T Nation

Developmental Issues at 16


#1

Before I'm told that I'm being a *****, please do hear me out. You can do so at the end if need be. Consensus has it that teens are supposed to be close to the peak of their lives and have massive energy. I don't feel any of that and am tired more than I have any right to be.

This will be a very long winded post, but if you took the time for any insight, I would be so very grateful.

-age: 16 and 3 months
-5'11
-32' waist
-163 pounds, 13-15% bodyfat
- pubic hair is dense, moderate leg hair , armpit hair moderate , no stomach or chest hair, very light hair above upper lip.

-fat distribution and history.
I was fat as a kid, and slimmed to a lean 160 at 14 years old. There's been some fluctuation since.
I noticed I store more on my legs than I used to, and on the face. Doesn't seem to be as sharp and pointed as the original 160.

-symptoms: I've never been good at sports, but my performance has been shot. I can no longer focus on the ball and my head pounds instead of the adrenaline rush I used to get. Its like my perception of time speeds up rather than slows. This concentration issue has been apparent in school, and it takes seconds to register what is being said. There is heavy mental fog, and grades have suffered.

At age 14, I would get hard properly. Now, it is relatively weak. I don't rarely get morning wood. No height, voice, hair or pubertal development has been seen since 13 years 9 months.

-My diet has been 1g protein/lb, .5g fat/ lb, filling the remaining foods as I see fit. I get plenty of vegetables. I usually eat more white meat, so saturated fat has been on the low side but I plan to add red. This will be remedied. I supplement Vitamin D3 and calcium

-I have no relevant prescriptions.

I have not touched any sort of anabolic steroid or prohormone of any sort.

Training right now is a 5X5, 3 times a week, with about 1.5 hours worth of volume.

-Labs:
TESTOSTERONE FREE, FEMALE,PEDI MALE 48.0 38.0 - 173.0 pg/mL
T4, FREE 0.97 0.61 - 1.64 ng/dL
TSH 2.13 0.50 - 4.40 mIU/L

This next one is done by the same lab, on a different day. The range is for teens, including a portion of which are pre pubescent.
TESTOSTERONE, TOTAL, PEDIATRIC 143 158 - 826 ng/dL L

It may be important to note that all of the above levels were taken at around 3 pm

I had another panel done at 8 am by another lab. I do not have the list of results. She said they were "normal". I have requested the results. I was told the

total test was 204 (I assume ng/dL).
Bone age, 19 years old. This signifies puberty is nearly over.

My pediatric endo told me the test was "only slightly below normal", and that I was obsessing. While I fully admit that I am concerned, I genuinely feel that this is justified. Given my history, I am scared that I will not finish developing.

Even when things were much brighter at age 14, there was mental fog. I fear my voice, hair, penile and testicular growth have been damaged. She is pressing for a second lab before taking action, and she told me that its not that bad. She told me depression is the root of my issues, and would have me take anti depressants before TRT.

I know that there is a very negative opinion on doctors on these boards, but I would not like to put her down in any way, even over the internet. But what can I do? Is TRT an option? It seems my levels were never any good in the first place and weight fluctuations made it worse. If you subscribe to digit ratio theory, my index to ring finger ratio is very high, indicating low testosterone in the womb. I have long limbs as well. Does this point towards Klinefelter's Syndrome?

If you've stuck it out this long, thank you. If you have any advice on what to do, that would be amazingly helpful.


#2

I am having trouble accepting that a 16YO writes so well!

Your depression is from the effects of the low hormones.

How are your testes hanging? Firm or soft?

You need these labs to know if you are primary or secondary:
-FSH
-LH

If these are low, injecting hCG can be used as a challenge to verify that the testes are functional with lab work for T, FT. Same can be done with oral medications using nolvadex. Do not use Clomid!

Read the advice for new guy sticky and the thyroid basics and:
- post your waking and mid afternoon oral body temperatures
- TSH, fT3, fT4

Other labs:
- DHEA-S

You are tall enough, so no worry there. Low estrogen levels lead to taller growth. It is E2 that caused the bone growth to stop. That is why women are shorter and why guys who get high T levels early are often shorter. The high T levels come with higher E levels.
- E2 [estradiol]

Low LH/FSH [secondary hypogonadism]: With young guys and low T, docs need to consider that there is a pituitary adinoma interfering with normal function. This symptom should not be ignored. A MRI is required. But typically, these are prolactin producing. So a lab for prolactin can be helpful. If prolactin is elevated or high, then a MRI can be ordered and the medical expense justified.

