2.
36 yrs old gentelman k.c.o
Hypogonadism on testosterone inj
Came regularly for testesterone inj only
Case
3.
How to diagnose hypogonadism & types of it
Indication & contraindication for starting T inj
for how long we give testosterone
What are the side effect of testosterone
How do we f/u such pt in primary care
objectives
4.
Hypogonadism in a male refers to a decrease in one
or both of the two major functions of the testes:
1- sperm production
2- testosterone production.
These abnormalities can result from disease of the
testes (primary hypogonadism) or disease of the
hypothalamus or pituitary (secondary
hypogonadism).
5.
6.
primary hypogonadism:
If the serum testosterone concentration and/or the
sperm count are below normal and the serum LH
and/or FSH concentrations are above normal.
Secondary hypogonadism:
If the serum testosterone concentration and/or the
sperm count are below normal and the serum LH
and/or FSH concentrations are normal or low.
7.
8.
9.
DIAGNOSIS
based upon the presence of signs and symptoms of
male hypogonadism and unequivocally low serum total
testosterone concentrations between 8 and 10 AM on at
least two occasions .
10.
11. Population screening for male hypogonadism has not been shown
to be cost-effective and is not recommended.
Testosterone assessment is recommended in men with a disease or
treatment in which testosterone deficiency is common and in whom
treatment may be indicated. This includes men with:
Obesity.
Metabolic syndrome (obesity, hypertension, hypercholesterolaemi).
Pituitary mass, following radiation involving the sellar region and other
diseases in the hypothalamic and sellar region.
End-stage renal disease receiving haemodialysis.
Treatment with medications that cause suppression of testosterone levels -
e.g. corticosteroids and opiates.
Moderate to severe chronic obstructive lung disease.
Infertility.
Osteoporosis or low-trauma fractures.
HIV infection with sarcopenia.
Type 2 diabetes mellitus.
Candidates for testing
12.
total testosterone
free testosterone
steroid hormone-binding globulin.
LH+ FSH to differentiate primary from secondary
hypogonadism
Brain MRI
Investigation
13.
14.
Total testosterone : (normal range, 300 to 1,000 ng
per dL [10.4 to 34.7 nmol per L])
Hypogonadism: < 200 ng per dL (6.9 nmol per L).
(AACE)
15.
hypogonadotrophic hypogonadism
MRI: pituitary micoadenoma
Had b/l maldescended testicles….left orchidopexy
was done at age of 6 months
Rt testis was removed at age of 5-6 yrs
Back to the case
16.
Pt been treated w/ testosterone+ human chorionic
gonadotrophin (hcg)
Repeat semen analysis showed consistent
azospermia
FSH & LH measured in 2000 were lower than normal
** pt was on testosteron for> 10 yrs
20.
Indication for testesterone
Delayed puberty (idiopathic, Kallmann syndrome)
Klinefelter syndrome with hypogonadism
Sexual dysfunction and low testosterone
Low bone mass in hypogonadism
Adult men with low testosterone and consistent and preferably multiple
signs and symptoms of
hypogonadism following unsuccessful treatment of obesity and
comorbidities
Hypopituitarism
Testicular dysgenesis and hypogonadism
Type 2 diabetes mellitus with hypogonadism
European Association of Urology 2015
21.
22.
23. RISKS/SIDE EFFECTS COMMENTS
Benign prostatic hypertrophy
28–30
No clear evidence
Cardiovascular
31,32,36
No clear effect on these cardiovascular risk factors: total
cholesterol, high-density lipoprotein cholesterol, C-
reactive protein, or insulin sensitivity
Liver toxicity
35
Usually does not occur at physiologic doses; oral
formulations should be avoided in men for this reason
Polycythemia
11,19
More common in men taking higher doses
Virilization (i.e., alopecia, hirsutism, acne)
32–35
Men and women: usually dose and duration related
Testosterone side effect
26.
PSA : at baseline, at 3&6 months and then annually (strong
recommendation; moderate- to low-quality evidence).
A digital rectal examination should be performed at
baseline, at 6 months and then annually following onset of
treatment (weak recommendation; very-low-quality evidence).
The patient should be referred to a urologist for consideration of a prostate
biopsy for any of the following:
•A prostate nodule that is palpated at any time.
•A serum PSA concentration (confirmed by a repeat value) that rises by more
than 1.4 ng/mL in any one-year period.
•A PSA velocity that is greater than 0.4 ng/mL per year for two or more years,
beginning six months after initiation of testosterone therapy
27.
DEXAat basline and after 1-2 years.
If a bone fracture or bone density in the osteoporotic
range was a presenting finding of hypogonadism,
bone density should be reassessed every two years
until it becomes normal or stabilizes. If it stabilizes
and is still in the osteoporotic range, pharmacologic
treatment for osteoporosis should be initiated.
28.
Liver function , every three to six months.
Only necessary with oral preparations.
Lipids: annually
30.
if contraindications to therapy arise
if there is no improvement after an adequate
therapeutic trial (weak recommendation; moderate-quality evidence).
Up to six month ( specified by British guidelines )
candian guideline
31.
AAFP 2006: Testosterone Treatments: Why, When, and
How?
A practical guide to male hypogonadism in the primary
care setting, ncbi , 2010
Hypogonadotropic Hypogonadism Revisited, ncbi 2013
Diagnosis and management of testosterone deficiency
syndrome in men: clinical practice guideline,
CMAJ December 8, 2015 vol. 187 no. 18 First
published October 26, 2015, doi:10.1503/cmaj.150033
uroweb.org/wp-content/uploads/EAU-Guidelines-
Male-Hypogonadism-2016.pdf
REFERNCES
Editor's Notes
There are no consistent guidelines for the level of total testosterone that defines hypogonadism; however, many studies use the American Association of Clinical Endocrinologists
