Testosterone Guidelines Flashcards
What is the lower limit of a normal testosterone?
Guideline 1: A total testosterone level below 300 ng/dL is a reasonable cut-off in support of the diagnosis of low testosterone
When should you measure testosterone?
Guideline 1: testosterone levels should be measured conducted in an early morning fashion (peak between 3-8 AM)
How many low testosterones should be measured to diagnose low testosterone?
Guideline 2: TWO total testosterone measurements that are taken on separate occasions
How do you diagnose testosterone deficiency (not just low testosterone levels)?
Guideline 3: The clinical diagnosis of testosterone deficiency is only made when patients have low total testosterone levels combined with symptoms and/or signs
In whom should you consider measuring testosterone in even in the absence of symptoms or signs associated with testosterone deficiency?
Guideline 4: Clinicians should consider measuring total testosterone in patients with a history of unexplained anemia, bone density loss, diabetes, exposure to chemotherapy, exposure to testicular radiation, HIV/AIDS, chronic narcotic use, male infertility, pituitary dysfunction, and chronic corticosteroid use
Should you use a validated questionnaire to define patients who are candidates for T replacement?
Guideline 5: The use of validated questionnaires is not currently recommended to either define which patients are candidates for testosterone therapy or monitor symptom response in patients on testosterone therapy.
but you can still use them to supplement your thorough history. One such sample questionnaire is the Aging Male Survey (AMS)
Once a person has a diagnosis of low testosterone, what is your next blood work?
Guideline 6: serum luteinizing hormone levels (LH)
If someone has low testosterone levels combined with low or low/normal luteinizing hormone levels, what other test should you order?
Guideline 7: serum prolactin level
Guideline 11: (prior to starting treatment) measure hemoglobin and hematocrit (and warn men of the increased risk of polycythemia)
Guideline 12: (prior to starting treatment) PSA should be measured in men over 40 years of age
What causes hyperprolactinemia?
Medications, most commonly dopamine antagonists (but also anti-psychotics, anti-emetics, proton pump inhibitors, calcium channel blockers, opiates, and selective serotonin reuptake inhibitors) may cause hyperprolactinemia.
Chronic medical conditions, such as hypothyroidism, renal failure, and cirrhosis are associated with hyperprolactinemia as well.
Who should you refer to an endocrinologist?
Patients with persistently high prolactin levels of unknown etiology should undergo evaluation for endocrine disorders
What should you measure in a testosterone deficient patients who present with breast symptoms or gynecomastia prior to the commencement of testosterone therapy
Guideline 9: Serum Estadiol
What should a testosterone deficient man who is interested in fertility have done and be warned of?
Guideline 10: Men with testosterone deficiency who are interested in fertility should have a reproductive health evaluation performed prior to treatment.
Guideline 16: The long-term impact of exogenous testosterone on spermatogenesis should be discussed with patients who are interested in future fertility
What should clinicians should inform testosterone deficient patients about their heart?
Guideline 13: That low testosterone is a risk factor for cardiovascular disease
Patients should be informed that testosterone therapy may result in improvements in what?
Guideline 14: erectile function, low sex drive, anemia, bone mineral density, lean body mass, and/or depressive symptoms
Patients should be informed that the evidence is inconclusive whether testosterone therapy does what?
Guideline 15: improves cognitive function, measures of diabetes, energy, fatigue, lipid profiles, and quality of life measures
What should clinicians say about prostate cancer and testosterone therapy?
Guideline 17: Clinicians should inform patients of the absence of evidence linking testosterone therapy to the development of prostate cancer
Guideline 18: Patients with testosterone deficiency and a history of prostate cancer should be informed that there is inadequate evidence to quantify the risk-benefit ratio of testosterone therapy.
What should clinicians say about venothrombolic events and testosterone therapy?
Guideline 19: Patients should be informed that there is no definitive evidence linking testosterone therapy to a higher incidence of venothrombolic events
What should clinicians say about cardiovascular events and testosterone therapy?
Guideline 20: Prior to initiating treatment, clinicians should counsel patients that, at this time, it cannot be stated definitively whether testosterone therapy increases or decreases the risk of cardiovascular events (e.g., myocardial infarction, stroke, cardiovascular-related death, all-cause mortality)
What is one thing all testosterone deficient men who are overweight or physically inactive should be counseled on as far as one treatment any man should do?
Guideline 21: All men with testosterone deficiency should be counseled regarding lifestyle modifications as a treatment strategy (weight loss and exercise will naturally boost testosterone in these men)
When supplementing testosterone, what testosterone level should you try to achieve?
Guideline 22: Clinicians should adjust testosterone therapy dosing to achieve a total testosterone level in the middle tertile of the normal reference range (450-600)
What should you not prescribe men who are currently trying to conceive?
