell your testicles to produce.

Clomid sort of acts like LH and tells your testicles to start producing testosterone.
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1616953 tn?1443835511
The lab results your seeing aren't normal for a man your age.  I would find a doctor I trusted and map out a plan.   There are some drugs that rev up your production.  Clomid is one I think.  I'm not against hormone replacement but as my doctor told me this is pretty much a one way street,  Your testicles shut down and will atrophy after being shut down long enough.  On the other hand  having a healthy level of hormones can be a wonderful thing.  Read up on the topic.  Talk to a good doctor.
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Avatar universal
Your numbers are low.  Being overweight doesn't help as more of the testosterone you make is converted into estrogen, which further blocks testosterone receptors.

I would strongly recommend you get a lot more blood testing.

Full thyroid panel to include; TSH, Free T4 and Free T3. Be sure to DEMAND the Free T3 as so many dr's are reluctant to test for it.  And make DOUBLE sure it is for the FREE T3, and NOT Total T3.  

ALso get more than just total Testosterone checked to include:  Total T, Free Testosterone, SHBG and Estradiol.  Yes estrogen.

If you have higher SHBG and/or higher estrogen it would be sucking all your Testosterone leaving little Free testosterone which is all your body uses and you will have low T symptoms.

Not saying it is one or the other or both. But at your age you have the total T level of about a 70 year old man!  And that is NOT anything close to "normal".

Understand that the reference range for total Testosterone is NOT correlated to age.  So they use a single range for a 20 something year old man as they do a 65 year old man.  And if you happen to be a 20 something year old man and you have a result at the low end of the so called range, they pronounce you normal. But you would be "normal" really only for a MUCH, MUCH older man.

I read at least one article that a 40 year old man should have a total T of about 600 and it would decrease to about 400 by the age of 60.  Which is about 1% loss every year of age.

Also SHBG is important for two reasons.  First, it is important to recommend a  treatment protocol.  For example a person who is higher in SHBG would be LESS likely to respond to Clomid, as it tends to further increase sex hormone binding globulin (SHBG) which simply ties up the extra  testosterone, so your total T may go up. But you get zero effect because the active free Testosterone remains low, or could even go lower.  Also SHBG is used to determine frequency of injections of testosterone.  Low SHBG needs lower does more frequently, while normal or even high SHBG can have larger doses taken less frequently.  men with Low SHBG generally have more difficulties finding a testosterone replacement protocol that works for them as things are so sensitive.

Total T is almost meaningless.  Free Testosterone is the most important.  People tend to start having symptoms of low T when their free T gets at or below 10.  One hormone clinic I am aware of says the minimum for a man for free T is 13 and some men need to go even higher.
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15695260 tn?1549593113
Hello and welcome to MedHelp's forums.  Thanks for your question.  It's important to trust your doctor.  It can be hard at times when it is a specialty that seems to be limited in terms of the number of doctors that are available to do that kind of work and endocrinology is one of those in which there always seems to be more patients than doctors.  But if you can, then yes.  It's advisable to seek a second opinion from a doctor you feel more comfortable with.  It may or may not change the outcome but then you will at least have confidence in your plan of action.

It would be really important to rule out any underlying reasons for issues of low testosterone and if they diagnosed you with secondary hypogonadism.  They would look for issues such as diabetes ,issues with your pituitary gland, what medications you are taking.  In general, being obese can cause it as well.  We are happy you work on your weight maintenance program and think that is terrific!  Keep that up.  But it must be said that primary and secondary hypogonadism can both be congenital.  

If hormone replacement therapy is warranted it's the typical treatment for this.  Your numbers are still within normal but at the low range, which is 290 to 1,100 ng/dl.

Here is some information: https://www.mayoclinic.org/diseases-conditions/male-hypogonadism/symptoms-causes/syc-20354881

If you are dissatisfied with your previous doctor, by all means, get a second opinion.  Let us know how it goes.  Best of luck to you.
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