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Forum Name: Endocrinology Topics

Question: Testosterone deficiency and flushing


 BRN - Mon Jan 30, 2006 6:56 pm

This is my first post on this website; I'm hoping to find some guidance into the next steps to figure out whats wrong with me. I'm 23 years old, and recently got out of the military less than a year ago. For the most part I'm suppose to be in good health but I"m not. Gradually over the past year I've experienced severe pain in my joints and bones, to include my hips and lower back, my legs, arms, and hands. Sometimes I lose strength in hands, almost like arthritis. But that's not all. I also get extreme flushing on my neck and face for no reason. I'm tired, depressed, sick to my stomach and my body hurts. Mine you, all this just started happening in a year span. I work out religiously; I used to run 5 miles a day and now I can't even jog. I also lift weights but I now I have to stop that because of the pain.
I have been to several doctors and I can't get an answer for this. I've been checked for different types of arthritis and all came back normal. I've been on different medications to stop the pain and nothing has fixed it. I've taken anti-histamine for the flushing and it didn't even slow it up. I'm not sure what to do at this point. Can it me an immune disorder of some type. What about low testostirone? If anyone has any suggestions please let me know. Thanks
 Dr. Shank - Tue Jan 31, 2006 6:48 pm

Dear BRN:

As you suggested, testosterone deficiency can cause flushing. It certainly can cause weakness, and it rarely causes neuropathy (a type of nerve damage), but it would not explain your nausea. Furthermore, the flushing is usaully over the entire body, although it can be confined to the face and neck.

There is a rare type of neuropathy that causes flushing above a level on the chest that varies between individuals and tends to raise over time. Usually, the flushing occurs after eating. However, this is almost exclusively seen in people who have had very poorly controlled diabetes for many years, and that hardly seems probable for someone who was discharged from the military less than a year ago.

Carcinoid syndrome is a collection of symptoms and physical findings that often include flushing. This is caused by a rare tumor that is usually too small to be seen on imaging studies, but which can make tremendous quantities of any of a large variety of hormones and other powerful chemicals. Most of them are benign. They are most commonly recognized in the intestines or colon, but they may occur in the lungs, stomach, pancreas, and even odd places like the urinary bladder. Usually, but not always, the hormones and other substances that they produce in excess can be identified by careful testing. Often, the testing needs to be done more than once, because the secretions of the tumors can change through the day and from day-to-day. Even without the lab tests, however, a dramatic worsening of symptoms after some trigger (such as eating, urinating, breathng cold air) may be a valuable clue to the presence and location of the tumor. One of the classic products of carcinoid tumors is serotonin, which can cause flushing, diarrhea, and abdominal pain, among other symptoms. Another common product is histamine, which can cause similar symptoms, plus itching or shortness of breath; I have a patient whose carcinoid tumor seemed to produce (until recently) only histamine, and he has only gotten relief with extremely high doses of octreotide (a synthetic version of a hormone that usually reduces the size and activity of carcinoid tumors), classic antihistamines, and the H2-blockers (antihistamines that are used to block production of stomach acid). A word of caution: Don't let anyone tell you, "If you do have carcinoid, it's malignant and metastatic to the liver, anyway." A little knowledge is an awful lot of ignorance! And if do have carcinoid (unlikely, but worth considering), make sure an endocrinologist, NOT an oncologist, treats you for it.

I have also seen a patient with symptoms very similar to yours who was told first by another endocrinologist and then by me that he needed tests for possible carcinoid tumor. The fact that his symptoms usually occurred about 1/2-1 hour after eating added to the clinical impression that he might have carcinolid syndrome, most likely from a carcinoid tumor in his small intestines or colon. However, nothing showed up on repeated testing, and I was not able to identify another cause. I am still not sure why he went to a large depression clinic, since he not think that he was depressed, and screening questions did not suggest depression, but he went. They told him that they did not believe he was depressed, but gave him extensive tests for depression, anyway. To everyone's surprise, the test results indicated severe depression. To my surprise, treating him with antidepressants has given him the first two weeks without disabling symptoms in three years. Since the medications that he was given would be expected to severely worsen symptoms from the most common forms of carcinoid syndrome (another reason that I had not tried them!), it now seems pretty unlikely that he has a carcinoid tumor. I do not know of any other cases like this, but it does raise the possiblity that treating your depression (AFTER screening for carcinoid syndrome) might even help your other symptoms.

