Other topics of endocrine

Question 1

Congenital or acquired during childhood = delayed puberty

Acquired = variable, with “testosterone deficiency syndrome” → decreased libido, ED, poor morning erection, hot sweats, depression, fatigue, decreased ability for physical activity, infertility, gynecomastia, headache, fracture

Answer 1

hypogonadism

Question 2

Deficient testosterone secretion by the testes from
– insufficient gonadotropin secretion by pituitary (hypogonadotropic) (secondary)
Low testosterone with normal/low LH
– pathology in testes (hypergonadotropic) (primary)
Testicular failure with high LH, Klinefelter syndrome, XY dysgenesis, androgen insensitivity
Or both

Partial male hypogonadism can also be seen in normal aging, obesity, illness (spermatogenesis is generally preserved)

Answer 2

hypogonadism

Question 3

hypogonadotropic is

Answer 3

secondary

Question 4

hypergonadotropic is

Answer 4

primary

Question 5

History!
PE: decreased body, axillary, beard, pubic hair, with loss of muscle mass and weight gain, decreased testicular size
Always palpate testes for masses! (Leydig cell tumors can secrete estrogen)

Morning (before 10am) total testosterone + free testosterone
———-Total <300
———-Free <35
Confirm with repeat
Measure PRL + LH (prolactinoma)
Serum estradiol (cirrhosis, estrogen tumors)
Gynecomastia = partial 18-ketoreductase deficiency
Screen for hemochromatosis
MRI if:
–Severe hypogonadism (total <150)
–Elevated serum PRL
–Other pituitary hormone deficiencies
–Symptoms of mass lesions

Answer 5

hypogonadotropic hypogonadism

Question 6

History!
PE: decreased body, axillary, beard, pubic hair, with loss of muscle mass and weight gain, decreased testicular size
Always palpate testes for masses! (Leydig cell tumors can secrete estrogen)
Low serum testosterone with compensatory increase in FSH + LH
Klinefelter syndrome can be confirmed with karyotyping
Biopsy reserved for younger patients with unclear reasoning

Answer 6

hypergonadotropic hypogonadism

Question 7

how do you treat hypogonadism?

Answer 7

Testosterone replacement for:
- boys who have not entered puberty by age 14
- men with primary testicular failure
- severe hypogonadotropic hypogonadism with serum testosterone <150
- men with low or low-normal testosterone along with elevated serum LH

Testosterone trial -
In men w/o elevated serum LH levels and average of at least 2 morning serum total testosterone levels <275 if they have 3/6 symptoms:
ED, poor morning erection, low libido, depression, fatigue, inability to perform vigorous activity

Question 8

Symptoms worrisome for malignancy = asymmetry, location not immediately below areola, unusual firmness, nipple retraction, bleeding or discharge

Examine both seated and supine

Answer 8

gynecomastia

Question 9

Palpable glandular breast tissues in males, with variety of causes, commonly in puberty for boys who are overweight and subsides spontaneously in 1 year

Aging, neonatal period, puberty, obesity

Adult = drug therapy (HIV antiretroviral therapy like efavirenz or didanosine, spironolactone, athletes who abuse steroids)

True gynecomastia in older men is a sign of a serious disorder

Answer 9

gynecomastia

Question 10

PE: distinguish true glandular (tender) from softer fat (diffuse and nontender)
Pubertal = tender discoid enlargement 2-3 cm below areola

LABS: liver, renal function
Endocrine testing, prolactin, serum beta-hCG and estradiol to screen for malignancy
→beta-hCG levels = testicular tumor or malignancy
Karyotype for Klinefelter syndrome

Unclear cases require bilateral mammography + chest CT
—Suspicious mammogram → US-guided FNA
High serum hCG or estradiol ⇒ confirm with repeated testing ⇒ testicular US, if normal ⇒ CT of adrenal glands, others if needed

Answer 10

gynecomastia

Question 11

how do you treat gynecomastia

Answer 11

Pubertal gynecomastia generally resolves spontaneously in 1-3 year
Drug induced resolves within months once offending drug is removed

SERM therapy for true glandular gynecomastia = raloxifene

Aromatase inhibitor - anastrozole

Testosterone therapy for those with hypogonadism

Surgery for persistent or severe

Question 12

Increased hair production in chin, upper lip, abdomen, chest, acne, anovulation/amenorrhea, de-feminization with decrease in breast size and loss of feminine adipose tissue

Virilization → frontal balding, muscularity, clitoromegaly, voice deepening (often pointing to androgen-producing neoplasm)

Answer 12

hirsutism and virilization

Question 13

terminal hair growth in women in a male pattern
PCOS
Or idiopathic, enzyme defects, neoplastic, medications

Answer 13

Hirsutism

Question 14

male physical characteristics in women such as pronounced muscle development, deep voice, male pattern baldness, severe hirsutism

Answer 14

virilization

Question 15

PE: pelvic exam may show clitoromegaly or ovarian enlargement that may be cystic or neoplastic, HTN

LABS:
-Serum androgen testing to screen for rare occult adrenal/ovarian cancers
In those with mod-severe hirsutism, mild with menstrual disturbance, worsening
-Total testosterone + free testosterone
→ serum >200 or free >40 indicates need for manual pelvic exam + US
If negative, adrenal CT scan

-Androstenedione >1000 = ovarian/adrenal neoplasm
-DHEAS>700 = adrenal source of androgen
-serum FSH/LH
→ elevated if amenorrhea is due to ovarian failure
→ LH:FSH ratio >2 common in PCOS

Answer 15

Hirsutism and virilization

Question 16

how do you treat Hirsutism and virilization

Answer 16

Stop any drugs causing it or treat underlying cause
Laser and topical treatments – shaving, waxing, bleaching, electrolysis
Eflornithine = slows hair growth
Minoxidil

Medication options:
Oral contraceptives
Spironolactone
+ Metformin
Flutamide and bicalutamide
Finasteride
Statin in PCOS
Steroid replacement
GnRH agonist

Surgery and removal of tumors
– postmenopausal women can undergo laparoscopic bilateral oophorectomy (If CT scan is normal)
– congenital adrenal hyperplasia/infertility and treatment resistance = laparoscopic bilateral adrenalectomy