Dr. Turek's annual review course.

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. 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. 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. 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. 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. SM Harman et al. JCEM. 86: 724, 2001
Age and SHBG Levels

7. Age and Testosterone
Younger Older
Bioavailable T
Bioavailable T
SHBG-T SHBG-T

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Good Luck!