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What Causes Secondary Hypogonadism?
Question: To find the cause of the secondary hypogonadalism...? is my hypothalamus working as expected?
Brief Answer:
Mote details please
Detailed Answer:
Good day
A very complex question indeed. could you provide a bit more of the history ?
What's your LH and testosterone levels? Have you had an MRI of pituitary done?
There could be several reasons from genetic causes to acquired causes.
To answer further, I need a bit more information. your history, ,test results etc. Please attach reports if possible
regards
Binu
Mote details please
Detailed Answer:
Good day
A very complex question indeed. could you provide a bit more of the history ?
What's your LH and testosterone levels? Have you had an MRI of pituitary done?
There could be several reasons from genetic causes to acquired causes.
To answer further, I need a bit more information. your history, ,test results etc. Please attach reports if possible
regards
Binu
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hello Doctor,
I have attached the results (MRI, T levels, LH etc), however due to limitations of 10 XXXXXXX report, i have sent an email to attachments@ healthcare magic.
If you could ask little details on history on your questions, i will give the specifics.
I have attached the results (MRI, T levels, LH etc), however due to limitations of 10 XXXXXXX report, i have sent an email to attachments@ healthcare magic.
If you could ask little details on history on your questions, i will give the specifics.
Brief Answer:
Questions
Detailed Answer:
Hello,
Sincere apologies for the delay in reply. Noted the reports. Infact, your Free testosterone has been quite in normal rage. Free testosterone is a sophisticated test i hope your lab has done the free testosterone calculation based on SHBG and total testosterone levels rather than direct estimation. Your Semen analysis, LH, FSH and MRI pituitary are normal. Total testosterone is low .
Regarding the questions?
Do you use alcohol? What is your height, weight and Body mass index? Being overweight/obese or having uncontrolled diabetes are few of the causes of low total testosterone.
What symptoms do you have/had ?
How is your erection and libido?
Do you get early morning erections?
Are you depressed or use any medications?
Regards
Binu
Questions
Detailed Answer:
Hello,
Sincere apologies for the delay in reply. Noted the reports. Infact, your Free testosterone has been quite in normal rage. Free testosterone is a sophisticated test i hope your lab has done the free testosterone calculation based on SHBG and total testosterone levels rather than direct estimation. Your Semen analysis, LH, FSH and MRI pituitary are normal. Total testosterone is low .
Regarding the questions?
Do you use alcohol? What is your height, weight and Body mass index? Being overweight/obese or having uncontrolled diabetes are few of the causes of low total testosterone.
What symptoms do you have/had ?
How is your erection and libido?
Do you get early morning erections?
Are you depressed or use any medications?
Regards
Binu
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
1.Do you use alcohol? i drink twice a month and that too a glass or two of wine/beers.
2.What is your height, weight and Body mass index?
5"9 is my height (173 cm) and 172 pounds is my weight
3.Being overweight/obese or having uncontrolled diabetes are few of the causes of low total testosterone. I am not obese and have tested my blood sugar as well and its under the limit.
4.What symptoms do you have/had ?
I was having fatigue which comes and goes, that was the reason why i went to physician and diagnosed with low vit-D and while testing the Testosterone it was in low range (270). Hence doctor suggested clomid 25mg for 20 days and tested the T-level it became 540 ng/DL (on Aug'15), then i took clomid 25 mg for 10 days, i felt some ED problems then i stopped taking clomid from Oct 11th onwards and tested my T level on Oct 19th and it was 503 ng/DL.
5.How is your erection and libido?
Even when my T level was around 270 ng/DL , my libido was normal and erection seems to normal. After taking clomid for a month my erection improved (little stronger and last longer).
However now i am having low libido and having trouble in maintaining erections.
6. Do you get early morning erections?
Not all days i get morning erections, but i do get them.
7.Are you depressed or use any medications?
I don't think i am depressed and my cortisol level seems to normal too. Clomid i was taking now i am not taking. Doctor ordered a T level blood in 3 weeks until then i will not take clomid.
However my doctor don't have any clue on how to proceed further for additional diagnosis, thats the reason i am reaching out to this forum. As i stated earlier each part work separately ( Pituitary , testes).. i have question on whether my pituitary getting enough signal from Hypothalamus ? what test help to measure GnRH? while other hormones like Prolaction, TSH, Cortisol seems to normal which is again originates from Hypothalamus and pituitary. which tells that hypothalamus also working. Please suggest how to proceed.
2.What is your height, weight and Body mass index?
