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Cipriani S, Todisco T, Ghiandai N, Vignozzi L, Corona G, Maggi M, Rastrelli G. Biochemical predictors of structural hypothalamus-pituitary abnormalities detected by magnetic resonance imaging in men with secondary hypogonadism. J Endocrinol Invest 2021; 44:2785-2797. [PMID: 33970435 PMCID: PMC8572185 DOI: 10.1007/s40618-021-01586-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/30/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Organic conditions underlying secondary hypogonadism (SH) may be ascertained by magnetic resonance imaging (MRI) of the hypothalamic-pituitary region that could not be systematically proposed to each patient. Based upon limited evidence, the Endocrine Society (ES) guidelines suggest total testosterone (T) < 5.2 nmol/L to identify patients eligible for MRI. The study aims to identify markers and their best threshold value predicting pathological MRI findings in men with SH. METHODS A consecutive series of 609 men seeking medical care for sexual dysfunction and with SH (total T < 10.5 nmol/L and LH ≤ 9.4 U/L) was retrospectively evaluated. An independent cohort of 50 men with SH was used as validation sample. 126 men in the exploratory sample and the whole validation sample underwent MRI. RESULTS In the exploratory sample, patients with pathological MRI findings (n = 46) had significantly lower total T, luteinizing hormone (LH), follicle stimulating hormone (FSH) and prostate specific antigen (PSA) than men with normal MRI (n = 80). Receiver Operating Characteristics analysis showed that total T, LH, FSH and PSA are accurate in identifying men with pathologic MRI (accuracy: 0.62-0.68, all p < 0.05). The Youden index was used to detect the value with the best performance, corresponding to total T 6.1 nmol/L, LH 1.9 U/L, FSH 4.2 U/L and PSA 0.58 ng/mL. In the validation cohort, only total T ≤ 6.1 nmol/L and LH ≤ 1.9 U/L were confirmed as significant predictors of pathologic MRI. CONCLUSION In men with SH, total T ≤ 6.1 nmol/L or LH ≤ 1.9 U/L should arise the suspect of hypothalamus/pituitary structural abnormalities, deserving MRI evaluation.
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Affiliation(s)
- S Cipriani
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Department of Experimental Clinical and Biomedical Sciences "Mario Serio", Careggi Hospital, University of Florence, Florence, Italy
| | - T Todisco
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Department of Experimental Clinical and Biomedical Sciences "Mario Serio", Careggi Hospital, University of Florence, Florence, Italy
| | - N Ghiandai
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Department of Experimental Clinical and Biomedical Sciences "Mario Serio", Careggi Hospital, University of Florence, Florence, Italy
| | - L Vignozzi
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Department of Experimental Clinical and Biomedical Sciences "Mario Serio", Careggi Hospital, University of Florence, Florence, Italy
- I.N.B.B., Istituto Nazionale Biostrutture e Biosistemi, Rome, Italy
| | - G Corona
- Endocrinology Unit, Medical Department, Azienda Usl Bologna Maggiore-Bellaria Hospital, Bologna, Italy
| | - M Maggi
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Department of Experimental Clinical and Biomedical Sciences "Mario Serio", Careggi Hospital, University of Florence, Florence, Italy
- I.N.B.B., Istituto Nazionale Biostrutture e Biosistemi, Rome, Italy
- Endocrinology Unit, Department of Experimental Clinical and Biomedical Sciences "Mario Serio", Careggi Hospital, University of Florence, Florence, Italy
| | - G Rastrelli
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Department of Experimental Clinical and Biomedical Sciences "Mario Serio", Careggi Hospital, University of Florence, Florence, Italy.
