Why would TRT not work?

Mew · May 25, 2018, 5:46am

What is going on here?

Can people please stop trying to cause flame wars or whatever.

We are all here looking for answers to our problem, that much is a given.

And we should all be grateful that those with greater knowledge in this area have chosen to share such knowledge with us.

Debating wether that be Dr Crisler, Shippen or otherwise should not be the issue. Healthy debate is encouraged but really, we are here to work together, likely try treatments and hopefully, recover.

Josh, discussing members with other Doctors is probably not the best way to accomplish this. Jim and Hypo, I hope you will change your mind and continue to stick around, regardless of any beefs you may have with one or two members.

Thanks… guys just use some common sense instead of trying to stir up a hornet’s nest.

J89 · May 25, 2018, 5:46am

Hypo, my point is that Dr Crsler is by no means just any old GP or “some” endocrinologist and I only mentioned that to make a point that he is very thorough with his patients and how could he miss somthing, considering he says he has baseline levels? There is probably a good chance he does IMO considering how many patients end up in his care who are screwed from finasteride.

In no way was I saying that you think Dr Crisler is not a competent doctor. In fact Ive heard you say a lot of very GOOD things about him. I know you respect Dr Crisler and his work, there is no issue there.

I completely understand what your saying in your original post. About how refernece ranges for testosterone are not age specific and how all sorts of problems can arise when you add testosterone to a hypogonadal patient such as SHBG can increase, E can increase and if untreated can cause problems.

Some of us here know this stuff already. So does Dr Crisler, Josh has claimed that Dr Crisler has said that even with all of this considered, some do not recover. This is what baffles me.

Your right though, and it could be a far reaching hormonal issue that would be impossible to get accurate before and after tests for. I am not saying your wrong at all. I am just saying that a lot of guys have a lot of what you mentioned covered and are still not cured yet. And if we cant rely on past or present bloods, how do we treat it when that fails?

Hypo, I will say again that your input here is VERY important to me and everyone else here. You have already helped fix up one patient and that is HUGE.

I also dont know why people keep going on about how if Dr Crisler posted here, there would be some kind of showdown between Hypo and him. Where did this come from? IMHO, I think Dr Crisler and Hypo would agree on almost everything.

Jim1234 · May 25, 2018, 5:46am

Mew:

What is going on here?

Can people please stop trying to cause flame wars or whatever.

We are all here looking for answers to our problem, that much is a given.

And we should all be grateful that those with greater knowledge in this area have chosen to share such knowledge with us.

Debating wether that be Dr Crisler, Shippen or otherwise should not be the issue. Healthy debate is encouraged but really, we are here to work together, likely try treatments and hopefully, recover.

Josh, discussing members with other Doctors is probably not the best way to accomplish this. Jim and Hypo, I hope you will change your mind and continue to stick around, regardless of any beefs you may have with one or two members.

Thanks… guys just use some common sense instead of trying to stir up a hornet’s nest.

I don’t have any beefs with anyone and will stick around. How could I have abeef with Hypo when I read the first two sentences of his post and skip the rest. I just not going to post about PCT anymore. I think the message boards (not this one) will be the next thing taken down by the police. Some people post from overseas so you are OK

Jim1234 · May 25, 2018, 5:46am

HIGHLY UNLIKELY !

J89 · May 25, 2018, 5:46am

OK, “almost EVERYTHING” was a little optomistic…lol. But what I am saying is they would agree on how complex mens hormones are and Hypo seems to have a good grasp on that. We know that Dr Crisler thinks that there is more to this than just adding TRT and so does Hypo.

No two people are ever going to whole heartedly agree on ANYTHING especially complex topics such as hormones and especially post finasteride hormones.

Jim1234 · May 25, 2018, 5:46am

If you locked Dr John in a room for 24 hours by himself there would be an argument

Hypo-is-here · May 25, 2018, 5:46am

J89:

Hypo, my point is that Dr Crsler is by no means just any old GP or “some” endocrinologist and I only mentioned that to make a point that he is very thorough with his patients and how could he miss somthing, considering he says he has baseline levels? There is probably a good chance he does IMO considering how many patients end up in his care who are screwed from finasteride.

In no way was I saying that you think Dr Crisler is not a competent doctor. In fact Ive heard you say a lot of very GOOD things about him. I know you respect Dr Crisler and his work, there is no issue there.

I completely understand what your saying in your original post. About how refernece ranges for testosterone are not age specific and how all sorts of problems can arise when you add testosterone to a hypogonadal patient such as SHBG can increase, E can increase and if untreated can cause problems.

Some of us here know this stuff already. So does Dr Crisler, Josh has claimed that Dr Crisler has said that even with all of this considered, some do not recover. This is what baffles me.

Your right though, and it could be a far reaching hormonal issue that would be impossible to get accurate before and after tests for. I am not saying your wrong at all. I am just saying that a lot of guys have a lot of what you mentioned covered and are still not cured yet. And if we cant rely on past or present bloods, how do we treat it when that fails?

Hypo, I will say again that your input here is VERY important to me and everyone else here. You have already helped fix up one patient and that is HUGE.

I also dont know why people keep going on about how if Dr Crisler posted here, there would be some kind of showdown between Hypo and him. Where did this come from? IMHO, I think Dr Crisler and Hypo would agree on almost everything.

I have read your post carefully, much I cannot comment on as it is for others to comment upon, but I have to say I do not agree with one of your main points.

Dr Crisler may have referred to baseline results regarding testosterone alone, or free testosterone etc or he may have referred to patients with similar end levels or he may have meant X, Y or Z.

He isn’t here and so I cannot comment on what he actually said in terms of context and meaning.

What I will say is there is no way that a whole bunch of healthy people just happened to have propecia specific in-depth baselines prior to use and then just all happened to then achieve all the same baseline levels in x number of hormones levels via TRT or endocrine altering meds and also all ended up with all ratios back to the same as baseline.

And you know what even if all that was managed (absolutely no chance) were the DHT to T ratios the same? Were the free testosterone to free estradiol ratios the same, what about the SHBG to estradiol ratio if you don’t have free estradiol given it is almost never measured? I am telling you now this has not happened.

Sorry but I refuse to believe that could happen, because it could not and I am not even sure Dr Crisler has said that because the information is second hand.

What frankly is now leaving me very miffed is this side issue, something I have already answered has completely engulfed the entire nature of my original posting and the original question in the thread. I am sure people would gather new information from re-reading my original answer a number of times.- but that isn’t going to happen.

