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Year 2 Medicine > Endocrine Aspects of Male Hypogonadism > Flashcards

Endocrine Aspects of Male Hypogonadism Flashcards

1
Q

Testosterone is a … hormone

A

steroid

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2
Q

Testosterone is secreted in both men and women, where?

A

testes, ovaries, adrenals

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3
Q
  • Normal young men produce how much testosterone a day?
  • how much is derived from adrenal secretions?
A
  • 7mg
  • less than 5% is derived from adrenal secretions
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4
Q
  • Testosterone in blood is largely bound to … protein, with only about …% present as free hormone
    • about … is bound to albumin
    • …% is bound to sex hormone-binding globulin
A
  • Testosterone in blood is largely bound to plasma protein, with only about 2% present as free hormone
    • about half is bound to albumin
    • 44% is bound to sex hormone-binding globulin
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5
Q

The Testes contain two anatomical units:

  1. … tubules in which inhibin B and anti-Mullerian hormone are synthesized by Sertoli cells and sperm are produced
  2. An … containing Leydig cells that produce androgens and peritubular myoid cells
A
  1. Seminiferous tubules in which inhibin B and anti-Mullerian hormone are synthesized by Sertoli cells and sperm are produced
  2. An interstitium containing Leydig cells that produce androgens and peritubular myoid cells
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6
Q

Seminiferous tubules - part of testes

  • inhibin B and anti-Mullerian hormone are synthesized by … cells and … are produced
A

inhibin B and anti-Mullerian hormone are synthesized by Sertoli cells and sperm are produced

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7
Q

What is a Sertoli cell?

A

A Sertoli cell is a “nurse” cell of the testicles that is part of a seminiferous tubule and helps in the process of spermatogenesis, the production of sperm.

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8
Q

What are Leydig cells?

A
  • Leydig cells are interstitial cells located adjacent to the seminiferous tubules in the testes.
  • The best-established function of Leydig cells is to produce the androgen, testosterone, under the pulsatile control of pituitary luteinizing hormone (LH)
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9
Q

What are peritubular myoid cells?

A

A peritubular myoid (PTM) cell is one of the smooth muscle cells which surround the seminiferous tubules in the testis

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10
Q

Androgens are synthesized from … and are produced primarily in the … (testicles and ovaries) and also in the … glands

A

Androgens are synthesized from cholesterol and are produced primarily in the gonads (testicles and ovaries) and also in the adrenal glands.

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11
Q

Androgens: Synthesis

  • … is needed to convert cholesterol to pregnenolone
  • pregnenolone is converted either to … or D…
  • these converted to testosterone
  • once these are in circulation - 5alpha reductase converts testosterone into …
  • Or, aromatase converts it into … (… required)
A
  • LH is needed to convert cholesterol to pregnenolone
  • pregnenolone is converted either to progesterone or DHEA
  • these converted to testosterone
  • once these are in circulation - 5alpha reductase converts testosterone into DHT
  • Or, aromatase converts it into estradiol (FSH required)
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12
Q

Testosterone: The hypothalamic-pituitary-testicular axis

  • In the hypothalamus there is … secretion of … - acts on pituitary leading to …
  • Secretion of LH and FSH
  • LH and FSH are composed of … glycoprotein chains
  • LH is involved in release of …
  • FSH is involved in … and Inhibin B …
A
  • In the hypothalamus there is pulsatile secretion of GnRH - acts on pituitary leading to …
  • Secretion of LH and FSH
  • LH and FSH are composed of two glycoprotein chains
  • LH is involved in release of Testosterone
  • FSH is involved in spermatogenesis and Inhibin B secretion
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13
Q

Testosterone: Mechanism of Action

  • Like other … hormones, testosterone penetrates the target cells whose growth and function it stimulates
  • Androgen target cells generally convert testosterone to … before it binds to the androgen receptor
  • Alternatively, testosterone can be … to …, which exerts effects that are independent of, opposite to, or synergistic to those of androgen
A
  • Like other steroid hormones, testosterone penetrates the target cells whose growth and function it stimulates
  • Androgen target cells generally convert testosterone to 5-alpha dihydrosterone befire it binds to the androgen receptor
  • Alternatively, testosterone can be aromatized to estrogens, which exerts effects that are independent of, opposite to, or synergistic to those of androgen
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14
Q

Testosterone action

  • regulation of … secretion by the hypothalamic-pituitary system
  • initiation and maintenance of …
  • formation of the … phenotype during embryogenesis
  • promotion of sexual … at puberty and it’s maintenance thereafter
  • increase in … body mass and decrease in … mass
A
  • regulation of gonadotropin secretion by the hypothalamic-pituitary system
  • initiation and maintenance of spermatogenesis
  • formation of the male phenotype during embryogenesis
  • promotion of sexual maturation at puberty and it’s maintenance thereafter
  • increase in lean body mass and decrease in fat mass
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15
Q

Why is testosterone important?