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Lunenfeld B, Mskhalaya G, Zitzmann M, Corona G, Arver S, Kalinchenko S, Tishova Y, Morgentaler A. Recommendations on the diagnosis, treatment and monitoring of testosterone deficiency in men. Aging Male 2021; 24:119-138. [PMID: 34396893 DOI: 10.1080/13685538.2021.1962840] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
The relative proportional increase of the elderly population within many countries will become one of the most significant social transformations of the twenty-first century and, for the first time in history, persons aged 65 or above outnumbered children under five years of age globally. One in four persons living in Europe and Northern America will be aged 65 or over. One of the goals of ISSAM is to raise awareness of the special health needs of older men. Since a significant number of aging men will eventually become testosterone deficient, the Hypogonadism panel of ISSAM updates its guidelines.
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Affiliation(s)
- Bruno Lunenfeld
- Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
| | | | - Michael Zitzmann
- Center for Reproductive Medicine and Andrology/Clinical and Surgical Andrology, University Hospital of Münster, Münster, Germany
| | - Giovanni Corona
- Medical Department, Endocrinology Unit, Maggiore Bellaria Hospital, Bologna, Italy
| | - Stefan Arver
- Department of Medicine/Huddinge Karolinska Institutet and ANOVA, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Kalinchenko
- Department of Endocrinology, People's Friendship University of Russia, Moscow, Russia
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Pituitary magnetic resonance imaging abnormalities in young female patients with hypogonadotropic hypogonadism. Obstet Gynecol Sci 2019; 62:249-257. [PMID: 31338342 PMCID: PMC6629987 DOI: 10.5468/ogs.2019.62.4.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/05/2018] [Accepted: 01/29/2019] [Indexed: 11/21/2022] Open
Abstract
Objective To elucidate the association between clinical and laboratory characteristics and pituitary magnetic resonance imaging (MRI) abnormalities in young female patients with hypogonadotropic hypogonadism (HH). Methods We retrospectively investigated a series of 74 female patients (age range, 14–42 years) with normoprolactinemic HH who underwent pituitary MRI. Pubertal milestones and hormonal features of patients with small pituitary glands (PGs) and space-occupying lesions were compared with those of patients with normal PGs. Results The overall frequency of abnormal PGs was 35.1%, with space-occupying lesions observed in 8 patients (10.8%), and small PG observed in 18 patients (24.3%). The mean serum gonadotropin level was not different between patients with and without pituitary MRI abnormalities (P>0.05). Space-occupying lesions were not associated with low gonadotropin levels, type of amenorrhea, or presence of secondary sex characteristics. The frequency of space-occupying lesions was higher in patients with interrupted puberty (25.0%) than in patients who did not go through puberty (4.8%) or had a normal puberty (9.8%), but were not statistically significant (P>0.05). Small PG was associated with low gonadotropin levels and type of amenorrhea (P<0.05). Conclusion Clinically significant space-occupying lesions were not associated with low gonadotropin levels, type of amenorrhea, or presence of secondary sex characteristics. However, the frequency of space-occupying lesions was higher in patients with interrupted puberty than in patients who did not go through puberty or who with normal puberty.
