Pharmacological Treatment of Adult and Pediatric Hypogonadism

Pharmacological Treatment of Adult and Pediatric Hypogonadism

Testosterone Replacement Testosterone Replacement Introduction Introduction

Presented By:Presented By:

Carol Sednek FNPCarol Sednek FNP

IntroductionIntroduction

Inadequate testosterone (T) Inadequate testosterone (T) production (andropause)production (andropause)

Decline in sperm production by the Decline in sperm production by the testestestes

Affects 2-4 million menAffects 2-4 million men

Prevalence increases with agePrevalence increases with age

5% receive treatment; where are the 5% receive treatment; where are the other 95%?other 95%?

Clinical manifestations of Clinical manifestations of andropauseandropause

Sexual: ED, infertility, shrinking testesSexual: ED, infertility, shrinking testes

Brain/Behavioral: fatigue, poor motivation, Brain/Behavioral: fatigue, poor motivation, depressed mood, irritability, sleep depressed mood, irritability, sleep disturbance, poor concentration or memorydisturbance, poor concentration or memory

Physical: gynecomastia, male body hair Physical: gynecomastia, male body hair loss, low bone mineral density, muscle loss, low bone mineral density, muscle wasting, increase body fat, mild anemiawasting, increase body fat, mild anemia

Symptoms are subtle over timeSymptoms are subtle over timeModified by presence of co morbidities. Modified by presence of co morbidities.

In prepubescent males the signs and In prepubescent males the signs and symptoms may also include:symptoms may also include:

1.1.Small testes, phallus and prostateSmall testes, phallus and prostate

2.2.Scant pubic and axillary hairScant pubic and axillary hair

3.3.Disproportionately long arms and Disproportionately long arms and legslegs

4.4.Persistently high pitched voicePersistently high pitched voice

Citation: Meacham, Randall MD 2009 Citation: Meacham, Randall MD 2009

Distinguishing Primary from Distinguishing Primary from Secondary HypogonadismSecondary Hypogonadism

Primary (testis dysfunction); T is low Primary (testis dysfunction); T is low in association with high LH and FSH in association with high LH and FSH levelslevels

Secondary (hypothalmic or pituitary Secondary (hypothalmic or pituitary dysfunction): T is low in association dysfunction): T is low in association with normal or low LH and FSH. with normal or low LH and FSH.

Secondary may be caused by tumor Secondary may be caused by tumor or infiltrative diseases. or infiltrative diseases.

Causes of Secondary Causes of Secondary HypogonadismHypogonadism

Pathological; Kallmann syndrome, Pathological; Kallmann syndrome, Hemochromatosis, pituitary adenoma, Hemochromatosis, pituitary adenoma, hypopituitarism, genetic syndromeshypopituitarism, genetic syndromes

Functional; Drugs (opioids, glucorticoids Functional; Drugs (opioids, glucorticoids estrogens, anabolic steroids). Acute and estrogens, anabolic steroids). Acute and chronic illness (liver, renal, heart, lung and chronic illness (liver, renal, heart, lung and Diabetes). Morbid obesity, sleep apnea. Diabetes). Morbid obesity, sleep apnea. Aging. Aging.

Testosterone Replacement Testosterone Replacement TherapyTherapy

Testosterone esters; IM; 100mg q week, 200mg q Testosterone esters; IM; 100mg q week, 200mg q 2 weeks; inexpensive roller coaster $100. _HDL2 weeks; inexpensive roller coaster $100. _HDLTestosterone pelletts; SC; 2-6 75mg pelletts q 3-6 Testosterone pelletts; SC; 2-6 75mg pelletts q 3-6 months; manufacturer $150. -HDLmonths; manufacturer $150. -HDLBuccal Testosterone 30mg BID close to Buccal Testosterone 30mg BID close to physiologic range, $250. -HDLphysiologic range, $250. -HDLTestosterone patch; non scrotal topical, mimics Testosterone patch; non scrotal topical, mimics circadian rhythm, $250. normal HDLcircadian rhythm, $250. normal HDLTestosterone gel, 5g/day, levels in physiologic Testosterone gel, 5g/day, levels in physiologic range, possible transmission to intimate contacts. range, possible transmission to intimate contacts. $300. normal HDL$300. normal HDLNovel Testosterone therapy; phase III trail for US Novel Testosterone therapy; phase III trail for US approval; Europe 1,000mg Q10-14 weeks. approval; Europe 1,000mg Q10-14 weeks.