Flushing can also be manifestation of infections. I have seen chronic sinus infections, chronic prostatitis, and chronic urinary tract infections (usually associated with kidney stones that did not pass) that were missed for years by other physicians.

Unfortunately, there are a lot of things that can cause nausea, including neuropathy, adrenal insufficiency, intestinal bacterial overgrowth syndromes, ulcers, blockage (including severe constipation), and common parasitic conditions (such as Giardia lamblia). Of these, the only one that is likely to cause body aches is adrenal insufficiency, but that is more likely to cause abdominal pain.

Fatigue is another symptom that has a lot of different possibe causes, ranging from almost any endocrine disease, to sleep disorders, to depression, to infectious diseases, to rheumatologic disorders, to . . . well, just about anything. Fatigue is a very sensitive indicator that A health problem exists, but it is not very specific for WHICH one(s).

There are almost as many things that can cause weakness. The one clue you mentioned about losing strenth in you hands raises a question of carpal tunnel syndrome. Of course, carpal tunnel syndrome is pretty common, but it is especially common with hypothyroidism, diabetes, and acromegaly due to an excess of somatotropin (better known as "growth hormone" in kids, but actually the main pituitary hormone in adults).

Unfortunately, body aches are another signal that something is wrong, without making it clear what is wrong. Most endocrinologists are discovering that vitamin D deficiency is surprisingly common and often produces "vague" symptoms, such as body aches. Not everyone agrees (a long story!), but many of us also find that deficiency of somatotropin can produce profound fatigue, depressive symptoms, weakness, and sometimes pain.

One condition that causes fatigue and body aches and that is often associated with depression is fibromyalgia syndrome. There are many ideas about what causes it (and some who discount its existence), but the best current explanation is that it is a type of neuropathy. At any rate, it responds to the same drugs that many other forms of neuropathy do (especially certain "antiseizure" drugs). Usually, the depression associated with fibromyalgia syndrome does not improve much with antidepressants, even though some of them are used for neuropathies (not very effectively, in my experience, despite their popularity).

It is hard to explain all of your symptoms with just one thing, but an extremely rare group of hereditary conditions called "multiple endocrine neoplasias" could go along way. These conditions are characterized by various endocrine tumors that sometimes occur in different glands in the same person. In the form that often produces pituitary tumors, a pituitary tumor could produce too much of one hormone, but damage the rest of the pituitary gland's ability to produce one or more of the other five pituitary hormones.

Is your flushing associated with sweating, warmth, fevers, chills, wheezing or difficulty breathing, diarrhea, itching, chest pain, low blood pressure or dizziness/faintness? Do you have unusual headaches? Have you ever had any head trauma? Where does your body hurt? Does the pain seem to be in your joints, in the bones, or in the muscles? What type of pain do you feel? Is there any pattern in the time of day when the pain is worst? Have you had any change in your weight? Have there been any changes from your normal skin color? Have you had any exposures to heavy metals? Do you have any problems with your sleep? Do you feel refreshed when you awaken?

I believe that a thorough evaluation by an endocrinologist would be a good starting point, but it does not seem likely that all of your problems will fit neatly into one endocrine diagnosis. You are located in Jacksonville, FL, which is the home to the American Association of Clinical Endocrinologists and a number of very good endocrinologists. I suggest that you check our their web site, http://www.aace.com, to locate an endocrinologist.

You mentioned that you have been tested for different types of arthritis. That is outside of my specialty, but some of your symptoms do strongly suggest a rheumatologic condition. Some, but not all, of your symptoms sound like polymyalgia rheumatica or dermatomyositis. Systemic lupus erythematosis is a great mimic, but I would assume that the testing you had has made that unlikely. Inflammantion of the blood vessels (vasculitis) can produce all kinds of seemingly unrelated symptoms and be extremely difficult to diagnose. If you have not seen a rheumatologist, you might ask to be referred to one, even though you have had a number of arthritis tests.

I hope that this is been helpful to you.
 BRN - Wed Feb 01, 2006 8:24 am

Thank you for replying to my post Dr. Shank.

