Hypogonadism PDF

HYPOGONADISM: CONGENITAL AND ACQUIRED TESTOSTERONE DEFICIENCY Emily Bodfish, MPAS, PA-C PA 511- Clinical Medicine I Emory & Henry University School of Health Sciences ANDROGENS Testosterone: Made primarily in testes Most potent androgen Converted t...

HYPOGONADISM: CONGENITAL AND ACQUIRED TESTOSTERONE DEFICIENCY Emily Bodfish, MPAS, PA-C PA 511- Clinical Medicine I Emory & Henry University School of Health Sciences ANDROGENS Testosterone: Made primarily in testes Most potent androgen Converted to Dihydrotestosterone or estrogen DHEA: Made in adrenals Less potent Can be converted to testosterone in periphery Testosterone in Men Needed for appropriate sexual development Normal skeletal formation and maintenance Normal bone marrow function Normal muscular development and maintenance Sense of well being, libido, potency  Testosterone Production Hypothalamus produces GnRH which acts on anterior pituitary Anterior pituitary produces both LH & FSH which acts on testes LH - Leydig cells – produces testosterone FSH - Sertoli cell – produces sperm Only 2% is free testosterone & 98% is bound Albumin-bound T 38% TESTES ~ 95% OF PRODUCTION IN M ALES SHBG-bound T 60%  Testosterone Production Cont. Adrenal cortex secretes multiple prohormones that are converted into testosterone in the peripheral tissues ADRENAL ~ 5% OF PRODUCTION IN M ALES Androgen metabolism and actions. SHBG, sex hormone–binding globulin. Male Hypogonadism Deficient testosterone secretion by the testes 4 to 5 million men in the US affected by hypogonadism ↑ prevalence = older age, obesity, DM, HIV, COPD, CHD, renal disease, opioid or glucocorticoid therapy Hypogonadism Classifications Primary hypogonadism Secondary hypogonadism (hypergonadotropic): Testicular (hypogonadotropic) : dysfunction = ↓ spermatogenesis hypothalamus &/or pituitary gland &/or ↓ testosterone dysfunction = Failure of GnRH, LH or FSH secretion ↑ LH, ↑ FSH ↓/normal LH & FSH Primary Hypogonadism Causes Klinefelter’s syndrome HIV/AIDS Unilateral or bilateral cryptorchidism Infections such as mumps orchitis Varicocele Drugs: Opioids, marijuana, spironolactone, corticosteroids, Toxins such as heavy metals or alcohol ketoconazole, anticonvulsants, & Testicular trauma such as radiation or immunosuppressants chemotherapy Alcohol Chronic renal failure  Klinefelter’s Syndrome MC chromosomal abnormality among males Caused by the expression of an abnormal karyotype, classically 47,XXY Incidence of about 1:500 males Found only in males & detected at puberty Testes usually become firm, fibrotic, small, & nontender to palpation Have an increased risk of cryptorchidism, decreased penile size, delayed speech, learning disabilities, psychiatric disturbances, & mediastinal malignancies Up to 75% of affected boys experience some gynecomastia at puberty Secondary Hypogonadism Causes Congenital GnRH deficiency (i.e. Kallman syndrome, Prader-Willi syndrome) +/- anosmia/hyposmia Acquired (more common) Pituitary disease Head or pituitary trauma Sellar mass lesions Hyperprolactinemia Diabetes Obesity Neoplasm Chronic systemic illness such as chronic obstructive pulmonary disease Drugs: Opioids, glucocorticoids, GnRH analogues, exogenous estrogen or androgen The Effect of Hypogonadism Based On Age of Onset NEONATAL PERIOD ADULT Cryptorchidism Infertility Microphallus Decreased libido/potency Ambiguous genitalia Decreased energy/muscle mas Decreased bone density PRE-ADOLESCENCE Maybe decrease in testicular size Lack of secondary sex characteristics, (NL teste=15-20 ml) or consistency Eunuchoid body habitus Gynecomastia Pre-pubertal testes ( 54 while on TRT→ hold TRT until Hct normalizes Lipid Profile: Treat any lipid abnormality to minimize CV risk Hemoglobin A1C: Screen for diabetes Sleep Study: Untreated sleep apnea contraindication to testosterone therapy Tobacco Dependency (Smoking): Contraindication to TRT  Testosterone Therapy Not Recommended for Those Who: Desire fertility in near future Untreated obstructive sleep apnea Have breast or prostate cancer Severe lower urinary tract symptoms Have a palpable prostate nodule or Uncontrolled heart failure induration Myocardial infarction or stroke within PSA > 4 last 6 months PSA > 3 with high prostate cancer risk Thrombophilia Elevated Hct  Alternative Hypogonadism Therapies Clomiphene Human Chorionic Gonadotropin Not FDA approved for use in the (hCG) treatment of hypogonadism Traditionally used in hypogonadal men desiring fertility Treatment for hypogonadotropic hypogonadism Supports spermatogenesis & intra- testicular testosterone production Selective estrogen receptor modulator→ blocks the estrogen Less likely to cause the adverse effects receptor in the hypothalamus and on prostate health, hematocrit, sleep pituitary gland, increasing FSH & LH apnea, & gynecomastia Not associated with adverse effects on PSA, hematocrit, & gynecomastia