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    Testosterone deficiency

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    Assessment & Plan (short)

    Testosterone deficiency
    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

    Educational

    Education:
    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.
    THERAPY:
    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.

    #1 Dealing with Male Hypogonadism and Low Testosterone

    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

    Organ systems
    • Urology
    Medical field
    • Internal medicine
    Setting
    • Outpatient
    Author
    jason
    Page info

    Originally created: September 3, 2021 by jason

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    Number of revisions: [xyz-ips snippet="numrevisions"]

    References
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