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I got a copy of the latest ACTH / Cortisol results (Test #3) myself and haven't been in for a follow-up with my Endo, but does this look like Primary Adrenal Insufficiency or am I just jumping to conclusions?

Test #1 - ACTH Stim Test (Done @ 2:00pm):
Baseline Cortisol - 3.2
Baseline DHEA(S) - 461 (110-370) - (135% of range)
Baseline Pregnenolone - 11 (13-208) - (-1% of range)
30 Min Cortisol - 12.7 (Ref >20) - More than doubled, but Low
60 Min Cortisol - 15.2 (Ref >20) - More then doubled, but Low

Test #2 - Saliva Cortisol Panel:
Morning - 7 (13-24) - "Depressed"
Noon - 6 (5-10)
Evening - 4 (3-8)
Midnight - 8 (1-4) - "Elevated"
Cortisol Burden - 25 (23-42)
DHEA - 9 (3-10)

Test #3 - Various Blood Tests:
ACTH - 69 (7-50) - (144% of range)
Cortisol @ 11:00a - 8.8 (4-22 @ 9:00am) - (26% of range)

It also bugs me that my DHEA(S) is High, but my Pregnenolone is Low. I thought Pregnenolone was a precursor to DHEA - does this mean I'm not making enough Pregnenolone from Cholesterol, or am I using it up too quickly to make DHEA/Progesterone/Aldosterone and all their products?

Any insight from anyone?
[QUOTE=mkgbrook;3542203]Well you can add a DHEA supplement first thing in the morning. Issue there is do not exceed 20 mg and if you suddenly get really bad acne.. it is normally from more DHEA than you can handle.
...[/QUOTE]
[QUOTE=TheAntiEndo;3541879]
...
Test #1 - ACTH Stim Test (Done @ 2:00pm):
Baseline DHEA(S) - 461 (110-370) - (135% of range)

Test #2 - Saliva Cortisol Panel:
DHEA - 9 (3-10)
...[/QUOTE]
My DHEA and DHEA(S) look pretty high as it is. Will the supplement take some of the stress off my Adrenals by not having to make so much on its own, or would that give me too much? (And Acne has always been a problem, so nothing to lose there...)

I'm really trying to stay off as many supplements as I can until we figure this whole thing out so I don't "Muddy up the waters". (Except for Iron, which I have to start taking because Red Cross donations and all this blood work have made me mildly Anemic.)
I've seen at least a thousand acth stims with serum acth over the years I've been doing this and never seen the combo of values you have. Your stim suggests secondary AI. I've never seen a secondary (going by a stim that doubled or more from a low value) with serum acth greater than 43. I've never seen a primary who doubled or more on the stim. I look for upper 40's to low 50's for a good acth. Your DHEA suggests primary. I recommend you read what wrote about interpreting the acth stim and acth serum tests. [url]http://www.healthboards.com/boards/showthread.php?t=472296[/url]


Your pregnenolone suggests hypopituitarism (acth, LH and FSH regulate pregnenolone which breaks down into DHEA, cortisol and sex hormones, so low pregnenolone suggests ACTH, LH and FSH are low).

Very wierd set of tests you have. I'm thinking you should be retested with ITT test instead of ACTH stim though ITT is used to stim, CRH, ACTH, cortisol and growth hormone and I recommend these all be tested in the ITT.

I recommend you get aldosterone and renin tested (fast salt 24 hours) especially if you have salt wasting symptoms (hard to handle outside heat, excessive sweating, excessive urination). Low renin (labs usually give the range for non fasting salt which is around 3-6, non fasting is about 3-24) is what secondaries have 99% of the time. Primaries have high renin. Aldosterone, fasting salt is around 4-22, labs usually give non fasting salt range. Secondaries will have low potassium 99% of the time, though some are in the middle of the range and it could go either way then. Primaries have high potassium, though some are in the middle of the range.

I recommend you also get total and free testosterone, LH, FSH, Estradiol, SHBG, igf-1. In primary hypogonad men, most will be top of the LH and FSH range to just above, secondary hypogonad men, 99% will be low, but in range.

