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Dr. Paul Turek: Male Hypogonadism and Testosterone

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Dr. Turek's annual review course.

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Dr. Paul Turek: Male Hypogonadism and Testosterone

  1. 1. Male Hypogonadism & Testosterone Annual Review Course 2018 Paul J. Turek MD FACS, FRSM The Turek Clinics, Beverly Hills, San Francisco, Silicon Valley Former Professor and Endowed Chair, UCSF
  2. 2. Testosterone Synthesis Cholesterol PregnenolonePregnenolone 17OH-Pregnenolone DHEA17OH-Pregnenolone DHEA Deoxycorticosterone 11-Deoxycortisol Corticosterone Cortisol Aldosterone Progesterone 17OH-Progesterone 17,20 Desmolase Testosterone 17β-hydroxysteroid dehydrogenase TESTIS Androstenedione ADRENAL Estradiol DHT
  3. 3. Androgen Effects on the Normal Male Body Hair Bone marrow- stem cells Behavior- mood/memory Bone-growth, density Blood-clotting, HDL Heart-vasodilation Fat-reduction Kidney- erythropoietinLiver-proteins Muscle-anabolic Male sex organs- maintenance Maserati Ghibli
  4. 4. Albumin bound 60% SHBG bound 40% Free/unbound 1-2% Forms of Testosterone in the Body SHBG-T Free T Albumin-T Total Testosterone Bioavailable Testosterone
  5. 5. Age and Testosterone Levels SM Harman et al. JCEM. 86: 724, 2001 Baltimore Longitudinal Study of Aging Prospective, 40 year study. N=890 men Total T Free T
  6. 6. SM Harman et al. JCEM. 86: 724, 2001 Age and SHBG Levels
  7. 7. Age and Testosterone Younger Older Bioavailable T Bioavailable T SHBG-T SHBG-T
  8. 8. T Replacement: Benefits Muscle mass/strength Decreased body/visceral fat Increased bone density Increased libido (older men) Improved mood/cognition Less fatigue/ well being Cardiovascular benefit Improved erections Yes Yes Yes Yes Maybe EvidenceSymptom/Finding Maybe Maybe Not usually
  9. 9. Testosterone Replacement: When 1. Patients must have appropriate, consistent symptoms/signs 2. Morning total testosterone x 2 must be unequivocally low 3. Obtain LH and Hct with second total testosterone 4. Stratify by Hct and LH if total testosterone is low: • Hct >50 likely hemochromatosis, Refer to PCP/Endo • LH low, check prolactin and consider MRI pituitary 5. If low T, normal Hct and any LH, testosterone deficiency confirmed 6. Check PSA if >40 yo The Endocrine Society Guidelines, 2010 AUA Clinical Guidelines, 2018
  10. 10. Testosterone Replacement: When >300ng/dL<300ng/dL Normal; No RxRepeat am TT LH, Hct Low TT Any LH NL Hct Low TT Low LH Rx Prolactin Symptoms/Signs Am Total T LowTT Hct >50 Hemochromatosis referral Pit MRI PSA if > 40yo T Deficiency
  11. 11. Testosterone Replacement: When EMAS n=3177 men Eugonadal Primary hypo 2ndary hypo Tajar et al. JCEM. 2010, 95: 1810 TesticleSertoli Cells Leydig Cells T Anterior Pituitary FSH LH LH Total T Opioids DM Obesity Prolactin Hemachrom.
  12. 12. Testosterone Replacement: When Further eval. before Rx Discuss Rx Discuss lifestyle Δ SERM hCG Aromatase In. High Candidate for Rx Risk for CV events? Exogenous T Aim for 450-600ng/dL Fertility desired? Low Yes No
  13. 13. T Replacement: What? Route Preparation Specific Risks Oral Methyl/flouxy- First pass inactivation; hepatoxicity mesterone Parenteral T cyp/enanth/ IM injection; peaks and troughs propionate Highest rate of side effects Parenteral-LA Long acting T IM injection; peaks and troughs Transdermal Patch Site reaction/welts; falls off w/sweat patch Transdermal Multiple kinds Daily use; transference; odor gels Buccal Sticky lozenge Twice daily dosing; adherence loss Nasal Spray/gel Thrice daily dosing; sinusitis Sub Q 75-100 pellets Spitting; erythema; procedure to place
  14. 14. Testosterone Replacement: Contraindications Known or suspected prostate cancer. Known or suspected breast cancer. RELATIVE: Elevated hematocrit. RELATIVE: Pre-existing obstructive sleep apnea. RELATIVE: IPSS >19/35.
  15. 15. Worsening Obstructive Sleep Apnea. Infertility. Guaranteed oligo or azoospermia. Polycythemia. Most common reason for Discontinuing T. Associated with increased risk of thromboembolic disease if Hct >50. Water retention CV disease. controversial risk. Testosterone Replacement: Risks
  16. 16. A 55 yo man is being treated for hypogonadism. His baseline PSA is 1.8 with a normal DRE. How should you follow him on testosterone therapy? a)PSA at 3 mos and then annually b)PSA at 3 mos intervals for 2 years and then annually c)PSA at 1 year and then discuss with patient d)No need to repeat PSA
  17. 17. T Replacement: Monitoring Start Therapy 63 9 12 240 mos 18 Sx’s Hct PSA Bone scan Sx’s Hct PSA Sx’s Hct PSA Sx’s Hct (PSA) Bone scan The Endocrine Society Guidelines, 2010 AUA Clinical Guidelines, 2018 STOP no Δ
  18. 18. Good Luck!

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