If no other cause can be found, also consider http://en.wikipedia.org/wiki/Klinefelter_syndrome
However, this is typically not evident/discovered until a few years older.

Read those stickies carefully!!!!!!!!!!!!
Read those stickies carefully!!!!!!!!!!!!
Read those stickies carefully!!!!!!!!!!!!


#3

Right, thank you for replying. The testes seem to be in between. The "sac" is usually not pulled uptight, except for when it's cold, nor does it soften very often. When it is soft, maybe once a month, the testes hang low. Unless you are talking about the firmness of the testes themselves, which I guess are uh... fairly firm?

I understand that FSH/LH are required and will obtain those. But what do you mean HCG can be used as a "challenge"?

So I've read the stickies, and will get body temperatures. I will get those labs that I need. I do already have TSH though, at 2.13, so that seems to be fairly good. From my understanding, Low FSH/LH means pituitary disfunction, so possibly a adenoma/tumor. Otherwise its Klinefelter's.

I read up on those two. Klinefelter's seems possible, but it seems the diagnosis is based off symptoms of low T, rather than anything caused by the mutation specifically. (Limb lengths, wide hips, lack of hair/ secondary sexual development)

Do you believe the eating bit was bad enough to really have caused the problem? The endo seems to be leaning towards that and depression as the cause of low test. I'm thinking the other way around for the depression. Aren't large amounts of high schoolers depressed with fine test?


#4

Your TSH is not good, it is a warning. The TSH lab ranges are a major problem - wrong. You think that everyone in the 9:1 [ 0.50 - 4.40] range are all functioning properly? Need temperatures! We know that your iodine intake has been low. Iodized salt is never enough to fix iodine deficiency.

Diet and depression are linked and the other hormone systems are never passive players.

LH and FSH control your testes. Start using google and Wikipedia. LH controls T production. hCG activates the LH receptors in the testes the same way as LH. You can take hCG as a 'challenge' and see how the testes respond by looking for the expected increase in TT and FT. Also check E2. 250iu EOD SC injections would do. Do not allow a hack doctor to prescribe high doses as they can desensitize your LH receptors, making thing worse. You could do 500iu EOD max. Nolvadex tablets can do the same. That is a SERM. Docs often want to use clomid, resist that as there can be nasty sides for some guys, docs do not understand this.


#5

Okay, I have recorded temperatures for a few days. With the old thermometer, I have been at 97.0-97.2 in the mornings, and 98.3-98.6 in the afternoon. A new thermometer has yielded similar results yesterday, but today's was 97.9 and 99.1. I will note that most of the time, it takes multiple readings to build up to a final temp, and I sometimes do not have that time in the morning. I've only started measuring to the side of the mouth, in the "pits" to the left and right of my tongue for two days. Before, I put it dead center, which may have skewed results.

So, I am seeing a General Practitioner tomorrow, due to scheduling issues with the endo. I'm hoping the GP is more open minded as well, as she has been great in the past. I will request the following labs to be done in 4 days.
TT/FT
LH/FSH
Estradiol, specify to avoid ultrasensitive
Prolactin
PSA
DHEA-s, specify the "s"
fT3, fT4
rT3, rT4

Also, I have had difficulty in finding a compound pharmacy with HCG. What should the dosing be for nolvadex? Does 20 mg EOD sound right?


#6

Not thyroid!: "I will say that low levels indicate thyroid issues "

rT4 does not exist and rT3 is typically ordered when:
- based on other thyroid labs
- adrenal fatigue is suspected, do you have stress issues, causes or events?

If LH/FSH levels are not low, then you probably have primary hypogonadism. In that case, hCG [or SERMs] will not be effective.

If sounds like you should improve iodine status in any case. But might be worth holding off until the thyroid labs are done.


#7

You probably don't need to test PSA at your age that is a prostate cancer marker.

Dhea is probably high as well since your young, but you could test that if you want.

If your going for a full thyroid test, you could also ask to check antibodies TPO and TGAB that will be more useful than rt3.

I'm guessing you live at home and your mom cooks for you?

You should educate her about iodine and its role in thyroid health and breast cancer prevention. Hopefully she will cook with iodized salt if she isn't already.


#8

Here's a little update. I saw the doctor, and got the previous labs done. I did not add in TPO/ TGAB in time, but did the rt3. I'll get them all back at the doctors office in a few days. I am adding in more iodized salt as well, but will wait for any significant doses.

The thing is, I may have to bring up a protocol on the spot. Would it be possible for you to look over these steps?