  • sharper …
  • increased … mass
  • strong …
  • pleny of ….
  • confidence
A
  • sharper mind
  • increased muscle mass
  • strong bones
  • pleny of energy
  • confidence
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16
Q

Male hypogonadism is defined as decrease in one or both of the two major functions of the testes - what are these?

A

sperm production or testosterone production

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17
Q

Disease of testes is what type of hypogonadism?

A

primary hypogonadism

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18
Q

Disease of the hypothalamus or pituitary is what type of hypogonadism?

A

secondary hypogonadism

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19
Q

Primary hypogonadism:

  • Testerone levels are below normal and the serum … and/or … are above normal

Secondary hypogonadism:

  • Testerone levels are below normal and the serum … and/or … are normal or low
A
  • Testerone levels are below normal and the serum LH and/or FSH are above normal
  • Testerone levels are below normal and the serum LH and/or FSH are normal or low
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20
Q

Causes of Primary Hypogonadism:

  • … syndrome is most common
  • a condition in which one or both of the testes fail to descend from the abdomen into the scrotum - what is this called?
  • Idiopathic causes
  • Torsion
  • Trauma
  • Radiation
  • Infection - such as …
A
  • Klinefelter syndrome is most common
  • Cryptochidism
  • Idiopathic
  • Torsion
  • Trauma
  • Radiation
  • Infection - mumps
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21
Q
  • What is Klinefelter syndrome?
  • It can result in what?
A
  • Klinefelter syndrome is a genetic condition that results when a boy is born with an extra copy of the X chromosome.
  • Can result in primary hypogonadism
22
Q

Causes of Secondary Hypogonadism:

  • Congenital … deficiency
  • Hyper…
  • … analog
  • Androgen
  • Excessive use of …
  • Illness
  • Eating disorder - which one?
  • … disorder
A
  • Congenital GnRH deficiency
  • Hyperprolactinemia
  • GnRH analog
  • Androgen
  • Opioids - excessive use
  • Illness
  • Anorexia Nervosa
  • Pituitary disorder
23
Q

Clinical features of Hypogonadism

  • First trimester - … genitalia to ambiguous genitalia to partial …
  • Third trimester - child will have a …
  • Prepubertal - failure to undergo or complete …
A
  • First trimester - Female genitalia to ambiguous genitalia to partial virilization
  • Third trimester - child will have a micropenis
  • Prepubertal - failure to undergo or complete puberty
    *
24
Q

