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Man - 21 - High prolactin levels?
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Man - 21 - High prolactin levels?

Hello
I am a 21 year old man.
I had erectile dysfunction and terribly low libido for 5 years. (no more morning erections :(, half-solid erections)
I recently decided to go to a urologist to check what is wrong.
He ordered testosterone and prolactin dosing.
Results:
Prolactin 21.67ng/mL (normal<18 in men) but shouldn't it be around 8 at my age?
Total Testosterone: 521 (normal between 100something-1000something) but shouldn't it be around 670-700 at my age?
Therefore I have 2 questions:
1- Do I have a hyperprolactinemia? If so, is a microadenoma of the pituitary possible? (remember it's been 5 years now)
2- Are such levels of prolactin and testosterone in a 21 year old man responsible for all these symptoms?

Thank you and happy new year
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Avatar_n_tn
Hello,
     First of all, you should get the answers to your questions from a doctor only. However, I will give you the answers, I think are correct. I am also interested to know what your Urologist told you about the test results, please let us know about it.

1." Do I have a hyperprolactinemia? If so, is a microadenoma of the pituitary possible? (remember it's been 5 years now) "

Do you have any symptoms of  head ache or mental confusion ? Five years is quite Ok, it seems there are cases of microadenoma not being detected for life and found out only during an autopsy. In any case, I would think you need to do further follow up tests like evaluation of  other pituitary hormones like TSH, LH, FSH etc. to find out where they stand. You will also need to do an MRI to find out if there is any microadenoma and get treated if it is there.  May be, you need to also consult a Neurologist or an Endocrinologist for these evaluations, if advised by your Urologist.

2- " Are such levels of prolactin and testosterone in a 21 year old man responsible for all these symptoms? "
Yes, with prolactin level I would think so, but the T level looks quite Ok to me.

3. " Total Testosterone: 521 ( normal between 100something - 1000 something ) but shouldn't it be around 670-700 at my age? "

I would think 521 as a good level.

Good luck,
Solace


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Avatar_m_tn
Thank you for your kind reply.
In fact, I am a med student so I truly know my endocrinology well.
What puzzles me is that my urologist says my troubles are only psychogenic! (hey! 5 years man!) But he mentioned that he's generally used to see men with very high prolactin levels so I'd better go check with an endocrinologist. (he's not used to treat men with borderline levels)
According to many sources, prolactin >20ng/mL in a man is dubbed hyperprolactinemia, mild prolactinemia. Prolactin lowers testosterone secretion but my levels of PRL are not that high (but may have caused a small reduction in T levels from 650+ to 521?)
Moreover, IF i do have HPRL, it can't be due to a macroadenoma. (usually leads to very high levels of PRL), I don't take medications. I have no liver or renal insufficiency.
hmmmmm what's left? hyperstrogenemia? (where will this come from?) primary hypothyroidism? (hmmm I have no flagrant hypothyroidism syndrome) microadenoma? (5 years on and it's still at 21.67ng/mL?)
I'm quite stunned.
You sure PRL at 21.67ng/mL causes trouble?
I need to find an organic cause for this erectile dysfunction. Can't be psychogenic!
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Avatar_n_tn
Hello,
  
Wish you a happy,prosperous and healthy New year.  
  
Nice to know that you are from the medical field, I would request you to share your knowledge here to help others in need.
I also can not buy the idea of psychogenic theory, there must be definite physiological factors behind. By the way, does the medical community believe that the Testosterone  level of a healthy youngster like you should necessarily be of the order of 700 ?, as far as I could understand, anywhere within the range should be acceptable so long as one does not suffer from any related health problems, mainly sexual health. As I understand, the graph of the T range is supposed to represent healthy twenty year old guys  covering a large population and geographical base and not the age factor. I can give you some medical links confirming my belief, please let me have your views about it.
I am sure, you would know more about the interaction of the hormones, but still why don't you take an MRI and rule out any possibility of any benign macroadenoma ?. As  I have already mentioned, some times they even go unnoticed and are detected only when tests are done for some other problems.

