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Author Topic: What to do in my case? Vitamin D, high prolactin/gluten, which blood tests...  (Read 2400 times)

Perene

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Hello all,
I stumbled upon this site yesterday and found to be a great source of information.

Please allow me to share my case, I have multiple questions that I have yet to see discussed at length.

- First of all, I discovered that my Accutane treatment from 2011 may have caused my gradual loss of libido. The whole story is discussed here: https://www.acne.org/messageboard/topic/295030-repairing-the-long-term-damage-from-accutane/?do=findComment&comment=3582096

I don't have old blood tests, but recent ones showed the following:

ALL NORMAL:

Uric acid = 4,9 mg/dL.
Creatinine = 0,9 mg/dL
Glucose = 92 mg/dL
CBC/Hemogram = all results OK
Lipid Profile: all OK. Example: total cholesterol 172 mg/dL. HDL cholesterol 68 mg/dL, etc.
Aspartate Aminotransferase (AST) = 20 U/L
Alanine Aminotransferase (ALT) = 21 U/L
Urea = 47 mg/dL
T4 = 1,05 ng/dL
TSH = 2,0700 µIU/mL

NOT OK:

25-Hydroxy Vitamin D = 26 ng/mL in August. After 3 months taking 7000 UI (2 pills, once a week), in November = 40,46 ng/mL (now normal levels. Will take one pill for 3 months to see how things will evolve from there)

Prolactin = 25 (in August and November). Normal for men = 2,60 - 13,10 ng/mL

Total testosterone = 3,09 ng/mL in August. 4,19 ng/mL in November (mostly because of the vitamin D)
Free testosterone = 6,15 before, now 6.91

Further tests: MRI pituitary fossa (sella turcica) (+ abdominal ultrasound). Both normal (requested by the endocrinologist).

**********************
Here are my questions:  :D

- I'll measure my vitamin D months from now, but as you can see only after 3 months of taking two 7000 UI pills once a week I got 40 (recent medical recommendations are for at least 50 - 40 is the least someone can have to consider himself vitamin D suficient). The only moment the Sun hits my skin is when I go to the gym in the morning, walking half a mile.

Even then I cover my body (long sleeve shirt, sunscreen protector...). My skin is very white compared to others in my family.

The doctor prescribed only ONE 7000 UI pill a week, He says that I won't need to continue buying it and after March 2018 my body will continue to have the current levels, of at least 40.

And vitamin D raised my total testosterone levels.

Is it true I won't need to continue taking for the rest of my life?

*****
What further blood tests I need to do to evaluate my health? For example, FSH, LH, DHT, Zinc, DHEA, T3, SHBG are all necessary and need to be done to add their results to what I have in total and free testosterone? I'll also do a spermogram with a urologist just to make sure things are 100% normal.

The only symptom I am 100% sure of having today is low libido. I don't think I have low energy or cognitive problems, yet I'll assume I am not in perfect condition and next month I'll visit a nutritionist and see if it's viable to get a personal trainer to improve my workout routine, since I heard a more demanding is required to raise testosterone levels (high intensity training).

*****
Diet:

This is the one I was adopting for these blood results:

********
BREAKFAST
********

Wholemeal bread - 2
Skimmed milk + OAT
Scrambled egg (1)
Ricotta cheese
Detox juice
CINNAMON
BACON (2 pieces)
Prune (1)

********
LUNCH
********
CARROTS
SPINACH
WHITE POTATO
BEANS and WHITE RICE (2-3 TBSP)
BROCCOLI FLORETS
GARLIC
CILANTRO
LETTUCE
MUSHROOM

T-BONE STEAK (another option during the week: SALMON STEEK). Once a week: WHOLE PASTA
OLIVE OIL

********
DINNER
********

GRILLED CHICKEN BREAST
BLACK OLIVE

THYME
OREGANO
ONION
TOMATOES
CHIVES
BALSAMIC VINEGAR

********
SNACKS
********

1 protein bar
Greek yoghurt
Brazil nuts
Pumpkin seeds
Macadamia nuts
Hazel nuts

*****

I was thinking about the high prolactin, and saw that gluten in the diet can raise these levels for men, which is also detrimental. For example, the bread, the protein bar (which I'll see if can be replaced by Whey Protein), and even the Lindt dark 85% chocolate (1 for the whole month) all have gluten. And that's not all:

[edited by moderator]

I was eating linseed in the morning, and the bread had this in the list of ingredients. The above link and this study:
https://goo.gl/JK8RGj

Are both saying FLAX and multigrain breads have too much phytoestrogen, while rye bread have less. The protein bar is also high on the list. I couldn't find rye bread, only a gluten free one that uses rice flour in the list of ingredients (quinoa and others, but not linseed).