Symptoms/Signs of hypogonadism

  • Incomplete … development, eunochoidism
  • decreased sexual desire and activity
  • decreased sponatenous …
  • breast discomfort, …
  • decreased body … (Axillary and pubic), decreased …
  • very small or shrinking … (Esp <5ml)
  • inability to …, low/zero sperm counts
  • lose height, low-trauma fracture, low BMD
  • lose … bulk and strength
  • hot …, …
A
  • Incomplete sexual development, eunochoidism
  • decreased sexual desire and activity
  • decreased sponatenous erections
  • breast discomfort, gynecomastia
  • decreased body hair (Axillary and pubic), decreased shaving
  • very small or shrinking testes (Esp <5ml)
  • inability to father children, low/zero sperm counts
  • short height, low-trauma fracture, low BMD
  • lose muscle bulk and strength
  • hot flushes, sweats
25
_Less specific symptoms/signs of hypogonadism_ * Lack of ... * emotions? * poor ... and ... * disturbance of ... * mild ... * normochromic, normocytic, in the female range * increased ... ... * diminished ... or ... performance
* Lack of **energy, motivation, initiative, aggressiveness, self-confidence** * **feeling sad or blue, depressed mood, dysthymia** * poor **concentration** and **memory** * **sleep** disturbance, increased sleepiness * mild **anaemia** * normochromic, normocytic, in the female range * increased **body fat, BMI** * **diminished physical or work performance**
26
_Conditions with a High Prevalence of hypogonadism (screening suggested)_ * diseases/mass of what part of pituitary? * medications such as ... (3) * ... or low trauma ... - esp in young * infertility * type ... diabetes mellitus * Moderate to severe ... * ESRD and maintenance hemodialysis * ...-associated weight loss
* diseases/mass of what part of pituitary - **sella turcica** * meds - **glucocorticoids, ketoconazole, opioids** * **Osteoporosis** or low **trauma** fracture - esp in young * **infertility** * **Type 2** diabetes mellitus * Moderate to severe **COPD** * ESRD and maintenance hemodialysis * **HIV**-associated weight loss
27
_Relevant medical history - hypogonadism_ * ... and sexual development * Past/present major ... * Past/present ... deficiency * What drugs are we interested in? * ... and ... problems * major ... events * related ... Hx * Recent changes in body - esp in the ... * ... problems
* **Puberty** and sexual development * Past/present major **illnesses** * Past/present **nutritional** deficiency * **All prescription/non prescription drugs** * **relationship** and **sexual** problems * major **life** events * related **family** Hx * Recent changes in body - **breasts** * **testicle** problems
28
_Examination - hypogonadism_ * amount of ... ... - comparison to family members * ... exam for enlargement/tenderness * size and consistency of ... * size of the ... * signs of severe and prolonges hypogonadism, including ... (4) * loss of .. ... * reduced ... ... and strength * ... * smaller ... * ... span
* amount of **body hair** * **breast** exam for enlargement/tenderness * size and consistency of **testicles** * size of the **penis** * signs of severe and prolonged hypogonadism * loss of **body hair** * reduced **muscle** **bulk** and strength * **osteoporosis** * smaller **testicles** * **arm** span
29
_Investigations - Hypogonadism_ * Serum ... - do this before .. am in a ... state * .../... (2 hormones?) * SHBG - known as ... * ... function test * ... analysis * Karoyotyping * ... function testing * CT or MRI? * ... scan
* Serum **testosterone** - **before** **9 am in a fasting state** * **LH/FSH** * **SHBG - known as Sex hormone binding globulin** * **Liver** Function Test * **Semen** analysis * **Karoyotyping** * **Pituitary** function testing * **MRI** scan * **DEXA** scan
30
_Guidelines on screening - Hypogonadism_ Initial screen = ... total testosterone * Levels are highest in the ... * Normal testosterone is generally ... dependent * Confirmation = ... ... total testosteron * Free or bioavailable * Do not screen during acute or subacute ... * Illness, malnutrition, and certain medications may temporarily ... testosterone
Initial screen = **morning** total testosterone * Levels are **highest** in the morning * Normal testosterone is generally **age** dependent * Confirmation = **repeat morning** total testosteron * Free or bioavailable * Do not screen during acute or subacute **illness** * Illness, malnutrition, and certain medications may temporarily **lower** testosterone
31
What is this flowchart for?
Hypogonadism screening
32
Testosterone circulates mostly bound to ... (SHBG)
Sex hormone binding globulin
33
_What lowers SHBG:_ * Moderate ... * ... syndrome * ...thyroidism * Use of * ... * ... * ... steroids
* Moderate **obesity** * **Nephrotic** syndrome * **Hypo**thyroidism * Use of **•Glucocorticoids** **•Progestins** **•Androgenic steroids**
34
_What raises SHBG:_ * younger or older? * Hepatic ... * ...thyroidism * Anti... * what sex hormone? * ... infection
* younger or older - aging * Hepatic **cirrhosis** * **hyper**thyroidism * Antic**onvulsants** * what type of hormone? - **estrogens** * **HIV** infection
35
What is this flowchart for?
diagnosing hypogonadism - primary or secondary
36
_Treatment for hypogonadism_ * What hormone? * How is it given? * Inform of side effects!!!!
* Testosterone - given by gel, injection or buccal/patch/pellet
37
