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Male Hypogonadism

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Endocrine department

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Male Hypogonadism

  1. 1. MALE HYPOGONADISM
  2. 2. Definition Male hypogonadism is a clinical syndrome caused by androgen deficiency which may adversely affect multiple organ functions and quality of life. Sources: Guidelines on Male Hypogonadism. European Association of Urology 2015. Nieschlag E, et al. Andrology: male reproductive health and dysfunction. 3rd edn. Springer-Verlag Berlin Heidelberg 2010 ISBN 978-3-540-78354-1
  3. 3. SECONDARY HYPOGONADISM RABI’ATUL ‘ADAWIYAH BINTI MOHAMAD 10-6-76
  4. 4. KALLMANN SYNDROME. GnRH deficiency with anosmia PITUITARY DISORDERS hyperprolactinemia INFLAMMATORY DISEASE Sarcoidosis, Histiocytosis and Tuberculosis HIV/AIDS MEDICATIONS OBESITY NORMAL AGING CONCURRENT ILLNESS
  5. 5. PATHOGENESIS Dhamirah Sakinah Binti Makmon 10-6-75
  6. 6. CLINICAL PICTURE AHMAD NAUFAL B NORDEEN 10-6-16 SITI AISYAH BT AHMAD FAIZAL 10-6-85 SITI KHADIJAH BT MANSOR 10-6-89 SITI ZULAIKHA BT SAIAN 10-6-90
  7. 7. Primary hypogonadism Secondary hypogonadism Genetic: Klinefelter’s syndrome (common) Congenital: anorchia Kallman Syndrome Pituitary gland tumor
  8. 8. Klinefelter’s syndrome • Muscle mass is decreased, • muscle strength is diminished Increase BMI and body fat percentage
  9. 9. Erectile dysfunction • Small testis • lack scrotal pigmentation • Small penis (< 8 cm long in adults). • Loss of pubic hair • axillary hair • terminal hair growth along the midline towards the umbilicus.
  10. 10. Infertility related to low sperm count Reduced libido and activity Gynecomastia • Bilateral enlargement of male mamillary gland and fat Depression
  11. 11. INVESTIGATIONS Siti Suhaila binti Mohaad Sariff 10-6-91 Siti Aisyah binti Rusman 10-6-92 Siti Najwa binti Khamsul 10-6-94 Siti Nurul Afiqah binti Johari 10-6-95 Siti Baizury binti Hassan 10-6-96
  12. 12. Investigations To determine testosterone deficiency we must consider: - Clinical signs and symptoms (already mentioned) - Laboratory values
  13. 13. Physical examination
  14. 14. Hormonal Assays 1. Early morning serum testosterone levels 2. Early morning FSH and LH levels 3. Prolactin level, if increase suggesting more investigations on pituitary gland 4. PSA assay
  15. 15.  Prepubertal (either 1ry or 2ry) Differentiate by measuring early morning LH and FSH levels (8-10 AM)  1ry hypogonadism: low level of testosterone, high-normal or high levels of LH and FSH  2ry hypogonadism: low level of testosterone, normal to low levels of LH and FSH *If both physical examination and serum chemistry tests are normal, constitutional pubertal delay must be considered
  16. 16.  Postpubertal (S&S include loss of libido, erectile dysfunction, depression, osteoporosis, regression 2ry sexual characteristics)  1ry gonadal failure: low testosterone, increase FSH and LH. FSH measurement important because of longer half life & > sensitive than LH  Hypothalamic-pituitary disorders (2ry): low testosterone and low to normal FSH and LH
  17. 17. Karyotyping  To diagnose any chromosomal abnormalities – Klinefelter’s syndrome, Noonan’s syndrome
  18. 18. Radiological Imaging 1. Magnetic Resonance Imaging (MRI)  To screen for hypothalamic or pituitary disease  Undescended testis
  19. 19. 2. Dual Energy X-ray Absorptiometry (DEXA) - Bone mineral density
  20. 20. Other assessment  Formal assessment of intellectual changes, mood, and cognitive changes  Assessment of prostate by DRE
  21. 21. MANAGEMENT OF MALE HYPOGONADISM
  22. 22. GOAL THERAPY MALE HYPOGONADISM  SHAFIRA BINTI SHAHAMEN (10-6-104)
  23. 23. GOAL THERAPY The goal of hormone replacement therapy in these men is to restore hormone levels to the normal range and to alleviate symptoms suggestive of hormone deficiency. This can be accomplished in a variety of ways, although most commonly testosterone replacement therapy (TRT) is employed.
  24. 24. GOAL THERAPY  Restore Sexual Function, Libido, Well-Being, and Behavior  Produce and Maintain Virilization  Optimize Bone Density and Prevent Osteoporosis  Possibly Normalize Growth Hormone Levels in Elderly Men  Potentially Affect the Risk of Cardiovascular Disease  Restore Fertility in Cases of Hypogonadotropic Hypogonadism
  25. 25. CONTRAINDICATIONS TO TESTOSTERONE THERAPY SHAHIZAN BINTI MOHD RASID 10-6-102
  26. 26. 1.Breast carcinoma (history or presence) 2.Prostate carcinoma (history or presence) 3. benign prostatic hyperplasia 4.Abnormal digital rectal examinations 5.Elevated levels of prostate-specific antigen 6.Age (no limit established; possibly older than 80 years) 7.Psychopathology 8.Sleep apnea (potential for worsening) 9.Hypercoagulable states 10.Polycythemia (hematocrit >51%) Conditions that contraindicate of testosterone therapy:
  27. 27. Some other chronic diseases: -Diabetes -Heart Disease -Liver or kidney disease
  28. 28. Drug interactions with testosterone -Testosterone may interfere with the action of certain drugs. -Examples: 1.Warfarin (Coumadin) for thinning blood 2.Insulin or any oral drugs for diabetes 3.Propranolol (Inderal) 4.Oxyphenbutazone 5.Imipramine 6.Any kind of corticosteroid drug 7.Some herbal products
  29. 29. Testosterone therapy in adult male hypogonadism
