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Male Hypogonadism: Perspectives on Diagnosis, Dialogue and Therapy

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Dr Sanjay Kalra, Karnal    06 March 2021

  • Hypogonadism or testosterone deficiency (TD) is a clinical and biochemical syndrome characterized by low levels of testosterone (T) with associated signs and symptoms. There is decreased functional activity of the gonads.
  • Classification of male hypogonadism–
  • Hypergonadotropic hypogonadism/primary: High LH, FSH, low testosterone; Hypogonadotropic hypogonadism/secondary: Low LH, FSH, low testosterone.
  • Organic and functional: Organic – Any proven pathology affecting the hypothalamic-pituitary-gonadal axis; should be treated with conventional medications (gonadotropins or testosterone) accordingly; Functional – Absence of any recognized organic alterations in hypothalamic-pituitary-gonadal axis; should be treated first by resolving or improving the associated comorbidities.
  • Androgen deficiency increases with age in healthy men. Incidence in middle-aged men is 2.1-12.8%. In Indian men, there is a 20-48% prevalence in men above 40 years of age.
  • Up to 85% of late onset hypogonadism is due to a functional impairment of the hypothalamus-pituitary-testicular axis, mostly secondary to metabolic conditions.
  • Men with higher total testosterone concentrations had 42% lower risk of type 2 diabetes than those with lower concentrations, in meta-analyses.
  • Screening questionnaires – Androgen Deficiency in Aging Males (ADAM); Quantitative ADAM (qADAM); Aging Male Survey (AMS); Massachusetts Male Aging Study (MMAS); Hypogonadism Impact of Symptoms Questionnaire (HIS-Q).
  • The sensitivity for the ADAM is about 97%, for the AMS 83% and the MMAS 60%. Specificity was 30% for the ADAM, 59% for MMAS and 39% for AMS.
  • Three things which determine signs and symptoms of low testosterone – Age/suddenness of onset; severity of androgen deficiency; underlying cause.
  • How to make correct diagnosis – 3 things to remember: Signs and symptoms suggestive of hypogonadism; early morning fasting sample for testosterone; levels below 300 ng/dL on 2 separate days.
  • Goals of testosterone therapy in adults – Ensure no untoward side effects are present; maintain normal testosterone levels; symptom improvement.
  • Various formulations of testosterone – Intramuscular injections; oral and buccal preparations; transdermal patch; gels.
  • Concerns with testosterone therapy – Increased hematocrit levels; CV mortality; prostate carcinoma.
  • Monitoring of therapy – Biochemical: Hematocrit; Prostate-specific antigen; Ultrasound prostate; Clinical – Unexplained aggression and violence; Sexual hyperactivity; male pattern alopecia, sudden onset or worsening; darkening of skin; gynecomastia, sudden onset.
  • Most guidelines recommend against TTh in patients with metastatic or locally advanced prostate cancer and in patients at high risk for recurrent prostate cancer.
  • In males with hypogonadism, testosterone replacement usually improves gynecomastia.
  • Use TTh in stable coronary artery disease (CAD) patients or in stable heart failure; avoid in unstable CAD, decompensated heart failure.

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