Australian Doctor 9th Aug Issue | Page 27

ausdoc . com . au 9 AUGUST 2024

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Figure 8 . Orchidometer . Figure 10 . Micrograph showing normal sperm count ( left ) and azoospermia ( right ).

Figure 9 . Steroid acne .

Figure 11 . Coronal ( A ) and sagittal ( B ) T1 weighted MRIs with contrast with arrow indicating the location of a microadenoma .

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1 . Which TWO statements regarding low testosterone in men are correct ? a Men with organic hypogonadism may have serious underlying disease that needs appropriate management . b Recommend weight loss medications or bariatric surgery to all middle-aged men with overweight . c A low serum testosterone is often a marker of poor health in many older men . d Successful care of comorbidities rarely improves general health or non-specific androgen deficiency-like symptoms .

2 . Which THREE are typically features of organic hypogonadism ? a Low libido . b Gynaecomastia . c Consistently and severely low serum testosterone . d Normal-sized testes .

3 . Which THREE are typically features of functional hypogonadism ? a Normal serum testosterone . b Erectile dysfunction . c Low energy . d Low mood .

4 . Which TWO statements regarding organic hypogonadism are correct ? a Gonadotropin therapy is helpful in achieving fertility in men with primary organic hypogonadism . b Organic hypogonadism is caused by medical disease affecting the male hypothalamic-pituitary-testicular axis . c Organic hypogonadism is generally reversible . d Testosterone replacement rectifies the clinical features of androgen deficiency but does not restore fertility .

5 . Which THREE of the symptoms commonly attributed to androgen deficiency have been described as clustered with a low testosterone level ? a Reduced sexual thoughts . b Erectile dysfunction . c Reduced morning erections . d Low libido .

6 . Which TWO statements regarding functional hypogonadism are correct ? a Functional hypogonadism is a diagnosis of exclusion .

EVALUATION OF LOW TESTOSTERONE IN MEN

b Data suggest that healthy ageing is associated with marked decreases in testosterone levels . c Functional hypogonadism is considered irreversible . d Evidence suggests that low testosterone is a sensitive biomarker of poor health , rather than a causal factor .

7 . Which ONE is the most common contemporary cause of severe hypogonadism in older men ? a Type 2 diabetes . b Androgen deprivation therapy for prostate cancer . c Obesity . d Normal ageing .

8 . Which THREE statements regarding the assessment of hypogonadism are correct ? a There is no role for testosterone measurement in asymptomatic men . b On clinical assessment , do not miss clues to an underlying organic aetiology . c Do not make a diagnosis of androgen deficiency based on a single low testosterone level .

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d Testosterone assays are standardised so ensure an appropriate one is used .

9 . Which TWO statements regarding the exclusion of organic hypothalamicpituitary-testicular axis pathology are correct ? a Most older men with obesity and lowered testosterone will have organic pathology . b The testosterone cut-off level below which pituitary imaging is indicated is not well defined . c If prolactin is not elevated , pituitary imaging is not necessary . d In men with low serum testosterone and nonelevated gonadotropins , the probability of organic hypothalamic-pituitary pathology is inversely related to BMI , age , number of comorbidities , and testosterone concentration .

10 . Which THREE are major causes of secondary osteoporosis in men ? a Hypogonadism . b Decline in sex hormone binding globulin . c Glucocorticoid exposure . d Excess alcohol consumption .

PAGE 25 or osteoporosis . Hypogonadism is a clinical diagnosis based on a combination of consistent symptoms and signs , confirmed by repeated and consistently low morning fasting testosterone levels .

Once the diagnosis of hypogonadism is made , an individualised diagnostic workup is required to establish the cause ; it is essential that this is done before testosterone treatment is considered . Importantly , testosterone treatment does not improve , but instead , compromises fertility .

Organic pathology with underlying pituitary or testicular disease is more likely in younger , leaner otherwise healthy men who present with more specific clinical features and markedly low testosterone levels . In contrast , there is no recognisable pituitary or testicular pathology in most older men with obesity and comorbidities who present with less specific clinical features and more modest testosterone reductions . In these older men , low testosterone is a robust biomarker of poor health and should prompt assessment for comorbidities . Indeed , erectile dysfunction is usually due to neurovascular disease and therefore a strong predictor of future cardiovascular events . Erectile dysfunction , therefore , does not usually respond to testosterone treatment ( see part two of this series ). Making a distinction between organic hypogonadism and so-called late-onset hypogonadism has important implications for the management in men presenting with a lowered serum testosterone , which will be discussed in part two of this series .

References Available on request from howtotreat @ adg . com . au