Ask The Urologist Anything (Dr Michael Rotman)

[DrRotman]

Hi Zentech,

Your case is not unusual as I have many patients with this type of condition and it is frustrating as they do all the recommended things and still do not return to where they were at baseline both numbers wise and symptoms wise. Some people do suffer from permanent dysfunction after using illegal steroids and testosterone and hcg may be the only solution. Given your young age however, you do have a higher likelihood of recovering and returning to baseline but the tradeoff may be feeling less than optimal for quite some time. Good luck in your decision process.

Dr Rotman,

I have been diagnosed with anabolic steroid induced hypogonadism (ASIH) at the age of 24, following several years of use as a competitive bodybuilder. My primary symptoms include low libido, ED, brain fog, and fatigue.

I am under the care of an endocrinologist in Australia who did the standard workup before I started HCG (prolactin, thyroid, e2, total and free test, LH, FSH, SHBG), and sent me for a pituitary MRI. My MRI results were normal, and my bloodwork revealed normal LH and FSH, low IGF-1 and growth hormone, as well as a total testosterone of 7.5 (12-32 reference range). Free test was 188 (280-720).

I haven't touched a steroid in over 12 months and have tried 3+ months of clomid monotherapy to no avail. I then tried 3 months of clomid and HCG combined (prescribed and monitored by the endo). At first the HCG worked wonders, and then one day it suddenly stopped working. Followup bloodwork revealed that my test had doubled, but was only 15 on a 12-32 range. Now he is talking about testosterone + HCG.

What are your thoughts? Is there any other way to recovery? I am struggling to find a single documented case like mine anywhere, even among message boards. I would also like to ask you whether you think Clomid could cause any of my symptoms, as it has been used continually for the past 6 months at 25mg a day.

 

[charile12]

Hi doc. I live on long island and may see you soon. I am on trt for sencondary hypogonadism. tried clomid, raised my lh to about 7 but only raised T to 500. Still have some low t symptoms. I started injections from endo. Gave me 200 mg bi-weekly. But I am injecting 100 1x per week. (same dosage - just more frequent) I am not concerned about fertility so I have not asked for hcg - at this point am glad he offered injections.
My question - should i be taking hcg even though i dont care about fertility? I am just thinking that LH may have other roles in the body. ALso, would clomid low dose or even 1 per week keep pituitary producing LH/FSH while on t inj? Also, if my Thyroid Ft3 and ft4 are on the low normal range, would that cause a low -t?
Thank you for your time Dr.

 

[charile12]

I have another question in addition to post below Dr. Rotman., sorry for the long post,
I have a history of uric acid kidney stones. I was excreting lots of uric acid. My uric acid in my serum was for last 2 years high normal end. (7.2 and 7.4 on end range of 8.) I was taking allopurinol for many years and stopped about 2-3 years ago.
I was reading some info online of uric acid can affect T or vice versa.
I stopped allopurinol because I thought i can keep the urine uric acid under control. I barely did.
Can you please comment on this? would reducing my serum uric acid "magically" raise my T back to normal?

Hi doc. I live on long island and may see you soon. I am on trt for sencondary hypogonadism. tried clomid, raised my lh to about 7 but only raised T to 500. Still have some low t symptoms. I started injections from endo. Gave me 200 mg bi-weekly. But I am injecting 100 1x per week. (same dosage - just more frequent) I am not concerned about fertility so I have not asked for hcg - at this point am glad he offered injections.
My question - should i be taking hcg even though i dont care about fertility? I am just thinking that LH may have other roles in the body. ALso, would clomid low dose or even 1 per week keep pituitary producing LH/FSH while on t inj? Also, if my Thyroid Ft3 and ft4 are on the low normal range, would that cause a low -t?
Thank you for your time Dr.

 

[Vince]

uric acid, particularly when it involves kidney stones, a prescription agent like allopurinol may be the best solution, at least until we gain a better understanding of how to control this process naturally. ​

 

[1Draw]

I would try this remedy first before taking a drug. See #13 & #18.... If it doesn't work, you can always take a drug.

20 Benefits of Drinking Lemon Water and Honey in the Morning.

http://www.fitnessandpower.com/fitn...drinking-lemon-water-and-honey-in-the-morning

 

[charile12]

Thanks. Actually I can attest to that. It does help dissolve the stones and pass them. I have a problem where I can not breakdown protein (purines) to well. So my 24 hr urine tests always come up with high uric acid, even when I limit my purine intake. Lemon does not help be breakdown the protein but it helps with the PH of the urine so I dont form stones as quick - it does not help with my root problem though.

 

[DrRotman]

Hi Charlie, lots of issues to address. One- you need to make sure your Thyroid levels are in the normal range to obtain optimal T levels. Two- hcg has many beneficial effects inn addition to preserving fertility, such as preventing atrophy and improving your own T levels by mimicking LH. Clomid does not do these things other than maintaining fertility when taken alone though some use it in conjunction with Testosterone though the jury still out if this is protective. Three- you need to control uric acid levels to prevent gout and kidney stones, both of which can be debilitating when uncontrolled. The data on its effect on T is scant nor should it matter. In addition to lemon water mentioned above, potassium citrate can break down and prevent your kidney stones if they are uric acid. I doubt this has anything to do with your hypogonadism.