None of this side issue relates to the original question in this thread or my original post…If I didn’t answer the point/side issue fair enough but I have- now multiple times…

I know everyone is having a chat and chipping and such like and I know some people have read what I have written and some nice comments have been made, all that is great. But I just think the original post has been almost entirely shunted off into a railroad siding. No comments have been raised regarding a single issue in my post and it is pushing up the daisies lol

In all honesty I don’t think I’m going to post such detailed information in future, it just gets lost in translation. It has left me constantly having to rectify something I wasn’t saying, constantly having to refer to a side issue etc; it isn’t worth me putting in the effort, just to end up having to fight fires.

I’ll stick to short simple posts and make simple points in future.

Legenden_1999 · May 25, 2018, 5:46am

OK then, if you feel no one has read (and understood) your initial post, then you are wrong. I’ll take up the disscution if noone else will…

Make sence, BUT if is not correct that most hypogonadal people feels an massive improvement when they get their T up in top of the reference range and holds their E2 in check?

How come this has not worked for ANY propecia sufferes I have heard of who has tried TRT?

Hypo-is-here:

When you have blood pathology it gives you a set of numbers and supposedly normal reference ranges. One major problem is that the numbers do not analyze themselves and there are many human errors due to ignorance of the issues at hand. There numbers are often not interpreted in relation to one another and they are often overly relied upon to the exclusion of symptoms. Misinterpretation of hormone assays and a general lack of knowledge means that patients are often misled and misdiagnosed and believe that they have a healthy hormonal status when they do not.

At the gp level you may have a one point serum testosterone test, if it is in the normal range you will be told you are ok. But this does not take into account a whole range of other factors that lower the crucial level of free testosterone such as SHBG, estradiol etc.

Such testing as you can see is flawed.

I am aware of that, and I think many of us here are aware of that.

Hypo-is-here:

In the UK the Society for Endocrinology has a policy statement that it has released concerning how low testosterone (hypogonadism) should be evaluated.

In the policy statement it says and I quote verbatim from the link below;

In the presence of symptoms of androgen deficiency it is appropriate to measure a 9am testosterone test and if it is around the 10nmol/l mark, endocrine referral is appropriate.
Unquote

endocrinology.org/policy/doc … erone.html

Yet

Many men have testosterone levels above this abstract, nonsensical plucked out of the air theoretical man made boarderline figure and have hypogonadism/low testosterone.

If a man in the UK has a testosterone level of 13nmol/l they will probably not get a further more in-depth analysis of their hormonal status due to the above policy statement despite the fact that a high SHBG level could render a very low crucial free testosterone level (the UK NHS does not measure free testosterone at all).

Many testosterone assays are calibrated in such a way that a level above 10nmol/l would be deemed normal and the individual would not be passed on for endocrine referral yet, you could have Klinefelters or Kallman Syndrome with a level like that.

In the link below you can click on the top right picture. That is the picture of a man who has Kallman Syndrome, he has a serious genetic problem that has resulted in major androgen/estrogen problems- yet his testosterone level is 10.6nmol/l. If you convert this level to the US range it comes out as 306ng/dl. The US has many far more forward thinking doctors, but even so many US doctors and the AACE (American Association of Clinical Endocrinologists) would think this testosterone level would probably be ok.

But this man is far from being ok from an androgen/estrogen standpoint. It is something that highlights the problems inherent in strictly interpreting hormonal assays.

get-back-on-track.com/en/pro … _03_01.php

I am not saying any of us here have genetic problems that affect the amount of androgens and estrogens produced, that we have testicular failure or that we have a problem relating to the sensitivity to androgens……the point above was just another example of the problems with looking strictly at the hormone assays and playing the numbers game.

I would also say that the supposed “normal” reference range is an abstract theoretical normal and that many people within that range do not have normal levels for them. Pathology does not have all the answers and it should only be used as a guide in combination with symptoms- it should never be used as a rule.

Not much new for me here, but I have also read shippens book

Actually, in Denmark they are divided into agegroups…

Hypo-is-here:

This is another startling reason that highlights the flawed nature of using the reference ranges in a strict manner. There are probably very few areas of medicine where allowances are not made for age. We would not expect a 90 year old man to be the same as an 18 year old man whether we mentioned heart function, blood pressure, mental function, muscular development, etc etc. Yet when we measure testosterone we are putting everyone in the same basket irrespective of age.

The bottom of the male reference range for testosterone is often said to be around 10nmol/l or 288ng/dl, but is this normal for young men?

The fact is most studies and top andrologist agree that this is not normal for young men. In a very large study of over 3000 (Dabbs study) military personnel between the age of 21 and 34 it was found that the average testosterone level for a 32 year old was 31nmol/l (894ng/dl). That was the average serum testosterone level not the highest. Of course that is only one study, but if that was anywhere near approaching correct then it would certainly be fair to say that 10nmol/l (288ng/dl) was anything but normal for most young men.

Most studies I have seen have 22-25 nmol/l as the mean for men aged 24-34 yo.

Most docs no, but the anti ageing doctors some of us see, are aware.

Hypo-is-here:

Do they understand also understand the limitations of the estradiol reference range in men and know that it too is of limited help given that A) laboratory assays of this nature are often calibrated around female reference ranges and that B) again there is no differentiation in age ranges and that the upper third of the reference range is often very unhealthy for men’s androgen status?

Does your doctor understand that SHBG is not just a mediator for testosterone, but also is crucially a mediator for estrogens and that low SHBG can also cause high free estradiol (which is crucial but isn’t measured anywhere).

Many doctors, particularly in the UK look to LH and use that to help diagnose problems. Many think that if testosterone is boarderline low on the male reference range that problems should be diagnosed on the basis of LH. Such thinking is that if LH is high then the body needs more testosterone, but not enough is being made, therefore the problems is one of testicular failure and primary hypogonadism, conversely the thinbking is if LH is low that not enough testosterone is being made and the problem is hypothalamic/pituitary in origin.

Often doctors will think there is no problem if testosterone is borderline low and LH appears normal.

Most of us are secondary with low T and low LH which means our testies are OK but our head are not. I agree it takes a good doctor to figure out this is a problem, when most older hypogonadal men have high LH.

Hypo-is-here:

But estradiol has an enormous impact on LH and the HPTA negative feedback system and can often ensure a normal LH level in the setting of low testosterone. Dr Eugene Shippen speaks eloquently of this problem in his book the Testosterone Syndrome. He explains how the body can be tricked into thinking it has sufficient testosterone by having too high a level of estradiol and he describes this as a form of secondary hypogoandism that is caused not by a diseased state but simply too much estradiol; he refers to this as metabolic hypogonadism.