Monitoring during therapyMonitoring during therapyT, PSA, HCT, HG, LFT, Lipids. 3-6 month T, PSA, HCT, HG, LFT, Lipids. 3-6 month intervals and then yearly. intervals and then yearly. Digital rectal exam; prostate cancer (+1.5; Digital rectal exam; prostate cancer (+1.5; biopsy). Some recommend prostate biopsy biopsy). Some recommend prostate biopsy prior to initiating therapy. prior to initiating therapy. Hepatic; increase with oral formsHepatic; increase with oral formsSleep apnea; exacerbation of breathing by Sleep apnea; exacerbation of breathing by central mechanisms rather than changes central mechanisms rather than changes in airway. in airway. Other Effects; breast tenderness, -Other Effects; breast tenderness, -testicular size, site pain, skin reactions, testicular size, site pain, skin reactions, acne, hypertension. acne, hypertension.

Therapeutic replacementPresented by: Mary Walton FNP

Goals of replacement therapy:1. restore lean body massand sexual function2. Increase energy and wellbeing3. Improve mood and cognition4. Increase lean body mass5. Reduce CVD risk6. Stabilize physiological levels of testosterone

A low testosterone level does not necessarilyindicate hypogonadism

Before replacement is considered a complete H&P and diagnostic tests must performed

The H&P and laboratory tests will help determine if there is hypogonadism and if it is primary or secondary

These Diagnostic tests should be done before considering Testosterone replacement:1. Total Testosterone (nml range 300-900ng/dl)2. Free Testosterone: abnormal if <5ng/dl3. TSH4. FSH5. LH6. CBC for base line (may have mild anemia)7. PSA8. Seminal fluid analysis (for infertility)9. If concerned about Total testosterone level may consider a sex hormone binding globulin which can decrease the total testosterone

Side effects of Testosterone Replacement:1. Testicular atrophy, infertility2. Acne3. Edema, fluid retention4. Gynecomastia5. Erythrocytosis6. BPH7. Prostate cancer progression8. Increased CVD risk (controversial)9. Sleep apnea

Testosterone replacement should be avoided in men with:1. Prostate cancer 2. Heart failure (NYH III & IV)3. Renal insufficiency4. Severe liver disease

Injectable Testosterone:1.Testosterone Cypionate2. Testosterone Enanthate

administered IM 50-400mg every 2-4 weeks Side effects include Fluctuating levels of

Testosterone, mood swings, elevated HGB & HCT

Subcutaneous implants (pellets) Administered SQ at a dose of 150-450mg

(2-6 pellets) every 3-6 months Side effects include possible expulsion of

the pellets, and incision is required for implanting and removing.

Topical Testosterone:1. The patch: 5mg/daySide effects include skin irritation

2. Gel: 5g/daySide effects include skin irritation and possible transmission to intimate contacts

3. Buccal Testosterone: 30mg BIDSide effects: oral irritation, alteration in taste

Testosterone esters; IM; 100mg q week, 200mg q 2 weeks; inexpensive roller coaster $100. _HDL

Testosterone pelletts; SC; 2-6 75mg pelletts q 3-6 months; manufacturer $150. -HDL

Buccal Testosterone 30mg BID close to physiologic range, $250. -HDL

Testosterone patch; non scrotal topical, mimics circadian rhythm, $250. normal HDL

Testosterone gel, 5g/day, levels in physiologic range, possible transmission to intimate contacts. $300. normal HDL

Novel Testosterone therapy; phase III trail for US approval; Europe 1,000mg Q10-14 weeks.

Aphrodisiacs:• Ginseng• Raw Oysters• Kelp• Onion• Spanish Fly• Rhinoceros horn• Yohimbine• Tiger penis

• When you have a patient on Testosterone you should monitor him using the following guidelines:

Anabolic Steroids

Presented By: Susan Pomering FNP

What are anabolic steroids

Anabolic steroids are synthetically produced variants of the naturally occurring male hormone testosterone.

Both males and females have testosterone produced in their bodies: males in the testes, and females in the ovaries and other tissues.

The full name for this class of drugs is:

androgenic (promoting masculine characteristics)

anabolic (tissue building)

steroids (the class of drugs).

History of steroids

Steroids were developed in the 1940s in Germany and used experimentally on their troops during World War II, the drugs ability to stimulate tissue growth and protein synthesis lead them to believe that the drug might be beneficial to treat burn victims and other war accidents

Legal use of Steroids

Steroids are used for treating anemia, because of it's ability to increase the production of red blood corpuscles. They are also used for treatment of leukemia, cancer and at times steroids are also used for general strengthening therapy. Steroids have also been tried in combination with other drugs as a means of helping AIDS patients.