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Mulhall JP, Trost LW, Brannigan RE, Kurtz EG, Redmon JB, Chiles KA, Lightner DJ, Miner MM, Murad MH, Nelson CJ, Platz EA, Ramanathan LV, Lewis RW. Evaluation and Management of Testosterone Deficiency: AUA Guideline. J Urol 2018; 200:423-432. [DOI: 10.1016/j.juro.2018.03.115] [Citation(s) in RCA: 185] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2018] [Indexed: 12/16/2022]
Affiliation(s)
- John P. Mulhall
- American Urological Association Education and Research, Inc., Linthicum, Maryland
| | - Landon W. Trost
- American Urological Association Education and Research, Inc., Linthicum, Maryland
| | - Robert E. Brannigan
- American Urological Association Education and Research, Inc., Linthicum, Maryland
| | - Emily G. Kurtz
- American Urological Association Education and Research, Inc., Linthicum, Maryland
| | - J. Bruce Redmon
- American Urological Association Education and Research, Inc., Linthicum, Maryland
| | - Kelly A. Chiles
- American Urological Association Education and Research, Inc., Linthicum, Maryland
| | - Deborah J. Lightner
- American Urological Association Education and Research, Inc., Linthicum, Maryland
| | - Martin M. Miner
- American Urological Association Education and Research, Inc., Linthicum, Maryland
| | - M. Hassan Murad
- American Urological Association Education and Research, Inc., Linthicum, Maryland
| | - Christian J. Nelson
- American Urological Association Education and Research, Inc., Linthicum, Maryland
| | - Elizabeth A. Platz
- American Urological Association Education and Research, Inc., Linthicum, Maryland
| | | | - Ronald W. Lewis
- American Urological Association Education and Research, Inc., Linthicum, Maryland
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Lau DHW, Mumtaz FH, Thompson CS, Mikhailidis DP. Erectile dysfunction: a need for greater awareness. ACTA ACUST UNITED AC 2016; 124:214-6. [PMID: 15493779 DOI: 10.1177/146642400412400516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Research has led to effective treatment regimes for erectile dysfunction (ED). Convincing evidence links vascular risk factors (hypertension, diabetes mellitus, hyperlipidaemia and smoking) with ED. This association is not surprising since the corpus cavernosum is a modified vascular tissue. This review presents a brief account of the aetiology, diagnosis and treatment of ED. There is a need to raise awareness of this condition and to make appropriate treatment available to patients.
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Affiliation(s)
- David H W Lau
- Department of Urology, Royal Free and University College Medical School, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, England
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Dalvi M, Walker BR, Strachan MWJ, Zammitt NN, Gibb FW. The prevalence of structural pituitary abnormalities by MRI scanning in men presenting with isolated hypogonadotrophic hypogonadism. Clin Endocrinol (Oxf) 2016; 84:858-61. [PMID: 26733239 DOI: 10.1111/cen.13015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 12/28/2015] [Accepted: 12/31/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hypogonadotrophic hypogonadism (HH) is commonly associated with ageing, obesity and type 2 diabetes. The indications for pituitary imaging are controversial, and current guidelines are based on small case series. DESIGN Retrospective case series from a secondary/tertiary endocrinology referral centre. PATIENTS All men presenting to the Edinburgh Centre for Endocrinology and Diabetes with hypogonadotrophic hypogonadism (testosterone <10 nmol/l and normal prolactin) from 2006 to 2013, in whom pituitary MRI was performed (n = 281). All HH patients referred in 2011 (n = 86) were reviewed to assess differences between those selected for pituitary MRI and those who were not scanned. RESULTS Pituitary MRI was normal in 235 men (83·6%), with 24 microadenomas (8·5%), 5 macroadenomas (1·8%) and 1 craniopharyngioma (0·4%) identified. The remaining 16 (5·7%) comprised a range of minor pituitary abnormalities including small cysts and empty sella. All men with abnormal imaging studies had otherwise normal pituitary function. Imaging abnormalities were associated with a significantly lower age at presentation (50 vs 54 years, P = 0·02), but no differences in testosterone or gonadotrophin levels were observed. Current Endocrine Society guidelines would have prompted imaging in only three of six patients with significant pituitary pathology. CONCLUSIONS Structural pituitary disease is more common in isolated HH than in the general population, and current guidelines do not accurately identify 'at-risk' individuals. Full anterior pituitary function testing has a low yield in patients presenting with hypogonadism. The optimal strategy for determining the need for pituitary imaging remains uncertain.
