Androgen Deficiency in Men Flashcards
What is androgen deficiency?
Clinical syndrome with characteristic symptoms and signs
Low testosterone levels
Absence of transient/reversible causes of low testosterone levels
What are the symptoms of androgen deficiency?
Non-specific - Decreased sense of wellbeing - Poor concentration - Tiredness - Poor stamina - Mood change - Depression - Irritability - Sleep disturbance Sexual - Reduced libido - Erectile dysfunction rare - Infertility Organ specific - Reduced muscle mass and strength - Osteoporosis and fracture - Increased fat mass - Breast discomfort
What are the issues associated with measuring testosterone levels?
No age-related reference ranges
- For younger patients, aim for mid-normal range
- Can be lower for older patients
- If within normal range, do they need hormone replacement?
Lack of standardisation
Inaccuracy in low range
When is the risk of osteoporosis and fracture increased in relation to androgen deficiency?
If found in younger patients; ie, <50
What are the signs of androgen deficiency?
Gynaecomastia Loss of body hair - Axillary - Pubic - Decreased shaving Very small/shrinking testes - especially <5 mL Low-zero sperm counts Mild anaemia
What does the clinical presentation of male hypogonadism depend on?
Age of onset
What are the features of male hypogonadism if onset is during the first trimester?
Partial virilisation
Ambiguous genitalia
If complete deficiency: female external genitalia
What are the features of male hypogonadism if onset is during the third trimester?
Micropenis
Cryptochidism
What are the features of male hypogonadism if onset is during pre-puberty?
Incomplete pubertal maturation Testes <4 mL Eunochoidal body habitus Gynaecomastia Decreased peak bone mass
What are the features of male hypogonadism if onset is during adulthood?
Decrease in - Libido - Mood - Stamina - Muscle mass and strength - Bone mineral density Increased fat mass
When is free testosterone measured instead of total testosterone?
Any condition where sex hormone-binding globulin (SHBG) altered
What does it mean if serum total testosterone is normal?
Eugonadal
What do you do if serum total testosterone is low?
Repeat test > if normal > eugonadal
What do you do if serum total testosterone is borderline?
Calculated free testosterone, to rule out falsely low total testosterone
What may it mean if leutenising hormone (LH) is elevated?
Decreased testosterone secretion
What are LH and follicle stimulating hormone (FSH) levels in primary androgen deficiency?
Elevated
What are LH and FSH levels in secondary androgen deficiency?
Low/(inappropriately) normal
What are some examples of acquired primary androgen deficiencies?
Testicular damage - Trauma - Orchitis - Toxins Drugs - Spironolactone - Ketoconazole
What are some examples of congenital primary androgen deficiencies?
Klinefelter syndrome Cryptorchidism Mutations in androgen biosynthesis enzymes LF/FSH receptor mutations Myotonic dystrophy
What are some examples of structural secondary androgen deficiencies?
Tumour Surgery Radiation Trauma Infiltration - Iron overload - Sarcoidosis - Histiocytosis
What are some examples of genetic secondary androgen deficiencies?
Kallmann’s syndrome
Idiopathic hypogonadotropic hypogonadism
LH/FSH beta subunit mutations
What are some examples of functional secondary androgen deficiencies?
Hyperprolactinaemia
Morbid obesity
Cushing’s syndrome
What are some examples of partial or transient androgen deficiencies?
Acute illness
Chronic disease
Drugs
What effect does hyperprolactinaemia have on gonadotropins?
Inhibitory
What is the genetic abnormality in Klinefelter’s syndrome?
90% 47, XXY
What are the features of Klinefelter’s syndrome?
Testes <4 cm, firm, “pea-like”
Azoospermia > infertility
Total testosterone commonly low/normal, LH high
More rapid total testosterone decrease with ageing
Puberty triggers germ cell extinction
What are the differential diagnoses if the testes are not palpable?
Anorchism
Bilateral cryptorchidism
What are the differential diagnoses if the testes are less than 5 mL?
Kallmann’s syndrome
- Anosmia
Hypogonadotropic hypogonadism
Klinefelter’s syndrome
What are the differential diagnoses if the testes are between 8 and 15 mL?
Germinal damage
- Toxins
- Idiopathic
What are the differential diagnoses if the testes are between 15 and 20 mL?
Varicocele
Drugs
Idiopathic
When are natural testosterone levels highest in the body?
0800-1000
If sperm are viable in a case of androgen insufficiency, why are they harvested before androgen therapy is started?
Therapy decreases FSH and LH so testes stop producing sperm
What are the different modes of delivering androgens?
Tablets - Not used, because too many side effects Gel/patches - More steady release 8-10 week/3 monthly injections - Take time to peak and then wane
When is non-classical androgen deficiency common?
Ageing
Chronic disease
What are the principles of management for testosterone therapy?
Establish treatment goals
Achieve adequate total testosterone levels
Monitor treatment response
Monitor for adverse effects
What are the adverse effects of testosterone therapy?
Erythrocytosis Acne and oily skin Deranged LFTs Enlarged prostate Reduced sperm production and fertility
What are the contraindications to testosterone therapy?
Evidence of prostate cancer Breast cancer Erythrocytosis/hyperviscosity Untreated obstructive sleep apnoea Severe lower urinary tract symptoms Class III/IV heart failure Desire to have children