5"9 is my height (173 cm) and 172 pounds is my weight
3.Being overweight/obese or having uncontrolled diabetes are few of the causes of low total testosterone. I am not obese and have tested my blood sugar as well and its under the limit.
4.What symptoms do you have/had ?
I was having fatigue which comes and goes, that was the reason why i went to physician and diagnosed with low vit-D and while testing the Testosterone it was in low range (270). Hence doctor suggested clomid 25mg for 20 days and tested the T-level it became 540 ng/DL (on Aug'15), then i took clomid 25 mg for 10 days, i felt some ED problems then i stopped taking clomid from Oct 11th onwards and tested my T level on Oct 19th and it was 503 ng/DL.
5.How is your erection and libido?
Even when my T level was around 270 ng/DL , my libido was normal and erection seems to normal. After taking clomid for a month my erection improved (little stronger and last longer).
However now i am having low libido and having trouble in maintaining erections.
6. Do you get early morning erections?
Not all days i get morning erections, but i do get them.
7.Are you depressed or use any medications?
I don't think i am depressed and my cortisol level seems to normal too. Clomid i was taking now i am not taking. Doctor ordered a T level blood in 3 weeks until then i will not take clomid.
However my doctor don't have any clue on how to proceed further for additional diagnosis, thats the reason i am reaching out to this forum. As i stated earlier each part work separately ( Pituitary , testes).. i have question on whether my pituitary getting enough signal from Hypothalamus ? what test help to measure GnRH? while other hormones like Prolaction, TSH, Cortisol seems to normal which is again originates from Hypothalamus and pituitary. which tells that hypothalamus also working. Please suggest how to proceed.
Brief Answer:
Suggestions
Detailed Answer:
Good day,
Thank you . Noted your reply. Even when your testosterone was 270, you had normal libido and eractions. Testosterone need to be checked more than once before we plan the treatment. It fluctuates many a times. In your case, i would be keen to stop all treatment and recheck fasting testosterone, SHBG and LH between 7 to 9 am. It should be a fasting blood sample.
All other hormones are normal, your hypothalamus seems to be normal too. MRI didnt pick up any structural lesions as well. It is difficult to meaure GnRH. With a normal LH level, your hypothalamus-pituitary signalling seems normal.
Do you snore while sleeping?? Obstructive sleep apnea is yet another important cause of low testosterone levels and fatigue. Please request your doctor to transfer your case to an endocrinologist who can examine you and help further. Endocrinologists are trained to deal with such a situation.
My other suggestion is to do an IGF-1 which will rule out adult growth hormone deficiency as a cause of fatigue.
Suggestions
Detailed Answer:
Good day,
Thank you . Noted your reply. Even when your testosterone was 270, you had normal libido and eractions. Testosterone need to be checked more than once before we plan the treatment. It fluctuates many a times. In your case, i would be keen to stop all treatment and recheck fasting testosterone, SHBG and LH between 7 to 9 am. It should be a fasting blood sample.
All other hormones are normal, your hypothalamus seems to be normal too. MRI didnt pick up any structural lesions as well. It is difficult to meaure GnRH. With a normal LH level, your hypothalamus-pituitary signalling seems normal.
Do you snore while sleeping?? Obstructive sleep apnea is yet another important cause of low testosterone levels and fatigue. Please request your doctor to transfer your case to an endocrinologist who can examine you and help further. Endocrinologists are trained to deal with such a situation.
My other suggestion is to do an IGF-1 which will rule out adult growth hormone deficiency as a cause of fatigue.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you Doctor for your response. I have clarified some of the points/questions mentioned above and i have couple of questions to ask.
Anwer#1: Here are my answers to T-level exams:
Initially T level was tested @ 12:00 which came around 250 ng/dL, to confirm that there was another test taken @ 08:00 with fasting which came as 272 ng/dL, this is how doctor concluded i could have low T levels.
Answer#2: All these diagnosis was done by Endocrinologist only. However he doesn't seems to be knowing much of info, hence i am going to another endo. thats why i am asking these questions so that i can check with my new endo.
Answer#3: I do snore in the night, but if the snoring is the cause then my levels shouldn't responded to clomid correct?
Questions:
=======
Here is my understanding on gonadal endo system, please correct if i am wrong.
Hypothalamus --> Pituitary --> testes --> -ve feedback to secrete/inhibit gNRH.