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Affiliation(s)
- Mazhar Dalvi
- Edinburgh Centre for Endocrinology and Diabetes, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - Brian R Walker
- Edinburgh Centre for Endocrinology and Diabetes, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - Mark W J Strachan
- Edinburgh Centre for Endocrinology and Diabetes, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - Nicola N Zammitt
- Edinburgh Centre for Endocrinology and Diabetes, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - Fraser W Gibb
- Edinburgh Centre for Endocrinology and Diabetes, NHS Lothian and University of Edinburgh, Edinburgh, UK
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Hirsch D, Benbassat C, Toledano Y, S'chigol I, Tsvetov G, Shraga-Slutzky I, Eizenberg Y, Shimon I. Pituitary imaging findings in male patients with hypogonadotrophic hypogonadism. Pituitary 2015; 18:494-9. [PMID: 25246077 DOI: 10.1007/s11102-014-0601-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
CONTEXT Data on pituitary imaging in adult male patients presenting with hypogonadotrophic hypogonadism (HH) and no known pituitary disease are scarce. OBJECTIVE To assess the usefulness of pituitary imaging in the evaluation of men presenting with HH after excluding known pituitary disorders and hyperprolactinemia. DESIGN A historical prospective cohort of males with HH. PATIENTS Men who presented for endocrine evaluation from 2011 to 2014 with testosterone levels <10.4 nmol/L (300 ng/mL), normal LH and FSH levels and no known pituitary disease. RESULTS Seventy-five men were included in the analysis. Their mean age and BMI were 53.4 ± 14.8 years and 30.7 ± 5.2 kg/m2, respectively. Mean total testosterone, LH, and FSH were 6.2 ± 1.7 nmol/L, 3.4 ± 2 and 4.7 ± 3.1 mIU/L, respectively. Prolactin level within the normal range was obtained in all men (mean 161 ± 61, range 41-347 mIU/L). Sixty-two men had pituitary MRI and 13 performed CT. In 61 (81.3%) men pituitary imaging was normal. Microadenoma was found in 8 (10.7%), empty sella and thickened pituitary stalk in one patient (1.3%) each. In other four patients (5.3%) a small or mildly asymmetric pituitary gland was noted. No correlation was found between testosterone level and the presence of pituitary anomalies. CONCLUSIONS This study suggests that the use of routine hypothalamic-pituitary imaging in the evaluation of IHH, in the absence of clinical characteristics of other hormonal loss or sellar compression symptoms, will not increase the diagnostic yield of sellar structural abnormalities over that reported in the general population.
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Affiliation(s)
- Dania Hirsch
- Endocrine Institute, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel,
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Lunenfeld B, Mskhalaya G, Zitzmann M, Arver S, Kalinchenko S, Tishova Y, Morgentaler A. Recommendations on the diagnosis, treatment and monitoring of hypogonadism in men. Aging Male 2015; 18:5-15. [PMID: 25657080 PMCID: PMC4648196 DOI: 10.3109/13685538.2015.1004049] [Citation(s) in RCA: 208] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Accepted: 12/26/2014] [Indexed: 01/02/2023] Open
Abstract
Hypogonadism or Testosterone Deficiency (TD) in adult men as defined by low levels of serum testosterone accompanied by characteristic symptoms and/or signs as detailed further on can be found in long-recognized clinical entities such as Klinefelter syndrome, Kallmann syndrome, pituitary or testicular disorders, as well as in men with idiopathic, metabolic or iatrogenic conditions that result in testosterone deficiency. These recommendations do not encompass the full range of pathologies leading to hypogonadism (testosterone deficiency), but instead focus on the clinical spectrum of hypogonadism related to metabolic and idiopathic disorders that contribute to the majority of cases that occur in adult men.