Plus I was drinking skimmed milk every day, and eating ricotta cheese. A greek yoghurt (no fat) before going to bed.

Here's what I am suggesting to do at this point before seeing the nutritionist for him to prescribe a new diet:

- Cut the milk and cheese. Only 2 days a week
- Coffee with no sugar instead of milk in those days (only in the breakfast).

- Include sweet potatoes instead of bread, for 3 days a week.
- Include avocado 2 of these days.

- In 2 days of the week I would eat this gluten free bread, with peanut butter.

- For meat (4 times a week): KNUCKLE
- The rest of the week (with the salad and black beans/white rice, I would eat fish, salmon/sardines or tuna)

What do you think? I am saying this because it's questionable if dairy products didn't also lowered my testosterone levels, even though it's the fat milk that gets the blame.

As for cheese should I select one with more fat in it?

Oh, and dried apricots too have more phytoestrogen than others, and I was eating one everyday.

***********

In that ebook I mentioned in the acne forum the author says the following about accutane and libido:

[edited by moderator]

- Try relatively high-dose supplemental vitamin B 6 (but avoid excessive doses that may induce a peripheral neuropathy; see the vitamin B 6 section for more information).

- Try other supplements, herbs, and drugs, as discussed elsewhere in this book.

- Stringently avoid other things that may decrease the testosterone level or effect (such as phytoestrogens and antiandrogens).

- Consider using supplemental testosterone. It is useless to use your blood testosterone level to gauge whether or not this is necessary. Judging from tests conducted on people with Accutane-induced sexual dysfunction, Accutane does not seem to appreciably lower the blood testosterone level. What it apparently does is partially block some of the effects of testosterone. This decreased responsiveness is analogous to someone who is hard of hearing. To some extent, you can compensate for their disability by speaking louder. A partially deaf ear needs more sound, and someone who is less responsive to testosterone needs more testosterone. Of course, there are drawbacks to the use of supplemental testosterone. Because the testosterone susceptibility of most areas of the body is not affected, increasing the testosterone level enough to restore libido and sexual sensation may trigger unwanted changes elsewhere, such as alopecia and acne.

- If you are a man, avoid things that increase your estrogen level.

- Avoid things that increase sex hormone binding globulin.

Among other things.
« Last Edit: December 29, 2017, 10:55:11 pm by PeakT »

cujet

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My Vit D levels are right at 30, even living in South Florida, driving a convertible, flying regularly, working outside regularly and taking at least 2500 Vit D per day.

I've been told by my Rheumatologist that it's common to see low Vit D in those with autoimmune disease.
57 years old
Autoimmune Hashimoto's, near zero natural T production
Cause: severe mononucleosis in my early 30's
Weight 220
Height 5' 10"
180mg NPthyroid (natural desiccated pigs thyroid)
Labs (Oct 2017) , my T=730, TSH 0.03, T3+T4 mid-range normal.
 
10% compounded creme. T=725, which feels just right.

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Cataceous

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Statistically speaking, the main problems associated with low vitamin D occur when 25-Hydroxy Vitamin is less than 20ng/mL. It's with dubious justification that the low end of the range was raised to 30 ng/mL. Read this article, for example: https://www.nytimes.com/2017/04/10/health/vitamin-d-deficiency-supplements.html

The elevated prolactin is of interest. Were these tests performed after a 12 hour fast and 24 hours of abstinence from sexual activity? It's possible a doctor would suggest trying a course of cabergoline.
I am not a medical doctor; any suggestions are meant to be discussed with your doctor.
Age: 60, Ht: 5'10", Wt: 154 lbs
Protocol: 3.2 mg TE subQ qd, 2.4 mg TP subQ qd, 20 mcg GnRH subQ 5.25x/d, 6.25 mg DHEA bid, 12.5 mg enclomiphene qod
Approximate levels (peak): TT: 700 ng/dL, E2: 30 pg/mL, DHEA-S: 300 ug/dL, SHBG: 30 nMol/L

Perene

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Statistically speaking, the main problems associated with low vitamin D occur when 25-Hydroxy Vitamin is less than 20ng/mL. It's with dubious justification that the low end of the range was raised to 30 ng/mL. Read this article, for example: https://www.nytimes.com/2017/04/10/health/vitamin-d-deficiency-supplements.html

