Hi harvorama1-ga, thanks for your question.
As usual, this answer is not a substitute for medical advice or direct
medical evaluation. I will first look at your question focusing on
testicular cancer and then look at it from a more endocrinological
point of view.
==============
Testicular Cancer
==============
Your doctor is wise to consider testicular cancer. Although most
cases present between the ages of 15-35, this type of cancer can occur
at any age. It's a relatively rare tumor (about 2-3 new cases per
100,000 males per year in the US) [Smith's Urology]. Testicular
cancer has a very high cure rate - even higher when diagnosed early.
The testicular ultrasound (aka sonogram), as stated below in
Campbell's, is 95% sensitive and specific for testicular cancer and
does not involve exposing you to ionizing radiation (like an X-ray).
Basically it's a noninvasive low-risk test to detect a potential
cancer that, if found, is highly curable - high yield, low risk.
One of the standard Urology texts (Campbell's) outlines the diagnostic
pathway for testicular cancer:
"Unfortunately, delays in the timely and accurate diagnosis of
testicular cancer continue to be a significant problem. [123] Moul
(1994) noted a mean duration of symptoms of 26 weeks before diagnosis
in a review of 4948 testicular cancer patients. Both patient and
physician factors contribute to this delay in diagnosis. Painless
scrotal masses are often ignored, whereas testicular cancers
presenting with scrotal pain are treated as epididymitis up to 18% to
30% of the time ([19] Bosl et al, 1981; [144] Prout et al, 1984).
Almost 20% of patients present with signs or symptoms of metastatic
disease such as back or abdominal pain, weight loss, neck mass,
gynecomastia, or breast tenderness ([19] Bosl et al, 1981; Thornhill
et al, 1987; [15] Bosl et al, 2000). Patients have undergone
unnecessary mastectomy or laparotomy or prolonged therapy for back
pain without a diagnosis of testicular cancer being considered ([143]
Post and Belis, 1980; [125] Moul and Moellman, 1992; [124] 2000).
A careful history and physical examination, as well as serum ??human
chorionic gonadotropin (HCG), ?-fetoprotein (AFP), and lactate
dehydrogenase (LDH) testing, are helpful in establishing a correct
diagnosis. Scrotal sonography is extremely accurate in identifying
solid intratesticular lesions with greater than 95% sensitivity and
specificity.
Walsh: Campbell's Urology, 8th ed., 2002. Elsevier. pp. 2920-2921.
As mentioned above, one usually also looks at the serum HCG, AFP, and
LDH as tumor markers. I would trust an endocrinologist to pick the
right tests and interpret them correctly. They have special training
in the physiology hormone levels and may be better than the GU surgeon
at pin pointing the cause of these abnormalities, particularly if they
are due to something outside of the genitourinary system (for example
in the pituitary or other organ). There isn't really a reason to see
a urologic oncologist (or genitourinary (GU) surgeon) until you have
the results of the ultrasound, since the GU surgeon is unlikely to
operate without a diagnosis or target for biopsy. If you do
ultimately go to a GU surgeon, it's very helpful to have an ultrasound
in hand on the first visit. Otherwise, they will likely see you,
order an ultrasound, then have to see you again when the results are
back. The endocrinologist is essentially saving you a wasted visit to
the GU doc before you have the right tests complete.
There are multiple types of testicular cancer, the most common being
seminona (35%). More than 50% of spermatocytic seminoma cases are
found in men over 50. You can get details on the other types at these
eMedicine sites:
http://www.emedicinehealth.com/articles/20872-1.asp
http://www.emedicine.com/med/topic2250.htm
http://www.emedicine.com/radio/topic680.htm
There are multiple secondary effects that can hint at hormonal
imbalance caused by testicular cancer or other etiologies. Here is a
brief summary:
"Gynecomastia is present in 5% of all germ cell tumors but may be
present in 30-50% of Sertoli and Leydig cell tumors. Its cause seems
to be related to multiple complex hormonal interactions involving
testosterone, estrone, estradiol, prolactin, and hCG. Hemoptysis may
be seen in advanced pulmonary disease..."
"Anemia may be detected in advanced disease. Liver function tests may
be elevated in the presence of hepatic metastases. Renal function may
be diminished (elevated serum creatinine) if ureteral obstruction
secondary to bulky retroperitoneal disease is present."
Smith's General Urology. 16th ed. Tanagho EA, McAninch JW Eds. McGraw-Hill, 2004.
If you would like more detailed information on some specific
testicular cancer, treatment options, etc., if you are found to have
this type of cancer, I would recommend posting a separate question
focused on this topic.
============
Endocrinology
============
DHEA (Dehydroepiandrosterone Sulfate, DHEA-S) is produced by the
androgenic zone of the cortex (outer portion) of the adrenal glands,
which sit just above the kidneys in the abdomen.
