Primary, secondary or mixed both?

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Hypogonadism

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Hello guys, what do you think, is this secondary or primary hypogonadism, or both in mixed?
Ran couple bloodworks, months between them.
Went to the Urology who checked my testicles they were small-normal(borderline arthropy) and soft.
Then i went to the testicle ultrasound and they ultrasounded somehow: normal, and normal size. Doc thinks im primary, but i think my fsh levels is too low for primary hypo diagnosis. Isnt fsh levels more ”accurate” to do diagnosis because: FSH has longer half life, is more sensitive, demonstrates less variability than LH.
What do you guys think, primary, secondary or mixed both?

Couple Bloodworks:

-Lh: 3.5 (2.5-7) (IU/I)
-Fsh: 1.3 (1-12) (IU/I)
-total testosterone: 10 (12-45)nmol/l
-free testostosterone: 143 (235-670)pmol/l

-Lh: 3.3 (2.5-7) (IU/I)
-Fsh: 1.2 (1-12) (IU/I)
-total testosterone: 7 (12-45)nmol/l
-free testosterone: 111 (235-670)nmol/l
-prolactin: 160 (73-407) mU/I
 
Defy Medical TRT clinic doctor
Secondary hypogonadism is associated with low levels of testosterone and normal to low levels of LH and FSH.
 
Hello guys, what do you think, is this secondary or primary hypogonadism, or both in mixed?
Ran couple bloodworks, months between them.
Went to the Urology who checked my testicles they were small-normal(borderline arthropy) and soft.
Then i went to the testicle ultrasound and they ultrasounded somehow: normal, and normal size. Doc thinks im primary, but i think my fsh levels is too low for primary hypo diagnosis. Isnt fsh levels more ”accurate” to do diagnosis because: FSH has longer half life, is more sensitive, demonstrates less variability than LH.
What do you guys think, primary, secondary or mixed both?

Couple Bloodworks:

-Lh: 3.5 (2.5-7) (IU/I)
-Fsh: 1.3 (1-12) (IU/I)

-total testosterone: 10 (12-45)nmol/l
-free testostosterone: 143 (235-670)pmol/l

-Lh: 3.3 (2.5-7) (IU/I)
-Fsh: 1.2 (1-12) (IU/I)
-total testosterone: 7 (12-45)nmol/l

-free testosterone: 111 (235-670)nmol/l
-prolactin: 160 (73-407) mU/I

Doc thinks im primary

WTF!


*Men with secondary hypogonadism demonstrate repeatedly low testosterone with simultaneously low or inappropriately normal LH and FSH levels.

*Low or inappropriately normal LH and FSH levels in association with low testosterone levels suggest secondary hypogonadism due to disorders of the pituitary or hypothalamus.






MEASURE GONADOTROPIN CONCENTRATIONS TO DISTINGUISH PRIMARY VERSUS SECONDARY HYPOGONADISM

If a diagnosis of hypogonadism is confirmed, serum gonadotropin, LH, and FSH concentrations should be measured to determine whether the origin of hypogonadism is a disorder of the testes (primary hypogonadism), or pituitary or hypothalamus (secondary hypogonadism).3,4 Serum LH and FSH should be measured in the same sample as testosterone, usually together with a repeat testosterone measurement after an initial low testosterone level or less commonly with an initial testosterone measurement.

Men with primary hypogonadism exhibit repeatedly low testosterone with simultaneously high LH and FSH concentrations (FSH typically being higher than LH). High LH levels indicate reduced testosterone negative feedback and production by Leydig cells of the testes. High FSH levels indicate seminiferous tubule dysfunction (reflecting reduced inhibin B negative feedback) and impaired sperm production but is a more sensitive indicator of primary testicular dysfunction than high LH levels. If high LH and FSH are measured in the same sample as an initial testosterone measurement, men with normal serum testosterone with high LH and/or FSH concentrations might be identified. These men have mild or subclinical primary hypogonadism (also called compensated hypogonadism), analogous to subclinical hypothyroidism.