Question#1. Pituitary & testes seems to working to individually, why its not working on the whole on its own?
i) Testes seems to working and here is why,
As my sperm count was normal even when my T level was with 270 ng/DL, thus says testes working fine, to confirm when we give clomid T levels went upto 540 ng/DL which confirm testes was able to generate the Ts which it get signals.
ii) Pituitary also working and here is why,
FSH & LH levels were normal with the low T-levels (272 ng/dL) and with the clomid the levels are elevated which means pituitary was able to produce lh/FSH when it get signals from Hypothalamus.
question#2: about hypothalamus & its treatment
When we give clomid it seems hypothalamus was able to give signals to pituitary to generate LH & FSH.
i) Does it says there isn't enough estrogen to signal hypothalamus? but it doesn't seems , as the E2 level are normal.
ii) If enough estrogen is generating , then why hypothalamus not signaling pituitary?
iii) if the problem is with hypothalamus then its called "Tertiary hypogonadism". is there any cure for this?
Anwer#1: Here are my answers to T-level exams:
Initially T level was tested @ 12:00 which came around 250 ng/dL, to confirm that there was another test taken @ 08:00 with fasting which came as 272 ng/dL, this is how doctor concluded i could have low T levels.
Answer#2: All these diagnosis was done by Endocrinologist only. However he doesn't seems to be knowing much of info, hence i am going to another endo. thats why i am asking these questions so that i can check with my new endo.
Answer#3: I do snore in the night, but if the snoring is the cause then my levels shouldn't responded to clomid correct?
Questions:
=======
Here is my understanding on gonadal endo system, please correct if i am wrong.
Hypothalamus --> Pituitary --> testes --> -ve feedback to secrete/inhibit gNRH.
Question#1. Pituitary & testes seems to working to individually, why its not working on the whole on its own?
i) Testes seems to working and here is why,
As my sperm count was normal even when my T level was with 270 ng/DL, thus says testes working fine, to confirm when we give clomid T levels went upto 540 ng/DL which confirm testes was able to generate the Ts which it get signals.
ii) Pituitary also working and here is why,
FSH & LH levels were normal with the low T-levels (272 ng/dL) and with the clomid the levels are elevated which means pituitary was able to produce lh/FSH when it get signals from Hypothalamus.
question#2: about hypothalamus & its treatment
When we give clomid it seems hypothalamus was able to give signals to pituitary to generate LH & FSH.
i) Does it says there isn't enough estrogen to signal hypothalamus? but it doesn't seems , as the E2 level are normal.
ii) If enough estrogen is generating , then why hypothalamus not signaling pituitary?
iii) if the problem is with hypothalamus then its called "Tertiary hypogonadism". is there any cure for this?
Brief Answer:
Complex physiology
Detailed Answer:
Very complex questions indeed.
Hormone actions and coordination of glands may vary from person to person. So many external factors also modify these which include, stress, sleep, alcohol, smoking, certain medicines, diseases etc.
Snoring and sleep apnea affects the hypothalamus-pituitary -gonadal signaling . It is an established cause of central hypogondasim ( secondary/tertiary).
You responded to clomed which means that your hypothalamus and pituitary physiology even though a bit lazy, still responds to stimulation. Clomed works by blocking the estrogen levels in pituitary and hypothalamus. Estrogen exert a negative feed back effect and LH and FSH levels are reduced. So when we block the actions of estrogen by Clomed, pituitary secrete LH and FSH more effectively which happened in your case.
You need to understand that total testosterone levels are very variable and free testosterone is the bioactive testosterone which is physiologically active. Sperm count is not based on blood testosterone levels. It is based on FSH and also intra testicular concentration of testosterone.
It is a very complex area and many a times, a pin point explanation can not be given. However, we need to look for causes. It appears that your hypothalamus-pituitary-testes axis is structurally normal and intact , but it is a bit LAZY. But it responds to stimulation as demonstrated by the effect of Clomed. There could be many reasons for this Lazy axis. Diabetes, Overweight/obese, Smoking, alcohol, Physical inactivity, depression, and SNORING and SLEEP APNEA are proven causes.
Complex physiology
Detailed Answer:
Very complex questions indeed.
Hormone actions and coordination of glands may vary from person to person. So many external factors also modify these which include, stress, sleep, alcohol, smoking, certain medicines, diseases etc.
Snoring and sleep apnea affects the hypothalamus-pituitary -gonadal signaling . It is an established cause of central hypogondasim ( secondary/tertiary).
You responded to clomed which means that your hypothalamus and pituitary physiology even though a bit lazy, still responds to stimulation. Clomed works by blocking the estrogen levels in pituitary and hypothalamus. Estrogen exert a negative feed back effect and LH and FSH levels are reduced. So when we block the actions of estrogen by Clomed, pituitary secrete LH and FSH more effectively which happened in your case.
