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MD2 Endocrine > Androgen Deficiency in Men > Flashcards

Androgen Deficiency in Men Flashcards

1
Q

How are testosterone levels measured?

A

As total (TT) or free (FT) testosterone

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2
Q

List 11 symptoms of androgen deficiency in men (9 negative and 4 positive)

A

DECREASED:

Sexual development (eunuchoidism, aspermia)

Fertility (low or zero sperm count)

Libido

Spontaneous erections

Body hair

Testes (esp less than 5mL)

Height (low trauma fracture, low bone mineral density)

Muscle bulk and strength

Energy, motivation, initiative, aggression, concentration, mood, sleep

POSITIVE Sx:

Breast discomfort and gynaecomastia

Hot flushes and sweats

Increased fat mass

Mild anaemia

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3
Q

Describe the clinical presentation of male hypogonadism with onset in 1st trimester

A

If partial virilisation: ambiguous genitalia If complete deficiency: female external genitalia

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4
Q

Describe the clinical presentation of male hypogonadism with onset in 3rd trimester

A

Micropenis

Cryptochidism

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5
Q

Describe the clinical presentation of male hypogonadism with onset pre-puberty

A

Incomplete pubertal maturation

Testes ≤ 4mL

Eunochoidal body habitus (long-limbed, slim, underweight)

Gynaecomastia

Decreased peak bone mass

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6
Q

Describe the clinical presentation of male hypogonadism with onset in adulthood

A

Decreased libido

Decreased mood and stamina

Decreased muscle mass and strength

Decreased bone density Increased fat mass

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7
Q

List 4 conditions associated with decreased SHBG concentrations

A

Moderate obesity*

Nephrotic syndrome*

Hypothyroidism

Use of GCS, progestins and androgenic steroids

*Particularly common conditions associated with alterations in SHBG concentrations

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8
Q

SHBG

A

Sex hormone-binding globulin

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9
Q

List 6 conditions associated with increased SHBG concentrations

A

Ageing*

Hepatic cirrhosis*

Hyperthyroidism

Use of anticonvulsants* and oestrogens

HIV infection

*Particularly common conditions associated with alterations in SHBG concentrations

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10
Q

Describe the regulation and production of testosterone

A
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11
Q

What is the reference range for normal testosterone?

A

No age-related reference ranges

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12
Q

What are the major limitations of testosterone assays?

A

Lack of standardisation

Inaccuracy in low range

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13
Q

How is the clinical syndrome of androgen deficiency defined?

A

Characteristic symptoms and signs

Unequivocally low testosterone levels with absence of transient or reversible causes of low testosterone levels

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14
Q

What actions should be taken if a low TT result is received?

A

Repeat the test: any normal level received = eugonadal

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15
Q

What is the significance of calculated FT (cFT)?

A

If TT is borderline but SHBG is abnormal, look at cFT to rule out falsely low TT

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16
Q

What might an elevated LH indicate?

A

Decreased testosterone secretion

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17
Q

List some acquired causes of primary androgen deficiency

A

Testicular damage: trauma, orchitis, chemotherapy, radiotherapy, toxins

Drugs: spironolactone, ketoconazole

18
Q

List 5 congenital causes of primary androgen deficiency

A

Klinefelter syndrome

Cryptorchidism

Mutations in androgen biosynthesis enzymes

LH/FSH-receptor mutations

Myotonic dystrophy

19
Q

Identify some causes of secondary androgen deficiency

A

Structural (pituitary/hypothalamus): tumour, surgery, radiation, trauma, infiltration (haemochromatosis, sarcoid, histiocytosis)

Genetic: Kallmann’s syndrome, “idiopathic” HH, LH/FSH beta subunit mutations

Functional: hyperprolactinaemia, morbid obesity, Cushing’s syndrome

20
Q

What blood results would be expected in primary vs secondary androgen deficiency?

A

Primary: LH/FSH elevated

Secondary: LH/FSH low/normal

21
Q

List 3 partial/transient causes of androgen deficiency

A

Acute illness

Chronic disease: ESKD, COPD, HIV, T2DM

Drugs: glucocorticoids, opioids, GnRH agonists, anabolic steroids

22
Q

Describe the natural Hx of Klinefelter’s syndrome

A

Puberty triggers germ cell extinction

More rapid TT decrease with ageing

23
Q

What are the main features of Klinefelter’s syndrome?

A

Testes less than 4cm, firm (“pea-like”)

Azoospermia: usually infertile, occasionally spearm retrievable with testicular microdissection

Require speech therapy and educational support

24
Q

What blood test results are expected with Klinefelter’s syndrome?

A

TT commonly low or normal (more rapid decrease with ageing)

LH high

25
Q

What is Klinefelter’s syndrome?

A

XXY

26
Q

What does a non-palpable testis suggest?

A

Anorchism

Bilateral cryptorchidism

27
Q

What does a testis less than 5mL suggest?

A

Kallmann’s syndrome, hypogonadotropic hypogonadism

Klinefelter’s syndrome

Other hypergonadotropic syndromes

28
Q

What does a testis 8-15mL suggest?

A

Germinal damage

Toxins

Idiopathic

29
Q

What does a testis 15-20mL indicate?

A

Varicocele

Drugs

Idiopathic

30
Q

What does a testis 10-20mL suggest?