The elevated prolactin is of interest. Were these tests performed after a 12 hour fast and 24 hours of abstinence from sexual activity? It's possible a doctor would suggest trying a course of cabergoline.
Don't they say now that 12 hours of fasting is not needed? It seems this is a recent recommendation, and I believe in both exams I stopped eating at 8 pm and did those tests at 7 am at least. At this point I don't have enough libido to bother with "fapping" or women, and this is not only psychological, for reasons such as "going my own way", it's definitely a side effect from the Accutane treatment in 2011, I remember in 2012 my libido was VERY HIGH, if I were to measure, it was like that:

- Before-treatment (which I did correctly, following all procedures): 6, 7
- One year after treatment: depression and 10, 11
- 2017: 3

What I am suggesting is to increase testosterone naturally and to decrease the prolactin levels, the latter by removing some gluten food from my diet, because from what I read these gluten foods are exactly what is increasing prolacting.

Some of the things I was including in the diet were perhaps responsible for the low test too, such as the bread or perhaps milk and cheese with almost no fat.

My current weight is 143 lbs (65 kg) and I have 33 years, 5 feet 7 inches (1.70m). Years ago I had 20-40 pounds more, I lost weight not mostly due to the workout routine, which is not very demanding at all, but the removal of certain foods with more carbohydrates and by adding that protein bar.

After I have a new diet prescribed and a new workout routine I'll see if things will improve and I'll clarify if vitamin D is needed for the rest of my life by doing further blood tests when I stop taking.

It seems my current testosterone levels (4) are still low (5-6 would be the normal range), and at 4 I guess no TRT (which is needed for the rest of life) is required.

Then there's the idea of removing milk and cheese from the diet. What I decided to do at the moment is to limit them to 2 days instead of the whole week, and I have chosen one brand with more calcium and another cheese with some fat (and enough calcium too) and not much sodium. I was eating ricotta.

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Perene

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I got my last blood test results... any thoughts if further tests are needed?

Spermogram: the urologist said there's nothing wrong. Note: all Google Drive links are from the lab. They are written in portuguese.

https://drive.google.com/file/d/1Ci5RGN5y0E9B6wKAYVzgWC3QN3fj4dYW/view

STD tests taken 2 months after the last time I had sex (I waited all this time to make sure they would be accurate). Herpes igG is positive, but I never had any symptoms - it's only there like it is in 2 thirds of all people.
https://drive.google.com/file/d/0B2G56RW8rbATalZFSXlaNnBJcU0/view

First blood tests from August:
https://drive.google.com/file/d/0B2G56RW8rbATRUpJal84QWVHREk/view

Second blood tests from November, 2017 (remember: I took Accutane for months during 2011):
https://drive.google.com/file/d/19lNaLFmWcat8WRcLjns9XXd5NBOzYOU5/view

And now the last tests:
https://drive.google.com/file/d/1IIKeLtHovauXyw0YUtgyZ46N-P5hQEbO/view

From January 15, 2018.

Let's see:

All OK:

Uric Acid, Creatinine, Glucose, Complete Blood Count (why it showed Eosinophilia now? Will check that later), Lipid profile, Free T4, Urea, Aspartate transaminase, Alanine Aminotransferase and Thyroid-Stimulating Hormone (TSH). All of them in the reference ranges from the lab.

*************** RELEVANT RESULTS ***************

1) Total testosterone:
I said 3.09 in the 1st test, and 4.19 in the 2nd after 3 months taking vitamin D. I am still taking, this time 7000 UI/week and not 14000, for another 3 months (but I have plans to stop taking the supplement, and spend more time outside in the morning).

Now: 357 ng/dL. Lab ranges: 175 - 781 ng/dL

2) Free testosterone: 7.21. Lab ranges: Since 2011 it's calculated according to total test. and SHBG levels. According to Vermeulen, A. ET AL., 1999, the ref. ranges are 4.58 - 18.33 ng/dL for men, and 0.03 - 0.95 ng/dL for women.

3) SHBG (1st time I did this test): 32.6 nmol/L. Lab ranges: men from 20 to 50 years old: 13.2 - 89.5 nmol/L.

4) Vitamin D: still at 40's. Now 42.4 ng/mL.

5) Vitamin B-12 (1st time): lag ranges for men: 81 - 488 pg/mL. My result: 449 pg/mL.

6) FSH (1st time): 6.54 mUI/mL. Lag ranges for adult men: 1.27 - 19.26 MUI/ML

7) LH (1st time): 4.61 mUI/mL. Lag ranges for men: 1.24 - 8.62 MUI/ML

8 -- Gamma-Glutamyl Transferase (GGT) - 1st time: 18 U/L. Ranges: 7 - 45 U/L

9) Prolactin: 28.51 ng/mL. Ranges for men: 2.60 - 13.10 ng/mL. Previous results: 25-25. Once again high prolactin.