I have another question in addition to post below Dr. Rotman., sorry for the long post,
I have a history of uric acid kidney stones. I was excreting lots of uric acid. My uric acid in my serum was for last 2 years high normal end. (7.2 and 7.4 on end range of 8.) I was taking allopurinol for many years and stopped about 2-3 years ago.
I was reading some info online of uric acid can affect T or vice versa.
I stopped allopurinol because I thought i can keep the urine uric acid under control. I barely did.
Can you please comment on this? would reducing my serum uric acid "magically" raise my T back to normal?

 

[Bookersnookers]

Hi Dr. Rotman

I am a 39-year-old male with no family history of prostate cancer. I have been on TRT for five years. I am on TRT because like a fool I abused steroids for a couple of years in my early 20's. I had no issues while on TRT outside of a high hematocrit and high estrogen when my test dose was too high. My current test dose was a 100mg sub c once a week. During this five year journey, I have learned that I needed to be proactive in learning about the right treatment as many Dr's have no idea on how to treat low t. I had a great Urologist in NYC but moved in April of 2017 and started with a new DR.

I continued my 100 mg once a week with this new dr, and he drew blood on my first appointment in April. I had a second meeting in June and drew blood again. My third was in September, and he finally decided to review my bloodwork and revealed my PSA was a 2.75 than a 2 and then a 2.53. The morning of each blood draw I had sex. I never knew sex impacted PSA. After abstaining from sex, my PSA was a 2.20. He wanted to rush me into biopsy, and I declined.


I went for a second opinion and another blood draw. That blood draw reflected my PSA was a 2.20. This Dr gave me a rectal exam and said my prostate is enlarged, but the prostate was smooth. He told me to come off TRT and come back in 7 weeks. I am at week 4 and feel terrible. He wants to draw blood and see if the testosterone is causing the high PSA numbers. I went through my old blood work and found one lab from 8/2015, and my PSA was 1.75. He said the jump from 1.75 to the high of a 2.75 is concerning. He didn't think it was crazy the first DR recommended biopsy but felt coming off the TRT was the next best approach.


My good friend is a Dr. He is not a urologist. He thinks since I am under a 2.5, a smooth prostate even though enlarged, and no family with prostate cancer a biopsy is being overly cautious. He told me to continue my TRT use something to treat BPH and continue to monitor my PSA level.


What would you do if you had a patient in my situation? SHould I wait for another four weeks before having my PSA checked or can I go now? I would hate to come off TRT permanently. Its really changed my life for the positive.

Are you the Dr. Rotman in Lawrence Long island?

 

[lexer]

Bookersnooker
how old are you?
do you have any prostate enlargement symptoms ; weak urine stream, frequesnt urination? Do you wake up at night?
As far as psa, they not only look at the number, they look at the velocity of change. Example, you could have a very low psa of .4 and then 6 months later its .9 which is still low but its also a rather big change. That would/ could be concerning.
many doctors put patients out when doing a prostate biopsy, i know mine does. A lot of men are aftraid of a biopsy which really isnt painful. Still, many doctors understand some guys get anxiety over it and rather than have patients neglect a biopsy due to fear, they just put them out for 10 minutes and then conduct the biopsy. Ask your doc about that or find a urologist who does that. Many now do. Good chance you dont have cancer so relax and dont stress over it.

 

[jsr0367]

Dr Rotman:

I have been on TRT for 3 years now. As far as I can remember my PSA has always been in the 3.5-4.1 range - even before TRTR. Last July my PSA spiked to 5.83 and my urologist stopped TRT and prescribed Bactrim fof 3 weeks. My PSA dropped to 4.1 in a week and at the end of the 4 weeks I was down to 3.83. He restarted TRT in August. Then I noticed that I was putting on body fat and my weight was creeping up. In 4 months I was 7 pounds heavier and bodyfat up 2% (to 14 from 12). I asked my GP for a test for Estradiol in Oct and it was 54. I contacted my urologist and we dropped my Cyp to 120mg per week from 150mg per week IM. I noticed after month feeling more tired and loss of nocturnal erections. So in December we upped my Cyp to 140mg per week and started feeling better around Xmas. Saturday my Urologist ran labs in preparation for my 1/19/18 f/u visit. My PSA is back up to 4.9 I don't know what my Estradiol is because he doesn't test. He only tests for Testosterone, HCT and PSA. HCT is 52.

I suspect when I see him this Friday we will be scheduling a biopsy.

Looking for some thoughts on this issue. Is there a link between Estradiol and PSA? There seems to be but my urologist dismisses it.

Is there anything I should be doing?

 

[cfarone]

New Patients

Hi Guys,

I am always willing to answer any questions involved with TRT and it's urological implications. Will check back frequently answer all your questions. Thanks !