Since thyroid always goes hand in hand with primary and secondary AI, also recommend you get TSH, free T3, free T4, TPO and Tga thyroid antibodies tested. In men, primary hypothyroid will be above 2.2 and higher, secondary is 1.8 or lower. Between 1.8 and 2.2 not so clear which it is if frees are low and hypo symptoms.

Wouldn't hurt to get prolactin tested, but in most cases isn't important to men unless top or above range, then prolactinoma tumor should be investigated. Sometimes hypothyroidism can raise prolactin which usually comes down when thyroid is treated.

Hang in there.
I just posted this on the other thread.

My cortisol was at 5 % in the blood serum and only in normal region at 8 am. After i take my DHEA supplementation. ACTH Stim high.. 70 when normal <35

I am vit D deficient. Now aggressively treating this. Doesn't help the hypoT constipation issues.
I was vit B12, ferritin, and magnesium deficient.. But I have gotten those into the 40% range of normal and holding six months now.

My Hashimoto's antibodies are about 2000.
My CSF is at an elevated pressure and I have oligomeric banding and noted milan destruction.. MRI is clean.. as well as a bunch of other tests.. no MS or lupus.. so Hashimoto's encephalopathy is suspected. Go back in May for another round of testing on that one.

I am having issues with regulating thyroid meds because my T3 levels are/were 2 fold my T4 levels and I keep pushing my self hyperT in T3 while remaining hypoT in T4.

My endo claims I am normal because my TSH was 2 before meds.. all else was irrelevent. Bless her. So I am working with my IM and we are both in new territory. Know any good Endos with in 4 hours of Chattanooga, TN with this mess.

Right now my list is:
Thyroid: TPOAb, TGAb, TBG, TSH 3rd Gen, Ft3, Ft4, T2

Adrenals: ACTH, Cortisol 8 am, Aldosterone, and ACA, renin

Pituitary/hypothalamus: PTH, TRH

General AI: ANA

So anything I am missing? I am giving my blood chemistry a good 3 months to level out and equilibrate. So the Vit D and other mess will wait. Also any advice in getting rid of the water retention in the feet? Just the feet and my right ankle. Ocassionally my knees swell but that normally corresponds to a Hashi's flare and hypoT state. AHHHH! Okay better now. Crud.. I think I am working up to a hyperT swing again. This really sucks.

As too my Ca, Mg, K levels. The used to be high normal.. now they are dropping. Head injuries are a nil. Here is a familial kicker for you. My mom and one of her 4 sister's are Hashi's and Graves. Two more aunts are Hashi's and one is Graves. All five have AI's. None have exceeded a TSH of 2.5 even after a thyroidectomy or RAI was performed. ;) Secondary hypoT runs rampant with us. My mom's top TSH was 2.33 with only half a thyroid and an RAI uptake showing the remaining lobe dead. Aunt B1 2 RAIs and finally a TT max TSH 2.54. My Aunt B2.. due her TT max TSH 2.67. My max before meds 2.077. It is true I have yet to find a AI marker for secondary hypoT. However.. TPOAbs have been known to interfere with TSH binding receptors.. so maybe they work in two ways.

MG
Alright, Hormoneman, you asked for it! (and MG, watch it with the Thread Hijacking! ;))

It all started with Thyroid checks:

Thyroid #1 (Late Jan):
TSH - 1.26 (18.8% of range)
FT4 - 1.15 (25% of range, +6% from TSH)
FT3 - 367 (72% of range, +47% from FT4)

Thyroid #2 (Early Feb):
TSH - 0.825 (8.6% of range)
FT4 - 1.07 (19.2% of range, +10% from TSH)
FT3 - 362 (69.4% of range, +50% from FT3)
Reverse T3 - 24 (Ref: 11-32)
Anti-TPO (for Hashi's) - <10 (Ref: <35)
TSI (for Grave's) - 106 (Ref: <=125)

