Adult Onset Hypogonadism Flashcards by Alanna Parker

What is it?

clinical syndrome resulting from failure to product test OR normal amounts of sperm OR both
—- typically need to see low Test +++ symptoms

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Main RF

age — increase with age due to defects in all levels of the HP axis
—- decrease GnRH pulses
—- LH response to GnRH is decreased
— testicular response to LF is reduced (decrease in androgens)

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General trend seen with test + age

fluctuations during gestation + infancy
Complete drop in childhood
- spike during puberty then gradual decline with age (50+)

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T or F: Test has diurnal fluctuations in levels

T- peaks in the morning (am) + gradual decline throughout the day
— lowest at midnight

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What are the metabolites of testosterone

Estradiol— produced by CYP19 or aromatase
DHT - produced by 5 alpha reductase

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Main impacts of estradiol

Increase libido + impacts bone density

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Main impacts of DHT

Hair follicle growth (puberty —- follicular minimization later), external genitalia (maturation during puberty), prostatic disease (increase prostate growth)

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Main actions of test by itself (not metabolites)

increase mass + strength of muscle during puberty
RBC production
Bone growth
internal genitalia (during gestation )

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How does the HPG axis work

hypo releases GnRH
GnRH works on anterior pituitary to release FSH + LH
—- LH: testosterone production
FSH: sperm production

—- increase in test works as negative feedback on hypo

inhibin B: negative feedback on anterior pituitary to decrease LH + FSH release

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What is primary vs secondary hypogonadism

primary: something wrong at testes level
secondary: something wrong upstream (hypothalamus etc)

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Examples of organic causes of primary hypo

chemo
radiation damage
infections
testicular damage/torsion
advanced age
Klinefelter syndrome (XXY) genetic

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Examples of functional causes of primary hypo

Meds
ESRD

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Examples of organic causes of 2nd hypo

destructive disease of hypo or pituitary
tumour

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Examples of functional causes of 2nd hypo

meds: opioids, anabolic steroids, glucocorticoids, alcohol, weed
hyperprolactinemia: impact sensitivity to LH or FSH
obesity
excessive exercise
organ failure

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What test levels indicate primary hypo

low Test (+/- decrease sperm) + high LH/FSH

—- something wrong at testes level so brain working in overdrive to try to increase test levels

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What test levels indicate 2nd hypogonadism

low test (+/- low sperm) + low/normal FSH/LH

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T or F: In someone with primary hypogonadism, fertility can be restored with addition of hormones (GnRH pulses etc)

F- something wrong at testes level; can’t correct with hormones

2nd: fertility is restored

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Specific symptoms of hypogonadism/triad

Key: ED, decrease libido, decreased morning erection

** if have all 3– likely hypo **

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What are the less specific signs + symptoms of hypogonadism

decrease in energy, motivation, mood changes, impaired memory, sleep disturbances, hot flashes, decreased facial hair, central obesity, decreased muscle, increase in fat, osteoporosis

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What are the main 3 symptom categories of hypogonadism

Sexual
Somatic: fatigue, energy etc
Psychological: mood

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What are some potential complications/outcomes of hypogonadism

Weak association with low T levels but could include:
- decreased muscle mass + strength
- insulin R
- increased risk of CAD
- increased visceral fat
- increased risk of mortality

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General algorithm to hypogonadism diagnosis

if have SS of low T levels: look first at conditions or meds to see if any of them could impact axis
Measure total T levels bw 7-11am when fasting OR within 3 hours of waking

——- if < 12: repeat total levels in 1-4wks (confirm) alongside other tests (FSH =, LH< SHBG, TSH, prolactin)
—— if > 12: unlikely hypo

Repeat total test levels if OG < 12
—- if tT <8mmol/L——- hypo
— if tT >/= 8 but < /=12: look at free T levels

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What free T levels indicate hypo if tT >/= 8 but < 12

fT< 225 —- diagnosis

fT>/= 225: could give 3 mth trial period to see if helps

** general guidelines

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T or F: 50% of test is protein bound in serum

F- 98% —- almost all bound by proteins

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T or F: Test bound to SHBG is not bioavailable

T- irreversibly bound —— normally 44% —- if decrease in level: more free —- if increases: less F

Albumin + test binding level

50% —- F 4% bound to corticosteroid binding globulin (F)

How much test is normally free ? And what impacts it ?

