Male hypogonadism

Question 1

What is male hypogonadism in simple terms?

Answer 1

A low / reduced gonadal function

Question 2

What is primary hypogonadism?

Answer 2

The testes are primarily affected

Spermatogenesis is more affected than testosterone production

Question 3

What happens in primary hypogonadism that leads to an increase in LH / FSH levels?

Answer 3

Hypergonadotropic hypogonadism

A decrease in testosterone means there is less -ve feedback to the pituitary - the pituitary then secretes a higher amount of LH / FSH

Question 4

What is secondary hypogonadism?

Answer 4

Where the testes are capable of normal function and the hypothalamus / pituitary are affected

Both spermatogenesis and testosterone production are affected

Question 5

What happens in secondary hypogonadism that leads to a decrease in LH / FDH levels?

Answer 5

Hypogonadotropic hypogonadism

The LH / LSH levels are lower than normal despite a low testosterone level

Question 6

Give 2 congenital causes of primary hypogonadism?

Answer 6

Klinefelter’s syndrome
Y-chromosome deletion

Question 7

Give at least 2 causes of acquired primary hypogonadism?

Answer 7

Testicular torsion / trauma
Chemo / radiotherapy
Varicocele
Orchitis (mumps infection)
Medications (glucocorticoids)

Question 8

What is Klinefelter’s syndrome?

Answer 8

A NON INHERITED nondisjunction genetic cause of hypogonadism

Question 9

How is Klinefelter’s syndrome diagnosed?

Answer 9

Karyotyping

Question 10

Give clinical features of a patient with Klinefelter’s syndrome?

Answer 10

Infertile
Small, firm testes

Increased incidence of learning disability, cryptorchidism and psychosocial issues
Increased incidence of breast cancer and non-Hodgkin lymphoma

Question 11

Give 2 congenital causes of secondary hypogonadism?

Answer 11

Kallmann’s syndrome
Prader-Willi syndrome

Question 12

Give at least 2 acquired causes of secondary hypogonadism?

Answer 12

Pituitary damage (tumour, disease)
Hyperprolactinaemia
Obesity / diabetes
Medications (steroids, opioids)
Acute systemic illness
Eating disorders / excessive exercise

Question 13

What is Kallmann’s syndrome?

Answer 13

A genetic disorder characterised by isolated GnRH deficiency and hyposmia (reduced sense of smell) or anosmia (no sense of smell)

Question 14

What is isolated GnRH deficiency associated with?

Answer 14

Unilateral renal agenesis, red-green colour blindness, cleft lip / palate and bimanual synkinesis

Question 15

Give signs and symptoms of pre-pubertal hypogonadism?

Answer 15

Small male sexual organs
Decreased body hair
High-pitched voice
Low libido
Gynaecomastia
‘Eunuchoidal’ habitus
Decreased bone and muscle mass

Question 16

Give signs and symptoms of post-pubertal hypogonadism?

Answer 16

Normal skeletal proportions
Normal sexual organ size
Decreased libido
Decreased spontaneous erections
Decreased pubic / axillary hair
Decreased testicular volume
Decreased muscle and bone mass
Gynaecomastia

Question 17

What is the first test for suspected low testosterone?

Answer 17

AM testosterone

Question 18

If an AM testosterone is low two times?

Answer 18

Measure LH / FSH

Question 19

If LH / FSH levels are elevated?

Answer 19

Hypergonadotropic hypogonadism

Question 20

If LH / FSH levels are low / inappropriately normal?

Answer 20

Hypogonadotropic hypogonadism

Question 21

When should testosterone be measured?

Answer 21

Between 8 and 11 am

Question 22

How should hypogonadism be managed if fertility is important to the patient?

Answer 22

GnRH or gonadotrophin therapy
Sperm retrieval
Donor sperm

Question 23

What does management aim to achieve in patients who are not concerned about fertility?

Answer 23

Establish / maintain secondary sexual characteristics
Maintain sexual function
Improve body composition
Improve quality of life

Question 24

What is the choice of management of hypogonadism in patients not concerned about fertility?

Answer 24

Testosterone replacement therapy

Question 25

Give 5 ways of administering testosterone replacement therapy?

Answer 25

Transdermal gel
Oral capsules
Transdermal patches
Intranasal
IM injections

Question 26

Give the advantages and disadvantages of testosterone replacement therapy?

Answer 26

Advantages:
fast onset, convenient, mimics circadian rhythm

Disadvantages:
interpersonal transfer, skin irritation possible, non-compliance long term

Question 27

Give known contraindications of testosterone replacement therapy?

Answer 27

Prostate / breast cancer
Haematocrit > 50%
Severe sleep apnoea / heart failure

Question 28

What is the initial monitoring regime of testosterone replacement therapy?

What does the monitoring regime become after this?

Answer 28

Checks every 3-6 months in the beginning of treatment

Annually thereafter

Question 29

What should be checked when monitoring testosterone replacement therapy?

Answer 29

General health
Testosterone concentration
DRE and PSA
Haematocrit
Symptoms of sleep apnoea

Question 30

If anosmia is mentioned in an exam question - what hypogonadism condition is likely?

Answer 30

Kallmann’s syndrome

Question 31

If a male patient presents with infertility what is the 2 tests that should be done?

Answer 31

Semen analysis
AM testosterone

Question 32

Which hypogonadal condition ONLY affects males?

Answer 32

Klinefelter’s syndrome

Question 33

Which hypogonadal condition can affect both males and females, but much more commonly males?

Answer 33

Kallmann’s syndrome

Question 34

How often should nebido injections be given?

Answer 34

Every 10-14 weeks