An HDL cholesterol of 3 mg/dL?!

A 60-year-old male farmer was sent for a lipidology consultation because of a puzzling lipid profile.

His HDL was 3 mg/dL.

As an endocrinologist who is also a clinical lipidologist, I always keep my eyes open for those primary familial dyslipidemias, which I find so profoundly fascinating. My lipid practice is full of secondary dyslipidemia. It is a pleasant change to diagnose a primary lipid disorder. Not only do I have the opportunity to help that particular individual but I can also provide genetic counseling and screening recommendations to family members who might be at risk.

However, this gentleman did not have any of the rare primary hypoalphalipoproteinemias. Indeed, a few years ago his HDL was in the 30 to 40mg/dL range. Then, rather suddenly, his HDL began steadily decreasing over time: 18, 13, 10, 8, 5 mg/dL and finally to a low of 3 mg/dL!

Further questioning revealed that he had been initiated on oral methyl testosterone some months ago by an alternative care practitioner for unclear reasons. This agent was stopped and miraculously his HDL increased to 48 mg/dL. His AM total and free testosterones were normal on follow up testing.

I have seen low HDL due to exogenous androgens but never quite as low as this. The usual presentation is a young male with an HDL in the 10 to 20 mg/dL range sent to me for “hypogonadism.” They requested their primary care physician to check a testosterone and indeed it was low. Their testes are normal or sometimes small, their follicle-stimulating hormone/luteinizing hormone suppressed and prolactin normal. A few have already had a normal pituitary magnetic resonance imaging before coming to see me.

And yet, the picture does not fit.

Unlike most of the hypogonadal men I see, these are physically-fit, very muscular, young men who do not have any clinical features of insulin resistance or hypogonadism. They are usually not interested in further work up. Instead, they bluntly ask me: “So are you finally going to give me some testosterone?”

With sincere yet direct questioning, most eventually admit to a history of exogenous androgen or anabolic steroid use. Of the handful who continue to adamantly deny, I explain that before writing any prescription for testosterone, I must test for anabolic steroids. Once confronted with this, most of the others are honest about their use.

Only once has a gentleman ever abruptly ended our discussion, refused all further work up, and stomped angrily out of my office: “Well, if you’re not gonna prescribe it for me, I’ll just go somewhere else!”