DHEA can be decreased in Addison disease or adrenal hypoplasia.
Adrenal hypoplasia can be secondary to benign adrenal adenomas, which
don't function but can compress or replace the existing adrenal(s),
causing decrease in production of DHEA-S. DHEA-S is usually elevated
in adrenal tumors. Adrenal adenomas can usually be seen on CT of the
abdomen. The second reference below states that DHEA-S can be
increased in obesity, likely due to skewing of the sex hormone
production chain, which you can see here:
http://www.med.unibs.it/~marchesi/malesexhormones.jpg
Here is a detailed discussion of steroid hormone synthesis, if you
would like more details:
http://www.med.unibs.it/~marchesi/sterhorm.html
Analysis of the hormone synthesis pathway (see the second figure
above) shows that, for example, decreased activity of the
17-ketoreductase enzyme or overactivity of aromatase might lead to
decreased testosterone and increased estrone. Deficiency in
17-ketoreductase can lead to pseudohermaphroditism and gynecomastia
(enlargement of the breasts in males) if it is severe enough. This
may be one reason your endocrinologist obtained estrone, testosterone,
and DHEA levels - looking at both of them can help determine if and
where there is a defect in the biosynthetic pathway. If they're both
low, then one must look higher up the pathway for the cause.
___________________
Addison disease, also known as primary adrenal insufficiency, is most
common in people 30-50 years of age. Many of these patients have
antibodies against antigens in the cortex of the adrenal gland, which
suggests that this is an autoimmune disease. About 30% of patients
with anti-adrenal antibodies will progress to Addison disease. The
most common symptoms of Addison disease are weight loss, fatigue, mood
lability, etc., which don't sound like the symptoms you describe.
There are about 5-6 new cases of Addison disease per million people
per year.
You can find more details at eMedicine at this pages:
http://www.emedicine.com/med/topic42.htm
http://www.emedicine.com/derm/topic761.htm
Several drugs can cause Addison disease:
Ketoconazole: inhibits the adrenal cytochrome P450 steroidogenic enzymes.
Aminoglutethimide: blocks the early conversion of cholesterol to
pregnenolone by inhibiting the 20,22-desmolase enzyme.
Mitotane: blocks adrenal mitochondrial steroid biosynthesis.
Busulphan, etomidate, and trilostane: inhibit or interfere with
adrenal steroid biosynthesis.
Methadone: may deplete pituitary ACTH causing secondary adrenocortical
insufficiency in some patients.
If your endocrinologist suspects that you may have this disorder,
he/she may order one of a number of tests to work it up, including an
ACTH stimulation test, where a drug like ACTH (usually made in the
pituitary) and then measure the response of the adrenal glands to the
stimulation. When there is an absent, diminished, or poorly
functional intermediate enzyme in the long synthesis pathway, the
intermediate chemical (just before the enzyme block) builds up in the
system and can be measured as well. There are a multitude of other
diseases that can lead to Addison disease, which are listed in the
first eMedicine article above.
==================
Testosterone Therapy
==================
In terms of treatment, this is a decision that only you can make.
There are several drug delivery systems available that allow you to
pick the one most convenient for you, including gels, injections,
buccal systems (inside of the cheek), etc. You can read more at
RxList.com:
http://rxlist.com/cgi/generic3/striant.htm
The page above refers to the buccal system, but the systemic side
effects, etc., are similar regardless of the delivery system. The
local side effects obviously vary (e.g., mouth irritation with the
buccal system, etc.). You can read more by clicking on the "Warnings
/ Precautions" and "Side Effects / Drug Interactions" links at the
site above.
Here is a gel form of testosterone:
http://rxlist.com/cgi/generic2/androgel.htm
Here's a popular patch form:
http://rxlist.com/cgi/generic/testos.htm
Of course, you can always try any drug and stop if you personally have
too many side effects. I have seen some patients have an increase in
aggression and some mood issues with the injectable forms of
testosterone, but I have limited personal experience with it. The
links above give information surmised from looking at large groups of
patients.
___________________________
Here are some references:
Interpretation of Diagnostic Tests. Chapter 13: Endocrine Diseases.
pp. 569-703. Wallach JB. Lippincott, Williams, and Wilkins, 2000.
Principles and Practice of Endocrinology & Metabolism. Becker KL, Ed.
Chapter 237: Reference Values in Endocrinology. Lippincott, Williams,
and Wilkins, 2001.
___________________________
Search terms:
testosterone, estrone, DHEA, obesity, 17-ketoreductase deficiency, addison disease
I used Google and the NIH PubMed database via the Ovid search tool, as
well as multiple medical textbooks (available at medical libraries or
online for a fee).
___________________________
I hope this information was helpful. Best of luck with your struggle
with obesity - I know it's a long road. Please feel free to request
any clarification.
-welte-ga |