" You sure PRL at 21.67ng/mL causes trouble? "
Yes, that is what I think ( I am not from the medical field), please enlighten me if I am wrong.

" I need to find an organic cause for this erectile dysfunction "

  What ever you find in this connection, please come back let us know as it would help many youngsters who visit this site with such problems.

Good luck,
Solace
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Avatar_m_tn
Hello again
Actually, we, med students, learning endocrinology in books, don't have clinical experience like good endocrinologists do. Therefore, I'm only able to talk confidently about clearly elevated values of prolactin (35+ng/mL) and their effect on sexual function.
Problem with testosterone is that normal lab values cover a big big range going from around 100 to 1000. We never really got into this hassle and age-corrected advised values. I can't easily find scientific proof to what I'm saying in my endocrinology books but some websites (even though not that trustworthy) claim that testosterone levels in a 21 year old man should go far beyond 600 and that below 400 (even though 400 is "normal" according to lab) starts hormonal hell.
Here are some links to support what I am saying:
http://www.peaktestosterone.com/Testosterone_Levels_Male.aspx

http://www.mens-hormonal-health.com/normal-testosterone-levels.html
According to this link, I have the levels of a 65 year old man. hmmmm? prolactin effect? or is it, again, "normal"?

Besides, let me clarify something. A macroadenoma secreting prolactin is a >1cm benign tumor of the pituitary and it generally causes mass effect (sight problems and headache) as well as other deficiencies in general. In addition to these local symptoms, a MACROadenoma secretes a hell lot of prolactin with blood levels way beyond 200.
Thus, I cannot have a MACROadenoma.

Other things which can cause elevated blood prolactin levels are:
1- stress (puncture of the vein to draw blood as well as anxiety can elevate PRL levels)
2- exercise
3- primary hypothyroidism (marked by high TSH and low Free T4 as well as symptoms like face puffiness, fatigue, constipation, hypercholesterolemia, slow heart rate etc)
4- renal insufficiency (high creatinine and BUN)
5- liver failure (high ALAT and ASAT)
6- a lot of drugs
7- a MICROadenoma of the pituitary (1cm benign tumor of the pituitary and it generally causes mass effect (sight problems and headache) as well as other deficiencies in general. In addition to these local symptoms, a MACROadenoma secretes a hell lot of prolactin with blood levels way beyond 200.
Thus, I cannot have a MACROadenoma.

Other things which can cause elevated blood prolactin levels are:
1- stress (puncture of the vein to draw blood as well as anxiety can elevate PRL levels)
2- exercise
3- primary hypothyroidism (marked by high TSH and low Free T4 as well as symptoms like face puffiness, fatigue, constipation, hypercholesterolemia, slow heart rate etc)
4- renal insufficiency (high creatinine and BUN)
5- liver failure (high ALAT and ASAT)
6- a lot of drugs
7- a MICROadenoma of the pituitary (<1cm), secretes less PRL than a MACROadenoma.

My PRL level is bordeline. According to some website (and to common sense), I have a "mild" hyperprolactinemia. Can this slight elevation of PRL wreak havoc and shut everything off for 5 years? Hmmm
I do not take medications. I do not have kidney or liver problems. I cannot have a macroadenoma. I wasn't exercising before drawing blood.
I'm left with stress-induced hyperPRL or the hypothesis of a very small microadenoma.
I guess this needs to be reconfirmed with a new blood test.
I want to find an organic cause so badly. If I'm stuck with the "psychogenic" theory, I can't do much I fear. I cannot agree with my urologist. When you lose your morning erections, there must be something wrong. That can't be emotion-related only.

I will go ask my endocrinologist about all this. He's a legend and will surely know if that's the source of all this trouble.
Yet, isn't there anyone around here, who's had similar levels of prolactin and almost "normal" testosterone levels, but still had erectile dysfunction?