At first my doctor thought I had sero-negative arthritis or rhuematoid arthritis. I went to one of the best rhuematologists in Little Rock (I lived there until a few months ago) and he ran tests, and took x-rays and found nothing. I said that I didn't have arthritis or lupus even though the description sounds similar. My primary doctor also thought I had sjogrens syndrome because I feel dry and thirsty all the time. I drink about 20 glasses of water a day; its pretty much non-stop. And my nausia generally comes when I'm not drinking water. We ran blood tests for that and they came back negative as well. I asked her about carcinoid syndrome and she told me that the odds of me having it is rare and she never checked me. I will have it done though. The rhuematologist and my general doctor both told me to see an endocrinologist.

Whats odd about this whole thing is that I was completely fine, with no pain or depression ever in my life. But a little over a year ago I was playing racketball and started to feel pain in my arms and legs. A couple days later I fell on the court and couldn't walk for a few minutes because or back and leg pain. Shortly after that I started feeling sad and depressed all the time for absolutely no reason. I have always been extremely healthy and in great shape, running 5-7 miles a day, lifting weights all the time, but it seems like since that day my body has started crumbling. I have always been 6'2" and in the military they measure you all the time. Now, according to my last three doctor visits at different places I'm 6'1". I went from wearing a size 44 jacket to a 40. And I haven't stopped working out or changed my diet at all. All my muscle definition has started to go away. I have not went up a single pound in my bench press since May. And I also have extra weight around my stomach that just won't go away. No matter how much I run or lift. I only weigh 187 pounds but I used to be 195 of muscle. I wake up in the middle of the night because of bad circulation in my arms. They hurt and the pain wakes me up. My feet are also ice cold. How I described it to my girlfriend is that its like I had a glad that just stopped working all of a sudden and my body has been slowly crippling from the effects ever since.

My depression comes in waves. I can be totally happy and having a great time and within an hour just feel horrible and not want to talk to anyone. It might last a day or a week and then I'm fine again for a week or two. It's like my body is sending out too many chemicals or not enough at certain times and it really affects my mood.

What I regret to mention in my past post was that the flushing that I get on my face and neck I've always had. It may not have anything to do with the other things. I first noticed the flushing on my legs when I was in middle school. Over the years it has slowly traveled up my body and since about 2001-2002 it has been on my neck and face. I get it in the shower if the water is hot, if I'm under pressure, or for just no reason. I give a lot of presentations in my line of work and it really hampers my work abilities. My doctors seem to think that it is related but have no explanation for it.
 Dr. Shank - Wed Feb 01, 2006 4:29 pm

Dear BRN:

The information about your very cold feet is helpful. The redness and coldness of your feet strongly suggests Raynaud's phenomenon. This is due to spasms of the blood vessels. The classic presentation is cold skin, pain, and color changes from white (no circulation) to blue (stagnant blood) to red (increased blood flow to make up for the earlier reduced flow). Frankly, I find this "patriotic" color pattern to be rare. Usually, Raynaud's is asymptomatic or merely anoying, but extreme cases can result in gangrene. It is more common in women than men, is often aggravated by cold temperatures, emotional stress, or smoking, and is sometimes associated with rheumatologic conditions. Fortunately, it is readily treated. I am usually successful with low doses of a group of drugs that are commonly used to treat high blood pressure, the dihydropyridine-type calcium channel blockers. I have never found this treatment in the medical literature, but the results are often quite gratifying. A few people get swelling of the feet or ankles with the dihydropyridines, so my second-line therapy is nitroglycerin ointment--another highly effective treatment about which I have never seen anything in the medical literature. Nitroglycerine may cause headaches for the first few days, and it does need to be applied several times a day. The literature suggests that another group of medications usually used for blood pressure, the alpha-blockers, are also helpful, but my experience does not support their use.

Other possibilities for flushing that is exacerbated by warm showers are mastocytosis, histiocytosis X, or eosinophic granulomatosis. Basically, these are due to cells of the immune system that sometimes overgrow and overproduce their chemical products. The history that the flushing began in middle school, but that you were very athletic until recently, makes testosterone deficiency unlikely as the sole cause of your flushing.

