Clinical Approach to Male Reproductive Endocrine Disorders Flashcards
59 y/o male with fatigue and ED. Has gained 7lbs in 2 months. No longer exercises. Gets headaches. Hx of HTN, T2DM, and hyperlipidemia. Takes amlodipine, metfomrin, and simvastatin. BP: 138/82 HR: 72 RR: 16 BMI: 30 (obese) - mono-gynecomastia - normal prostate exam - HbA1c= 7.2 - TSH= 1.2 (normal) - free T4= 0.6 (low) - cortisol= 7.1 - total testosterone= 120 - free testosterone= 2.4 - LH= 1.2 (low) - FSH= 1.6 (low) - prolactin= 74 (HIGH) What should we do?
- MRI to look at the pituitary for a prolactinoma
What are some contributing factors to androgen deficiency (hypogonadism) in men?
- Klinefelter’s or Kallmann’s syndrome
- testicular injury
- mumps
- orchiectomy
- pituitary tumors
- pelvic or head irradiation
Does male testosterone decrease as we age?
- YES
What symptoms will you see with low testosterone?
- decreased libido
- sexual dysfunction
- fatigue
- decreased muscle strength and mass
- depression
- breast discomfort or gynecomastia
- loss of body hair
- shrinking testes
- height loss
- inability to father children
- hot flashes
When should you draw testosterone levels?
- in the morning when they are highest.
What is the normal range of testosterone?
- 300-1200 mg/dL
* tightly bound to sex hormone-binding globulin
What percent of testosterone is free?
- 2%
* so FREE testosterone is a VERY IMPORTANT TEST.
What will LH and FSH levels help us to distinguish?
- between primary (high LH and FSH) and secondary (low LH and FSH) gonadal failure
How will the testes look in Klinefelter’s (XXY)?
- small firm testes
What is the most common cause of organic impotence (inability to achieve or to maintain a penile erection)?
- DM
How do pts with Klinefelter’s present? (PICMONIC)
- azoospermia
- gynecomastia
- mental abnormalities
- elevated LH and FSH
- chromatin-positive smear
How do we treat Klinefelter’s?
- correct androgen deficiency
- treat the gynecomastia
- psychiatric care
What is myotonic dystrophy? (PICMONIC)
- chronically progressive disease due to tri-nucleotide repeats.
- lenticular opacities (aka cataracts confined to the lens)
- small testes
- normal puberty development
- leads to gonadal failure
Should you do a testicular biopsy in a pts with myotonic dystrophy?
- YES
* however in most cases of low testosterone, we do NOT do biopsies.
Should we treat myotonic dystrophy with androgen therapy?
- NO
What is important to know about seminiferous tubular failure?
- common cause of adult infertility
What is Noonan’s syndrome?
- the male version of Turner’s syndrome causing primary gonadal failure.
What are the clinical features of Noonan’s syndrome?
- cubitus valgus
- short stature
- webbe neck
- low set ears
- shieldlike chest
- ptosis
- pulmonic stenosis
*** What are the obesity-hypogonadism syndromes?
- Laurence-Moon-Biedl syndrom retinitis pigmentosas polydactylyl, mental retardation.
- Alstrom syndrome= retinitis pigmentosa, nerve deafness, DM, primary gonadal failure.
- Prader-Willi syndrome= hypotonia and mental retardation.
What is cryptorchidism?
- undescended testes
* treat with HCG or orchiopexy
What will you see with hypgonadotropic (Kallman’s) syndrome? (PICMONIC)
- anosmia (loss of sense of smell)
- hyposmia (reduced ability to smell)
- tall stature
- caused by failure to start or complete puberty due to defective migration of GnRH releasing neurons to the hypothalamus
How do we treat Kallmans?
- HCG
- Testosterone
What are the types of testosterone formulations?
- T enanthate
- scrotal patch
- nongenital transdermal system (most common)
- T gel (buccal)
- injectable in oil
- subcutaneous pellets
What are the side effects of testosterone?
- can reduce sperm count and testicular volume
- aggressiveness
- gynecomastia
- increased prostate size
- hepatotoxicity (peliosis hepatitis) with oral testosterone
