Male Hypogonadism

Question 1

What is the typical clinical presentation of Male Hypogonadism?

Answer 1

H/o:
Behavioral abnormalities --> Klinefelter's XXY
Chemo or radiation therapy, ETOH abuse
Anosmia --> Kallmann's 
Visual field cuts --> PITUITARY tumor
Medications

Question 2

What are some of the measurements which can aid in cuing you into a Male Hypogonadism PT?

Answer 2

Eunuchoid proportions:
More than 2cm difference between floor to pubis than pubis to crown

4 to 7cm in length

Question 3

What is the most important test you can order for a PT suspected of Male Hypogonadism?

Answer 3

SERUM TOTAL TESTOSTERONE
~~MOST IMPORTANT SINGLE TEST
~~30% difference in AM vs. PM; always get an AM Testosterone

SERUM FREE TESTOSTERONE
~~Use when obesity or aging is involved

PROLACTIN
~~Rule out pituitary involvement!

Question 4

What conditions could result in a false reading of testosterone levels?

Answer 4

Illness

Steroid therapies

(will give lower than true values)

Question 5

If the LH/FSH comes back and is elevated; but the testosterone is low.. What clinical condition is this?

Answer 5

Primary Hypogonadism

Question 6

If the LH/FSH comes back and is low and the testosterone is low; what clinical condition is this?

Answer 6

Hypopit PTs
Secondary Hypogonadism

(EVERYTHING IS LOW)

Question 7

Which form of hypogonadism is more commonly associated with gynecomastia?

Answer 7

Primary Hypogonadism

Question 8

What is the treatment therapy for male hypogonadism?

Answer 8

Testosterone enanthate
Testosterone cypionate

Suggested dose 100mg IM weekly

Transdermal –> Androderm (5mg / 24hr)

Question 9

What are some S/E of Testosterone therapies?

Answer 9

Acne
Gynecomastia
Physically aggressive behavior
PSA increase
Erythrocytosis  (GRAB CBC for hematocrit in these PTS)
Sleep Apnea
LOWER HDL cholesterol
CVD Risk

Question 10

Why do male adolescents have a high prevalence of gynecomastia?

Answer 10

Estrogen spikes before testosterone bump

This is why peak is 13 to 15y/o; but not common after age 17

Question 11

What is the pathogenesis; five factors of Gynecomastia?

Answer 11

Decreased androgens
Increased estrogens
Increased availability of estrogen precursors
Androgen receptors are blocked
Increased binding capacity of androgens to SHBG (sex hormone binding globulin)

Long story short Estrogen-Androgen imbalance

Question 12

Which drugs may cause gynecomastia?

Answer 12

Abx (ketoconazole, INH)
Antiulcer
     Cimetidine, Omeprazole, Ranitidine
Alcohol and illicit drugs
Tricyclic antidepressants
CVD Drugs
      Amiodarone, Ca channel blockers, methyldopa, spironolactone, digitoxin

Question 13

What is the work up for a PT with suspected gynecomastia?

Answer 13

Full PE
Drug Hx
Liver / Kidney Hx
Thyroid (TSH)
hCG
Testosterone 
Estradiol 
Prolactin

Question 14

Why do older males become hypogonadal?

Answer 14

Sex hormone binding globulin increases with age which ties up all the testosterone.

Less free testosterone –> S/Sx of hypogonadism

Question 15

What are the treatment guidelines for hypogonadism?

Answer 15

<200 ng/dL serum testosterone
10%Free T below normal + symptoms

Tx up until in the range of 300-400 ng/dL
Young male target: 500-600