ODP600 Is this a case of surreptitious hormonal supplements?

BACKGROUND: Hypogonadism in males results when there is either a failure of the testes to produce testosterone, hypothalamic or pituitary dysfunction. Although testosterone supplementation is used for documented hypogonadism, it has become widely abused, with a variety of false claims for promoting energy, virility, and muscular development, as well as enhanced athletic performance. We present a case of surreptitious abuse. CLINICAL CASE: A 63-year-old male with coronary artery disease, was initially consulted to endocrinology for evaluation of Graves’ disease with ophthalmopathy. He was treated with methimazole 5 mg daily. However, on subsequent visits, he requested measurement of testosterone levels. Laboratory tests showed FSH<0.2 mIU/ml (0.7-10.8); LH<0.2 mIU/ml; free testosterone 3050 pg/ml (35-155); total testosterone 7377 ng/DL (250-1100); prolactin 9.6 ng/ml; Hgb 14.7 g/dL (13. -17); HCT 45.5% (40-51); TSH 1.94 uIU/ml (0.358-3,74); Free T4 0.74 ng/dL (0.76-1.46); Free T3 2.60 pg/ml (2.82-3.98). When confronted with these values, he admitted that due to interest in building muscle mass and energy, for lifting weights, he was taking hormone and protein supplements ordered from an internet program. These therapies were claimed to enhance muscle mass and energy, increase testosterone and lower estrogen. He did not have blood tests for over 6 months, and it was not clear who monitored this plan. He was taking testosterone 400 mg injections of testosterone cypionate and proprionate twice weekly, as well as another form of oral testosterone, which amounted to more than double the total dose required to treat hypogonadism in 1 week. He was counseled about the risks of taking excess testosterone, for which he had no prior knowledge (including CAD, cardiomyopathy, erythrocytosis, coagulation abnormalities, major mood disorder, gynecomastia, increased risk for prostate cancer), and also that it is unclear whether he even had hypogonadism. He agreed to stop taking these supplements. Four months later, he reported slightly less energy, but he was not exercising due to back pain, and no other changes. Laboratory tests: Total testosterone 572 ng/dL, Free Testosterone 74.6, LH 3. 0 mIU/ml; FSH =3.4 mIu/ml (8-10.8). DISCUSSION AND CONCLUSION: Although hyperthyroidism can cause an increase in total testosterone via an increase in hepatic synthesis of SHBG, the free level is normal. Abnormally high testosterone levels in men are most commonly due to anabolic steroids taken to increase muscle mass and enhance athletic performance. It is also important to evaluate for other causes, such as adrenal or testicular tumors. This case is an example of a patient innocently taking unregulated and hazardous hormonal supplements for false claims, which may result in abnormal hormonal laboratory results, and lead to unnecessary and expensive evaluations. Therefore, it is important to take a good medication history, and to query abnormal lab results at each outpatient visit. Presentation: No date and time listed