During an infertility evaluation 18 years earlier, Jack (now 56) was found to have a low sperm count and elevated levels of prolactin, a hormone that helps women make breast milk but which is also present in men. After a brain MRI, Jack was told he had a pituitary tumor secreting prolactin and was put on a medication called bromocryptine to decrease the prolactin and shrink the tumor.
Over several years, Jack tolerated irritability, anxiety, rapid heart rate and excess sweating, all known side effects of bromocryptine.
Gradually, his dose was lowered to the point where the side effects became tolerable. However, over time, Jack developed a new set of symptoms – fatigue, moodiness, depression and loss of libido.
Labeled as depressed, he was put on sertraline, an antidepressant. The drug made him “very hyper” so he stopped taking it. Afraid his tumor would increase in size, Jack wanted to raise his bromocryptine dose back up, but feared the side effects. Frustrated that his only options seemed to be a life with fatigue, low sex drive and moodiness, or one plagued by irritability, anxiety and excessive sweating, he sought a neuroendocrine consultation.
Jack’s symptoms (low sex drive, fatigue, moodiness) were typical of low testosterone. When I measured his testosterone levels, they were indeed very low. So were his levels of lutenizing hormone (LH). LH comes from the brain’s pituitary gland and stimulates the testicles to make testosterone. High prolactin levels inhibit this process.
To evaluate the reason for Jack’s high prolactin, I ordered a new MRI brain scan. It showed that Jack had a longstanding condition called empty sella syndrome, which blocks the brain signals that slow down prolactin production. In other words, Jack’s problem was not a pituitary tumor secreting too much prolactin. In fact, he had no tumor at all (and therefore did not require bromocryptine for tumor shrinking).
In light of this discovery, I started Jack on a new regimen where he would apply a topical testosterone gel daily. This would compensate for his low LH levels and normalize his testosterone levels, which were responsible for his fatigue, low libido and depressed mood. As for his mildly elevated prolactin level, he would not need to do anything.
With high normal testosterone levels achieved, Jack felt energized with a normal libido and positive attitude. For several years now, he has stayed off bromocryptine and antidepressants without any difficulties.
When men develop symptoms of low testosterone – such as loss of sex drive, impotence, fatigue, muscle weakness and depression – blood measurement of testosterone levels is most accurate and should always be paired with the measurement of LH. Many conditions – ranging from head trauma to benign pituitary tumors to epilepsy, chronic stress and more – can lead to low testosterone and LH. The finding of low testosterone must not automatically be attributed to “male menopause,” which would show an associated high LH level and lead to urological investigations. Estrogen levels should also be followed and dealt with accordingly when treating testosterone problems.