Male Hypogonadism

> Causes and diagnosis of hypogonadism
> Treatment of Hypogonadism
> What are the advantages and disadvantages of differing approaches
   to testosterone replacement therapy?
> Benefits of testosterone replacement therapy
> Side effects of testosterone replacement
> What laboratory tests should be monitored during testosterone replacement therapy?

Causes and diagnosis of hypogonadism

Male hypogonadism is a condition of low male sexual hormone and as a result of that - low production of semen and infertility.

The male hypogonadism could be caused by diseased testicles themselves or abnormal signal from pituitary gland or hypothalamus. In the first case it is called Primary and in the second case – Secondary or Central hypogonadism. Most frequently Primary hypogonadism is a result of genetic condition called Klinefelter Syndrome, viral infection (mumps) trauma or chemotherapy. Most frequent causes of Central hypogonadism are alcohol or drug abuse, systemic disorders such as diabetes, obesity, chronic kidney or liver disease, chemotherapy or pituitary/hypothalamic tumors.   

The rate of hypogonadism increases with age from 4.1% in men aged 40-49 years up to 23% in men aged 70-79 years. In certain conditions, like in diabetes mellitus, the rate of hypogonadism increases up to 50%.

The signs and symptoms of hypogonadism include reduced libido and sexual activity, decreased spontaneous erection, breast swelling and tenderness, loss of body hair, reduced muscle bulk and strength and in a long standing cases - shrinking testes and low bone mass, associated with fractures.

The diagnosis of hypogonadism is based on low early morning testosterone measurements on two occasions. Additional diagnostic evaluations may include the following:

1. Pituitary function
2. Bone mineral density scan
3. Prostate specific antigen (PSA)

Further work-up needs to be done by endocrinologist or urologist to find the cause of hypogonadism and start on appropriate therapy. Dr. Naila Goldenberg, at the Jewish Hospital Cholesterol Center, has expertise in the diagnosis and therapy of hypogonadism.
 

Treatment of Hypogonadism

The treatment for hypogonadism includes the correction of underlying problem and replacement of testosterone. The testosterone may be administered via injections, as testosterone patch or gel. During the testosterone therapy, red blood cell count, prostate specific antigen and testosterone levels need to be monitored.
   

What are the advantages and disadvantages of differing approaches to testosterone replacement therapy?

Before 1990, intramuscular testosterone was the only available form of testosterone replacement in men with hypogonadism. Generic long acting testosterone esters (cyprionate and enantate) are currently available, making this type of treatment the most inexpensive and affordable. This formulation of testosterone requires IM injections every 1-2 weeks and is associated with rise and fall of testosterone level, which could be associated with mood swings and other symptoms. Local skin irritation occurs in one third of the patients.

Transdermal testosterone patch is available on the US market. It may cause a skin irritation (in up to 60%), but otherwise is generally well tolerated, restoring testosterone into physiological range.

Testosterone gel provides a very easy and convenient to use method for testosterone replacement.
 

Benefits of testosterone replacement therapy

Improvement of energy level, muscle mass, bone strength, anemia and erectile dysfunction.
 

Side effects of testosterone replacement

• Prostate hypertrophy may worsen; testosterone may uncover underlying prostate cancer.
• Testosterone is contraindicated in men with prostate and breast cancer.
• Priapism is a rare complication and more frequently reported in adolescents treated for delayed puberty, but still occurs in adults.
• Testosterone therapy may lead to worsening of obstructive sleep apnea and this needs to be monitored.
• Elevation of red blood cell count may occur as a result of testosterone therapy and therefore needs to be monitored.
   

What laboratory tests should be monitored during testosterone replacement therapy?

• Bone mineral density at the baseline and in 1-2 years
• Red blood cell count at baseline and in 3-6 months, then yearly.
• Symptoms of sleep apnea should be tested at 3-6 months then yearly
• PSA and digital rectal exam must be performed at 3-6 months, then according to guidelines for prostate cancer screening.