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Urology/Low testosterone?

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QUESTION: My husband has been a vegetarian for more than 20 years. He is 38 years old now. In the last 5 years he has had decreasing libido, fatigue, very poor sleep which he complains about. Our youngest child is 2 years old and we saw a sex therapist to be able to fall pregnant with her - I did fall pregnant rapidly with her however though at this stage there appeared to be the start of an erectile dysfunction. My husband is not on a healthy vegetarian diet at all and it is very possible that he is nutritionally deficient. He has also been getting illnesses more easily than he used to (infections, colds etc) He has complained that he is putting on weight too though he is not overweight.

I am writing because we are living in a totally sexless marriage (for 3 years now) and I feel that this is not normal and not due to any psychological causes. I have no idea whether there is still erectile dysfunction since we have had no sex. I have asked my husband to go to a urologist for a testosterone test and he says he will, however I also want to fall pregnant with a third child and want to know what it is he should tell the urologist before going there. Also are there any supplements he could take that might help in the meantime and is this possibly a nutritional imbalance? Finally can the insomnia be related to a urological issue or is it more likely due to stress - it has been worsening over the past few years.

Please could you advise me what the initial steps are to get this evaluated and what possible treatments there might be if it did turn out to be low testosterone.

ANSWER: There is no way to determine if this is a "nutritional imbalance" from the available information.  There clearly seems to be a significant loss of libido.  The most common causes for this in a male are depression and low testosterone levels.  His regular physician can check a testosterone level as it's a simple blood test.

Insomnia is not usually considered a urological issue.

There are no safe supplements he can take at this point, especially since we don't yet have a diagnosis.

Testosterone supplementation will decrease male fertility so if there is an interest in further pregnancies and his testosterone levels are deficient, his physicians should know.

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QUESTION: My husband went to see a urologist and these are his blood test results. The doctor has said they are within normal levels and left it at that despite the fact that he has the issues I mentioned in the previous letter.

Total testosterone 6.6 (normal 6.1-27.1 nmol/l) (this is 190ng/dl normals 175-780ng/dl)
SHBG 16.7 (normal 13.3-89.5)
Free testosterone 175.4 (normal 170.0-660.0)
TSH 2.55 (normal 0.2 - 3.5)
Prolactin 6 (normal 3-13)
Cortisol 226 (normal 185 - 624)
LH 2.6 (normal 1.2- 8.6)

It seems to me that his levels for testosterone are all on the very lowest side of normal and considering his age and the fact that testosterone is supposed to decrease even further with age and the fact that he is showing clear signs that have not been addressed that something is not right.

We have since I last wrote had sex once, but this is perhaps only because we have been talking about it so much and also because he had the tests.

Please could you tell me what we can do further or if we need to be referred to someone else (a doctor or a sex therapist or a psychologist or someone else)

Answer
Since his symptoms could be either related to depression or to borderline low testosterone, it would nto be unreasonable to have a clinical trial of supplementation.  So I would first get an opinion from an endocrinologist.  Most likely, they will request a repeat blood screen just to be sure.  

If that is not successful, then either a sex therapist or psychologist consultation would be reasonable.

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Stephen W. Leslie, MD

Expertise

Questions concerning erectile dysfunction, kidney stones and prostate disorders including prostate cancer. I have a special interest in kidney stone disease prevention.

Experience

Full time practicing urologist with 30 years experience. Associate Professor of Surgery and Chief of Urology at Creighton University Medical Center. Editor in Chief of eMedicine Urology internet textbook. Author of only NIH approved book written for patients by a urologist on the subject of kidney stones "The Kidney Stones Handbook". Inventor of the "Parachute" and "Escape" kidney stone baskets and the "Calculus" stone prevention analysis computer program.

Organizations
American Urological Association, Ohio State Medical Association, Sexual Medicine Society

Publications
Men's Health, Journal of Urology, Urology, Healthwatch Magazine, Emergency Medicine Monthly, eMedicine, "The Kidney Stones Handbook", and numerous articles in various newspapers. He is also the editor of the Urology Board Review by McGraw-Hill used by urologists to study for their Board Certification Examinations.

Education/Credentials
Graduate of New York Medical College with residencies completed at Metropolitan Hospital New York, Albany Medical Center and University of Wisconsin-Madison.

Awards and Honors
Thirlby Award of the American Urological Association. Rated as one the country's Best Urologists by the Independent Consumer's Research Institute

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