MEN'S HEALTH
LAB INVESTIGATIONS
The diagnosis of hypogonadism should be made after two early
morning total testosterone levels are less than 300. If the diagnosis of
low testosterone is made, further testing should be done to identify
if the cause is testicular, hypothalamic or pituitary.
Testosterone is bound tightly to sex hormone binding globulin
(SHBG). Free and loosely bound testosterone are called bio-available
testosterone. Bio-available testosterone is a calculated value and is
used more frequently than free testosterone as there is considerable
variability in its measurements.
Men with low testosterone levels and low LH levels need a pitu-
itary MRI regardless of prolactin levels as non-secretory adenomas
may be identified. Estradiol needs to be measured in men with breast
tenderness or gynecomastia.
It is essential to get baseline labs namely CBC, CMP and PSA
levels prior to starting testosterone therapy. Subsequently, once a
steady state of testosterone has been reached, the aforementioned
labs and a testosterone level must be checked every six months.
TREATMENT
The goal of treatment is to alleviate the symptoms of hypogonad-
ism, restore sexual function, libido and well-being. The goal is to
attain testosterone levels between 300 and 800 during testosterone
replacement.
Transdermal patches
Patches deliver testosterone continuously over a 24-hour period.
Application site reactions account for a majority of the adverse
effects associated with patches. Local reactions include pruri-
tus, blistering, erythema and dermatitis. There is a significant
percentage of patients that discontinue patches due to their
side-effects.
Topical Gels
There are several brand name gels available on the market.
The gels deliver 40-50 mg of testosterone daily. Androgel and
Testim are applied to the shoulders and upper arms daily while
Fortesta is applied to the thighs. Axiron is a liquid and applied
to the axilla daily.
Buccal and nasal delivery
Striant is a buccal system of delivery that is used twice a day.
Natesto is a nasal pump that is used every eight hours. These
alternate systems have failed to obtain a significant following
secondary to the more than once daily dosing.
Injectables
Testosterone cypionate and enanthate are the two most com-
monly used formulations of injectable testosterone. Peak levels
occur in 72 hours and wane over the next few weeks. There is a
wider fluctuation with injectables as opposed to patches or gels.
The advantage of injectable testosterone is its cost-effectiveness.
It takes several weeks to fine-tune the dosage and the injection
intervals to attain physiological levels of testosterone. A good
starting dose is 100 mg testosterone cypionate weekly that can
be titrated based on levels and alleviation of symptoms.
Testosterone Pellets
Testopel is an effective method of testosterone replacement.
Testosterone pellets are placed subcutaneously every four to
six months. Each pellet is 75 mg of testosterone, and a good
starting dose is 12 pellets. Careful monitoring of testosterone
levels will determine the the dosage and frequency of subse-
quent Testopel insertions.
Oral Testosterone
Oral testosterone is not recommended for testosterone re-
placement secondary to its potential for liver dysfunction on
account of the first-pass metabolism.
Other options
Clinicians may use aromatase inhibitors, HCG, SERM (selective
estrogen receptor modulators) in men with low testosterone
desiring to preserve fertility.
RISKS AND BENEFITS
The benefits of testosterone replacement in the hypogonadal male
are numerous. It improves sexual and erectile function, improves
general well-being, improves responsiveness to PDE-5 inhibitors,
improves exercise tolerance and decreases all-cause mortality.
Clinicians need to inform patients that hypogonadism is a risk
factor for cardiovascular disease. Cardiovascular benefits or harm
from testosterone therapy are inconclusive. Until there is defin-
itive evidence proving association between testosterone therapy
and subsequent major cardiac events, the recommendation is to
counsel patients that the current literature does not demonstrate
an increased risk.
There is no definitive evidence linking testosterone therapy to
thromboembolic events or development of prostate cancer.
CONCLUSION
Hypogonadism is a disease process that can affect men of all ages,
especially older men. For men with low testosterone levels, and
signs and symptoms of hypogonadism, a wide array of treatment
choices are available. Careful dosing and monitoring of lab values
and symptomatology are essential in the successful treatment of
these patients. All of us need to be able to recognize and treat these
patients appropriately to put an end to the unscrupulous “Low
T” clinics that are practicing bad medicine and to whom several
innocent and naïve patients are falling prey!
Dr. Rao is a practicing urologist at First Urology.
JULY 2019
29