34 HOW TO TREAT : MANAGEMENT OF LOW TESTOSTERONE IN MEN
34 HOW TO TREAT : MANAGEMENT OF LOW TESTOSTERONE IN MEN
Figure 1 . Approach to evaluation and management of possible hypogonadism in older men
9 AUGUST 2024 ausdoc . com . au
Low serum TT Normal FT
Pseudohypogonadism
BMI < 25 BMI ≥ 25
Eugonadism
Low testosterone is a biomarker of poor health and identifies men at risk of increased mortality , although the poor health is usually clinically obvious . Importantly , in obese men ,
1 . Which THREE are benefits of testosterone replacement in men with organic hypogonadism ? a Establishing or maintaining secondary sexual characteristics . b Establishing or maintaining sexual function . c Establishing or maintaining fertility . d Establishing or maintaining body composition .
2 . Which TWO are absolute contraindications to testosterone treatment ? a Venous thromboembolism . b Erythrocytosis . c Untreated high-grade prostate cancer . d Unevaluated prostate nodule .
3 . Which THREE statements regarding the testosterone formulations are correct ? a The injection can be selfadministered . b Testosterone gel may cause skin irritation . c The IM injection produces stable testosterone levels . d Products with a short half-life have less risk of iatrogenic hypogonadism .
4 . Which THREE are part of the ‘ athletic triad ’ in men ?
Diet and exercise to ↓ weight 7-10 %
Reassess in 6-12 months 9
Figure 9 . Approach to evaluation and management of possible hypogonadism in older men . testosterone increases with weight loss , suggesting that the HPT axis suppression is functional and reversible . As a first response to the ageing , obese man with a low-normal
How to Treat Quiz .
Measure fasting TT between 7AM-10AM Assess free T Repeat if low or low-normal
Normal serum TT Low FT
a High BMI . b Hypogonadism . c Low energy availability . d Decreased bone mineral density .
Assess for specific symptoms and signs
No cause identified
BMI < 25
Consider trial of testosterone therapy
5 . Which TWO statements regarding the lifestyle management LOH are correct ? a The increase in testosterone is proportional to the amount of weight lost . b The effects of age are the strongest risk factor for low testosterone . c Most older men presenting with a low testosterone have comorbidities . d It is very easy to achieve and sustain weight loss with lifestyle measures alone .
6 . Which THREE are possible benefits of testosterone therapy in older men with agerelated reductions in serum testosterone ? aImproved libido . b Consistent improvement in mood and cognition . c Reduction of type 2 diabetes
BMI < 25
testosterone , implement optimisation of lifestyle measures and comorbidities ( see box 2 ). Because there is limited evidence , testosterone therapy in men without organic
MANAGEMENT OF LOW TESTOSTERONE IN MEN
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in high-risk men . d Increase in lumbar spine BMD .
7 . Which TWO statements regarding testosterone treatment are correct ? a If first-line measures fail , determine if there is benefit from testosterone therapy . b Start with long-acting testosterone to ensure levels rise appropriately . c Avoid on-treatment testosterone levels that are higher than mid-normal . d The risk-benefit ratio is better in the older man with multiple comorbidities .
8 . Which THREE statements are correct ? a Treatment-associated increases in serum testosterone are associated with increased sexual desire and activity . b Erectile dysfunction responds better to a PDE5-I than to testosterone treatment . c The effect of testosterone on erectile function is significant . d Testosterone treatment
EARN CPD OR PDP POINTS
Low serum T and low FT
FSH & LH not elevated
Serum prolactin + Individualized evaluation for cause of HPT axis disorder Treat co-morbidities
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Measure serum FSH & LH
Cause identified
Treat cause + testosterone therapy if serum testosterone remains low
Normal serum TT Normal FT
Eugonadism
↑ FSH & LH
Primary Hypogonadism
Consider testosterone therapy
hypogonadism remains experimental , and is not recommended by Australian guidelines . 43 Further evidence from well-conducted clinical trials is required .
causes an increase in haemoglobin concentration .
9 . Which TWO statements regarding testosterone treatment are correct ? a It reduces fat mass but does not consistently improve measures of insulin resistance or glycaemic control in men with established diabetes . b It reduces falls risk . c HbA1c is the ideal metric to assess glycaemic changes during testosterone treatment . d It reduces the risk of prevalent diabetes in men who have a low to low-normal serum testosterone .
10 . Which THREE statements regarding testosterone treatment are correct ? a Testosterone treatment improves volumetric bone density and estimated bone strength in men with normal bone density at baseline . b Atrial fibrillation , acute kidney injury and pulmonary embolism have been reported in patients taking testosterone . c Testosterone therapy typically decreases PSA . d It is not known whether testosterone treatment stimulates the growth of pre-existing subclinical prostate cancer .
Box 2 . Principles in the approach to men with lowered testosterone levels without recognisable hypothalamicpituitary-testicular axis pathology
• The first-line approach focuses on assessment for and treatment of associated comorbidities : — Emphasise lifestyle measures , especially weight loss in overweight and obese men .
— Where appropriate in obese men , consider weight loss medications or bariatric surgery .
• Testosterone treatment is generally not recommended and should only be considered in very carefully selected symptomatic men with very low serum testosterone . — Consider testosterone where first-line measures fail , and only after explicit discussion regarding the experimental nature of this treatment , and the uncertainty regarding the risk-benefit ratio of testosterone therapy .
— Only initiate testosterone in consultation with a specialist .
• In general , younger , less obese men with lower testosterone levels and fewer comorbidities are more likely to derive benefit from testosterone treatment and may be at lower risk of adverse events .
• A 3-6 month trial is usually sufficient because if symptoms are caused by androgen deficiency , these should improve within 1-3 months . — Inform the patient at the outset that treatment will be stopped if there is no improvement in pre-defined treatment goals .
• Initially , avoid long-acting testosterone to enable rapid cessation of therapy should adverse events occur , and to reduce the risk of iatrogenic suppression of the endogenous HPT axis : — Risk of suppression of the endogenous HPT axis is relatively low with a short course of testosterone therapy .
Until better evidence is available , only consider testosterone therapy in men with age or obesity-related reductions in serum testosterone who do not have organic hypogonadism in a minority of carefully selected older men , in consultation with a specialist .
Testosterone treatment may be considered in older men with significant clinical features and very low testosterone levels that persist after a trial of lifestyle measures . Only consider this after a tailored diagnostic workup , exclusion of contraindications and appropriate counselling . Identify clear patient-specific treatment goals and implement a standardised monitoring plan to accompany treatment . Stop the testosterone if treatment goals are not met or adverse effects occur . The suggested approach appears in figure 9 .
References Available on request from howtotreat @ adg . com . au