So again the above highlights how expert analysis can be the crucial factor- not simply the blood tests.

Let’s look at another problem that I touched upon, the problem of not knowing your hormone levels prior to propecia use.

I think I’ll quote Dr Eugene Shippen from the Testosterone Syndrome here as you will see the a problem that everyone has;

Quote
To confine ourselves to testosterone for the moment, let me point out what is useless is the standard doctrine that according to which a man’s testosterone levels is within the normal range if it falls somewhere between 300ng/dl and 1000ng/dl.

Such a notion of normality is virtually meaningless, unless all you mean by it is 90 percent of all men do, in fact, have testosterone levels within this range. But a meaningful medical notion of normal surely contains an implicit approval of the level found, a suggestion that when a man’s testosterone is above the lower number and below the higher number, he can rest assured that he is basically on track. In other words, his health, and vigor should be supported rather than adversely affected by his level- he’s “normal”.

If that is what doctors mean when they refer to normal testosterone levels, then they are flat out wrong. Your own personal, “normal” level of testosterone probably is somewhere between 300ng/dl and 1000ng/dl, but no one can say where in the range it lies. You maybe somewhat too low at 600ng/dl, or you maybe adequate at 450ng/dl. By nature, you maybe a high testosterone male, and, without those baseline levels taken in youth, which you certainly don’t have, no one can tell for sure.

(My edit- in the above instance you can take youth to be prior to propecia use).

Back to verbatim quote
Let’s just consider the case of two very different men. One is a high testosterone male who normally averaged between 800ng/dl and 1000ng/dl when he was healthy and young. Now he is fifty, and has suffered a serious hormonal fall. His levels are now between 400ng/dl and 500ng/dl. This is a catastrophe, a 50 percent drop, and he feels every point of it. Now there comes another individual who in the days when he was young and healthy averaged between 400ng/dl and 500ng/dl. He too, has reached his fiftieth year, and his testosterone have also declined. They now average between 300ng/dl and 400ng/dl. The drop is relatively slight, an he notices little change in function. He still feels like a health specimen.

It is relatively easy to make such analysis. Unfortunately, in the real world, the physicians who are treating each of these men, don’t have the earlier numbers, the baseline youthful highs. All the physicians know is that one man has levels between 400ng/dl and 500ng/dl, while the other is between 300ng/dl and 400ng/dl. And surprisingly, the man with the lower level feels much better and reports far fewer symptoms.
Unquote

It is also true in the above that the person with the lower levels would be the one most likely to be diagnosed and treated.

I could go on to cover many, many, many more issues such as lognormal transformations of reference ranges and many other issues but I won’t.

Again nothing new here, just shippens words.

Raise in testosterone caused by Clomid doesn’t really count, cause only very few men will feel better this way. If it was this simple to do TRT, shots and gel would a thing of the past.

Without baseline readings we dont know if we are at the right level, but is it not correct that for most ppl on TRT it dosn’t matter if T is a little higher than before as long as the E2 is good and DHT is not too high?

Maybe, but why are ALL us who has tried unsuccessfull, when at least SOME nomal hypogonadal men trying TRT are not.

Hypo-is-here:

How do you know, even if you do replace your testosterone to the desired level that you do so in such a way that you do not cause a cascade of knock on effects on other hormones that cause you to feel poorer than you did prior to propecia use?

I mean you could quite easily replicate your testosterone level with a bit of luck, but what happens if this in turn results in a high level of estradiol and a consequently low androgen to estrogen ratio or lower level of free testosterone?

What if you replace your medication results in a high levels of SHBG and a consequently lower level of free testosterone?

What if your DHT level is lower than it was prior to propecia use, or what if its ratio to estradiol is poorer and you have resultant symptoms?

Can you see how complex this are of medicine can be?

Yes but these rules applies ALL on TRT.

Let me hear your thoughts, and no need to do it short for my sake.

JH

panic · May 25, 2018, 5:46am

If it’s not hormones, then what the hell could it be!?!?

panic · May 25, 2018, 5:46am

The reason I ask is because there are several stories of people getting back to normal (at least for a little while) by using herbal or naturnal fixes like broccoli treatment, tribulus, etc. Apparently, all these things do is give you a hormone boost for a short, until the body readjusts. Anyway, the fact is that they seem to work for a short period for some people. This reinforces hypo’s point.

Hypo-is-here · May 25, 2018, 5:46am

Legenden_1999:

OK then, if you feel no one has read (and understood) your initial post, then you are wrong. I’ll take up the disscution if noone else will…

Hypo-is-here:

Your endocrine system is like your own personal chemistry set, its levels, checks and balances are particular to you and so the same is true for me and each and every one of us.

If one hormone is out whether it be SHBG being higher than before, DHT slightly lower, free testosterone a little lower, estradiol slightly higher etc that can have knock on effects and be enough to disturb the hormonal synergy that is required for you to feel well. Remember it only takes one instrument to be out of tune in an orchestra for the collective sound and purpose to break down.

Legenden_1999:

Make sence, BUT if is not correct that most hypogonadal people feels an massive improvement when they get their T up in top of the reference range and holds their E2 in check?

Your comparison is not remotely helpful because the majority of men who have hypogonadism either have very basic problems of andropause or testicular problems. There are a high number of such men and they often respond very well to basic measures/medications.

A far better comparison would be men who have secondary hypogonadism and men who have issues relating to problematic SHBG levels etc. There are MANY men with such problems that certainly do NOT get better on the basis of simply having testosterone in the upper third of normal and E2 in check as you mention.

I know of many men with secondary issues that do not respond well to the principle you mention, one of them is ME LOL- some of these men do respond to other medications.

Legenden_1999:

How come this has not worked for ANY propecia sufferes I have heard of who has tried TRT?

Because I do not think the cause of the problems are remotely the same or as simple. I recall many years ago seeing Dr Shippen talking about these problems and even back then he was talking about propecia causing a very difficult to treat form of hypogonadism. You are comparing the general to the not so general and therefore not comparing like with like.

Hypo-is-here:

When you have blood pathology it gives you a set of numbers and supposedly normal reference ranges. One major problem is that the numbers do not analyze themselves and there are many human errors due to ignorance of the issues at hand. There numbers are often not interpreted in relation to one another and they are often overly relied upon to the exclusion of symptoms. Misinterpretation of hormone assays and a general lack of knowledge means that patients are often misled and misdiagnosed and believe that they have a healthy hormonal status when they do not.

