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Editor's note:
Mike wrote to me with his problems and included his thoughts on what he should do. Rather than paraphrase, I have included our correspondence and his thoughts here, so you can understand the eventual conclusion.

Mike - TRT, or not TRT? That is the Question

The first email: Best read with the attached Records
Basically I had symptoms of low Testosterone as I was having some occasional issues in the bedroom which got worse overtime, which was strange, as normally my sex drive is quite normal to high. It turns out I have very high cortisol and very low DHEA. Apparently DHEA is a precurser to Testosterone, Estrogen and DHT. Tested my testosterone and it was low normal by some ranges and considered just plain low by others. Some other tests suggested I have early stages of Hypothrodism but this under debate by some doctors. My TSH was 3 and some say anything above 2.1 can lead to issues eventually.
I really don't have that much stress to cause that amount of high cortisol but I do have ongoing stomach issues which can raise cortisol as well. I have done some tests and I have low stomach acid which is causing my stomach issues with indigestion and all that down the line. This probably raised my cortisol and high cortisol over time can lower DHEA as they both are made by the adrenals. I had dexamethasone suppression tests that proved the pituitary loop to the adrenals was working normally and I had a brain scan which did not show anything out of the ordinary. Do not have symptoms of Cushings disease either. My liver and pancreas show as functioning normal, at least by their standards.
So no one really knows why my cortisol is so high and my dhea is so low, I think it is probably the stomach and GI issues I have, so cleaning that up and seems to be working a bit so far, but too early to tell. Since the beginning of my tests, my cortisol has gone form very high to high normal now, but DHEA still low. Usually if the DHEA is suprressed by too much cortisol, then after you get the cortisol back down to normal ranges, the dhea may not come back up for some time if at all, so some doctors give the patient DHEA to get it back up to normal ranges and in many cases the dhea will stay there even after tapering off the dhea (or you may need to take just a small maintence dose of dhea for some time) The doctor prescribed me to take some DHEA for awhile and I will start next week.
Because I am taking DHEA which is can cause testosterone, estrogen and DHT to rise, I have to do tests and keep an eye on this levels, plus will do a PSA test now before I start the DHEA supplimentation to watch that as well. I have heard that it is actually the DHT at high levels that can cause issues with your prostate but not sure if that is true or not.
In any event, I will watch all the levels closely. Hope this works as I am not feeling myself these days. My stomach issues are better so that is a start and I suppose my energy levels are getting better slightly recently. Hopefully that means my cortisol is going down more now.
Well that is my story so far, and hopefully this can shed some insight to others
Nick did you see anyting in my words that makes sense or doesn't make sense?
Please let me know.

My response:
Thanks very much for this.
Your assessment of what is going on is, so far as I can see, spot on.
Estradiol is important, because that, in and of itself, would cause unpleasant symptoms similar to low Testosterone. Yours is 122, which is in the mid-range, but may moderate as treatment progresses. Ideally Estradiol should be at, or around, the lowest quartile in the range.
It will take time and if you can reduce stress levels, so much the better.
Everything points to your stomach acid condition being the root cause of this issue, so one would hope the hormones and minerals get corrected naturally as time goes on. It would be interesting to know what your B12 level is, because B12 is essential to absorbing minerals.
Presumably you have included diet alterations within the treatment regimen?
Are you on Betaine Hydrochloride?

Mikes Response:
Yes I am taking Betaine Hydrochloride (with Pepsin) with each large meal. I have no burning yet (even after 3 tablets with each meal) so that strongly suggests I have low stomach acid. Plus I feel at better so far. I eat lots of vegetables 3 or 4 times a week as well. Stomach is starting to clear up a bit now so hope it continues. Thanks for the note on Estradiol. I will watch it closely to see if it goes down into the lower normal range.
Quick questions for you.
- do you know what part of testosterone replacement therapy can cause cancer\tumors? Is it too much DHT (which I read a couple times on the net) or raising the levels of Testosterone above normal?
- also to avoid having my testicles shrink (my boys) can I use hCG to build them back up and at what intervals would I do that?

My Response:
TRT does not cause Cancer. There has been a lot made of Testosterone therapy causing Prostate Cancer, but, recent research has shown it not to be the case. It does, however, exacerbate existing Prostate Cancer via DHT, so it is wise to look at the PSA annually and have the Prostate felt by a doctor to make sure it is not enlarged.
I don’t think HCG, or TRT is advisable at this stage. I suspect your T levels will recover as the treatment progresses, however, it is wise to keep an eye on it to make sure. If it remains low, and 11.2 nmol/l is low, then it would be wise to check levels of LH and FSH again, together with Serum Testosterone. I say that, because your LH is suggestive of an inadequate Testosterone level, which would mean HCG would have zero effect.
Shrinkage of “the boys” tends to occur if the problem is in the Pituitary gland, resulting in LH and/or FSH being almost zero. This means the testicles are capable of producing. In that case HCG is an option. TRT given in that case, would reduce testicular size. If the testicles are failing, then the answer is TRT.
Right now however, I reckon the numbers cannot be relied upon, simply because of all the other problems. So hang tight and see what comes when you get tested next. With any luck, everything will be seen to be closer to normal.
I think too, it would be wise to get your B12 checked. This, as I found out when diagnosed with its deficiency, creates all kinds of problems, similar to those you are experiencing. It works with the stomach acid to absorb minerals, so it is worth making sure.

Mike's Response:
Yeah I just took a look at the site now and saw that link. and lots of good info. You are right, once I get my DHEA up to normal levels I will retest my T, LH and FSH to determine if I have primary or secondary hypogonadism and then address the TRT accordingly.

Glad to be on the road to recovery!

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