Welcome to the Hormone Highway!Many testicular cancer patients are faced with symptoms that may be related to an abnormal testosterone level. But is that really the problem? Unfortunately, the tests available to asses testosterone function are often confusing to both the patient AND his physician! The purpose of this article is to help explain this complicated subject in terms that you and I (and even your doctor!) should be able to understand. Here's an analogy--say that maintaining hormonal balance/well being is like driving a car and maintaining a steady speed/cruising down the freeway of life. The person is like a passenger, and if the car is cruising steady then he probably has no clue what the driver is doing to control the car. Please note that this is quite an elaborate analogy. Please bear with us.... Before we really get started, here are a few necessary definitions:
For the purposes of this discussion, we'll focus on the symptoms that are associated with a passenger believing the car is going too slow (low testosterone). It is very important to remember that MANY other conditions can make a passengers ride less than perfect, so despite the fact that we each have had recent engine (testicle) trouble, a full evaluation is necessary! Also, the issues of infertility are even MORE complicated and must be addressed by a specialist! Remember that checking a testosterone level (speedometer) can be quite good, but not always perfect. Speedometers may not show the actual speed, but they're usually close. Really fast probably means fast, and really slow probably means slow. Occasionally, speedometers (testosterone levels) are off in their number, but the dial still moves up when the car goes faster and down when the car slows down. Changes in "hormone binding globulin" levels (like changing the size of the tires) will shift the numerical value on the speedometer. If there is a reason to suspect abnormal tire size on your car (obesity, liver disease, nephrotic syndrome, marked malnutrition, estrogen exposure, etc), then you may need to consider trying another method such as a radar gun (free testosterone level) rather than the speedometer (testosterone level) as a gauge. Many cases are easy to interpret...symptoms lead one to check a speedometer reading (testosterone level). If it's below the range in which most people would feel symptoms too, then give the car a booster (testosterone supplementation). If it's not obvious (borderline testosterone level, or classic symptoms but a normal testosterone level), then figuring out what the driver (brain) thinks is a good way to know what's really going on! Even if the speedometer is broken, the driver (brain) can still sense what the speed is. Reading the driver's mind can be done by looking at the way the driver (brain) is manipulating the car by way of the gas pedal (LH/FSH hormones). Therefore, in patients with low testosterone symptoms and borderline or questionable testosterone levels...check the LH and FSH levels (and consider alternative tests of this hormone system AND alternative diagnoses!). Remember that just like a gas pedal is adjusted up and down as you drive down the road, LH levels normally fluctuate (it's secreted in a pulsatile fashion) and may require several measurements to see the trend--this is why an FSH level may be helpful as it has a more steady secretory pattern. Knowing BOTH the testosterone (speedometer) and the LH/FSH (gas pedal depth) gives one the power to figure out where a problem may be! Here are some common examples and how I would interpret them: Case A) Speedometer (testosterone level) low and gas pedal depth (LH/FSH levels) increased--the driver (brain) seems to believe the speedometer (testosterone level) and is pushing on the gas (LH) with no luck as the engine (testicle) is not responding well enough... the patient needs supplemental testosterone! (Unfortunately as many as 30% of us TC'ers may be in this category.) Some may wonder, if all TC patients have had recent engine trouble and now have a "smaller engine" (one testicle instead of two), don't we all have problems. The answer is complicated but generally speaking no--in most cases the remaining testicle can carry the load and produce enough testosterone (just like a smaller engine can usually maintain a car's speed down the highway). Case B) Speedometer (testosterone level) low and gas pedal depth (LH/FSH levels) normal--the speedometer is incorrect and the driver (brain) knows better, so keeps the gas pedal steady...NO NEED TO SUPPLEMENT testosterone. (This may be hard for some to accept but by checking not only the testosterone level but also the body's internal gauge of testosterone one sees that for this individual a "low" testosterone IS normal!) Case C) Speedometer (testosterone level) low and gas pedal depth (LH/FSH levels) decreased--either the speedometer is completely broken and the car is actually going very fast (RARE...and the testosterone level should be high) or the car is going slow and the driver (brain) has a problem and is not able to step in the gas...patient needs to have his brain (hypothalamus and pituitary gland) examined, probably with imaging and other hormone levels. Case D) Speedometer (testosterone level) normal and gas pedal depth (LH level) increased--the speedometer is incorrect and the driver (brain) knows better, so it is stepping on the gas to get more speed...patient needs supplemental testosterone if symptomatic! (This is somewhat controversial...some would say that the speed is normal but the engine is just inefficient requiring a constant stronger push on the gas pedal. I say that the driver (brain) is not happy and is asking for more.) Some research has shown that a great many TC patients MAY fall in this category ("Leydig cell dysfunction") and that it is present even before the orchiectomy and long after the orchiectomy. That would suggest that TC patients may have abnormalities (Though I'm not sure what those might be) that predispose us to both Leydig cell (testosterone producer) dysfunction AND the cancer (and possibly even other structural abnormalities). Case E) Speedometer (testosterone level) normal and gas pedal depth (LH level) decreased--despite what the speedometer reads, the driver (brain) senses that this is too fast and is easing off...patient has too much testosterone such as with excessive replacement (or bodybuilder on steroids). This can have other side effects including fertility problems. Many people at this site feel strongly about the concept of testing pre-orchiectomy testosterone levels. Here are my thoughts. 1. If you did not get a pre-orchiectomy testosterone level--don't be scared that you missed your one chance for assuring hormonal balance. As outlined above, using the combination of symptoms (passenger's experience), testosterone levels (speedometer), and perhaps free testosterone levels (speed radar gun) and LH/FSH levels (gas pedal depth), you and your doctor can effectively figure out a plan for you. 2. Keep in mind that a one time, pre-orchiectomy level may be misleading and NOT represent your true normal level. Many factors outlined above including hormone binding globulin levels and HCG levels affect a testosterone measurement. I'm not necessarily saying the a pre-orchiectomy level will hurt, but it could lead you down the wrong path and lead to many unnecessary worries and tests. One could argue that if you're going to get a pre-orchiectomy test, you should also check LH/FSH levels and a free testosterone. 3. In discussing this issue with two endocrinologist colleagues, both had the initial reaction that a pre-orchiectomy level is not ever necessary. However, after some pressing, both admitted that in adjusting a patient's supplemental testosterone dosing it MAY be of use. At the very least, it might provide a good starting point. 4. Ultimately the information available here and elsewhere (including from your doctors) must be mulled over by each patient to make the decision themselves! Brandon Hayes-Lattin MD The TCRC Links page has a large number of hormone related links and articles. If you are interested on exploring the subject even more, I encourage you to visit all of the links.  This page last updated on August 28th,1999
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