At the gp level you may have a one point serum testosterone test, if it is in the normal range you will be told you are ok. But this does not take into account a whole range of other factors that lower the crucial level of free testosterone such as SHBG, estradiol etc.

Such testing as you can see is flawed.

Legenden_1999:

I am aware of that, and I think many of us here are aware of that.

I must say I find this comment a little unfair and vexing to say the least. You maybe aware of these points and others maybe also, but then again there will be a lot more people besides who are not aware of this. For some this part of the post will be enlightening, for others maybe it is another part of the post. Often people will have felt in the back of their minds along these lines, but have not seen it put into words in black and white on a page in this manner before. Either way, does what you are saying invalidate what I said in any way at all?

I don’t think it does.

This feels like an attacking comment from you and I feel I have had to answer to justify myself and I don’t feel I should have had to do that.

To be fair I can hardly construct a post that contains 100% of information that no one is aware of can I?

You have read more than many others- how can I know what you know and what you don’t and only write about what you don’t know?

Think about that because what you are effectively asking for and criticizing is absurd.

I am not a mind reader, but it seems I am being attacked a little but for not being one. Again I still say this is helpful for quite a few people and therefore I was quite right to include it in the post.

Hypo-is-here:

In the UK the Society for Endocrinology has a policy statement that it has released concerning how low testosterone (hypogonadism) should be evaluated.

In the policy statement it says and I quote verbatim from the link below;

In the presence of symptoms of androgen deficiency it is appropriate to measure a 9am testosterone test and if it is around the 10nmol/l mark, endocrine referral is appropriate.
Unquote

endocrinology.org/policy/doc … erone.html

Yet

Many men have testosterone levels above this abstract, nonsensical plucked out of the air theoretical man made boarderline figure and have hypogonadism/low testosterone.

If a man in the UK has a testosterone level of 13nmol/l they will probably not get a further more in-depth analysis of their hormonal status due to the above policy statement despite the fact that a high SHBG level could render a very low crucial free testosterone level (the UK NHS does not measure free testosterone at all).

Many testosterone assays are calibrated in such a way that a level above 10nmol/l would be deemed normal and the individual would not be passed on for endocrine referral yet, you could have Klinefelters or Kallman Syndrome with a level like that.

In the link below you can click on the top right picture. That is the picture of a man who has Kallman Syndrome, he has a serious genetic problem that has resulted in major androgen/estrogen problems- yet his testosterone level is 10.6nmol/l. If you convert this level to the US range it comes out as 306ng/dl. The US has many far more forward thinking doctors, but even so many US doctors and the AACE (American Association of Clinical Endocrinologists) would think this testosterone level would probably be ok.

But this man is far from being ok from an androgen/estrogen standpoint. It is something that highlights the problems inherent in strictly interpreting hormonal assays.

get-back-on-track.com/en/pro … _03_01.php

I am not saying any of us here have genetic problems that affect the amount of androgens and estrogens produced, that we have testicular failure or that we have a problem relating to the sensitivity to androgens……the point above was just another example of the problems with looking strictly at the hormone assays and playing the numbers game.

I would also say that the supposed “normal” reference range is an abstract theoretical normal and that many people within that range do not have normal levels for them. Pathology does not have all the answers and it should only be used as a guide in combination with symptoms- it should never be used as a rule.

Legenden_1999:

Not much new for me here, but I have also read shippens book

Excuse me! Sorry but you are now taking the proverbial. Virtually none of the above is contained within any book that you care to mention. It is NOT in the Testosterone Syndrome, if you are saying it is quote me the page numbers!! Neither is it in The Testosterone Revolution or Androgen Deficiency In The Adult Male or indeed any other book like I say.

I have provided information above relating to the UK policy statement- that derives from the UK policy statement itself. I have provided information regarding the fact that it is possible to have within range testosterone levels whilst having Kallman Sydrome. I provided that from Schering pharmaceutical research. I have also related the above to the AACE and their guidelines/references on this condition. Again nothing at all from Dr Shippen.

In fact not a single word above derives from Dr Shippen or the testosterone Sydrome!!!

And unless you were also aware of the Schering research and the UK endocrine position etc etc then you certainly were very unlikely to have been aware of the above.

I don’t think you did know all of the above, even if you did; once again tell me how this remotely invalidates what was said (again read what I said in my last response on these lines) or what justified the winking one line put down?

I hope the rest of this mail isn’t along these lines. I have no problem with genuine questions, I welcome them but so far this isn’t good, so far it feel I am being attacked for providing good answers to a question and good information.

Hypo-is-here:

I bet few people realize that the reference range for testosterone was created with no differentiation for age.

Legenden_1999:

Actually, in Denmark they are divided into agegroups…

And?

I mean good on you Danes……but how exactly was my comment wrong?

I said quoting myself (I will highlight the operative word for you)……

I bet “FEW” people realize that the reference range for testosterone was created with no differentiation for age.

Again is anything I said wrong, anything unhelpful or misleading?

Hypo-is-here:

This is another startling reason that highlights the flawed nature of using the reference ranges in a strict manner. There are probably very few areas of medicine where allowances are not made for age. We would not expect a 90 year old man to be the same as an 18 year old man whether we mentioned heart function, blood pressure, mental function, muscular development, etc etc. Yet when we measure testosterone we are putting everyone in the same basket irrespective of age.

The bottom of the male reference range for testosterone is often said to be around 10nmol/l or 288ng/dl, but is this normal for young men?

The fact is most studies and top andrologist agree that this is not normal for young men. In a very large study of over 3000 (Dabbs study) military personnel between the age of 21 and 34 it was found that the average testosterone level for a 32 year old was 31nmol/l (894ng/dl). That was the average serum testosterone level not the highest. Of course that is only one study, but if that was anywhere near approaching correct then it would certainly be fair to say that 10nmol/l (288ng/dl) was anything but normal for most young men.

Legenden_1999:

Most studies I have seen have 22-25 nmol/l as the mean for men aged 24-34 yo.

