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  Hypogonadism
 
Author: Adrian Dobs Last modified: August 7, 2001
DIAGNOSTIC CRITERIA

  EPIDEMIOLOGY

  • Estimate that only 5% of hypogonadal men are being treated
  • Klinefelters syndrome occurs in 1 in approximately 750 live births.
  • In the Massacheusettes Study of Aging, approximately 20% of men were considered hypogonadal, based on younger men.
  • In the Baltimore Longitudinal Study on Aging, 25% (when using a total testosterone assay) to nearly 90% (using a free testosterone assay) were considered hypogonadal.

  RISK FACTORS

  • Age - declines in gonadal hormones can begin at 40 years of age
  • Chronic disease - HIV infection, diabetes mellitus, chronic renal failure, cancers
  • Acute disease - starvation, anesthesia
  • Medications - glucocorticoids, opoid analgesics

  SIGNS AND SYMPTOMS

  • Impaired sexual function - decreased libido, difficulty in attaining a functional erection
  • Osteoporosis, osteopenia, loss of height
  • Lethargy, depression, decreased energy
  • Gynecomastia
  • Infertility
  • Decreased muscle mass, decreased frequency of shaving

  DIFFERENTIAL DIAGNOSIS

  • Hypothalamic disorders - Kallman's syndrome, craniopharygioma, primary brain tumors, hemosiderosis from blood transfusions, post-irradiation
  • Pituitary disorders - Prolactinomas, non-secretory tumors, sarcoidosis, granulomatous invation, post-irradiation, aging
  • Testicular disorders - Klinefelters syndrome (XXY karyotype), post-irradiation therapy, aging, chemotherapy with alkylating agents (cytoxan), mumps orchitis, auto-immune destruction, trauma, previous
  • Androgen-insensitivity syndromes - complete resistance (female phenotype), Reifenstein's syndrome, Rose syndrome

  LABORATORY FINDINGS

  • Total testosterone (may be the most least expensive, reliable screen)with or without sex hormone binding globulin (SHBG), free testosterone by free dialysis method - All should be morning samples
  • Follicle stimulating hormone (FSH) and luteinizing hormone (LH) - will be high in primary testicular failure and inappropriately low in pituitary, hypothalamic, or aging etiologies
  • Prolactin
  • Estradiol or HCG - indicated in situations of feminization
  • Safety labs before treatment with testosterone is administered - CBC, prostate specific antigen (PSA), digital rectal examination to r/o prostate cancer

more...

 
TREATMENT
TESTOSTERONE ENANTHATE 200 MG I.M. Q 2 WEEKS
  • Cyprionate or proprionate forms can be used interchangably.
  • Men should be taught to self-administer.
  • Least expensive of testosterone replacment options.
  • The pharmacokinetics have been likened to a "roller coaster." Some men feel anxious on day one or have complaints of decreased sexual function at the end of the second week.
TESTODERM 5 MG PATCHES QAM
  • Pharmacokinetics tend to mimic a circadian rythym.
ANDROGEL 5 GM GEL QAM
  • Gel needs to be rubbed onto a large surface area.
  • Levels of serum testosterone tend to stay fairly steady throughout the day.
  • Serum total testosterone should be measured in 6 weeks to ensure appropriate dosing.
  • There can be some transference of testosterone if significant contact is made within one hour of application.
ANDRODERM 5 MG PATCHES QHS
  • Total testosterone levels should be measured in 6 weeks and adjustment to 7.5 or 10 mg doses should be made.
  • Peak levels of testosterone occur in 8-10 hours, thus patches tend to mimic a circadian rythym.
  • Skin irritation under the patch can occur. It can be alleviated by pre-application of a steroid ointment.
 
IMPORTANT POINTS/RECOMMENDATIONS
  • In all forms of testosterone replacement therapy, men should be screened prior to and during treatment for prostate cancer with a digital rectal exam and a serum PSA.
  • Hematocrits need to be monitored prior to and during treatment to ensure that levels do not rise above 52%.
 
REFERENCES
  1. Ferrini RL, Barrett-Conor E. ;  Sex hormones and age: a cross-sectional study of testosterone and estradiol and their bioavilable fractions in community-dwelling men. ;  Am J Epidemiol. 147(8):750-754,1998

  2. Blackman MR, Weintraub BD, Rosen SW, Harman SM. ;  Comparison of the effects of lung cancer, benign lung disease, normal aging on pituitary-gonadal function in men. ;  J Clin Endocrinol Metab. 66:88-95,1988

  3. Zmuda JM, Cauley JA, Kriska A, et al ;  Longitudinal relation between endogenous testosterone and cardiovascular disease risk factors in middle-aged men. A 13-year follow-up of former Multiple Risk Fctor Intervention Trial participants. ;  J Epidemiol. 146(8):609-617, 1997

  4. Morley JE, Kaiser FE, Perry HM, 3rd et al. ;  Longitudinal changes in testosterone, luteinizing hormone, and follicle-stimulating hormone in healthy older men. ;  Metabolism. 46(4):410-413, 1997

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