help interpreting hormone levels

[isaac2]

I'm very confused and distressed after receiving totally different interpretations of my hormone levels by different doctors (two GPs and one endocrincologist).  First my symptoms: over a period of 7 months, continually declining sex drive, ED (often), fatigue, "brain fog," malaise, hot flashes, difficulty exercising.  I also seem to be losing weight/muscle mass and have very strange feeling of emptiness in testes.  I am 37, very little body fat, and was otherwise pretty healthy.  

These are my blood test results:
cortisol am 337 nmol/L (138-650)
oestradiol 153 pmol/:L (<160)
Testosterone (roche method): 29.9 nmol/L (10.0 - 28.0)
Sex hormone binding Globulin  46 nmol/L (15-50)
Free androgen index 65% (15-100)
Free testosterone 61 pmol/L (43-138)
DHEAS (Roche method) 4.9 umol/L (2.5 - 13)

Now one doctor said I had adrenal insufficiency and low free testosterone and DHEAS and prescribed bioidentical hormones -- T cream and DHEAS (as well as Indol-Carbinol to reduce estrogen).  She assured me no risks.  But I was worried about how this would affect natural hormone production and went to an endo for 2nd opinion (but did start taking Indol-Carbinol).  The endo said the first doctor was frankly out of her mind and my levels were normal (but couldn't offer any help on my symptoms, which continue to get worse).  I am at a total loss now and extremely anxious.    
First, what other tests can I have done?  What could be causing this?
Second, is there really no risk in taking bioidentical hormones?  Can it make you infertile?

Thank you for your help!

[Brian134]

I understand your frustration, and have been going through a somewhat similar experience.  18 months ago, I went to my internist with a range of symptoms I'd had for a while, but which had noticeably worsened in the previous months--fatigue, lethargy, memory problems, mental fuzziness, ED/low libido, etc.  I told him something had to
be out of balance, but was it vitamins, hormones, or what?

What came back as most obviously abnormal was low testosterone--he mistakenly tested total instead of free until I and endo "corrected" him.  After he (again mistakenly) started me on T injections--contraindicated with my PSA of 4.79.  After a biopsy, which was "clean" but only upped my PSA due to trauma (also had coexisting prostatitis), it was October before my PSA came down to point where T-gel therapy would have been OK.  Then it went quickly went up again out of range.

When the endo ordered a range of blood tests in January--not planning to see me until
early April, my thyroid number (TSH--thyroid stimulating hormone) came back at
4.89 (with lab's normal ,40--4.0), indicating hypothyroidism.  I've researched this in-
tensively, and find that the symptoms I originally presented with in Oct 2006 were
characteristic of this low-thyroid condition, which is grossly underdiagnosed by most
doctors.  (An estimtated 26 million have it, half undiagnosed). " Hypo" or low thyroid
can easily be confused with many symptoms of aging, or low testosterone, or adrenal
fatigue, and even (I believe) apnea--as well as possible pituitary or other hormonal
problems.  Most doctors, relying on training in med school and arbitrary criteria from
labs, have been slow to realize that patients can have serious, multi-symptomatic
hypothyroidism (with many or few symptoms, with no typical pattern) even though
their TSH is right at or below the upper end of the "normal" range claimed by their
lab.  Many won't diagnose or treat these "subclinical" cases, for fear of overtreating
to the point of hyperthyroidism (giving too much hormone replacement).  That shouldn't
really be a concern, since patients have some clear symptoms when they begin to
reach that hormone level.  It just requires periodic testing and adjustment of the
medication level as needed...

Hypothyroidism (mostly likey I'd guess), adrenal or pituitary problems can cause
low testosterone and its symptoms and consequences.  No way to know in your
case without a TSH (and even then, if it isn't above "normal," meaning "low level")
the doc may not take your symptoms seriously.  To start, I'd recommend checking
out About.Thyroid (the thyroid component of About.com, anyway) moderated by
Mary Shomon; also, StopTheThyroidMadness.com, which is clear and helpful
despite what might deem an overly dramatic name.  (Not overly dramatic to those
who have gone undiagnosed for many years, even decades.)

If your doctor won't cooperate, or claims a "normal" TSH shuts the door on treatment,
check out the list of "Top Thyroid Doctors" on the "Madness" website.  These are
simply internists or endocrinologists (mostly) who are patient-oriented, nor numbers-
driven, and will normally treat based on symptoms and not just arbitrary numbers alone.

Shomon recommends some good books, many of which you'll probably find at
Barnes & Noble.

Good luck,
Brian

[Stephen Liroff, MD]

Anxiety is a problem that may require medical intervention. You can find a list of psychiatrists/psychologists/sex therapists in the phone book, by web search, or contacting the local medical society. You do not need a referral to see another physican. If you are in an HMO, you may not be able to get the fees paid without a referral, however. If you you are in an HMO, consider getting another primary care's opinion and management.
Free testosterones may not be very accurate I(depends on the lab) especially in the face of  a normal total value. Note that your free testosterone was normal.
S.A.Liroff,M.D.

This information is provided for general medical educational purposes only. It
does not  necessarily reflect the opinions of Henry Ford  Hospital  or the
Vattikuti Urologic Institute.  Please consult your physician for diagnostic
and treatment options pertaining to your specific medical  condition

[isaac2]

Dear Dr. Liroff,
Thank you for your reply.  I have thoroughly examined all lifestyle and relationship factors (and I don't take any street drugs or medications) and do not believe any of them to be a significant cause.  I have asked my GP to a referal to a specialist (urologist or endocrinologist) and for a repeat test, but  he has refused so far, saying it is probably "anxiety."  Also, my last test was in the morning, which makes me think the borderlerline testosterone measurement was actually very low.  What else can I do?  Are there are any other physical causes of declining free testosterone (can a high estrogen level be the culprit?  If so, how can that be lowered?)  
Thank you

[Stephen Liroff, MD]

Your lab values are all normal with the exception of your testosterone which is at the borderline of normal. Testosterone levels in younger men (you qualify) do vary in the course of the day and are highest in the morning. A repeat value obtained in the morning may well demonstrate a higher value. However, the overall picture is that of normality from a laboratory point of view.
You  then have to look at medications as many of them affect libido and energy. Any street drugs? Also, work demands may leave us increasingly tired and less interested in sex. Then their are relationship issues to address. Is the relationship with your partner such that you are interested in being sexually active?  How about your partner's body? Do you continue to find this partner interesting?
You might do best to see a sexual therapist or a physician who specializes in sexual dysfunction (beyond inserting penile prostheses).
I do not have an opinion on bioidentical  hormones. What little I have  read makes them sound attractive, but I would not take or prescribe them without a demonstrated hormone deficiency and then monitoring the levels achieved.
Hope you find the answer for you.
S.A.Liroff, M.D.

This information is provided for general medical educational purposes only. It
does not  necessarily reflect the opinions of Henry Ford  Hospital  or the
Vattikuti Urologic Institute.  Please consult your physician for diagnostic
and treatment options pertaining to your specific medical  condition