I have seen many studies also. The Dabbs was a very interesting study because its subjects were of optimal health being in the military; most studies involve men already in hospitals or attached to them for some reason, this can potentially offer a bias and a more unhealthy group of men and potentially a lower end reference range. Also the Dabbs study had over three thousand people, which is a LOT larger than most studies. I am not saying this means that the Dabbs study proves that the range would be higher for optimal health, but it is certainly interesting and worth thinking about hence my reason for including it. Dr Malcolm Carruthers who has been one of the leading endocrinologists in the world for over 20 years included it in his second book (Androgen Deficiency In The Adult Male) which was written for the medical fraternity not the layman- it was good enough for Dr Carruthers and he deemed it interesting enough for future andrologists, so I deemed it interesting enough for us.

Hypo-is-here:

The pharmaceutical company that makes Androgel/Testogel Schering have their own figures relating to normal levels and it is their opinion that levels of 10nmol/l (288ng/dl) are more typical of men near the end of life as opposed to young men.

Here is the link showing this- please click on the second to last box on the left that shows typical testosterone levels at differing ages.

get-back-on-track.com/en/pro … _01_02.php

So all the above shows problems relating to analysis, but there are more issues;

Does the doctor concerned know how to calculate the testosterone to estrogen ratio?

Legenden_1999:

Most docs no, but the anti ageing doctors some of us see, are aware.

I would hope so, that is good.

I think there are quite a few guys here that are not so fortunate and so the point is worth spelling out, don’t you agree? I think it is one more point that sits well within the context of my post and not worth leaving out?

Hypo-is-here:

Do they understand also understand the limitations of the estradiol reference range in men and know that it too is of limited help given that A) laboratory assays of this nature are often calibrated around female reference ranges and that B) again there is no differentiation in age ranges and that the upper third of the reference range is often very unhealthy for men’s androgen status?

Does your doctor understand that SHBG is not just a mediator for testosterone, but also is crucially a mediator for estrogens and that low SHBG can also cause high free estradiol (which is crucial but isn’t measured anywhere).

Many doctors, particularly in the UK look to LH and use that to help diagnose problems. Many think that if testosterone is boarderline low on the male reference range that problems should be diagnosed on the basis of LH. Such thinking is that if LH is high then the body needs more testosterone, but not enough is being made, therefore the problems is one of testicular failure and primary hypogonadism, conversely the thinbking is if LH is low that not enough testosterone is being made and the problem is hypothalamic/pituitary in origin.

Often doctors will think there is no problem if testosterone is borderline low and LH appears normal.

Legenden_1999:

Most of us are secondary with low T and low LH which means our testies are OK but our head are not. I agree it takes a good doctor to figure out this is a problem, when most older hypogonadal men have high LH.

Wrong the problem is often not with your head!!!

First of all, let’s refer to the hypothalamus/pituitary as opposed to heads as you may confuse newbie’s big time LOL

Go back and read your Testosterone Syndrome…

Page 49 states I quote

Shippen Quote
In many men, high levels of estrogen cause an actual slowdown in testosterone production. The mechanism of action is that the female hormone occupies some of the hypothalamic receptors for testosterone in the brain. The hypothalamus interprets this as if it were testosterone filling those receptor sites. The hypothalamus is tricked into acting as if testosterone levels in the body are high, and so fails to send out the hormones that would tell the pituitary gland to stimulate testosterone production in the gonads. This is a form of the secondary hypogonadism that we discussed in the last chapter, dependent now NOT UPON A DISEASE STATE or pharmaceutical side effect or mere aging but purely upon an inappropriately high level of estrogen.
Unquote Shippen

Note: please remember that SHBG is regarded as an estrogen due to its greater binding affinities for androgens over estrogens and certainly has the same impact on the HPTA as estrogen regarding the metabolic issues.

The point I am making is that your claim is categorically wrong. Most people here do NOT have a problem with their hypothalamus/pituitary. There ARE a lot of people here who have no problem or diseased state as Shippen puts it, but rather a lot of people here who have resultant metabolic hypogonadism….where the problem is the negative feedback upon the HPTA and NOT a problem with the HP itself. I have helped to cure a guy of Propecia problems who had this very type of condition post Propecia use.

Given the mutifactoral problems that Finasteride and Propecia can cause and the vast array of differing endocrine profiles- yes many do seem to have problems as you mention. But most people- not at all. I have already seen many people on this site and many people generally who have what appear to be metabolic/ negative feedback issues as opposed to what you have referred to.

Hypo-is-here:

But estradiol has an enormous impact on LH and the HPTA negative feedback system and can often ensure a normal LH level in the setting of low testosterone. Dr Eugene Shippen speaks eloquently of this problem in his book the Testosterone Syndrome. He explains how the body can be tricked into thinking it has sufficient testosterone by having too high a level of estradiol and he describes this as a form of secondary hypogoandism that is caused not by a diseased state but simply too much estradiol; he refers to this as metabolic hypogonadism.

So again the above highlights how expert analysis can be the crucial factor- not simply the blood tests.

Let’s look at another problem that I touched upon, the problem of not knowing your hormone levels prior to propecia use.

I think I’ll quote Dr Eugene Shippen from the Testosterone Syndrome here as you will see the a problem that everyone has;

Quote
To confine ourselves to testosterone for the moment, let me point out what is useless is the standard doctrine that according to which a man’s testosterone levels is within the normal range if it falls somewhere between 300ng/dl and 1000ng/dl.

Such a notion of normality is virtually meaningless, unless all you mean by it is 90 percent of all men do, in fact, have testosterone levels within this range. But a meaningful medical notion of normal surely contains an implicit approval of the level found, a suggestion that when a man’s testosterone is above the lower number and below the higher number, he can rest assured that he is basically on track. In other words, his health, and vigor should be supported rather than adversely affected by his level- he’s “normal”.

If that is what doctors mean when they refer to normal testosterone levels, then they are flat out wrong. Your own personal, “normal” level of testosterone probably is somewhere between 300ng/dl and 1000ng/dl, but no one can say where in the range it lies. You maybe somewhat too low at 600ng/dl, or you maybe adequate at 450ng/dl. By nature, you maybe a high testosterone male, and, without those baseline levels taken in youth, which you certainly don’t have, no one can tell for sure.

(My edit- in the above instance you can take youth to be prior to propecia use).

Back to verbatim quote
Let’s just consider the case of two very different men. One is a high testosterone male who normally averaged between 800ng/dl and 1000ng/dl when he was healthy and young. Now he is fifty, and has suffered a serious hormonal fall. His levels are now between 400ng/dl and 500ng/dl. This is a catastrophe, a 50 percent drop, and he feels every point of it. Now there comes another individual who in the days when he was young and healthy averaged between 400ng/dl and 500ng/dl. He too, has reached his fiftieth year, and his testosterone have also declined. They now average between 300ng/dl and 400ng/dl. The drop is relatively slight, an he notices little change in function. He still feels like a health specimen.