Saliva Sex Hormones (as part of "Test #2" mentioned in first post):
Free Testosterone - 39 (50-80 pg/mL) - (-35% of range)
Progesterone - 39 (5-95 pg/mL) - (38% of range)
Estradiol - 10 (1-3 pg/mL) - (450% of range)

Addendum to "Test #3" mentioned in first post:
T, Total - 248 (241-827) - (1% of range)
T, Free - 73 (34-194) - (24% of range)
T, Free & Weakly Bound - 166 (84-402) - (25% of range)
Albumin - 5.0 (3.6-5.1) - (93% of range)
SHBG - 14 (8-48) - (15% of range)
LH - 1.8 (1.5-9.3) - (3.8% of range)
FSH - <0.7 "Undetectable" (1.6-8.0)
Prolactin - 6.1 (2.0-18.0) - (25.6% of range)
IGF-1 - 266 (106-255) - (107% of range)
ACTH - 69 (7-50) - (144% of range)
Cortisol @ 11:00a - 8.8 (4-22 @ 9:00am) - (26% of range)

CBC (last week):
WBC - 4.8 (4.0-11.0)
RBC - 4.77 (4.60-6.10)
HGB - 13.4 (13.5-18.0)
HCT - 39.3 (41.0-53.0)
MCV - 82.3 (80.0-98.0)
MCHC - 34.1 (32.0-36.0)
RDW - 14.4 (11.5-14.5)
PLT - 220 (130-400)

CMP (last week):
Glucose, Fasting - 82 (70-100)
Sodium - 142 (135-145)
Potassium - 4.2 (3.5-5.5)
Chloride - 103 (98-107)
CO2 - 27 (23.0-31.0)
Anion Gap - 12 (7-16)
BUN - 11 (5-25)
Creatinine - 0.9 (0.5-1.4)
Calcium - 9.6 (8.7-10.2)
Bilirubin, Total - 0.5 (0-1.0)
Bilirubin, Direct - 0.0 (0.0-0.4)
Total Protein - 7.4 (6.3-8.2)
Albumin - 4.9 (3.5-5.0)
AST (SGOT) - 32 (14-50)
ALT (SGPT) - 35 (21-72)
Alk Phosphate - 97 (50-136)
GGTP - 23 (8-78)
eGFR - >60 (Ref: >60)

Iron / Anemia Profile (Last Week):
Iron - 66 (60-180)
Iron Binding - 400 (200-400)
Percent Saturation - 16.5% (14-55%)
Ferritin, Serum - 8 (25-335)

Lipid Panel (Last week):
Cholesterol, Total - 150 (Ref: <200)
Triglycerides - 211 (Ref: <150)
HDL - 29 (40-59)
LDL - 79 (Ref: <100)
VLDL - 42 (No Ref given)
LDL/HDL Ratio - 2.7 (Ref: <3.55)
TC/HDL Ratio - 5.2 (Ref: <4.97)

Various Other Labs (Last Week):
Vit B12 - 355 (Ref: >240)
RBC Folate - 1150.1 (Ref: >160)
Phosphorous - 3.5 (2.5-4.5)
Uric Acid - 6.0 (3.5-8.0)
Relative Retic - 1.85% (0.1-2.0%)
Absolute Retic - 88 (5-94)

I've read the ACTH "Inperpretation Guide" on other forums (STTM) before, and I too was leaning towards Secondary, but my ACTH vs Cortisol looks like my Pit knows it's too low and is "raising it's voice" (we don't yell/shout in our household :D) to try to get more Cortisol.

Do you have references (that are legal to post here) that state that low Pregnenolone is a marker for Hypopituitarism? I thought since Preg. was a precursor for DHEA, and since my ACTH is probably high all the time, that it is all used up making DHEA and the other Adrenal products, (but not Cortisol for some reason - maybe an enzyme deficiency that is blocking Cortisol synthesis?). Doesn't the high ACTH in response to chronic lower Cortisol make Hypopituitarism less likely? (FSH/LH are low, but we'll get to that later). Also, since Aldosterone isn't ACTH depentent, wouldn't Pregnenolone need to be indepentend of ACTH as well, (or am I out in left field)?