Generally 2% — varies based on SHBG levels — SHBG levels normally increase with age

When should we order fT levels

1) SHBG levels may be decreased: obesity, DM, hypothyroidism,; if on: glucorticoids, androgenic steroids 2) SHBG increased: aging, HIV, cirrhosis, hyperthyroidism ; anticonvulsants, Estrogens 3) Total test level is borderline (>/=8 but

Testosterone product options

1) oral 2) injectables 3) transdermal: gel and intranasal

What is the name of the oral test agent

Testosterone undecanoate/Andriol - normally 120-160mg in 2 doses daily —- must be taken with fatty foods (increase A) + clinical responses vary

What are the injectable forms of test

1) Testosterone cypionate 100mg/mL (depo-testosterone) 2) Testosterone enanthate 200mg/mL (Delatestyrl)

General dosing for injectable test

100-200mg every 1-4 weeks depending on formulation

Which injectable test contains cotton seeds?

Test cypionate

Which injectable test contains sesame oil

Test enanthate

What is the advantage of test enanthate over cypionate

- more concentrated —- use smaller V to delivery same dose (more tolerable)

Disadvantages of injectable test

increased fluctuations in T levels

Advantages of transdermal test

keeps stable concentrations, flexible dosing + easy to apply

Disadvantages of transdermal test

daily application - can be transferred during intimate contact (need certain time before showering)

General dosing for testosterone 1% gels

5-10g qAM — 10% is absorbed - apply to abdomen, shoulder, upper arms

Differences in Androgel vs Testim

Androgel: pump and packet form - need to wait 5-6 hours before showering - smaller Cmax Testim: > 2 hours before shower - preferred because higher Cmax + AUC by 30%

What is Natesto 4.5%

intranasal test spray - use 1 spray in each nostril TID TDD: 33mg (each spray —5.5 mg) multiple daily dosing but rapid A

AEs of Test use

aggressive behaviours increase in PSA levels possible - cancer: may cause recurrence or progression (if have cancer)

T or F: Test in CI in those with CVD as it increases the risk of thromboembolic events

F- thought to originally increase risk of thromboembolic events —— not good evidence

What are the absolute CI for test therapy

known/suspected breast or prostate cancer —- if active or high risk of recurrence

What are the “relative” CI for Test therapy

had localized prostate cancer; currently no evidence of active cancer —- could use but with caution

What are the main GoT for treating hypogonadism

- improve symptoms: KEY TREAT PT NOT # - reach eugonadal test levels

How long after starting therapy should you see effect generally

3-6 mths - sexual +psychological: 1-3- mths -somatic take longer: 6-12 mths

What level of hematocrit if a CI to testosterone therapy

Hematocrit > 54%

When should test levels be measured during therapy

at 3+ 6 mths; once stable — annually

When should PSA levels be measured

Before therapy (baseline), 3+ 6 mths and then annually

When should you get DREs done

Before therapy, 6 mths after starting then annually

How often should BMD be tested in some on test with osteoporosis

every 1-2 years once start therapy

What do we do if we see no improvement at 3-6 mths FU

—- check test levels ——— if normal: consider other diagnosis ——- if low: check compliance, consider increasing dose, or change RoA

What to do a 3-6 mths FU if symptoms improving

Look at AEs experience - AEs experienced that aren’t related to dose/RoA —- stop therapy — if AEs related to dose/RoA: change - none—- continue to monitor

When to check test levels if switch to oral regimen

2-3 hours AFTER dose

When to check test levels if on injection

midpoint during interval

When to check test levels if using transdermal gel

anytime after the first 1-2 wks of use

When to check test levels if use the intranasal gel

20mins to 2 hours after morning dose

Interaction of Insulin and test

- test may decrease glucose level (increase hypo risk) —- may need to decrease SU or insulin dose

Interaction of test with anticoagulants

increase sensitivity to them —- increase bleeding risk

Interaction of corticosteroids and test

enhance edema (caution in cardiac or renal or hepatic disease )

T or F: test may impact thyroid fxn tests

T- may decrease TBG and decrease TT4 levels

Adult Onset Hypogonadism Flashcards

(62 cards)