It is relatively easy to make such analysis. Unfortunately, in the real world, the physicians who are treating each of these men, don’t have the earlier numbers, the baseline youthful highs. All the physicians know is that one man has levels between 400ng/dl and 500ng/dl, while the other is between 300ng/dl and 400ng/dl. And surprisingly, the man with the lower level feels much better and reports far fewer symptoms.
Unquote

It is also true in the above that the person with the lower levels would be the one most likely to be diagnosed and treated.

I could go on to cover many, many, many more issues such as lognormal transformations of reference ranges and many other issues but I won’t.

Legenden_1999:

Again nothing new here, just shippens words.

Of course I have used Shippen’s words. But I love the way you phrase that;

Nothing new and just Shippens words.

What about people who have not read Dr Shippens VERY important words on this matter?

I imagine, probably correctly that this is quite a few people.

The logic you are using here is implies I offer nothing, that I am wasting people’s time.

But I haven’t just quoted Shippen like some parrot have I?

I have placed his words and shown I have been quoting him in the context of a wider post that has detailed many factors. Of course I have quoted him because it was relevant and I didn’t need to reinvented the bloody wheel (shakes head).

By logical extension, when someone quotes a source in an exam, or when they do so in a medical white paper or reference etc then it is a waste of time….

I’m sorry but how can I be anything other than frankly irritated by this constant picking away at my post with terrible logic and whole unreasonable attacks?

I don’t think you are playing fair I think you are hurling mud, burning barns etc.

Any bloody fool can sling mud or burn barns….I was hoping that if someone engaged me on the subject that it would be civil and reasonable- this has not been fair and once again highlights to me why I am not posting something so detailed and complex ever again.

I would have welcomed full and frank debate and fair even if tough criticism of my words…but this just feels like open season with Dick Chenney and I’m not in the shooting party if you follow my drift

Hypo-is-here:

I will move onto the subject of replacement.

When you replace testosterone with TRT, or when you try and get your body to produce more testosterone with HCG or Clomid or GnRH etc, how do you know you are reaching the testosterone level that suits you and supported good health prior to propecia?

How do you know if it is too high or too low?

Legenden_1999:

Raise in testosterone caused by Clomid doesn’t really count, cause only very few men will feel better this way. If it was this simple to do TRT, shots and gel would a thing of the past.

Let’s face it you didn’t start this mail to engage in reasoned debate. You just wanted me to be wrong from the outset and have simply proceeded to hurl mud at everything you have seen….very disappointing. But I’ll continue to answer- I have got this far afterall.

First of all I know of some men who do well on Clomid who have not done well on any other form of medication. It is a case of horses for courses. Some men with very particular problems do well on that; others do well on HCG only others with TRT and HCG etc etc. Gels and shots tend to fair well with greater numbers of men with hypogonadism. But like I said earlier that is to compare this select group to a wider group where perhaps comparisons are not apt. Also I can tell you of men who do very badly on gels and or shots. There is no moral right or wrong in this, no perfect medication.

Of course NONE of this has anything to do with the point I raised which was irrespective of chosen med how do you know if in raising testosterone, how do you know if you have reached a level that is suited to you and not to high or too low- without a baseline from prior to propecia use?

This sounds straightforward, but if you are ill it is far from straightforward, because with TRT or endocrine meds and without those baselines you do not know if ill;

Whether that is down to a new elevated estradiol level, or an new elevated SHBG level or too low a level of med and TRT or too high a level of TRT- perhaps in relation to a low SHBG etc etc.

Finding out what might be causing you to be ill can be difficult given the permutations.

This I feel was a more than valid point given the remit of the original question and the context of my post/answer.

You were not being remotely fair yet again.

I would also say to discount Clomid as a medication as you have is wholly unreasonable, I say this in the knowledge that some men have been ill on anything but clomid, where they have recovered their health.

Hypo-is-here:

Either could cause you to not feel well and have the symptoms of post propecia use.

Legenden_1999:

Maybe, but why are ALL us who has tried unsuccessfull, when at least SOME nomal hypogonadal men trying TRT are not.

I have already answered this. Because I believe you are comparing apples with oranges.

HCG, GnRH, Clomiphene, Tamoxifen, Anastrozole etc none of them have any impact on testosterone levels for men with hypogonadism of pre pubertal origin. None of them have any impact on testosterone levels for men with complete testicular failure.

By your logic if we used these inappropriate meds they should raise testosterone levels because they have hypogonadism the same way many other men do, who have andropause or post pubertal secondary issues, or partial testicular failure etc.

But they do not work for these men.

Clearly we have differing meds that only work on certain forms of hypogonadism. Is it such a large step to take to see that propecia use is also often a form of hypogondism- as Shippen said that is difficult to treat? Is it difficult to understand the fact that different treatments maybe required? Difficult to see that maybe it is not as simple as your basic andropasue?

Finasteride IS an anti-androgen after all.

Hypo-is-here:

How do you know, even if you do replace your testosterone to the desired level that you do so in such a way that you do not cause a cascade of knock on effects on other hormones that cause you to feel poorer than you did prior to propecia use?

I mean you could quite easily replicate your testosterone level with a bit of luck, but what happens if this in turn results in a high level of estradiol and a consequently low androgen to estrogen ratio or lower level of free testosterone?

What if you replace your medication results in a high levels of SHBG and a consequently lower level of free testosterone?

What if your DHT level is lower than it was prior to propecia use, or what if its ratio to estradiol is poorer and you have resultant symptoms?

Can you see how complex this are of medicine can be?

Legenden_1999:

Yes but these rules applies ALL on TRT.

Yes and some causes and problems are FAR more complex than others- hence Shippen’s quote.

Also I am not saying that hypogonadism is the ONLY cause of problems. I have answered a specific question as to why TRT can fail and provided very factual answers as to how that can happen. There are plenty of pet theories that do the rounds, but I do not deal in them because it is pointless. Propecia absolutely does cause problems with sex steroids- we know this is a fact. It is an antiandorgen- we know this is a fact. I keep my answers on the straight and narrow of the facts.

If it is revealed that one or more of the following are affected;

thyroid
adrenals
Brain
Liver
Etc

And this is shown to be true factually- then I would read up on those facts, educate myself and have present a more wide ranging factual answer to this questions of this nature.