Prolactin acts this way:
When it goes up, it alters the normally pulsatile secretion of GnRH (LHRH) in the hypothalamus, therefore affecting the also-pulsatile secretion of LH and FSH, which will result in low testosterone levels.
When one's got a MACROadenoma secreting prolactin, his very high levels of prolactin will practically take his testosterone levels down to 150-200, which is quite logical, and cause hypogonadism.

The association between slightly elevated prolactin and "normal" testosterone (in the 400-500-600) + erectile dysfunction is possible, as far as I understand. I'm only sure of PRL beyond 35ng/mL.
In such cases, giving extra testosterone will not ameliorate the condition. PRL levels need to be taken down.

In addition to all this, prolactin has got a direct central effect on brain neurotransmitters and circuitry, altering erection and libido even more. That's why, perhaps in men with PRL beyond 25 and testosterone around 500, you can still have erection problems.

All my problem rises from the "borderline" prolactin value. I hope it's not stress-related. I need to find something wrong to hold on to and correct.

Sorry for the long post.
Glad to share with the community.
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Avatar_m_tn
Oops I wrote something wrong in (7) about the microadenoma. It is less than 1cm large and secretes way lower PRL quantities than a macroadenoma. Mass effect doesn't generally exist.
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Avatar_n_tn
Hello,
      You are right about the effect of prolactin, slightly over the normal range appears not to affect much, only macroadenoma  (>1cm) secreting high values of prolactin is said to affect libido and its mass effect is supposed to be more of a problem both on pituitary and on optic nerves. In any case, please let me know regarding the views of your Endo.

As far as I could make out from most of the medical sites, the full range of testosterone is applicable to youngsters like you, and the range is given to cover large population base and geographical areas. There is a separate age adjusted graph given to include the age factor. For example, have a look at the graph B given in the following article for age related adjustment of the T reference range :

http://www.andrologyjournal.org/cgi/reprint/29/6/610

Or, have a look at the age related reference range specified by Mayoclinic :

http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/83686

Again what really matters is free T and bio available T and not the total T value.

Now, leaving prolactin effect  for the time being, what about your levels of adrenal hormones, are you sure they are Ok? If you are not sure, you should check them also.

Hoping to get more feed back from you,

Solace  
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Avatar_m_tn
I will go to my endocrinologist in the upcoming 2 weeks and let you know what happens. Fingers crossed it's prolactin. I don't wanna end up with "everything is normal" answers :/
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Avatar_f_tn
I have a 2 cm non functional pituitary tumor. I am a female but at age 18 it caused slight elevation in my testosterone levels. Produced small amounts of breastmilk from then on out except when pregnant (on #4). Was diagnosed with the macroadenoma at current age of 25. My prolactin levels were very slightly out of normal range and my cycle had stopped. Thus the MRI was ordered with contrast to check into pituitary issues. Without my cycle stopping I didn't have much else for signs. Maybe a slight decrease in sexual activities. So for a man I would assume a non functional tumor would be hard to locate without symptoms of mass effect I hear so much of.
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Avatar_n_tn
Hello,
  
" So for a man I would assume a non functional tumor would be hard to locate without symptoms of mass effect I hear so much of. "

Madam, you are absolutely right about your assumptions. Here is a medical link that confirms your assumption :

http://neurosurgery.ucla.edu/body.cfm?id=1123&ref=86&action=detail

So, how did you go about the treatment process ?

Solace
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Avatar_m_tn
Hello what were your prolactin levels then?
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Avatar_m_tn
Sorry question to JaneRae and not solace21.
PS: correction "back then*" instead of "then"
Thank you
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Avatar_f_tn
I have not done anything for treatment aside from taking cabergoline for a couple of months to control the hormones. We conceived our 4th child and soon after that birth I have another MRI and consult scheduled.