  30. 30.  For hypogonadism caused by testicular failure, male hormone replacement (testosterone replacement therapy, or TRT) is used.  TRT can restore sexual function and muscle strength and prevent bone loss.  In addition, men receiving TRT often experience an increase in energy, sex drive and sense of well-being.
  31. 31.  Testosterone therapy should provide physiologic range of :  serum testosterone levels (generally between 280 and 800 ng/dL)  dihydrotestosterone and estradiol levels. These would allow optimal virilization and normal sexual function.  In late teenage male patients with delayed puberty, testicular size should be monitored for evidence of onset of puberty.
  32. 32. Types of testosterone replacement therapy  Injections  IM injections  Are safe and effective  eg : Testosterone undecanoate  Androderm Patch  Applied each night to the back, abdomen, upper arm or thigh  The site of application is rotated to lessen skin reactions  Gel  Androgel, testim, axiron, fortesta  Avoid skin to skin contact before the gel is completely dry.
  33. 33.  Gum and cheek (buccal cavity)  Striant  Implantable pellets  Testopel : surgically implanted under the skin  Need to be replaced every 3 to 6 months
  34. 34. SIDE EFFECTS OF TRT • Stimulation of prostate tissue, with perhaps some increased urination symptoms such as a decreased stream or frequency • Increased risk of developing prostate cancer • Gynecomastia • Increased risk of blood clots • Worsening of sleep apnea • Decreased testicular size • Increased aggression and mood swings • May increase risk of heart attack and stroke
  35. 35. MONITORING TRT
  36. 36. Gonadal stimulation in hypogonadotropic hypogonadism By : SITI NUR JANNAH SHAARI 10-6-97
  37. 37.  Gonadotropin /GNRH therapy- only for hypogonadotrophic hypogonadism  Uses : -to induce puberty in boys -treat androgen defic in hypo. hypogonadism -initiate& maintain spermatogenesis in hypogonadotropic men who wants fertility
  38. 38. Gonadotropin therapy to induce puberty  How? hCG binds to Leydig cell LH receptors and stimulates the production of testosterone.  Peripubertal boys with hypogonadotropic hypogonadism and delayed puberty can be treated with hCG instead of testosterone to induce pubertal development.  The initial regimen of hCG is usually 1,000 to 2,000 IU administered intramuscularly 2-3 times a week  The clinical response is monitored, and testosterone levels are measured about every 2 to 3 months.
  39. 39.  The advantages of hCG over testosterone -the stimulation of testicular growth, -greater stability of testosterone levels and fewer fluctuations in hypogonadal symptoms -stimulating enough intratesticular testosterone to allow the initiation of spermatogenesis.  The disadvantages of hCG : the need for more frequent injections & the greater cost.
  40. 40. Gonadotropin therapy  Male patients with onset of hypogonadotropic hypogonadism before completion of pubertal development may have testes generally smaller than 5 mL. These patients usually require therapy with both hCG and human menopausal gonadotropin (or FSH) to induce spermatogenesis. Men with partial gonadotropin deficiency or who have previously (peripubertally) been stimulated with hCG may initiate and maintain production of sperm with hCG therapy only. Men with postpubertal acquired hypogonadotropic hypogonadism and who have previously had normal production of sperm can also generally initiate and maintain spermatogenesis with hCG treatment only . Fertility may be possible at sperm counts much lower than what would otherwise be considered fertile. Counts of less than 1 million/mL may be associated with pregnancies under these circumstances.
  41. 41.  Therapy with hCG is generally begun at 1,000 to 2,000 IU intramuscularly two to three times a week, and testosterone levels should be monitored monthly  It may take 2 to 3 months to achieve normal levels of testosterone.  When normal levels of testosterone are produced, examinations should be conducted monthly to determine whether any testicular growth has occurred. Sperm counts should also be assessed monthly during a 1-year period.
  42. 42.  In general, the response to hCG can be predicted on the basis of the initial testicular volume  If spermatogenesis has not been initiated by the end of 6 to 12 months of therapy with hCG or LH, administration of an FSH-containing preparation is initiated in a dosage of 75 IU intramuscularly three times a week along with the hCG injections.
  43. 43. GnRH Therapy  In patients with an otherwise intact pituitary gland and hypogonadotropic hypogonadism, synthetic GnRH can be given in a pulsatile fashion subcutaneously through a pump every 2 hours.  GnRH therapy is monitored by measuring LH, FSH, and testosterone levels every 2 weeks until levels are in the normal range, at which point monitoring can be adjusted to every 2 months. GnRH can be used to initiate pubertal development, maintain virilization and sexual function, and initiate and maintain spermatogenesis.  In most patients, these effects may take from 3 to 15 months to achieve sperm production . As with gonadotropin therapy, fertility can be achieved with very low sperm counts—often in the range of 1 million/mL.  GnRH may be more effective than gonadotropin stimulation in increasing testicular size and initiating spermatogenesis in many patients with hypogonadotropic hypogonadism .

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