Prevalence of use

More than a half million 8th- and 10th-grade students are now using these dangerous drugs, and increasing numbers of high school seniors say they don't believe the drugs are risky."

National Institute on Drug Abuse

Ease of Obtaining

Young people have abused anabolic steroids meant for animals by getting access to veterinary steroids. These steroids are often cheaper and easier to obtain than anabolic steroids designed for peop.

Steroid users are often risk-takers who use a variety of harmful substances. Twenty-five percent of steroid users share needles, which increases the risk of infectious disease.

Some evidence shows that anabolic steroids can be addictive, but more research is needed. There is evidence that large doses of anabolic steroids affect the brain's chemistry and produce mental changes.

Common types of steroids AbusedThe illicit anabolic steroid market includes The illicit anabolic steroid market includes

Steroids that are commercially available Steroids that are commercially available in the U.S. including:in the U.S. including:

FluxoymesteroneFluxoymesterone (Halotestin), (Halotestin), MethyltestosteroneMethyltestosterone NandroloneNandrolone (Deca-Durabolin, (Deca-Durabolin,

Durabolin), Durabolin), OxandroloneOxandrolone (Oxandrin), (Oxandrin), OxymetholoneOxymetholone (Anadrol), (Anadrol), TTestosteroneestosterone, , StanozololStanozolol (Winstrol). (Winstrol).

Common Types of steroids abusedVeterinary steroids that are commercially Veterinary steroids that are commercially

available in the U.S. include available in the U.S. include boldenoneboldenone (Equipoise), (Equipoise), miboleronemibolerone, and , and trenbolonetrenbolone (Revalor). (Revalor).

Other steroids found on the illicit market Other steroids found on the illicit market that are not approved for use in the that are not approved for use in the U.S. include U.S. include ethylestrenolethylestrenol, , methandriolmethandriol, , methenolonemethenolone, and , and methandrostenolonemethandrostenolone

How are they taken

Anabolic steroids dispensed for legitimate medical purposes are administered several ways including intramuscular or subcutaneous injection, by mouth, pellet implantation under the skin, and by application to the skin (e.g. gels or patches). These same routes are used for purposes of abusing steroids, with injection and oral administration being the most common.

Abusers may take anywhere up to 100 times the normal therapeutic doses of anabolic steroids. This often includes taking two or more steroids concurrently, a practice called “stacking.”

How are they taken

Abusers will often alternate periods (6 to 16 weeks in length) of high dose use of steroids with periods of low dose use or no drug at all. This practice is called “cycling.”  

Another mode of steroid use is called “pyramiding.” With this method users slowly escalate steroid use (increasing the number of drugs used at one time and/or the dose and frequency of one or more steroids), reach a peak amount at mid-cycle and gradually taper the dose toward the end of the cycle.

 

How They are Taken

Doses of anabolic steroids used will depend on the particular objectives of the steroid user. Athletes (middle or high school, college, professional, and Olympic) usually take steroids for a limited period of time to achieve a particular goal. Others such as bodybuilders, law enforcement officers, fitness buffs, and body guards usually take steroids for extended periods of time.

The length of time that steroids stay in the body varies from a couple of days to more than 12 months

Psychological Symptoms of Anabolic Steroid Use

Psychological symptoms include: Mood swings Sleep disruption Aggressive behavior Extreme irritability Delusions Impaired judgment because of feelings that nothing can

hurt you Paranoid jealousy Euphoria or an exaggerated feeling of well-being Depression after stopping steroids Lack of sexual drive after stopping steroids

Consequences of Anabolic Steroid UseMen

infertility

breast development

shrinking of the testicles

male-pattern baldness

Women

enlargement of the clitoris

excessive growth of body hair

male-pattern baldness

Consequences of Anabolic Steroid UseLiver

cancer

peliosis hepatitis

tumors

Musculoskeletal System

short stature (if taken by adolescents)

tendon rupture

Anabolic Steroid UseConsequences

Skin

severe acne and cysts

oily scalp

jaundice

fluid retention

Cardiovascular system

increases in LDL

decreases in HDL

high blood pressure

heart attacks

Left ventricular hypertrophy

Steroid Alternatives

A variety of non-steroid drugs are commonly found within the illicit anabolic steroid market. These substances are primarily used for one or more of the following reasons:

serve as an alternative to anabolic steroids

alleviate short-term adverse effects related to anabolic steroid use

mask anabolic steroid use

Steroid Alternatives

Drugs serving as alternatives to anabolic steroids include

clenbuterol, human growth hormone, insulin, insulin-like growth factor, gamma-hydroxybutyrate (GHB).

