Androgen Deficiency & Hormone Manipulation in Males

What is Hypogonadism?

Technically, hypogonadism has been defined by the FDA as a testosterone lower than roughly 10 nmol/L. From a clinical perspective, however, this is insufficient. A better way to approach this syndrome is to think of it as a constallation of clinical and lab findings and to appreciate that there is no one specific test that can make the diagnosis or determine what treatment should be used.

 

  1. Low testosterone level. There are many different ways to measure testosterone levels, but using a total testosterone level of about 10 nmol/L (or 300 mg/dL)
  2. Symptoms and signs suggestive of hypogonadism
    1. Physical/metabolic: muscle mass, energy and strength, difficulty building muscle
    2. Psychological:  low mood, 'mental foginess', sleep disturbance.
    3. Sexual: decreased libido, orgasm, erectile function

 

Note that these symptoms are non-specific and can be associated with a number of conditions, including 'life'. There is no agreed upon set of symptoms or lab test that establishes the diagnosis. It is more of a 'gestalt'.

 

Measurement and Monitoring of Testosterone Replacement

 

Monitoring of treatment results is always necessary. There are 2 things which we are looking for:

 

  1. An increase in serum testosterone the target level (usually between 15 and 25 nmol/liter)
  2. Improvement in the symptoms for which the testosterone was prescribed.

 

It is important that the blood is drawn at the appropriate time as this can significantly affect the measured level. Timing differs based on the type of testosterone supplementation.

  1. Testosterone injection: how we draw testosterone levels will depend on what we are looking for
    1. A 'peak' level can be drawn the day after the injection and a 'trough' level the morning that you are due for the injection. These will help determine the total dose and the frequency of dosing (the peak level corresponds with the risk of polycythemia and the trough with the potential symptoms of 'testosterone crash')
    2. Blood level should be drawn 1 (ONE) week after the last injection. The target level is between 400 - 700 ng/dl (or roughly 10-20 nmol/L)
  2. Testosterone gels and patches: blood level can be drawn in the morning

 

Calculating Bioavailable Testosterone by Measuring Total T, Albumin and SHBG

 

Treatment

 

Testosterone replacement/supplementation can be very beneficial in select circumstances. However, testosterone replacement is not a “cure all” for men, despite much marketing to the contrary. There are pros and cons to testosterone supplementation and these can be discussed with your physician.

Note that testosterone will increase libido and energy, but will not on their own improve erections.

 

There are 2 general ways to increase testosterone levels

  1. Give testosterone directly
    1. Skin gels
    2. Injections (into muscle or under the skin)
    3. Pills by mouth
  2. Prompt the body to make more testostone

 

TESTOSTERONE FORMULATIONS

* may not be available in Canada yet

 

FORMULATIONS TO INCREASE THE BODY'S OWN PRODUCTION OF TESTOSTERONE

These treatments are primarily used to treat men with infertility and in general are not used in men with hypogonadism. They can indirectly increase the levels of testosterone. Note that all of these medications are used 'off-label' and require subspecialty expertise for prescribing and monitoring.

 

 

Testosterone Supplementation and Prostate Cancer

 

Advanced prostate cancer is often treated with medications that either lower or block the action of testosterone. Some people have assumed that increasing testosterone either causes prostate cancer in otherwise normal men or promotes progression of prostate cancer in men without advanced disease – this is probably not true. As of 2013, there are a few guidelines regarding testosterone supplementation and prostate cancer.

 

  1. Men receiving testosterone supplementation to physiologic levels should not worry about an increased risk of developing prostate cancer The incidence and types of prostate cancer are the same in men regardless of testosterone supplementation.
  2. Men who have prostate cancer which is being observed (active surveillance) and which is not advanced, there is probably no risk or making the cancer worse if testosterone is supplemented to physiologic levels*
  3. Men whom have had prostate cancer treated and in whom the disease is not advanced probably do not have any risk of progression if testosterone is supplemented to physiologic levels*
  4. Men with advanced prostate cancer should avoid testosterone supplementation*

 

*Talk to your urologist about the options and current evidence. Monitoring is always required. Advanced disease includes men who have disease which has spread outside the prostate to the lymph nodes or bone. It has been hypothesized that testosterone helps prostate tissue 'differentiate' into more normal tissue. There are clinical trials underway to answer these questions better.

 

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