There is a normal variation in the height of about 1/2 inch through the day. A whole inch would be abnormal, if you were accurately measured. Usually, the measurements are made with the (very poor!) stadiometers on the back of a weight scale, without proper positioning, and without regards to whether or not someone is wearing shoes. Given your back pain and apparent loss of height, a DEXA bone density test would be justified, but it would be uncommon to have true loss of height due to thinning of the bones (osteoporosis) with compression fractures at your age.

The most obvious explanation for the sudden onset of pain is neurologic. To have pain in both the arms and the legs (on both sides?) suggests a process in the spinal cord in the neck. Another possibiity is multiple sclerosis. in that case, the symptoms tend to be fluctuant and are usually worse when you are warm. It is often associated with depression. Fibromyalgia syndrome also needs to be considered.

The loss of muscle mass despite continued exercise and the belly fat are compatable with testosterone deficiency, but they are also characteristic of glucocorticoid excess (Cushing's) and somatotropin ("growth hormone") deficiency syndrome. however, the later two conditions are typically associated with weight gain, rather than weight loss.

Do you have dry eyes, as well as dry mouth? The definitive test for Sjogren's is a biopsy of the minor salivary glands of the inner lip. Schermer's test for decreased tear production may also help to support a diagnosis. Although it is hard to make an association with your other symptoms, damage to the back part of the pituitary gland (posterior pituitary, or neurohypophysis) or damage to a part of the brain called the hypothalamusan can also cause extreme thirst; if it is due to an infarct (loss of circulation) to the posterior pituitary, the onset can be so suddent that people can pinpoint the time it started to the minute! Again, adrenal insufficiency (Addison's) can cause loss of fluids, weakness, fatigue, nausea and vomiting, and weight loss, but it is not associated with flushing or belly fat.

The sudden changes in mood can be seen with deficiencies of sex hormones (Think of women in menopause.), but bipolar affective disorder (manic-depression) needs to be excluded.
 BRN - Fri Feb 03, 2006 1:16 pm

I have looked into Cushings and hypopituitarism and I have almost every symptom. My question is can I have Cushings without getting the excessive weight gain? All my research says that you get fat buildup in your stomach, upper back (between shoulders) and a rounded face. I have a very strict diet in which I eat no junk food, sugars, high protein, moderate carbs, and I work out all the time. I've been eating like this for years. I have the extra weight on my stomach that wont go away so is it possible that I can have Cushings? I went a month without working out and still eat extremely healthy and I gained 10 pounds.
About 4 years ago I was exposed to an active case of TB while in the military. I became a PPD reactor and went on INH. Is there a connection between TB medication and any possible syndrome? It seemed like I read a lot of information that mentions TB medicaion but not in any detail. I took the meds for about 9 months so I finished them in 2002. In between 2002-2004 (when all this started happening) the only thing I experienced was lack of oxygen when I ran. My body could take the beating but I just couldnt breathe. This still plagues me. Can the effects of such medications gradually build up and cause all these problems? I was finally able to get an appointment with an endocrinologist but its 8 weeks away. I only found one that would even see me in this entire city because my old doctor didn't send me to one for a specific test. I was told by everyone that I had to have a doctor tell them to test for ______ (fill in the blank) before they would see me.
 Dr. Shank - Fri Feb 03, 2006 8:24 pm

Dear BRN:

The short answer is, yes, you can have Cushing's without generalized weight gain. Textbooks present the "cartoon" versions of the disease. The most important other cause of such belly fat is somatotropin deficiency (In fact, it is possible that Cushing's causes the belly fat by its effect to reduce somototropin secretion.).

I am sorry that you had so much difficulty seeing an endocrinologist. Apparently, what has happened is that most of the endocrinologists in your area will only see patients in consultation (in other words, providing advice) to another physician. Since your physician did not ask for advice, they are afraid of offending him.

INH does not build up and cause Cushing's disease.

How do you know that you have a lack of oxygen when you run? Has this actually been measured, or have people assumed that "short of breath" means "short of oxygen"? Even most "lung specialists" assume the later, even though oxygen deficiency is RARELY the cause of shortness of breath (Basically, it only causes shortness of breath just before you die! Nearly all cases are due to increased work of breathing, a few are due to build up of carbon dioxide, and a very few are due to excess acid in the blood.).

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