-If LH/FSH is low or Prolactin high,
I ask for HCG at 250 iu EOD. If nolvadex is the only option, is it 20 mg EOD?(Most of the dosing info I can find is for certain bodybuilding uses, which may not be the same for my context). I then retest TT/FT/E2 for increases after, say, 2 weeks?

What should long term therapy with an adenoma look like?

Either way, if this is the case, I will request a pituitary MRI for an adenoma.

-If LH/FSH is high or normal
I will request a karyotype. If it is Klinefelter's or a genetic disease of some sort, I go on the Testosterone/HCG/AI method in the stickies.

Do I have the cases right? I'm sorry if I'm being pushy and redundant, but I'm really trying to wrap my mind around piece by piece. I don't want an oversight to bite me later. But hey, thank you for your time. It is amazing that you stick with and help so many people clueless people. The stickies are great, and I feel more capable of dealing with this problem because of them.


#9

FruitS,

I'll comment on the adenoma part, since KSman is handling the other stuff. If you do have an adenoma, it's most likely a prolactinoma. They are the most prevalent. However, any adenoma would interfere with pituitary function and block LH to the testes. The second most prevalent is growth hormone secreting adenomas.


You can rule both these out by getting IGF-1 and prolactin tested. Positive tests would be well beyond the normal range, which would then be verified by an MRI.

IF test comes back positive, treatment for prolactinoma is 1/2 of a very small tablet if cabergoline 2 times a week. The other option is bromocriptine, but I would advise against that because of a number of side effects. For growth hormone adenoma, somatostatin analog (Octreotide, Lanreotide) injections once a month are 70% successful in suppressing growth hormone production.

This treatment is for life because of the large possibility of recurrence.

Secondary treatment option if less invasive treatment fails is surgical removal, but we will cross that bridge if the time comes.


#10

You will not be able to direct the doctor very much with your learning.

MRI's are costly and would be justified if prolactin is elevated. Otherwise, not a simple situation. Lets get lab results and not second guess all of the possibilities.


#11

I got my lab results back early. Two sets actually.

From a month ago, beginning of Janurary,

IGF-1 283 (201-648 for 16 year olds)
IGF Binding Protein-3 5050 (2380-6400)
LH 3 mIU/mL Males for 20-70 Year olds (1.5-9.3)
FSH 9 mIU/mL for 13-70 years (1.4-18.1)
Prolactin 11.9 ng/mL (2.1-17.7)
Testosterone 209 (241-827) I mistakenly said it was 204 before.
TSH 3.26 uIU/mL (.36-3.7)
free T4 1.13 ng/dL (.76-1.46)

-From one week ago. I had started to use large amounts of iodized salt for 1.5 weeks before the time of the test. It was also by a different lab

Testosterone total 315 ng/dL (300-950 Tanner Stage 5) (85-1200 Tanner stage IV)
Free Testosterone 12 ng/dL (9 to 30)
Ferritin 89.5 (26-388) ng/ML
Free T3 3.0 (2.18-3.98)
Free T4 1.21 (.76-1.46)
TSH Highly sensitive 3.78 (.358-3.74)

WBC Count 3.2 (4.5-13.5) K/ul
Mean Platelet Volume 8.0 (9.4-12.4)FL
Auto Lymphs 52.2 (25-48) %
Absolute Neuts 1.1 (1.56- 6.130) K/uL

ACTH 13 pg/mL (10-60) am collection
DHEA-S 200 (89-457)
Estradiol S (stands for sensitive?) 23 pg/mL (10-40)
Sex Hormone Bind GL 16 nmol/L (10-57)
Vid D Total 45.7 ng/mL (30-100)

FSH 7.78 (Appears to be two ranges?: 1-8, 1.4-18.1)MIU/mL
LH 2.83 (1.5-34.6) MIU/mL massive range??
Prolactin 13.3 NG/ML (2.1-17.1)
Serum Cortisol 17.4 UG/DL (4.3-22.4)

A couple of things. The total test has increased by about 100, but I have not changed anything but adding iodized salt. Is that an unusual free test range?

The TSH has somehow increased since December. The FSH and LH are strange, and the ranges are larger than I was expecting.

Also, I had a couple extra labs I didn't mention back in December
White Blood Cell Count 3.7 (4.5-11)K/uL
Neutrophils 37.7 (45-70)%
Lymphocytes 50.4 (25-50) %
ABS Neutrophils Instrument 1.39 (1.8-8) k/uL

White blood cells are chronically low and lymphocytes are high?