I really don't recall numbers. When I was 18 prolactin was never brought up. At current age they told me but all I can remember is they said it was just out of normal range. I had just given birth to our 3rd child whom passed away and that level could have been elevated because of the birth. Or it could have been an effect of the compression on the stalk.
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Avatar_f_tn
I am a 48 yr old female and when I ran across your post I was looking for something else, but if you don’t mind I will put my 2 cents in. I have been dealing with a high prolactin count since I was approx 24 yrs old. Signs may have shown up earlier but birth control can mask symptoms. Being a med student and doing your homework is great but let me warn you that this can also mislead you. I have a cousin that also has high prolactin and neither of us follow the “rules”. You had asked “hmmmm what’s left”, well I have Empty Sella Turcica. I was finally diagnosed 8 months ago. The main thing that I would like to say is that your high prolactin count can & will wreak havoc on your whole system.( Maybe YOUR body needs to be below 10ng to function properly) One of my biggest complaints to the many doctors that I saw over the years was that my libido was GONE, not just low but gone. I saw an Endocrinologist for the first time last year when my count was at 324, more than 10 times what it should be. He ordered an MRI and told me that he expected the results to be a Prolactinoma of approximately 5cm.( I had an MRI 15 yrs ago and it didn’t reveal anything) It came back this time with a diagnosis of Empty Sella Turcica & I was put on Cabergoline. My count dropped to 48 by September (still high but I have not had it come back that low since it started being monitored) and shortly after that my libido woke up!!  I can also tell that my other hormone levels are returning to normal. I feel disgusted with all of the doctors that I saw over the years when I think back about the lack of concern and the easy fix to get this under control. I was told by one doctor that I likely have a high count because my “husband was probably a breast man”. I was given HRT (hormone replacement therapy) for my early menopause symptoms and it was hinted that my lack of libido was stress or other life issues.

