The Curbsiders podcast

#1 Dealing with Male Hypogonadism and Low Testosterone

February 17, 2016 | By

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.

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

Comments

  1. April 20, 2016, 2:33am Dani K writes:

    Great job guys. Love it.

  2. February 6, 2018, 4:28pm sean writes:

    Really useful information. Thank you

    • February 7, 2018, 11:35pm Matthew Watto, MD writes:

      Great to hear - thank you for the feedback!

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