Patient complains of fatigue, depressed mood, loss of muscle mass, weight gain, low libido and poor sexual function. Physical exam is *absent of* gynecomastia and testicular atrophy (less than 20-30 cc and soft consistency)
-Order AM total testosterone x1. If less than 300 then repeat total T with prolactin, FSH, LH, SHBG and bioavailable testosterone. Consider a brain MRI in young men. (free T, bioT and SHBG are more accurate in the morning)
-Treat modifiable risk factors: opiate abuse, heavy alcohol use, sleep apnea, obesity
-Recommend a trial of topical therapy at 40 mg daily. Goal total T is 400-700.
-Monitor PSA and CBC yearly.
Assessment & Plan (long)
Testosterone deficiency - Candidate for treatment
Mixed primary and secondary hypogonadism. Low testosterone x2, Low free/total and low LH in am. Discussed risks and benefits of hormone replacement therapy at length and patient opts for testosterone therapy with the monitoring requirements listed below.
-continue to treat modifiable risk factors: alcohol use, sleep apnea, obesity
-retest total testosterone, PSA and CBC after 6 weeks of therapy
-Monitor PSA and CBC every 6 months, consider DRE and Lipid panel as well
--refer to a urologist if PSA level greater than 4.0 ng/mL or more than 0.75 ng/ml increase in a year
--hematocrit (testosterone stimulates bone marrow production of erythrocytes)
-100mg testosterone cypionate weekly, Goal total T is 400-700.
-150-200mg twice daily estrogen blocker - DIM Supplement (Diindolylmethane) or Indole-3-Carbinol (I3C)
-Call us when your prescription arrives and we can set up a nursing visit to demonstrate proper injection techniques
Step 1) Check total testosterone (total T) between 7am and 10am. Testosterone is 60% bound to sex hormone binding globulin (SHBG), 39% albumin bound and 1% free testosterone.
Step 2) If total T is less than 300, then repeat total T but add FSH, LH, prolactin, SHBG and bioavailable testosterone. and PSA to establish baseline.
Step 3) Consider MRI if prolactin high or if low testosterone in a young male
Note: Obese males have low sex hormone binding globulin. This creates an artifact of low Total T (since 60% is bound to SHBG). Therefore, do not treat these patients unless they have low bioavailable testosterone.
Trial of topical therapy recommended. Apply in AM to mimic physiologic levels. Start at 40 mg. Consider repeat level in 2-4 weeks. Goal is Total T 400 to 700 and monitor for improved mood, energy and libido. If no improvement then stop therapy.
Note: Some patients may ask but use is not recommended in women.
Primary if testes unable to produce testosterone.
Secondary if pituitary is under producing gonadotropins.
Age related hypogonadism is controversial since men have a 1% per year loss of testosterone after age 30 years old.
Mixed 1y and 2y: sickle-cell disease, thalassemia, alcoholism, glucocorticoid treatment, and in older men
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