Australian Doctor 9th Aug Issue | Page 29

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NEED TO KNOW
Men with organic hypogonadism should — provided there are no contraindications — receive testosterone replacement , unless fertility is desired .
In men with organic hypogonadism , testosterone replacement improves the clinical features of androgen deficiency but does not improve fertility .
Men with organic hypogonadism seeking fertility require specialist management .
Older men who present with non-specific androgen deficiency-like symptoms and lowered testosterone , but who do not have organic hypothalamic-pituitarytesticular axis pathology , benefit from a holistic treatment approach . This includes measures to achieve a healthy body weight and optimisation of comorbidities such as depression and obstructive sleep apnoea .
The long-term benefits and risks of testosterone in such older men are not established . Further evidence to clarify the role of testosterone therapy in such men is required .

Management of low testosterone in men

Professor Mathis Grossmann Professor , department of medicine , Austin Health , University of Melbourne ; head of clinical andrology and consultant endocrinologist , endocrine unit , Austin Health , Heidelberg , Victoria .
Copyright © 2024 Australian Doctor All rights reserved . No part of this publication may be reproduced , distributed , or transmitted in any form or by any means without the prior written permission of the publisher . For permission requests , email : howtotreat @ adg . com . au .
This information was correct at the time of publication : 9 August 2024
INTRODUCTION
THIS is the second of a two-part
series on the investigation and management
of low testosterone in men . Part one covered an approach to the clinical and biochemical assessment of the man presenting with possible hypogonadism . Part two covers the management of low testosterone , which in many cases will involve strategies other than , or at least complementary to , testosterone therapy .
This How to Treat offers current evidence for the effectiveness of lifestyle measures as well as information on the risks and benefits of testosterone therapy in men with functional hypogonadism .
It aims to ensure GPs are proficient in managing men with organic hypogonadism with testosterone replacement , while being aware of the available testosterone formulations , and the contraindications to testosterone replacement .
It also aims to ensure the GP can confidently manage older men who present with androgen-deficiencylike symptoms and lowered serum testosterone in the absence of organic hypothalamic-pituitary-testicular axis pathology ( that is , with so-called functional hypogonadism ).
MANAGEMENT OF ORGANIC HYPOGONADISM
IT is established that , provided
there are no contraindications ( see table 1 ), men with organic hypogonadism should be treated with testosterone replacement to establish or maintain secondary sexual characteristics , sexual function , body composition and wellbeing .
Importantly , testosterone treatment does not improve fertility , and may even cause infertility , and should thus not be considered a reliable male contraceptive .
In Australia , the PBS subsidises
testosterone replacement , without restrictions , for men with hypogonadism from established testicular or pituitary disease ( see box 1 ). Currently available testosterone formulations and their advantages and disadvantages are listed in table 2 .
Testosterone treatment should never be started before the diagnostic workup is complete and a clear diagnosis of organic hypogonadism has been made , for the following three important reasons .
First , failure to do so may lead to missing important underlying pathologies such as a pituitary tumour .
Second , exogenous testosterone treatment supresses the hypothalamic-pituitary-testicular ( HPT ) axis even in healthy men , and once testosterone has been started , accurate evaluation for an underlying aetiology is almost impossible .
Third , testosterone treatment compromises fertility , whereas spermatogenesis in men with secondary hypogonadism can be restored with gonadotropin treatment .
MANAGEMENT OF FUNCTIONAL HYPOGONADISM
IN contrast to organic hypogonadism , the risk-benefit ratio of testosterone treatment in men 50 years and older with functional hypogonadism ( also referred to as late-onset hypogonadism [ LOH ]) is not known . 1 There are no large long-term randomised controlled clinical trials to inform about benefits important to the patient ( for example , improved quality of life , improved functional mobility or reduced mortality ) or therapy-associated risks .
The priority is the implementation of lifestyle measures ( especially achieving a healthy bodyweight ), and where appropriate for obese men , initiation of weight loss medications or , in selected men , referral for bariatric surgery . Optimisation of