#12

Have you had any injuries to the testicles or varicocele?

FSH is elevated. I don't know of its because you are so young and developing. LH is not moving with FSH.

FSH is for sperm

LH is for T

TSH does not look good. You should get a few more thyroid tests TGAB, TPO, thyroglobulin, and, ultrasound.

Do you have hematology and platelets tests?

Platelet volume is a little low as is WBC. Platelets test helps to check if your bone marrow is working properly.


#13

I have not had any injuries to the testicles.

I have no clue as to why LH and FSH are different. Is the context of the lab range significant in this case?

Platelets were 217 (150-400)

Also, Alk Phos 79 (102-417)

Should I ask for a nolvadex/ HCG restart?


#14

Have you ever had mumps?

You should rule out:

Autoimmune disease

Just to be safe a testicle ultrasound.

You also need to find a good specialist in immunology and check a few more things.

Low alkaline phosphate can be caused by hypothyroidism, but otherwise nothing to worry about too much.

Plan of action:

Go to better docs and rule out issues that can be affecting your CBC. Make sure the testicles are healthy.
Fix your thyroid.

DO NOT use a SERM or restart attempt since your FSH is already high and pushing it higher could damage the sertoli receptors. Try HCG at 250IU EOD and check if T goes up. That would be used to diagnose if you are primary or secondary.


#15

So yes to HCG?

The docs have convinced my parents that I am in the healthy range, and that its all in my head. I really dont know what to do, as my parents like being reassured

I dont feel any better after the number shot up to 315. Is it likely to increase more by itself?


#16

Have you had your testes checked out? Testicular cancer is a young man's disease, which can sometimes produce FSH.


#17

They dont appear bumpy. Do you suspect primary or secondary hypogonadism?

Edit: My body temps vary. Its either 97.3 in the morning and 98.1 later or 97.8 in the morning and 98.9 later. Is this cause for iodine replacement?


#18

replenishment

97.3 is a concern as is 98.1, the other numbers are good.

Given your high TSH, low iodine intake and the low costs and good possible benefits, you should try iodine replenishment.

What time of day was the lab work [AM cortisol should be 8AM]

Estradiol S is Serum

High FSH: If you are put on 100mg T for three weeks, your LH and FSH should -->zero. If FSH does not, then that is a diagnosis for a condition that produces FSH that is abnormal.

If you have a hCG challenge and T responds well, then the testes are OK and the problem is secondary hypogonadism.

In younger men, secondary always suggests a possibility of an adinoma. But most adinomas will produce abnormal prolactin levels - but not in all cases. So high prolactin can justify the diagnostic expense of a MRI. If prolactin is normal, then that is not a clear cut situation. But there could be a problem in its early stages.

Your fT3 and fT4 look good. So there should not be a problem with that unless you have rT3 blockage. That would be an adrenal issue. DHEA is made in the adrenals and your DHEA-S seems low for a young man. Cortisol, depends on time of day...

Related reading:


The problem that you have is that you are still very young and one would expect a lot more growth and virilization. You do appear to be a low T guy and lower E levels have allowed you to become tall for your age group. Are you still growing taller? If you introduce higher T levels, E2 will probably follow and close off the growth plates in your long bones. Some of this can be judged by interpretation of an X-ray of the hands/wrists. Some guys just are slow to develop, so docs will be very hesitant to interfere. But you might fine a doc who will start with some diagnostic interests because of your LH:FSH, low T and symptoms.


#19

The two most recent labs ( Total test 209 and 315 respectively) were done at 8 am. So they are 8 am cortisol. Sorry about the oversight.

Some days my temperature is fine as per the sticky (97.9 am to 98.8 pm). Others its low (97.3 am, 97.9 pm). I know, my writing was bad.

I am 16 right now, and haven't grown since 13 and 9months. Theres been no growth in anything since then(voice, hair, genitalia)An xray of my left hand puts my bone age at 19 years old. I do not know if that is a perfect indicator of puberty, but I was told that I'm done growing.Id place myself at tanner 4-5.

So you seem to have spelled out two possible courses of action. Go on test eth for 3 weeks to find possible testicular cancer, or HCG to determine cause of Low test. I should try HCG first, right?


#20

You should get a testicular ultrasound first to be safe.

HCG first to determine if primary or secondary. If its primary you have a better case for docs to give you T.

Check the other things I told you about

Lupus panel
Thyroid labs and ultrasound
Do what KSman suggested for thyroid
HCG 250 IU EOD