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HYPOGONADISM IN MALES - LATE-ONSET
Late onset hypogonadism is defined as clinical and biochemical syndrome characterized by older age, set of typical symptoms, and deficiency in serum testosterone levels.
The quality of life may be decreased and multiple organ systems may be adversely affected.
Prior to the start of testosterone substitution, there should be confirmation of low serum testosterone and a confirmation of need based on clinical findings.
Only if the potential benefit exceeds the risk, then replacement testosterone should be started.

Diagnosis

  • If testosterone level is low or at the lower limit of normal, the level should be repeated for confirmation
  • Follicle stimulating hormone (FSH) & luteinizing hormone (LH) levels should also be measured

Primary Hypogonadism (Testicular Origin)

  • Low testosterone level w/ increased FSH & LH suggest a testicular failure origin for hypogonadism

Secondary Hypogonadism (Hypothalamic-Pituitary Origin)

  • Low testosterone level w/ decreased FSH & LH is suggestive of a hypothalamic-pituitary origin of disease
  • Further endocrinological work-up may be needed

Evaluation

  • Assessment of androgen deficient related physical manifestations should be noted
  • Questionnaires may be used to evaluate climacteric symptoms, the patient’s well-being & sexual function
  • Prostate evaluation should be done including measurement of prostate-specific antigen (PSA) & digital rectal exam (DRE)

History

  • Full medical history should be undertaken including:
    • Investigation for diabetes mellitus (DM), hypertension, smoking, heart disease, sleep apnea
    • Medication history (eg use of opioids or high-dose glucocorticoid therapy)

Physical Examination

  • Measure body weight, heart rate (HR), blood pressure (BP), check complete blood count (CBC), urinalysis & blood chemistry parameters

Laboratory Tests

NOTE:

  • Serum testosterone level should be obtained between 07:00-11:00 am
  • Total testosterone level should be compared w/ the normal ranges established by each laboratory

Testosterone Serum Level

Normal Serum Testosterone

  • There are no specific lower limits of normal serum testosterone in older men
  • It is generally agreed that total testosterone level >12 nmol/L (345 ng/dL) do not require testosterone substitution

Low Level

  • Based on measurements taken in younger men, if total testosterone level is <8 nmol/L (231 ng/dL) then testosterone substitution should be considered

Low-Low/Normal Level

  • In patients w/ the following, testosterone substitution may be considered:
    • Total testosterone level between 8-12 nmol/L (231-345 ng/dL)

AND

  • Presence of above symptoms that are not due to other causes
  • Lipid profile & liver function tests are also recommended to assess the patient’s risk status

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