For me, while my prolactin continued to rise over time (my first prolactin count check it was at 55), my estrogen & progesterone stayed on the low side of normal. Because I didn’t have a pituitary tumor I was not having symptoms of headaches and vision problems. For my cousin (also female), her count NEVER went above 38 and yet it caused her reproductive system to basically shut down and she also has to take thyroid medication. She suffered with terrible headaches long before a tumor could be seen with an MRI. She now has a 2cm pituitary tumor.
Get an MRI & get your prolactin down to normal. I would love to hear everything just “wakes up” after 5 yrs of essentially being asleep.
Good Luck!
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Avatar_m_tn
Hello again,
Nice to hear from you all, especially Memphis483 :)
I'm surely gonna try my best to find an organic cause for the problem I have (low libido + ED). It's basically, like you said, ALMOST shut down. But my problem is the fact that my testosterone levels are "normal" (?) and prolactin MILDLY elevated. Therefore it needs an experienced endocrinologist.
I'm gonna see my endocrinologist (this dr is a legend, if he can't help i'm doomed) on monday :)
Fingers crossed Prolactin is the culprit!
Cheers
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Avatar_f_tn
I realized that with all the words that I posted earlier I really didn’t state what I meant to get across. This is simple “Cause & Effect”. Your prolactin is high. Maybe by medical standards, it is only slightly elevated but realistically is should be closer to 9 than 21, right? That means that it is likely >twice what it should be & this is definitely a problem. If ones prolactin is high then the effect is that your testosterone levels (in men, estrogen & progesterone in women) WILL be reduced. Now, that may still be within “normal” range (like my hormone levels) but that means that YOUR testosterone has been reduced and so 521 is certainly NOT your normal. (Maybe someone elses normal, but not yours) This is where the medical community fails us most, lumping us all into a box of normal or outside of normal. Just because one person functions perfectly with a 521 level doesn’t mean you will. ….as a matter of fact, you aren’t, right? So, now you & your Endo will just have to figure out what your Pituitary is trying to tell you :)
I do have a question for you, not to pry…but since I am fortunate to have a cousin that has many of the same issues, we talk. I recently found out that both of us have a few symptoms that are not listed anywhere as being a side effect of having high prolactin. We both stay tired, for me it’s not like I don’t function; I just never feel rested & have been that way since my teens. We both also struggle with constipation.  Also, have you ever had a head injury, even a minor one? I had a wreck on a motorcycle when I was 15 and had a minor concussion. I also fell and hit my head when I was 22, this wasn’t serious but I did hit pretty hard. I guess I will always wonder if either accident was the cause of my empty sella, now my pituitary is displaced by cerebral spinal fluid.
Make sure you post what your Endo has to say! You might think about calling your Endo a week or 2 before your appointment & ask if there will be any new or additional blood work that Dr. will want. You can possibly have that done before the appointment so that you will be able to discuss the results while you are there.  Again, Good Luck!
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Avatar_m_tn
Hello again,
I have some news. I went to my endocrinologist. He's like the god of endocrinology in my country.
Told him the story and mentioned that I've been to a urologist who downplayed my assumptions, yet still asked for Total testosterone and Prolactin tests in order to make me sleep on my laurels.
My endocrinologist said my prolactin level of 21.67 is in the normal range (:S) because prolactin has its ups and downs during the day and only a value of 40+ in a man should be considered elevated (:S).
My testosterone level (521) is normal according to him too.
He palpated my thyroid and said oh you have a goiter. Let's check your thyroid numbers.
TSH normal FT4 normal Anti-TPO negative
I am not hypothyroid. My endo is abroad now. I'll get back to him on february 7th to show him the results of my thyroid lab tests.
This, I fear, puts a dagger in my THIS IS ORGANIC theory :S
I fear I don't have the courage to push my endocrinologist into further investigations since I idolize him and trust him blindly.
Help?
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Avatar_m_tn
Hello?
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Avatar_n_tn
Hello,
     Thanks for your feed back.May be in this case, you may also have a look at your free T level and estrogen level and if you find them also within range, leave your hormone hunt to rest. Other things you have to worry about are the quality of food you take, does it contain adequate protein and trace elements like zinc, magnesium etc. and if you have any circulatory problem. If you think you are comfortable on this front also, better stop worrying and be happy.

Solace  
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Avatar_m_tn
I am 21 so no circulatory problems (due to diabetes mellitus for instance). I eat healthy food and don't think I have any kind of trace element deficiency. And concerning the hormone hunt, I really can't find a reason which would explain me having low free T (therefore high SHBG) or abnormal estrogen levels. I have a question. Do drs count on the erectile dysfunction description to classify it or do they all look the same? I mean not being able to have an erection at all when wanting to have one is something; and having a semi-solid erection whenever you want it is something else; add to that the continuous or intermittent loss of morning wood etc. Does for instance hormone-related ED have a specific profile compared to let's say psychogenic ED? This is truly mindboggling.
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Avatar_n_tn
Hi,
" Do drs count on the erectile dysfunction description to classify it or do they all look the same? "
Yah, I suppose they consider the two cases as different, as otherwise a differential diagnosis will not be possible. For instance, if one does not have the desire factor, it would be due to low free T or other hormonal imbalance and if one has the desire factor but inability to perform, it could be mostly due to a circulatory problems - like venous leakage, arterial blood flow problems etc. Again, inability to maintain may be mostly due some psychological factors.

