Unveiling the Hormonal Riddle in Michael

December 21, 2023by Dr. S. F. Czar0

Patient: Michael, a 45-year-old male, presented with a year-long history of declining libido, erectile dysfunction, fatigue, and decreased muscle mass. He reported difficulty concentrating, frequent mood swings, and reduced enjoyment of previously loved activities – Hormonal Riddle

Medical History:

Michael was generally healthy with no significant past medical conditions or surgeries. He admitted to moderate alcohol consumption and occasional recreational drug use but denied tobacco use. His family history revealed his father had low testosterone levels treated with replacement therapy.

Physical Examination:

Physical examination revealed reduced muscle mass, decreased testicular size, and no evidence of gynecomastia.

Laboratory Investigations:

  • Testosterone: 220 ng/dL (reference range: 300-800 ng/dL)
  • Estradiol: 30 pg/mL (reference range: 30-40 pg/mL)
  • Follicle-stimulating hormone (FSH): 12 mIU/mL (reference range: 1.5-12 mIU/mL)
  • Luteinizing hormone (LH): 10 mIU/mL (reference range: 1.5-9 mIU/mL)
  • Androstenedione: 180 ng/dL (reference range: 140-220 ng/dL)
  • Prolactin: 15 mIU/mL (reference range: 4-15 mIU/mL)
  • Thyroid function tests: Normal


Based on the clinical presentation, physical examination, and laboratory findings, Michael was diagnosed with hypogonadism. The mildly elevated FSH and LH along with low testosterone levels suggested primary hypogonadism as the initial diagnosis. However, the normal A levels cast doubt on this theory.

Further Investigations:

  • Genetic testing revealed a mutation in the cytochrome P450 aromatase (CYP19A1) gene, an enzyme involved in converting A to estradiol. This explained the normal A levels despite the low testosterone levels, as the genetic defect disrupted the downstream conversion.


  • Michael was prescribed testosterone replacement therapy, starting with a transdermal patch applied twice weekly. Regular monitoring of testosterone levels and potential side effects was initiated.
  • Genetic counseling was recommended to understand the implications of the CYP19A1 mutation and potential implications for family members.
  • Michael was referred to a psychologist for cognitive-behavioral therapy to address any psychological and emotional consequences of hypogonadism.


  • Within three months of initiating testosterone therapy, Michael reported significant improvements in libido, erectile function, energy levels, and mood. Muscle mass also gradually increased.
  • He continued regular follow-up visits for monitoring and dose adjustments as needed. The genetic counseling session provided valuable information and helped Michael make informed decisions about his health and future family planning.


This case study highlights the complex interplay between A and hypogonadism, emphasizing the importance of considering potential underlying genetic factors like CYP19A1 mutations. It also underscores the need for a comprehensive diagnostic approach and individualized treatment plans for patients with hypogonadism. Furthermore, it emphasizes the importance of addressing the psychological and emotional aspects of the condition in conjunction with hormonal management.

Hormonal Riddle: This case study is for educational purposes only and should not be used as a substitute for professional medical advice, diagnosis, or treatment.

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