10) Zinc (1st time): still waiting for results

Note:

Months ago I also did these two, and they came back OK:

- Abdominal Ultrasound and MRI scan - sella turcica

About additional tests, I am asking if these are necessary to investigate what sort of damage Accutane did, since we are talking about sexual dysfunction:

- Dihydrotestosterone (DHT)
- E2, which measures the amount of estradiol, a form of estrogen
- DHEA-S (dehydroepiandrosterone sulfate)
- Progesterone
- IGF-1 (Insulin-like Growth Factor-1)

Like I said, I am going to get to the bottom of this. I was even thinking of testing for other vitamins besides D-3 and B-12...

However I don't know if doing all or any of these is necessary.

*******
And now I see the Wikipedia article has been updated on this matter:

******* WIKIPEDIA: ACCUTANE *******

Isotretinoin is also associated with sexual side effects, namely erectile dysfunction and reduced libido.

https://www.medicines.org.uk/emc/medicine/15655

In October 2017, the UK MHRA issued a Drug Safety Update to physicians in response to reports of these problems.

>>>>>> "Drug Safety Update - Latest advice for medicines users - October 2017" (PDF). MHRA. 3 October 2017.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/655127/DSU-Oct-pdf.pdf

This was in response to an EU review, published in August 2017, which states that a plausible physiological explanation of these side effects "may be a reduction in plasma testosterone".

http://www.ema.europa.eu/docs/en_GB/document_library/Periodic_safety_update_single_assessment/2017/08/WC500234071.pdf

The review also stated that "the product information should be updated to include ‘sexual dysfunction including erectile dysfunction and decreased libido’ as an undesirable effect with an unknown frequency".

http://www.ema.europa.eu/docs/en_GB/document_library/Minutes/2017/09/WC500235426.pdf

There have also been reports of spermatogenesis disorders, such as oligospermia. 27 cases of sexual dysfunction report either negative dechallenge or positive dechallenge.

http://www.ema.europa.eu/docs/en_GB/document_library/Periodic_safety_update_single_assessment/2017/08/WC500234071.pdf

******* WIKIPEDIA: ACCUTANE *******

This link:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472884/

Says the following:

>>>>>> Diagnosis of Hypogonadism: Clinical Assessments and Laboratory Tests

****** In males, serum testosterone levels show a circadian variation, with the highest levels in the morning and lowest levels in the late afternoon. In young men, the variation in testosterone levels is approximately 35%. Although the normal range for serum testosterone might vary between different laboratories, the normal range for early morning total testosterone in healthy adult males is approximately 300 ng/dL to 1000 ng/dL. ******


If that's the case then my blood tests indicate I have normal levels. But that doesn't mean IDEAL LEVELS, which I assume are in the middle (500, 600), and never 300, 400.

Let's continue:

****** Prepubertal: Secondary hypogonadism is associated with low levels of testosterone and normal to low levels of LH and FSH. ******

****** The signs and symptoms of low testosterone in postpubertal adult males can be more difficult to diagnose and might include loss of libido, erectile dysfunction, diminished intellectual capacity, depression, lethargy, osteoporosis, loss of muscle mass and strength, and some regression of secondary sexual characteristics.

At the initial visit, the first objective is to distinguish between primary gonadal failure, in which low testosterone is accompanied by increased FSH and increased LH, and hypothalamic-pituitary disorders (secondary hypogonadism), with low testosterone and low to normal FSH and LH levels. *******

Do I fit in the latter case? Low testosterone levels and LOW TO NORMAL LH and FSH levels?

******* Initial laboratory testing should include early morning (8:00–10:00 AM) measurement of serum testosterone, prolactin, FSH, and LH levels. For the diagnosis of primary hypogonadism, FSH measurement is particularly important because FSH has a longer half life, is more sensitive, and demonstrates less variability than LH.

The aging male patient can present with signs and symptoms of low testosterone, including loss of libido, erectile dysfunction, diminished intellectual capacity, depression, lethargy, osteoporosis, and loss of muscle mass and strength. At the initial visit, laboratory testing should include early morning (8:00–10:00 AM) measurement of serum testosterone. In elderly men, testosterone levels decrease between 15% and 20% over the course of 24 hours.
*******

OK, I did all those tests early in the morning. I had to wake 2 hours earlier (I usually wake at 8:00 AM), but that was not an issue. As for all low testosterone symptoms I don't think I have any of these, including fatigue. Except for loss of libido. And depression was a symptom I had for a few years after the Accutane treatment. Now it's totally gone.

