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androgen insufficiency (hypoandrogenism, testosterone deficiency)

Also see andropause, hypogonadism. Etiology: 1) hypogonadism 2) orchidectomy 3) pharmaceuticals a) estrogen therapy b) opioids c) high-dose glucocorticoids 4) Klinefelter's syndrome 5) hypopituitarism 6) testicular feminization 7) hepatic cirrhosis 8) andropause* 9) levels drop in men with children * 40% of men > 45 years of age [4] Clinical manifestations: 1) incomplete or delayed sexual development [4] 2) diminished libido 3) diminished spontaneous erections 4) breast discomfort, gynecomastia 5) loss of axillary & pubic hair, diminished beard growth 6) very small or shrinking testes (< 5 mL) 7) infertility 9) loss of height, evidence of osteoporosis 10) hot flushes, sweats 11) diminished sense of well-being a) decreased energy, motivation, initiative, self-confidence b) depression, dysthymia 12) persistent & unexplained fatigue 13) cognitive impairment a) inability to concentrate b) memory impairment 14) sleep disturbance, hypersomnia 15) reduced muscle bulk & muscle strength 16) increased body fat, BMI 17) diminished physical performance or work performance [4] Laboratory: 1) normal serum estradiol 2) diminished serum testosterone (AM measurement) - free testosterone diminished - not recommended unless method is equilibrium dialysis - indicated if risk factors for diminished SHBG (obesity, older age) [4] 3) serum LH & serum FSH to distinguish primary from secondary androgen insufficiency 4) serum prolactin to assess pituitary disease 5) complete blood count (not routine) - mild anemia, normocytic, normochromic - in normal range for female 6) sperm count may be low (not routine) - may be indicated if fertility issues Special laboratory: - low bone mineral density Differential diagnosis: 1) depression 2) hypopituitarism Complications: - increased risk of cardiovascular disease - increased risk of mortality in elderly men [11] Management: 1) androgen replacement recommended for symptomatic patients only [4,6] a) testosterone b) Estratest (women) 2) confirmatory testing before treatment [4] 3) screening not recommended [3]

Related

androgen deprivation therapy (ADT) androgen or anabolic steroid andropause hypogonadism

General

endocrine disease

References

  1. Journal Watch 22(10):78, 2002 Bachmann G et al, Fertil Steril 77:660, 2002
  2. Guidelines on testosterone therapy in adult men with androgen deficiency syndromes (Endocrine Society) http://www.endo-society.org/quickcontent/clinicalpractice/clinical-guidelines/upload/AndrogensMenGuideline053006.pdf
  3. Bhasin S et al, Testosterone therapy in adult men with androgen deficiency syndromes: An endocrine society clinical practice guideline. J Clin Endocrin Metab 2006; 91:1995 PMID: 16720669 corresponding NGC guideline withdrawn Feb 2016
  4. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18. American College of Physicians, Philadelphia 2009, 2013, 2015, 2018.
  5. Internal Medicine News, July 2005, pg 1,22
  6. Bhasin S, Cunningham GR, Hayes FJ et al Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2010 Jun;95(6):2536-59 PMID: 20525905
  7. Wierman ME, Basson R, Davis SR et al Androgen therapy in women: an Endocrine Society Clinical Practice guideline. J Clin Endocrinol Metab. 2006 Oct;91(10):3697-710. Epub 2006 Oct 3. PMID: 17018650 (corresponding NGC guideline revised 10/15) - Wierman ME, Arlt W, Basson R et al Androgen therapy in women: a reappraisal: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014 Oct;99(10):3489-510 PMID: 25279570
  8. Bhasin S et al. Testosterone therapy in men with androgen deficiency syndromes: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2010 Jun; 95:2536. PMID: 20525905 http://content.nejm.org/cgi/content/full/NEJMoa1000485
  9. Corona G, Vignozzi L, Sforza A, Maggi M. Risks and benefits of late onset hypogonadism treatment: an expert opinion. World J Mens Health. 2013 Aug;31(2):103-25. Review. PMID: 24044106 Free PMC Article
  10. Paduch DA, Brannigan RE, Fuchs EF et al The laboratory diagnosis of testosterone deficiency. Urology. 2014 May;83(5):980-8. Review. PMID: 24548716
  11. Pye SR, Huhtaniemi IT, Finn JD et al Late-onset hypogonadism and mortality in aging men. J Clin Endocrinol Metab. 2014 Apr;99(4):1357-66. PMID: 24423283
  12. Bhasin S, Brito JP, Cunningham GR, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018 Mar 17. PMID: 29562364
  13. O'Rourke TK Jr, Wosnitzer MS. Opioid-Induced Androgen Deficiency (OPIAD): Diagnosis, Management, and Literature Review. Curr Urol Rep. 2016 Oct;17(10):76. Review. PMID: 27586511