Controlling Side Effects and Concealing UseDrugs used to treat the short-term

effects of anabolic steroid abuse erythropoietin, human chorionic gonadotropin tamoxifen.

Diuretics and uricosuric agents may be used to mask steroid use. 

Male Male

Hypogonadism

Hypogonadism

in Children

in Children

Types of Hypogonadism

There are two principal types of AHypogonadism, Primary and Secondary.

Primary - This type of hypogonadism is known as primary testicular failure — originates from a problem in the testicles.

Secondary Hypogonadism

Indicates a problem in the hypothalamus or the pituitary gland. Parts of the brain that signal the testicles to produce testosterone. The hypothalamus produces gonadotropin-releasing hormone, which signals the pituitary gland to make follicle-stimulating hormone (FSH) and luteinizing hormone. Luteinizing hormone then signals the testes to produce testosterone

Primary Hypogonadism

Hypogonadism can occur during fetal development, puberty or adulthood. Depending on when it develops, the signs and symptoms differ.

Fetal development If the body doesn't produce enough testosterone during fetal development, the result may be impaired growth of the external sex organs. Depending on when it develops, and how much testosterone is present, a child who is genetically male may be born with: Female genitals Ambiguous genitals Underdeveloped male genitals

Fetal Onset Hypogonadism Causes of ambiguous genitalia in a

genetic male may include: Impaired testicle development due to

genetic abnormalities or unknown causes. Leydig cell aplasia, a condition that

impairs testosterone production. Congenital adrenal hyperplasia. Certain

forms of this genetic condition can impair production of male hormones.

Androgen insensitivity syndrome, a condition in which developing genital tissues are unable to respond to normal male hormone levels.

Fetal Onset Hypogonadism

5alpha-reductase deficiency, an enzyme defect that impairs normal male hormone production.

Ingestion by mother of female hormones Estrogens, or anti-androgens. This is unusual, if a woman continues taking

BCP into pregnancy for several weeks. "nutritional supplements" contain plant

estrogens.

Causes of Primary Hypogonadism

Klinefelter syndrome Undescended testicles Mumps orchitis Hemochromatosis Injury to the testicles.

Causes of Secondary Hypogonadism Kallmann syndrome. Abnormal

development of the hypothalamus — the area of the brain that controls the secretion of pituitary hormones — can cause hypogonadism. This abnormality is also associated with impaired development of the ability to smell (anosmia).

Inflammatory disease. Certain inflammatory diseases such as sarcoidosis, histiocytosis and tuberculosis involve the hypothalmus and pituitary gland and can affect testosterone production, causing hypogonadism.

Causes of Secondary Hypogonadism Pituitary disorders. An abnormality in

the pituitary gland can impair the release of hormones from the pituitary gland to the testicles, affecting normal testosterone production. A pituitary tumor or other type of brain tumor located near the pituitary gland may cause testosterone or other hormone deficiencies. Also, the treatment for a brain tumor such as surgery or radiation therapy may impair pituitary function and cause hypogonadism.

Secondary Hypogonadism

Idiopathic hypogonadotropic hypogonadism associated with anosmia (the Kallmann syndrome) or with a normal sense of smell, is a treatable form of male infertility caused by a congenital defect in the secretion or action of gonadotropinreleasing hormone (GnRH).

Diagnosesd when patient has absent or incomplete sexual maturation by the age of 18.

Treatment

In boys, testosterone replacement therapy (TRT) can stimulate puberty and the development of secondary sex characteristics, such as increased muscle mass, beard and pubic hair growth, and growth of the penis. Pituitary hormones may be used to stimulate testicle growth. An initial low dose of testosterone with gradual increases may help to avoid adverse effects.

Treatment of Hypogonadism Idiopathic hypogonadotropic hypogonadism

was previously thought to require lifelong therapy. Sustained reversal of normosmic idiopathic hypogonadotropic hypogonadism and the

Kallmann syndrome was noted after discontinuation of treatment in about 10% of patient with either absent or partial puberty Therefore, brief discontinuation of hormonal therapy to assess reversibility of hypogonadotropic hypogonadism is reasonable