You need to understand that total testosterone levels are very variable and free testosterone is the bioactive testosterone which is physiologically active. Sperm count is not based on blood testosterone levels. It is based on FSH and also intra testicular concentration of testosterone.
It is a very complex area and many a times, a pin point explanation can not be given. However, we need to look for causes. It appears that your hypothalamus-pituitary-testes axis is structurally normal and intact , but it is a bit LAZY. But it responds to stimulation as demonstrated by the effect of Clomed. There could be many reasons for this Lazy axis. Diabetes, Overweight/obese, Smoking, alcohol, Physical inactivity, depression, and SNORING and SLEEP APNEA are proven causes.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
thank you doctor again for the answer and time. I know its complex physiology, however asked because you may come across similar case like me.
Brief Answer:
Step wise approach
Detailed Answer:
Yes indeed. I do see many patients with central hypogonadism ( hypogonadotropic hypogonadism) with normal MRI. We also do iron studies to rule out rare possibility of iron excess and iron deposition in pituitary. In young patients, if MRI is normal, mutation studies may be required to rule out rare genetic causes. Genetic tests may not be required in all cases though. These causes are very rare.
Step wise approach
Detailed Answer:
Yes indeed. I do see many patients with central hypogonadism ( hypogonadotropic hypogonadism) with normal MRI. We also do iron studies to rule out rare possibility of iron excess and iron deposition in pituitary. In young patients, if MRI is normal, mutation studies may be required to rule out rare genetic causes. Genetic tests may not be required in all cases though. These causes are very rare.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
thank you doctor. is that iron excess identified thru ferretin level? if so i think that has been tested in my cases. what are those genetic tests?
in addition to above question, what are common cause for this centerl hypogonadism?
in addition to above question, what are common cause for this centerl hypogonadism?
Brief Answer:
Transferrin saturation.
Detailed Answer:
Hi,
Iron excess is assessed by serum iron, ferritin and transferrin saturation levels.
There are certain gene mutations which cause central hypogonadism. After history and physical examination, in suspected cases, endocrinologist will prder those tests in consultation with a genetic specialist. Usually it is ordered in teen agers or young adults with hypogonadism with no obvious defects in MRI. Kallman's syndrome is one such cause and genetic tests are needed to diagnose.
Central hypogonadism is caused by either a mass lesion in pituitary or hypothalamus ( example: pituitary adenoma or craniopharyngioma). It could be also from Iron depositis, infiltrative diseases of any cause like sarcoidosis, tuberculosis, infections in pituitary, following bleeding in pituitary from any cause, trauma, snake bite etc. Besides, certain genetic disorders also can cause central hypogonadism. In addition, as i preiously mentioned, obesity, sleep apnea, diabetes etc are reversible causes of central hypogonadism
Transferrin saturation.
Detailed Answer:
Hi,
Iron excess is assessed by serum iron, ferritin and transferrin saturation levels.
There are certain gene mutations which cause central hypogonadism. After history and physical examination, in suspected cases, endocrinologist will prder those tests in consultation with a genetic specialist. Usually it is ordered in teen agers or young adults with hypogonadism with no obvious defects in MRI. Kallman's syndrome is one such cause and genetic tests are needed to diagnose.
Central hypogonadism is caused by either a mass lesion in pituitary or hypothalamus ( example: pituitary adenoma or craniopharyngioma). It could be also from Iron depositis, infiltrative diseases of any cause like sarcoidosis, tuberculosis, infections in pituitary, following bleeding in pituitary from any cause, trauma, snake bite etc. Besides, certain genetic disorders also can cause central hypogonadism. In addition, as i preiously mentioned, obesity, sleep apnea, diabetes etc are reversible causes of central hypogonadism
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
XXXXXXX Thank you Doctor. I have one last question, Ferretin test has been done (report attached), do we need refer transferretin to rule out iron absorption issues?
Brief Answer:
SINCE FERRITIN NORMAL, NO NEED OF OTHER TESTS
Detailed Answer:
Hi
wishing you a happy Diwali.
if ferritin is normal, then not to worry. But if the ferritin was abnormal, then we need other tests also.
In your case since ferritin was normal not to worry.
SINCE FERRITIN NORMAL, NO NEED OF OTHER TESTS
Detailed Answer:
Hi
wishing you a happy Diwali.
if ferritin is normal, then not to worry. But if the ferritin was abnormal, then we need other tests also.
In your case since ferritin was normal not to worry.
Note: For more information on hormonal imbalance symptoms or unmanaged diabetes with other comorbid conditions, get back to us & Consult with an Endocrinologist. Click here to book an appointment.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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