_Monitoring treatment of hypogonadism_ * testosterone levels ... hours after applying gel, if injection - do it when? * PSA - what does this stand for? * Digitial ... exam * blood count? * DEXA scan - why?
* Testosterone - **4** hours after - injection - check it just before injection * PSA - **Prostate-Specific Antigen (test)** * Digital **rectal** exam * Yes - **full blood count** * DEXA - scan is a high-precision type of X-ray that measures your bone mineral density and bone loss - **low testosterone affects bone density**
38
_Contraindications to Testosterone therapy_ * What cancers? * Lump/hardness on ... exam by DRE * PSA \>... ng/ml that has not been evaluated for prostate cancer * Severe untreated BPH (AUA/IPSS \>19) - What does this stand for? * Erythrocytosis (hematocrit \>...%) * Hyperviscosity - what is this? * Untreated obstructive ... apnea * Severe ... ... (class III or IV)
* **Breast or prostate cancer** * Lump/hardness on **prostate** exam by DRE * PSA \>**3** ng/ml that has not been evaluated for prostate cancer * Severe untreated **BPH** (AUA/IPSS \>19) - **Benign prostatic hyperplasia** * Erythrocytosis (hematocrit \>**50**%) * Hyperviscosity - condition in which blood isn't able to flow freely through your arteries * Untreated obstructive **sleep** apnea * Severe **heart failure** (class III or IV)
39
What is gynecomastia?
Gynecomastia, a benign proliferation of the glandular tissue of the male breast
40
_Gynecomastia_ * may be ... or ... * diagnosed on ... as a palpable mass of tissue of at least ... cm in diameter (usually underlying the nipple) * imbalance between ... and .. hormones * ...% of boys during puberty - transient * ...-...% in adult men
* may be **unilateral or bilateral** * diagnosed on **exam** as a palpable mass of tissue of at least **0.5** cm in diameter (usually underlying the nipple) * imbalance between **androgen** and **estrogen** * **60**% of boys during puberty - transient * **30-70**% in adult men
41
_Causes of Gynecomastia_ * Persistent ... gynecomastia * Can drugs cause it? * Idiopathic causes * Cirrhosis or malnutrition * ...gonadism * Testicular ... * ...thyroidism * Chronic renal ... - ... cell dysfunction
* Persistent **pubertal** gynecomastia * **yes - drugs can** * **Idiopathic** causes * **Cirrhosis** or **malnutrition** * **Hypo**gonadism * Testicular **tumour** * **Hyper**thyroidism * Chronic renal **insufficiency** - **Leydig** cell dysfunction
42
_Evaluation - Gynecomastia_ * Is the breast enlargement of recent onset or associated with ... or ...? * Is the breast enlargement due to increased glandular tissue or is it only ... tissue (pseudogynecomastia)? * Are there findings suggestive of breast ...? * Is there evidence of a testicular ..., which might lead to gynecomastia by producing ... or stimulating its production? * Can a cause for the breast enlargement be identified? * Is the patient ... by the breast enlargement?
* Is the breast enlargement of recent onset or associated with **pain** or **tenderness**? * Is the breast enlargement due to increased glandular tissue or is it only **adipose** tissue (pseudogynecomastia)? * Are there findings suggestive of breast **cancer**? * Is there evidence of a testicular **tumor**, which might lead to gynecomastia by producing **estrogen** or stimulating its production? * Can a cause for the breast enlargement be identified? * Is the patient **troubled** by the breast enlargement?
43
_History - Gynecomastia_ * Duration * Breast .../tenderness * ... disease * ... gain or loss * Use of ... * Exposure to ... * Fertility * Sexual ... * ... history
* Duration * Breast **pain**/tenderness * **systemic** disease * **weight** gain or loss * Use of **medical/recreational drugs** * Exposure to **chemicals** * Fertility * Sexual **fu****nction** * **family** history
44
_Examination - gynecomastia_ * ... is a condition in which women develop male-pattern hair growth and other masculine physical traits * Testicular ... * penis * sign of CLD or CRF - what is this? * thyroid * breast
* Virilisation * Testicular **size** * penis * sign of CLD or CRF - what is this? - **chronic liver disease / chronic renal failure** * thyroid * breast
45
_Investigation - gynecomastia_ * Testosterone * 2 hormones? * Pro... * LFT/U&E's * B-hCG * ... function tests * Estrogen * U/S chest and ...
* Testosterone * 2 hormones? - **LH and FSH** * Pro**lactin** * LFT/U&E's * B-hCG * **Thryoid function tests** * Estrogen * U/S chest and a **mammogram**
46
_Treatment - gynecomastia_ * Conservative - reassurance * Treatment of ... * ... prescribed - if patient's are having progressive gynecomastia * Affecting psychological wellbeing - ... is an option
* Conservative - reassurance * Treatment of **cause** * **Tamoxifen** - if patient's are having progressive gynecomastia * Affecting psychological wellbeing - **surgery** is an option
47
Are both LH and FSH involved in testosterone production?
No - only LH
48
Is GnRH secretion normally continuous?
no - pulsatile manner
49
Most testerone is bound to protein (albumin/SHBG) * T or F?
True
50
* High LH/FSH and low testosterone - what is the diagnosis?
Primary hypogonadism
51
* Low LH/FSH and low testosterone - what is the diagnosis?
secondary hypogonadism
52
Treatment for hypogonadism:
testosterone - gel or injection (2 option - 2 weekly or 3 monthly)

Year 2 Medicine (162 decks)

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