Guideline 23: Exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive
Guideline 27: Clinicians may use aromatase inhibitors, human chorionic gonadotropin, selective estrogen receptor modulators, or a combination thereof in men with testosterone deficiency desiring to maintain fertility
How long should you wait to start testosterone therapy in a person with a history of cardiovascular events?
Guideline 24: Testosterone therapy should not be commenced for a period of three to six months in patients with a history of cardiovascular events.
What type of testosterone should you not prescribe?
Guideline 25: Clinicians should not prescribe alkylated oral testosterone. (due to their liver toxicity)
You can prescribe testopils, gels, creams, liquids, sublinquial, IM, etc
Clinicians should discuss the risk of transference with patients using testosterone gels/creams. How do you prevent this?
Use an alternative therapy.
Wash hands well after applying
cover the area with clothing after drying
Wash skin prior to skin to skin contact
Wash clothes that touched testosterone separately
should you prescribe testosterone products that are compounded?
Guideline 28: Commercially manufactured testosterone products should be prescribed rather than compounded testosterone, when possible
When should men measure their total testerone level after starting testosterone therapy?
guideline 29: Clinicians should measure an initial follow-up total testosterone level after an appropriate interval to ensure that target testosterone levels have been achieved.
generally 2-4 weeks for gels, liquids and creams
short-acting IM or short-acting SQ pellets (testosterone cypionate or enanthate) mid-cycle after ~ 4 cycles
long-acting IM testosterone (testosterone undecanoate) ~ 15 weeks
anastrozole, clomiphene citrate, and hCG > 4 weeks after starting
long-acting SQ pellets (2-4 weeks to see if number of testopels is appropriate and then 10-12 weeks)
Once a patient is on a stable dose of testosterone therapy, how often should you check their testosterone?
Guideline 30 Testosterone levels should be measured every 6-12 months while on testosterone therapy. (Also check their H/H!)
Describe testosterone regulation in the body:
GnRH released from hypothalamus acts on anterior pituitary to stimulate release of LH and FSH (both act on testes)
FSH → Sertoli Cells → spermatogenesis
LH → Leydig cells → testosterone
Negative feedback to hypothalamus and anterior pituitary by both testosterone and through aromatase (estradiol)
What forms is testosterone found in the body:
60% bound to SHBG (not bioavailable, can measure in elderly or obese men)
Bioavailable:
1-2% free and remainder bound loosely to albumin
AR binds to testosterone and DHT (higher affinity)
What aspects of history are important in assessment of testosterone deficiency?
hypothyroid (similar sxs, measure TSH)
low libido
tiredness
mood altrations (irritability)
fogginess
decreased strength/stamina
loss of muscle mass
central obesity
opioids
corticosteroids
surgeries testis or head
torsion, trauma, orchitis
chemo or radiation
HbA1C, glucose control
PSA (over 40)
Labs to consider with low T
SHBG (older or obese)
TSH
PRL (severely low)
LH
HCT
PSA
HbA1C
Types of hypogonadism:
- Hypergonadotropic hypogonadism (primary) → testicular failure; low T, elevated LH
- Examples: gonadotoxin (chemo, RT), congenital (UDT, Kleinfelter’s), testicular insults (torsion, trauma, testis cancer), meds (spironolactone, ketoconazole)
- Hypogonadotropic hypogonadism (secondary) → low LH, low T (hypothalamus or pituitary problem)
- Examples: genetics (Kallmann, Prader-Willi), trauma (pituitary tumor, prolactinoma, RT, infarct), substances/neg feedback (opioids, steroids, marijuana), metabolic dz (DM, OSA, ESRD, malnutrition, obesity)
- Mixed (compensated hypogonadism) → low T normal/borderline low LH (adult onset)
Benefits of treating hypogonadism:
Sexual function (libido, erections, response to PDE5i)
Body composition (bone mineral, decreased fat, increase skeletal musc)
Psychologic (improved depression)
Cognitive (decreased memory loss, greater attention span)
Comorbidity mgmt. (improved glucose/lipid)
Risk of T treatment:
Impaired spermatogenesis (decreased T production in testis)
Erythrocytosis (higher with IM), keep <54%
Gynecomastia (aromatase)
OSA worsened??
CV risk, controversial
Contraindications to T replacement:
No absolute contraindications
Not ideal for fertility
recommended to avoid prostate cancer, breast cancer, severe OSA, Hct > 50%, severe LUTs, PSA . 4, male infertility
NONE of above are absolute contraindication
Other treatment options besides T for low T:
Not FDA Approved
SERMs: attenuating negative feedback of estrogen on hypothalamus and pituitary → increase LH (less likely to work with testis failure)
CLOMIPHENE CITRATE
Aromatase inhibitor: inhibit conversion of T → E
ANASTRAZOLE (LETROZOLE)
HCG: stimulate Leydig cell production of T (oral and generic)
what do you do if your patient on T therapy has Hct >54%
Men with significant polycythemia (Hct >54%) may require dose adjustment, periodic phlebotomy, or temporary/permanent T discontinuation.