Men with secondary hypogonadism demonstrate repeatedly low testosterone with simultaneously low or inappropriately normal LH and FSH levels. Some causes of hypogonadism are associated with defects in the testes and pituitary or hypothalamus, which is combined primary and secondary hypogonadism. However, in most cases, a hormone profile of either primary or secondary hypogonadism predominates. For example, in men with hemochromatosis, iron overload results in defects in the testes and pituitary but the latter is the dominant defect that results in gonadotropin deficiency and a hormone profile of low serum testosterone and low gonadotropin concentrations consistent with secondary hypogonadism.27

Serum LH and FSH measurements are usually performed by automated platform-based immunoassays. Most LH and FSH assays have sufficient sensitivity to distinguish low-normal from low values but are susceptible to immunoassay interference (eg, by high-dose biotin use). Although gonadotropin assays are not standardized, differences in values and reference ranges are small. The reference ranges for serum LH and FSH concentrations in well-characterized, healthy fertile young men are 1.6 to 8.0 IU/L and 1.3 to 8.4 IU/L, respectively.28 Assays with upper limits of reference range higher LH and FSH levels probably included older men or men with unrecognized impairment of spermatogenesis.






*Evaluation to Determine the Cause of Testosterone Deficiency

In men deemed to have testosterone deficiency, the measurement of serum LH and FSH levels is recommended to determine whether the patient has primary or secondary hypogonadism.1 Biotin supplements can interfere with some LH and FSH assays; therefore, these supplements should be stopped at least 3 days before the blood test depending on how much biotin the patient is taking. Men with elevated LH and FSH levels in association with low testosterone levels have primary testicular dysfunction. Karyotyping should be performed in these men to confirm whether they have Klinefelter syndrome, a common cause of primary testicular dysfunction. The other causes of primary testicular dysfunction include cancer chemotherapy, radiation to the testes, cryptorchidism, trauma, torsion, infectious orchitis, HIV infection, anorchia syndrome, and myotonic dystrophy.

Low or inappropriately normal LH and FSH levels in association with low testosterone levels suggest secondary hypogonadism due to disorders of the pituitary or hypothalamus. The causes of secondary hypogonadism include severe obesity; hyperprolactinemia; hemochromatosis; the use of opioids, glucocorticoids, androgenic-anabolic steroids, or androgen deprivation therapy with gonadotropin-releasing hormone (GnRH) agonists or antagonists; body image and eating disorders; idiopathic hypogonadotropic hypogonadism (IHH); head trauma; pituitary tumors or infiltrative disease; acromegaly and hypercortisolism; and pituitary surgery or radiation. Conditions such as aging, heavy alcohol use, hemochromatosis, and some genetic disorders may be associated with dual defects in the testes and pituitary.

In men with secondary hypogonadism, serum prolactin and ferritin levels should be measured, and other pituitary hormones should be evaluated. An imaging study, such as magnetic resonance imaging of the pituitary and hypothalamus, may be indicated to rule out the possibility of a space-occupying lesion, but the cost-effectiveness of an imaging study in the evaluation of middle-aged men with sexual dysfunction has been debated upon because the incidence of pituitary space-occupying lesions among such men is low. Diagnostic yield can be improved by performing imaging studies in men whose total testosterone level is <150 ng/dL or those who have hyperprolactinemia, panhypopituitarism, or symptoms of tumor mass effect, such as new-onset headache or a visual field defect.






Screenshot (12729).png

Screenshot (12730).png
 
Doc thinks im primary
-Lh: 3.5 (2.5-7) (IU/I)
Primary hypogonadism is normally diagnosed with high LH and secondary hypogonadism low LH. You would think a doctor who specializes in male reproductive health would know how to diagnose properly.

Your testicles are probably smaller than what's normal for you because they aren't getting much stimulation due to the low normal LH and this is why the tesicles appear arthropied.

Typically FSH is low alongside LH in secondary hypogonadism because the pituitary gland is defective.
 
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