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What are the symptoms and signs of androgen deficiency in men (general, sexual & organ specific features)?

- Low sense of well being, poor concentration
-tiredness, poor stamina
-mood change - depression, irritability

-reduced libido is almost universal
-erectile failure (rare)

Organ specific features
-reduced muscle mass and strength
-osteoporosis and fracture
-increased fat mass


What are the appropriate tests to confirm the diagnosis of androgen deficiency? And what do they mean?

Total (TT)or free (FT) Testosterone

N.B. No age related reference ranges. T assay characteristics lack standardization; Inaccuracy in low range

•Normal serum TT = eugonadal
•Low TT: repeat – any normal level= eugonadal
•Calculated FT(cFT): if TT borderline, SHBG abnormal to rule out falsely low TT
•LH (if elevated) may indicate decreased T secretion


What is the difference between classical androgen deficiency due to pathology of the hypothalamo-pituitarygonadal
axis and non-specific low testosterone levels due to aging and disease?

Non specific low testosterone levels due to ageing & disease is not powered to assess meaningful gains in important health outcomes or risk of cardiovascular disease or prostate cancer due to limited RCTs unlike pathology of HPA.

Hence risk benefit ratio therefore unknown and likely different in older men compared to young hypogonadal males


What does clinical Px of male hypogonadism depend on? Give examples

Age of onset.

1st trimester:
- Partial virilisation, Ambiguous genitalia.
- Complete deficiency: Female external genitalia

3rd trimester: Micropenis, Cryptorchidism

-Incomplete pubertal maturation -Testes


What are the causes of androgen deficiency? (Primary & secondary)

Primary: LH/FSH elevated
1. Acquired:
- testicular damage due to trauma, orchitis, toxins
- drugs; spironolactone, ketoconazole

2. Congenital:
- Klinefelter syndrome
- cryptorchidism
- LH/FSH-receptor mutations

Secondary: LH/FSH low/normal
1. Structural (Pituitary/hypothyroidism):
- tumour
- surgery/radiation/trauma
- infiltration; e.g. sarcoid, iron overload

2. Genetic
- Kallmann's syndrome
- idiopathic HH
- LH/FSH beta subunit mutations

3 Functional
- Hyperprolactinemia!
- Morbid obesity!
- Cushings syndrome!!


What are causes of partial/transient androgen deficiency?

- acute illness
- chronic disease e.g. ESRF, COPD, HIV, T2D
- Drugs: glucocorticoids, opioids, GnRH agonists, anabolic steroids


Describe Klinefelter's syndrome

•Prevalence 1:660, 25% diagnosed during lifetime; 90% 47, XXY
•Early Dx enables speech therapy, educational support
•Main feature testes


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

1. Hx & Examinations
2. Morning total Testosterone
- if normal, follow up.
- if low T (


Describe non classical androgen deficiency

•Common in ageing and chronic disease
•RCTs limited by small numbers, short duration, different inclusion criteria, surrogate outcomes
•Risk benefit ratio unknown and likely different in older men compared to young hypogonadal males
•Safety and efficacy remains to be evaluated in randomised controlled trials


What is the effect of testosterone replacement in hypogonadal men?

- increased serum TT
- increased body composition, prostate volume & haemoglobin
- increased energy & sex function


What types of testosterone products are available?

- Injection (deep intramuscular): 250mg/2 weeks. (+) widely available. (-) painful. Wide moody/energy swings. Having libido like a teenager in an elderly can be disturbing for the pt and the partner

- Transdermal (patch, cream, gel): build the dose up gradually. (+) suitable in bleeding disorders. (-) irritable patches.

- Subdermal implant. 800mg 6 monthly. (+) convenience. (-) unable to terminate rapidly

- Oral:2-3 tablets/day
- Others: ointment etc


What are the contraindications to testosterone replacement therapy?

•evidence of prostate cancer
–abnormal Digital Rectal Examination
–elevated PSA (> 3ng/ml)
–diagnosed prostate cancer

•breast cancer
•erythrocytosis (HCT > 52%) or hyperviscosity
•untreated obstructive sleep apnoea
•severe lower urinary tract symptoms (IPSS >19)
•class III or IV heart failure
•Desire to have child


What are the potential SE of testosterone replacement?

- erythrocytosis
- acne & oily skin
- detection of subclinical prostate cancer
- growth of metastatic prostate cancer
- reduced sperm production & fertility

- gynaecomastia
- male pattern balding
- worsening of BPH symptoms
- growth of breast cancer
- induction/worsening of OSA


Describe management of men with androgen deficiency

1. Lifestyle measures and treatment of comorbidities
2. Testosterone replacement therapy (consider SE & CI)

Monitor male pts on testosterone therapy with:
- Hx & examination 3/4-12 first year and then 1/12
- testosterone levels 3/12 after first initiation
- liver function 3-6/12
- prostate specific antigen 3/12 first & 6-12/12
- DRE: annually if unchanging
- lipids: 1/12
- haematocrit: baseline 3/12, and then annually
- BMD of lumbar spine, femoral neck & hip: 1-2 yrs after therapy in men w/ osteoporosis/low trauma fracture

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