A

Adult-acquired hypogonadotropic hypogonadism

Senescence

31
Q

Describe an approach for diagnostic evaluation of adult men suspected of having androgen deficiency

A
32
Q

Mr KF, 24 year old electrician, presents with wife of 2 years for evaluation of infertility; his wife has a child from a previous marriage which she conceived without difficulty

She reports that Mr KF is “quite passive sexually” and needs to be prompted to “perform his marital duties”; Mr KF agrees he “rarely feels like doing it”

Mr KF reports that his pubertal development has been “a bit slower” than his peers; he shaves every 3 days and is the tallest in the family, and although he works out he does not “bulk up like the other guys”

No Hx of testicular trauma or infections

Reports no significant health issues and takes no regular medications; recalls a childhood Dx of mild attention deficit disorder

O/E: note boyish-looking facial features and scant pubic hair, slight gynaecomastia, pea-sized testes (4 mL in volume) and firm

Ix?

A

Morning fasting TT

FSH

LH

Chromosomal analysis

Semen analysis

33
Q

Mr KF, 24 year old electrician, presents with Sx and signs of androgen deficiency

Morning fasting TT: 4.7nmol/L, repeat 5.6 nmol/L (RR 12-27)

FSH: 23.8 mIU/mL (RR 1.0-9.0)

LH: 14.3 mIU/mL (RR 1.0-10.0)

Chromosomal analysis: 47, XXY

Semen analysis: azoospermia

Dx?

A

Klinefelter’s syndrome

34
Q

Mr. ED, a 62 year-old accountant presents because he is “unhappy with his sex life”; hs libido is strong, but he has difficulty maintaining an erection

His wife is 15 years younger and unhappy about his performance; they often argue

He has tried an expensive intranasal spray that he obtained over the Internet but it “did not work”; he has come to ask about “hormone therapy for men”

Has not seen a “doctor for years” but denies other health issues; in recent years, he feels “more tired” and “lost some strength”, but denies headaches or visual disturbance

Smokes “10 cigarettes” a day and has “a few stubbies with the mates” on weekends, does not exercise

O/E: BP 150/90, BMI 30 kg/m2, appears well virilised and testicular volume is 25 ml bilaterally, visual fields normal to confrontation, 105cm waist circumference, R carotid bruit and reduced pedal pulses

Ix?

A

Morning fasting TT

SHBG

Calculated FT

FSH and LH

PLN

Iron studies

FPG

Lipids

MRI pituitary

35
Q

Mr ED presents with erectile dysfunction and complains of feeling “tired” in recent years

Examination unremarkable except for R carotid bruit and reduced pedal pulses, waist circumference 105cm

Morning fasting TT: 8.4 nmol/L, repeat 7.6 nmol/L (RR 10-27)

SHBG: 22 nmol/L (RR 10-50)

Calculated FT: 190 pmol/L, repeat 210 pmol/L (RR >230 pmol/L)

FSH: 3.2 mIU/mL (N 1.0-9.0)

LH: 4.1 mIU/mL (N 1.0-10.0)

Normal PLN

Normal iron studies

FPG: 7.9

LDL cholesterol: 4.5 nmol/L

MRI pituitary normal

Dx?

A

Non classical androgen deficiency, common in ageing and chronic disease

36
Q

Steps in testosterone therapy

A

Establish treatment goals

Achieve adequate TT levels

Monitor treatment response

Monitor for adverse effects

37
Q

How can testosterone therapy be delivered in Aus?

A

Injection (deep IM) of testosterone esters or enanthate every 2 weeks (cheapest and widely available)

Transdermal testosterone patch (suitable in bleeding disorders; also cream)

Subdermal implant of testosterone pellet (convenience - infrequent administration)

Oral testosterone undecanoate daily (safe, suitable in bleeding disorders)

Non-proprietary forms: troche, dragee, ointment

Recent additions: testosterone undecanoate (long-acting) 3-monthly IM injections (more reliable levels), gel daily application

38
Q

What are the indications for a PBS authority requirement for testosterone therapy in men with androgen deficiency?

A

Classic androgen deficiency due to hypothalamo-pituitary or testicular disorders: qualify

Men without classic androgen deficiency: men 40 and older with no established pituitary or testicular disorders other than ageing, confirmed by at least 2 morning blood samples taken on different mornings - androgen deficiency is confirmed by testosterone level under 8nM or 8-15nM with high LH (less than 1.5x upper limit of eugonadal RR > for young men)

39
Q

CIs to TRT

A

Evidence of prostate Ca (abnormal DRE, elevated PSA >3ng/mL, diagnosed prostate cancer)

Breast cancer

Erythrocytosis (HCT at least 52%) or hyperviscosity

Untreated OSA

Severe LUTS

Class III or IV HF

Desire to have child

40
Q

Potential adverse effects of testosterone replacement

A

Erythrocytosis

Acne, oily skin

Detection of subclinical prostate Ca

Growth of metastatic prostate Ca

Reduced sperm production and fertility, testicular atrophy

Fluid retention

Weak evidence of gynaecomastia, male pattern balding, worsening of BPH Sx, growth of breast Ca, induction or worsening of OSA

41
Q

What monitoring is indicated for male patients on testosterone therapy?

A

Hx and physical every 3-4/12 initially then annually

Testosterone 3/12 post-treatment until stable in normal range

PSA and DRE: baseline at 3/12, every 6-12/12 after depending on patient’s age

Annual lipids

Haematocrit: baseline, every 3/12, then annually

BMD of lumbar spine, femoral neck, hip: after 1-2 years of therapy in men with OP or low trauma #

MD2 Endocrine (11 decks)

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