#1 Dealing with Male Hypogonadism and Low Testosterone

February 17, 2016 | By Matthew Watto, MD

Miracle Cure of Libido Band Aid?

In their inaugural episode, join the Curbsiders as they tackle the hot topic of Low Testosterone by curbsiding with Endocrinologist Dr. Jeff Colburn, a leading clinician and educator in San Antonio, Texas.

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Take home points:

1. 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.
2. Treat modifiable risk factors: opiate abuse, heavy alcohol use, sleep apnea, obesity
3. Recommend a trial of topical therapy at 40 mg daily. Goal total T is 400-700.  Monitor PSA and CBC yearly.

Definitions:

• 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.

Symptoms:

Usually wife complains of husband with low libio and poor sexual function. Other non-specific symptoms include depressed mood, loss of bone and lean muscle mass, weight gain and fatigue.

Exam:

Look for gynecomastia and testicular atrophy (less than 20-30 cc and soft consistency)

Diagnosis:

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.

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.

Recommended resources:

1. American Association of Endocrinologists Clinical Practice Guidelines
2. Nguyen CP, et al. Testosterone and “Age-Related Hypogonadism”–FDA Concerns. N Engl J Med. 2015 Aug 20;373(8):689-91. doi: 10.1056/NEJMp1506632.

Recommended buys:

1. Orchidometer on Amazon
2. Washington Manual Endocrinology Subspecialty Consult