By the way, why don't you have a check up of your free T ans estrogen levels? Are you obese or lean type, are you very sure about your liver functions? Also, what about your Vit D and zinc levels? These are some of the questions you have to confirm, and most preferably by tests and not intuition.

solace
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Avatar_f_tn
Did your Endo run his own blood work on you & have your prolactin tested again? Values for prolactin are actually determined by the individual lab, i.e. one lab might say normal values are 4.8-23.3 where another lab might say 3.5-24.3. I am quoting those numbers because that is what is on MY lab reports from the labs that I have had blood work sent & I am a female (there is a statistical reason for these variances). At the different labs that my blood work has been sent, Endo's quote of 40+ would be high for a female!! And, 21.67 is at the very high side of normal for a female...you are a male..? My 22 yr old daughter had her prolactin tested last year & it was 13. I know you don't want to hear this since you really like the Endo, but get another opinion. You need blood work done 1st thing in the morning. This will give true high value. I was given the same type of dismissal for my prolactin and 15 yrs LATER I am finally getting treatment. 21.67 is too high for a male. You may have to insist that another blood test be run and arrange for it to be drawn as early in the day as possible & then get a copy of the lab results. I am still betting this is the answer to your ED. At your age, ED should not be a problem.  
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Avatar_f_tn
Look at the chart on this webpage, about half way down the screen.
"Typical Prolactin Values"
According to your Dr. your prolactin level being above that of a 1st trimester pregnant woman is "normal". Well, my level is "normal" too...for a 2nd trimester pregnant woman:)
I just don't buy it. If you were my son, I would make sure you had your blood work run again & got a second opinion.
http://en.wikipedia.org/wiki/Prolactin
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Avatar_m_tn
Thank you for your support. It is scary indeed if endos misinterpret bordeline sexual hormone and prolactin values. Any idea if a testosterone of  521 is normal at the age of 21? Will it lead to any kind of ED? Problem is my endo was so confident that my numbers are normal. He said PRL levels waver during the day and showed me a graph inside an endo book, claiming that you cannot talk about high PRL in a man below a 40+ threshold because of these natural daily ups and downs. Do you know anybody who had a mild hyperprolactinemia (20-35) with a clear ED? Thanks
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Avatar_f_tn
Sorry, I have no idea about male T levels & the effects on libido. I just know that if any of your numbers are borderline it is very difficult to get a Dr. to listen to you. I got the ole pat on the back "everything looks good, why don't you come back in 6 months and we will see how you are doing"....year after year & Dr. after Dr. Even when my levels were over 100 I was just told that I needed to come in more often and have it monitored closely. In the mean time, I went from having a fantastic sex life with my husband to just slowly losing interest, then all interest was gone. My periods got further apart & then just stopped sending me into early menopause. I felt like I couldn't pay someone to care about what was going on. The difference is, being a female, let's face it, I could still have sex, while a male will eventually not be able to.
I will agree with your Endo that prolactin will be at different levels at different times of the day. But if he didn't take blood how does he know that 21 isn't your low for the day & it may go up as high as 45 in the morning?
When I tried Googling hyperprolactinemia in males, I did see where T levels could be normal & mildly high levels of prolactin would cause ED. My understanding of the way prolactin works naturally in males is (correct me if I am wrong) after a man has an orgasm his prolactin levels rise for at least 20-30 minutes, this small elevation is what prevents a man from being able to immediately get another erection even though the desire is there. After the levels go down to normal & that can take a while for some men, a second erection can be achieved. This is why the medicine that I am on, Cabergoline is sold on the black market as a sex drug. It inhibits prolactin so that a man can perform quicker.
It is so much easier if your levels were crazy high where you didn't have to worry about whether you fit the text book cases or not.
Again, get another blood test, make sure it is early in the morning. Go to your regular Dr if you need. Make the appt to just have blood drawn & to go back & discuss it with him in a week or however long it takes to get the blood work back. If your Endo is going to wait until your levels reach 40+, you might need avoid getting into a sexual relationship....
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Avatar_f_tn
Read this. Maybe it will help. Don't try the vitamin b & zinc until you have had your blood work retested. You don't want to temporarily mask an underlying problem. If blood work comes back borderline again. I would start on high doses of the vitamins.

http://www.menshealthinstitute.org/2011/01/06/male-enhancement-how-to-reduce-recovery-time/
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