But I stay with what is proven and if you think I am wrong to do that then I would beg to differ.

Also I must say I have no ownership of the idea that propecia can only cause problems relating to hypogonadism. I welcome any hard evidence that can further this cause and help people here. But until such time, when all that is beyond the facts I have presented is half baked bull shit, theoretical unproven mumbo jumbo….then I feel bound to stick to what is known as that is the only thing that offer people genuine help.

If in a years time someone discovers that there is an element in this that affects X, Y, or Z that doesn’t relate to hypogonadism, it will still not alter the fact that A) many people do end up with hypogonadism from propecia use- fact! And B) you will not be able to say I told you so……because I am not disagreeing (how could anyone disagree with the potential unknown o a negative) or have a problem with anything factual being brought to the fore. I am simply basing everything on the facts at this current time as they are known.

Legenden_1999:

Let me hear your thoughts, and no need to do it short for my sake.
JH

You have been very unfair.

This is precelily why I am not making any more posts of this nature. You try to help but you end up in a stockade with shit being hurled at you.

The more you say the more people have a field day- irrespective of the legitimacy of anything you then end up fighting fires, trying to extricate yourself out of the mire etc.

A total waste of my time and efforts….really miffed.

Jim1234 · May 25, 2018, 5:46am

A total waste of my time and efforts….really miffed. Oh Poppycock, lol

Seriously what do you do for work ? These posts you write must take hours to come up with unless you have them saved in a file for repeat use.

So what exactly is your medical training ?

How did you work with Shippen on a patient ? Please explain because without a Hippa form it can’t be done and since your overseas i would think Shippen would have even more doubts. I never have heard of a Dr working with someone who is not a Dr on a patient

Since you work with Shippen can I email him and ask about you to see if your legit ?

Mew · May 25, 2018, 5:46am

Ok this is getting ridiculous guys, enough of the back and forth already.

What I’d prefer to see is us reading through the studies that have been posted in the Finasteride/Other Studies section and try and understand how Finasteride may have caused problems, since its mechanisms of action are well-documented there.

But this constant back and forth about Dr Shippen says this, I don’t believe you on that, etc is just a waste of time and energy. Hypo your insights are appreciated, perhaps it is best to steer clear of these debates and simply look at the facts that are presented – ie, the Studies and members’ blood tests, drugs that might kickstart the HPTA etc… any insights into how Finasteride caused problems or can be rectified are fine by me.

Otherwise if this goes on and gets nasty I may have to lock this thread… don’t want to do that though. We’re all in the same boat here, COME ON! Stop acting like kids and work together.

Hypo-is-here · May 25, 2018, 5:46am

I think I have been very reasonable considering- at any rate I am out of this debate.

What has been well demonstrated is you can’t post something in-depth and detailed given the nature of such forums- a shame.

P.S

Unlike many of the studies what I was relating was factual and relevant. Many of the studies lack relevance…studies on rats, unknown levels of finasteride etc etc. But there is no point in me trying to cast light with anything complex as it just doesn’t work.

Jim1234 · May 25, 2018, 5:46am

Mew,

Just let Hypo answer my questions. I’m sure many want to know how he was able to get a Dr to work with him as a consultant for another patient.

I’d also like to know his medical background as I’m sure many would.

J89 · May 25, 2018, 5:46am

Hypo Im not sure what it is you want us to say? I can only comment on myself here and I understand what your saying in your posts and ive replied to them to best of my knowledge. If that knowledge is limited in comparison to yours then I am sorry.

I think sometimes your confusing constructive criticism for someone trying to have a go at you. We are not having a go at you, if we think somthing doesnt sound right we will ask why?

Its good that you post in such detail and I hope you continue to do so in the future. It is important for the new guys to read this stuff and its also informative to see it put in a different way for those who have read about simlar theories already. I almost always get somthing out of your posts, so keep posting. A few may be sitting back a little because they are not as knowledgable as others on these subjects too.

So the meat and potatoes of what your saying is that this is or can be a very complex form of hypogonadism that is very difficult to treat. Can you tell us how we would go about treating it? If we cant rely on baseline levels and considering most have not got them, is it a case of trial and error to see if we can get a balance back?

Legenden_1999 · May 25, 2018, 5:46am

Hypo, my post was not ment as an attack on you. I think you have made a valid point, but I still don’t see any proof. Just like I myself don’t have any prove that there is more to this than proper TRT.

I speak only for myself when commenting, but we can easily agree shippen words is worth reading for all of us. I never intended to belittle them.

Im not sure why you took my post as critisism, when I was just writing down my impressions from your post. Afterall, you wanted people to focus on your original reply, right?

Im in another forum with many hypopituitary men, and most of them seems to do well on basic TRT. I still do not understand why you think it should be so complicated for us to get at least some improvement with TRT, when you yourself compare us to other men with secondary hypogonadism.

JH

Hypo-is-here · May 25, 2018, 5:46am

I’m not debating this further; as I don’t feel it is helpful for anyone. People can view the original post and what has been written subsequently and glean from it what they will. I felt I was fire fighting, constantly having to reference a side issue and ultimately being pelted with unfair remarks. I would have welcomed mature reasoned criticism or questioning, there was some of that but it was too thin on the ground. I don’t think it is worth anyone’s while trying to offer something substantial in the way of detailed information of this type, because they are going to come in for unfair treatment.

The more you write the more people have to throw at you.

I realize people feel that the questioning was not sniping, as some one on the end of it I have to disagree- sorry.

Nothing to do with the debate but putting something people may wish to know;

For all those that have metabolic hypogonadism via elevated SHBG levels;

Adding TRT and increasing testosterone is not likely to help.

Further increases in testosterone are just likely to be bound in the blood by SHBG. That is one major way in which TRT can fail to work for some.

If someone with elevated SHBG just throws testosterone into the equation it is not likely to help.

Conversely if SHBG is too low then throwing TRT at the problem is likely to result in large increase in free testosterone, but also free estradiol. Free estardiol is not measured anywhere, but trust me in that it is as important as free testosterone. Low SHBG and high levels of TRT can mean that you end up with estrogenic effects such as gynecomastia even when serum estradiol doesn’t seem high (due to amplification of the hormone).

People can take the above on board or disagree I will not comment further either way.

