Male Hypogonadism: Facts and Myths

HISHAM ALREFAI,MD,CCDCert. Endocrinology & DiabetesDiplomate, Clinical Lipidology

Hypertension FellowshipCert. Clinical Densitometry.

Case#1

A 49 years old man referred for diabetes management. Review of other symptoms is positive for fatigue, lack of motivation, and decreased libido with preserved erectile function. The exam revealed central obesity, A1C of 8.9%, elevated TG, and low HDL.

Which of the following about low testosterone in diabetics is true?

Hypogonadism is rare in diabeticsThe incidence of hypogonadism in diabetics

approaches 30% across all age groups. Hypogonadism occurs only in diabetic older than 65

year old.All men with diabetes will eventually develop

hypogonadism.

Based on recent studies, which of the following symptoms would make you suspicious of low level of testosterone?

Decreased level of energyLack of motivationDiminished libidoMoodiness and irritabilityErectile dysfunction

Case# 2

A 68 years old man is admitted with a hip fracture as a result of falling from standing position. Five ears earlier, he had a forearm fracture due to a minor injury. He admits losing 2 inches of height. Mild kyphosis is detected on exam

The Initial W/U should include all except:

CBCThoracic Spine XrayCMPVitamin D evaluationTestoterone levelDexa ScanBone Scan

Which one of the following do not need to be obtained prior to initiating T. ?

PSAHematocritProlactin, LH, and FSHGlucoseMRI of pituitary

Contraindications of Testosterone Replacement Therapy in Men

Known or suspected prostate cancerMale breast cancerKnown or suspected sensitivity to ingredients used in testosterone therapy systems

Petak SM, et al. AACE Clinical Practice Guidelines. Available at: http://www.aace.com/clin/guides/hypogonadism.html

Testosterone Therapy andPossible Prostate Changes

Increased risk of BPHIncreases in PSA levelsIncreases in prostate volumeStimulation of growth in previously undiagnosed tumors– No data support testosterone therapy as a cause of

prostate cancer

Hajjar RR, et al. J Clin Endocrinol Metab. 1997:82;3793-3796Basaria S, et al. Drugs Aging. 1999;15:131-142

Keep your finger on the prostate

Potential Risks of Testosterone Therapy

Prostatic hyperplasia and prostate cancer in those already at increased riskEdema in patients with preexisting cardiac, renal, or hepatic diseaseGynecomastiaPrecipitation or worsening of sleep apneaHepatic adverse effects with oral therapy

Petak SM, et al. AACE Clinical Practice Guidelines. Available at: http://www.aace.com/clin/guides/hypogonadism.html

Case#3

A 32 year old man is receiving narcotic therapy for advanced ankylosing spondylitis. He is complaining of night sweat and depressive mood.

What lab set would confirm the diagnosis of hypogonadism?

Total T of less than 200 ng/ml with elevated LHTotal T of less than 300 ng/ml with normal LHA recent drop of 300 ng/ml of Total T with normal LH Total T of 350 ng/ml with elevated LH

Which of the following treatment option is the mainstay of testosterone replacement therapy that avoids level swings?

Testosterone patchTestosterone pelletsTestosterone injectionsTestosterone gelBuccal testosterone

Endocrinology=Proper Hormone replacementMedicine: Quality of life> Quantity of life

The Endocrine society 2006 suggested measurement of T. for:

Type 2 DMOsteoporosis or low trauma fracture especially younger patients.Moderate to severe COPDESRD and hemodialysisHIV-associated weight lossMeds affect testosterone production such as glucocorticoids, ketoconazole, and opioidsSellar region disease.

Thank You