Hopefully in "Round 2" with my Endo, he'll do the Aldosterone/Renin tests, (along with the Estradiol since it was high on the Saliva stuff). I have the "Hard to handle outside heat" thing, but I live in the Southern States, so that doesn't say much. ;) I haven't noticed any "excessive sweating" or "excessive urination", but if it were congenital, (which I suspect it is), then I wouldn't have a good point of reference to compare "excessive" to. Potassium and Sodium look ok. I did have a slightly low Potassium of 2.9 once back in 1994, but that was a while ago.

Sex hormones are another puzzler. As you can see, my T's, SHBG, and my FSH/LH are low, but my IGF-1 and Albumin are high. He didn't check Estradiol (E2), but since it was pretty high on the Saliva testing, I suspect it's pretty high. I read in some Endo training materials that the Hypothalamus can't tell T from E2, so if E2 is high it will lower GnHR and thus drop LH/FSH, and lower T/DHT production. Since low T/DHT means E2 synthesis isn't as repressed, more E2 is produced, the Hypothalamus sees too much sex hormones, and the cycle continues. I don't have Gynecomastia, (male boobies), but I don't think that rules out "Male Estrogen Dominance". It may be something as simple as too much T is being Aromatased into E2, and could I just use something to slow down the conversion, but there isn't a lot of info on this topic that I've found. I've called my Endo and left several messages asking to come in and check E2 and Aromatase rate, but I haven't heard anything back yet.

Thyroid function looks normal, (as far as TSH vs FT4), since it looks like my Thyroid is "following orders" and making as much T4 as the Pit wants. I know the TSH is lowered, but I think that has to do with low Cortisol downregulating Thyroid function instead of Hypopituitarism. The real puzzler is what is causing my FT3 to be +50 percentile higher then my FT4. I thought it was low Cortisol which prevents binding of the T3 at the cell and thus causing an increase in circulating T3, (what I term "Effective Hypothyroidism" since it's there but I can't seem to use it). I also read on a few other boards that E2 and T3 both compete for the same receptors, so high E2 might also explain the extra floating T3, (but I don't have any references other then a few posts on a Body Building forum). I'm still a little unsure as to if the Hypothalamus looks at FT4 or FT3 to regulate the Thyroid, so the relative elevated FT3 could also be a factor in causing the lowered TSH.

Prolactin, WBC, and RBC look good, so I don't suspect a tumor.

Iron, Ferritin, HGB, and HCT are a bit low, but that has to do with giving myself temporary low-iron Anemia, as I stated previously.

(Is it just me, or is this starting to feel like an episode of "House"...) :(
I read somewhere that:
[QUOTE]Excess DHEA can cause excess levels of estrogen and testosterone, as well as creating a dependence. [/QUOTE]
Any truth to this?

My DHEA-S is up, but it's only about at 135% of range, and since my ACTH is about at 144% of range it might just be an appropriate response to the high ACTH.

If the statements is true, I could see things happening like this...
- Adrenals have a problem producing Cortisol (still need to figure this one out)
- Hypothalamus/Pit sees low Cortisol so ups CRH/ACTH to get more
- Adrenals try to respond but the best they can do is to raise DHEA, (and in doing so reducing the amout of Pregnenolone available)
- Excess DHEA is converted to estrogen (and a little to testosterone)
- Extra Estradiol is sensed by the Hypothalamus, so lowers GnRH
- Low GnRH means low FSH/LH
- Low FSH/LH means low testosterone
- Low testosterone/DHT means Estradiol synthesis isn't challenged, resulting in higher Estradiol production
- High Estradiol to testosterone ratio causes stress on the body
- Hypothalamus/Pit ups CRH/ACTH to get more Cortisol in response to stress
- Rinse & repeat

Would a low FSH/LH still convert extra DHEA to Estradiol, or would that throw my whole theory out the window?

I'm really looking forward to seeing what being on HC for a few months will do to this whole cycle, (if and when I ever get to the Endo to start HC...)





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