Hi Dr Rotman - I am 47 years old and have been fatigued and have had brain fog for 16 months and was just tested for low t. My testosterone level was 228 and I had low pm cortisol so my primary care physician referred me to an endocrinologist which cannot see me until March 5th. I live in upstate NY and would like to see a physician with experience with low t prior to March. Are you accepting new patients?

 

[CoastWatcher]

Hi Dr Rotman - I am 47 years old and have been fatigued and have had brain fog for 16 months and was just tested for low t. My testosterone level was 228 and I had low pm cortisol so my primary care physician referred me to an endocrinologist which cannot see me until March 5th. I live in upstate NY and would like to see a physician with experience with low t prior to March. Are you accepting new patients?

Dr. Rotman is accepting new patients. His practice is detailed here. http://www.michaelrotmanurology.com/?utm_source=gmb_auth

 

[cfarone]

Thank you for the response.

 

[pauloal13]

Doctor, what do you think is effective for anxiety?

 

[DrRotman]

Wow, that is a difficult question to answer. One needs to identify the source of anxiety first and then take it from there. The use of a psychiatrist to work your way through it can be very helpful.

 

[nurselyfe]

Dr. Rotman,

Background
24 y.o. healthy male here. I've been on TRT for 3.5 years, was not hypogonadic before TRT. Ran into issues this past May when I took way too much Anastrazole, while on 105mg T Cypionate per week. Ever since I did that, I have a myriad of physical and sexual symptoms that I have never had in my life, despite ceasing Anastrazole for over 5 months now, and blood work suggesting perfect health and hormone levels.

Symptoms:
· Complete absence of sebum
· Dry skin, hair, and mouth with texture changes on skin
· Severe diffuse head hair loss on entire scalp, from eyebrows, and eye lashes
· Severe diffuse hair loss on entire body
· Erectile dysfunction
· Very low libido
· Reduction of vascularity
· Reduction in blood pressure (128/82 to 110/68)
· Loss of aggression
· Slowed metabolism
· Muscle wastage, loss of blood flow to muscles, and inability to increase muscular endurance or strength
· Reduced appetite
· Increased body fat
· Slow nail growth and reduction in quality
· Cold sweats
· Cold extremities


Protocol 30mg T Cypionate EOD (~105mg per week)

TT 1006 (264-916)
FT 24.2 (9-26.5)
E2 35 (7.6-42.6)
SHBG 31 (16-55.9)
IGF1 267 (55-355)
DHEA-S 374.3 (164.3-530)
TSH 1.4 (.45-4.5)
fT4 1.26 (.82-1.77)
fT3 2.8 (2.0-4.4)
Thyroid Antibodies normal

Situation
Firmly believe I have acquired an estrogen insensitivity via an epigenetic pathway. Regardless if you agree with this or not, I have visited many doctors (endo's and uro's) and they seem to think my symptoms are due to me being on TRT since I did not "need" it to begin with.

My question to you, is this correct? Can TRT cause these symptoms? I felt incredible until I crashed my estrogen. I thought TRT is meant to combat these symptoms.

 

[dteran61]

Dr.Rotman,

I need your help I am in the bronx area and was on TRT at 200mg a week from a telemedicine place. I stopped as I wanted to be with a doctor face to face which is always better. Long story short Ive been off for almost 2 months and went to a urologist in New Rochelle on Friday, I was sent to quest and my labs came back at total test 91 and free at 17.1 this urologist said im completely normal which I feel he is insane im 28 this is upsetting.

 

[Jeanjoseph000]

Hi Dr R, I’m considering testopel pellets after seeing warnings of family contact with the gel. It claims it is safe for contact with others and doesn’t not transfer. My worry is, if it can get absorbed into the body they why can it get absorbed to the skin area where insert? Skin is a part of your body. Confused! Thank you!

 

[charile12]

Thanks. See u Thursday

My thyroid is def not optimal. I have an appointment to see you this coming Thursday. Can't wait!

Hi Charlie, lots of issues to address. One- you need to make sure your Thyroid levels are in the normal range to obtain optimal T levels. Two- hcg has many beneficial effects inn addition to preserving fertility, such as preventing atrophy and improving your own T levels by mimicking LH. Clomid does not do these things other than maintaining fertility when taken alone though some use it in conjunction with Testosterone though the jury still out if this is protective. Three- you need to control uric acid levels to prevent gout and kidney stones, both of which can be debilitating when uncontrolled. The data on its effect on T is scant nor should it matter. In addition to lemon water mentioned above, potassium citrate can break down and prevent your kidney stones if they are uric acid. I doubt this has anything to do with your hypogonadism.

 

[OMI100]

Dr. R we have a question posted by one of our members about The Stockholm-3 Model for Prostate Cancer Detection. I had never heard of it but did some searching. Do you have any information on this protocol or view on this?
https://www.excelmale.com/forum/sho...ockholm-3-Model-for-Prostate-Cancer-Detection

Thanks.....