Regarding how I have “got a Dr to work with me”, I have done this on a number of occasions via correspondence and/or phone calls where the Dr concerned has accepted layman support/representation on behalf of the patient. I have only acted in a layman’s capacity, but I have detailed what I see as potential problems which the Dr can decide to take onboard or choose to ignore. I have even disagreed with multiple consultant endocrinologists on behalf of one patient (one on the phone), got them to fire the endocrinologists concerned, got them to get a new consultation hundreds of miles away and then wrote a letter that the patient could present to the new andrologist.

I suggested a medication that might be helpful, the andrologist accepted or at least, just happened to go with the same medication as I suggested and the individual returned to full health.

I have done these things many times in the setting of hypogonadim but have more limited experience with Propecia. The one mentioned above was a Propecia patient.

Can I get success like that again for someone with Propecia based problems or was that a one off, I don’t honestly know. My reason for coming to this site was not to muck about posting theory, but to see if I could make any difference in helping people. If I can that, then that would be great. If I can’t then at least it won’t be through a lack of effort.

So I am staying out of debates or posting explanations from now on and will see if I can offer anything in the way of help for individual situations.

P.S

I may have limited time over the coming weeks but I will help anyone I can where I can…I can’t promise I’ll make a difference- perhaps I will be no help at all- but I will stick at it and give it a go.

Jim1234 · May 25, 2018, 5:46am

Well You still didn;t answer the question regarding your medical training or the HIPA forms required for a Dr to discuss another patient with ANYONE !

I’ll drop it as some of these guys think you can help them. I myself have major doubts about what you say and a “little birdy” told me all your doing is quoting medical literature and adding your own theories. By the way the “birdie” is a Endo who specializes in HYPOG and read your posts

Hypo-is-here · May 25, 2018, 5:46am

Jim,

I was responding to an earlier posts that related to what was being discussed and focusing on that, that is why I only answered a little of your question. If you feel I haven’t justified myself (not that I am sure I should have to) properly then I apologise.

You want to scrutinize who I am- absolutely fine with me.

All I would ask is;

Couldn’t you do that in a nice way and not start out by casting aspersions upon my character and hurling mud at my reputation.

I presume that is a fair request?

If you want you can pass me your endocrinologists phone number and I will call him and discuss the endocrinology of hypogonadism with him in detail in real time and answer any reasonable question your friend wishes to ask. That way you can at least be satisfied that I am not cutting and pasting bits of half baked research.

If your friend exists and is an endocrinologist he is wrong in saying what he has to you about me. If he comes off the phone thinking or saying anything unreasonable then we can set-up a second call that can be recorded via speaker phone that I will put on the net and link it to this site and people can hear for themselves if I know what I am talking about- ok!

I presume that would satisfy you and your friend and stop you from making unfounded allegations and casting unfounded aspersions?

Note:

I guarantee that you will not find any similar posting to those I have made anywhere on the internet (excluding the quotes that I have referenced- note not plagiarized).

I know this because I took an exorbitant amount of time collating my thoughts and composing my posts so that I could help people.

Seems to me I am being called into question by you precisely because my posts are so detailed. You presume that they must be cobbled together or on file…wrong on both counts. You hint at a criticism along the lines of if they are real that they must take a lot of time up etc

Seems to me like you just want attack me no matter what…

What message does this send out to anyone in future even thinking of sharing any detailed knowledge here?

Why is anyone going to want to put up their ass on the line when they know they will just get pelted with aspersions and abuse?

The other points you made…

As for working with Dr Shippen, please show me where I said I worked with Dr Shippen?

I said that I detailed information for Dr Shippen and got a patient to him.

In point of fact I detailed what problems this patient had a year or so before he saw Dr Shippen. I identified hypogonadal problems via pathology and symptomatology (but told him he required confirmation of this as I was only an educated lay person). I then spoke on his behalf to a Canadian endocrinologist who said that his patient did not have any androgen issues. He also had another endocrinologist who also said he did not have androgen issues. I felt these endocrinologists were both wrong and wrote a letter for him to present to an andrologist in Canada (who incidentally thought I was an andrologist from the letter- such is my extensive knowledge on this subject).

This andrologist wasn’t particularly great either and again couldn’t help this person.

I then stated that I felt the only when this individual was going to get the help I felt was required- namely Danazol to reduce SHBG and increase free testosterone was by going to see Dr Shippen. He then did this and showed my letter to Dr Shippen.

Dr Shippen thought that this person had androgen related issues, but he was not sure if Danazol was the right answer (the one I had suggested a year earlier). Dr Shippen tried various methods to sort this individual’s health out and settled with trying Danazol. The Danazol lowered this persons SHBG and increased free testosterone. It then resolved the patient’s symptoms and Dr Shippen has subsequently told him that he may require Danazol for life.

That is the factual account. Hopefully that helps you understand what happened.

So I got the guy help where two endocrinologists and an andrologists had failed. Not only that but he would not have even pursued these matters any further if I had not had correspondence with him to help him through this difficult time- posting for many, many months. His family thought he had psychiatric problems and his brother had told him to forget seeing doctors and talking to people on the internet because it was all in his head.

I do not say any of the above to look good. I am saying it because you are calling me into question when I have busted my balls to help people and get them genuine help.

I know I have made a huge difference here and with many, many other people regarding hypogonadal issues.

I was a member of the site below for over two years and this is the posting from when I left.

gynecomastia.org/smf/index.p … 889.0.html

Please view and go and post on that site and ask people what they thought of me.

Ask them if I helped anyone.

In fact if you only ask one question on that site go and ask that specific question.

I helped hundred, maybe thousands of people at that site for two years with little regard for my own time.

Go and do a search and read my posts as well- check me out see if I am a charlatan.

Answering your other points;

Please show me where I claimed to have a medical background or replaced the work of competent andrologist (even if I do as near dam as diagnose people and just get it confirmed by endos and andrologists a lot of the time) ?

Go back and read what I actually wrote.

As for speaking on behalf of patients;

The fact is the Canadian and UK endocrinologists I have spoken to on the phone had no problem whatsoever talking to me once they had been given verbal permission by their patients. Endocrinologists elsewhere have had no problem accepting letters written by me on their behalf. I must say I have never run into the problems you have spoken of.

So much so that I am not even aware of the need for these forms, If red tape had of got in the way and I had run into such a problem then I would be aware of it. As a lay person that has not run into this red tape I am not aware of it.

I hope this answers a lot.

I will answer any other question you may have if reasonable, but please can we both speak more calmly and nicely to one another from now on in (I’ll try to).

P.S

Please pm me your endocrinologists number once you have permission for me to phone him.