****** Total testosterone levels might be normal with hypogonadism if the SHBG levels are increased. Levels of SHBG increase with age, causing a decrease in bioavailable testosterone. If testosterone levels are low-normal but the clinical symptoms and signs indicate hypogonadism, measurement of serum total testosterone levels should be repeated and an SHBG level should be determined. With the total testosterone and SHBG levels, a bioavailable testosterone value can be calculated. A bioavailable testosterone calculator is available at www.issam.ch/freetesto.htm.

It is usually not necessary to determine FSH or LH levels in the aging male.
*********

And the article continues, explaining more about total/free test. and SHBG.

******* In selected patients, FSH, LH, and prolactin can be measured. If the FSH and LH levels are raised, this suggests a primary testicular cause, and if levels are low or normal, a hypothalamic or pituitary cause should be considered. A raised prolactin level suggests that further investigation of the pituitary gland should be undertaken. *******

The FSH and LH levels are not high. So that rules out the first suggestion.

"A hypothalamic or pituitary cause should be considered" (if the levels are low or normal - THEY ARE NORMAL). What kind of tests should I do to investigate this?

"A raised prolactin level suggests that further investigation of the pituitary gland should be undertaken." (3 different blood tests show exactly THAT. Not that high (25), yet still high for a man).

****** Hypothalamic or pituitary deficiency might be transitory or permanent. Transient secondary hypogonadism might be related to malnutrition or stress states and can be diagnosed by physical examination and evaluation of the patient’s growth chart. If permanent hypothalamic or pituitary hormone deficiency is suspected, serum levels of pituitary hormones and magnetic resonance imaging of the brain and pituitary should be obtained to screen for hypothalamic or pituitary disease. ********

Malnutrition or stress states?

Does that mean if I change my diet (which is not bad, still I have an appointment with a nutritionist this month, to do a complete overhaul - plus another specialist, to do the same for my workout routine, I go to the gym every day in the morning) I can fix this?

And stress might be related to sleeping 1, 2 hours less? If this is the case, then I can't neglect to inform that I was doing this in the past weeks, prior to this blood test.

"can be diagnosed by physical examination and evaluation of the patient’s growth chart" (Growth chart?)

"If permanent hypothalamic or pituitary hormone deficiency is suspected, serum levels of pituitary hormones" (Again, what kind of exam? To check these serum levels of pituitary hormones?)


"and magnetic resonance imaging of the brain and pituitary should be obtained"

Didn't I do that already? I said I did a "magnetic resonance imaging of the sella turcica region". Does that cover this suggestion?

"...to screen for hypothalamic or pituitary disease."

*******
Although the normal range for serum testosterone might vary between different laboratories, the normal range for early morning testosterone in male adults is approximately 300 ng/dL to 1000 ng/dL. An early morning total serum testosterone level of less than 300 ng/dL clearly indicates hypogonadism, and under most circumstances benefit will be derived from testosterone replacement therapy. A healthy male adult patient with a serum testosterone level greater than 400 ng/dL is unlikely to be testosterone deficient, and therefore clinical judgment should be exercised if he has symptoms suggestive of testosterone deficiency.
*******

I get it, I predict my testosterone levels will fall in the range of 400 ng/DL in the coming months when I change my lifestyle and spend more time outside (for vitamin D, since this also raises test. levels). I understand that TRT has a lot of issues and should be THE LAST RESORT. Only when all other options have been eliminated, and for TRT if the levels are even lower than mine. I heard people explaining that it's an artificial increase that will trick the body and prevent a natural improvement, it will probably need to continue for the rest of one's life, and there's the expenses and
dependency of taking another S.HIT.

The thing is: my actual testosterone levels are not OK by a long shot and anyone that says they are should get punched in the face. Testosterone levels now are lower than ever before:
http://thechart.blogs.cnn.com/2011/08/18/modern-life-rough-on-men/

Countless sources will tell that. Meaning we can't say this is OK just because most men are weaklings, because today standards of how masculine (and healthy) we are not the IDEAL ones.

******* Hypogonadism can be of hypothalamic-pituitary origin or of testicular origin, or a combination of both, which is increasingly common in the aging male population. It can be easily diagnosed with measurement of the early morning serum total testosterone level, which should be repeated if the value is low. Follicle-stimulating hormone, LH, and prolactin might also need to be measured. If the clinical signs and symptoms suggest hypogonadism but the serum testosterone level is near normal, then assay of serum testosterone should be repeated in conjunction with SHBG because serum testosterone might be normal in the presence of hypogonadism if the SHBG level is raised, which commonly occurs in elderly male patients. *******

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