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Affiliation(s)
- Bruno Lunenfeld
- Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
| | - George Mskhalaya
- Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
| | - Michael Zitzmann
- Centre for Reproductive Medicine and Andrology, University Clinics Muenster, Münster, Germany
| | - Stefan Arver
- Centre for Andrology and Sexual Medicine, Karolinska University Hospital and Karolinska Institutet Stockholm, Stockholm, Sweden
| | - Svetlana Kalinchenko
- Clinical Endocrinology, Peoples' Friendship University of Russia, Moscow, Russian Federation
| | - Yuliya Tishova
- Clinical Endocrinology, Peoples' Friendship University of Russia, Moscow, Russian Federation
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Grossmann M, Anawalt BD, Wu FCW. Clinical practice patterns in the assessment and management of low testosterone in men: an international survey of endocrinologists. Clin Endocrinol (Oxf) 2015; 82:234-41. [PMID: 25154540 DOI: 10.1111/cen.12594] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/15/2014] [Accepted: 08/18/2014] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To document current practices in the approach to low testosterone in older men. Given that recommendations are based on low-level evidence, we hypothesized that there would be a wide variability in clinical practice patterns. DESIGN Members of all major endocrine and andrological societies were invited to participate in a Web-based survey of the diagnostic work-up and management of a hypothetical index case of a 61-year old overweight man presenting with symptoms suggestive of androgen deficiency, without evidence of hypothalamic-pituitary-gonadal (HPT) axis disease. RESULTS Nine hundred and forty-three respondents (91·2% adult endocrinologists) from Northern America (63·7%), Europe (12·7%), Oceania (8·2%), Latin America and Caribbean (7·6%), and the Middle East, Asia, or Africa (7·8%) completed the survey. Response rates among participating societies ranged from 4·1-20·0%. There was a wide variability in clinical practice patterns, especially regarding biochemical diagnosis of androgen deficiency, exclusion of HPT axis pathology, and monitoring for prostate cancer. In a man with suggestive symptoms, 42·4% of participants would offer testosterone treatment below a serum total testosterone of 10·4 nmol/l (300 ng/dl). A total of 46·0% of participants were, over the last five years, 'less inclined' to prescribe testosterone to men with nonspecific symptoms and borderline testosterone levels, compared to 'no change' (29·3%) or 'more inclined' (24·7%), P < 0·001. CONCLUSIONS This large-scale international survey shows a wide variability in the management of lowered testosterone in older men, with deviations from current clinical practice guidelines, and a temporal trend towards increasing reluctance to prescribe testosterone to men without classical hypogonadism. These findings highlight the need for better evidence to guide clinicians regarding testosterone therapy.
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Affiliation(s)
- Mathis Grossmann
- Department of Medicine Austin Health, University of Melbourne, Heidelberg, Vic, Australia
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Gibb FW, Strachan MWJ. Androgen deficiency and type 2 diabetes mellitus. Clin Biochem 2014; 47:940-9. [PMID: 24768826 DOI: 10.1016/j.clinbiochem.2014.04.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 04/02/2014] [Accepted: 04/04/2014] [Indexed: 01/14/2023]
Abstract
The rising incidence of T2DM is well recognised and associated with trends in obesity and ageing. It is estimated that 2.8% of the world population had a diagnosis of diabetes mellitus in 2000, which is projected to rise to 4.3% by 2030. Diabetes, obesity and ageing are also associated with an increased risk of isolated male hypogonadotropic hypogonadism, often labelled 'late onset hypogonadism' (LOH) to distinguish it from hypogonadism secondary to distinct hypothalamopituitary pathology. Whether the incidence of hypogonadism is increasing is open to question; the past decade, however, has witnessed a marked increase in the prescription of testosterone replacement therapy. Testosterone deficiency appears to be particularly common in type 2 diabetes with a prevalence of 33% observed in one cohort of 103 men (mean age 54.7). However, the diagnosis of androgen deficiency states is not necessarily straightforward, depending amongst other factors, upon whether a biochemical threshold or a syndromic approach (mandating the presence of certain key clinical features) is employed. The pathogenic mechanisms underlying obesity and diabetes related hypogonadism remain unclear with several competing theories, most of which are not mutually exclusive. Whilst a large body of epidemiological evidence associates testosterone deficiency with increased risk of cardiovascular disease and mortality, little evidence exists to support a protective effect of testosterone replacement. The benefits of androgen replacement in younger men with pituitary disease are well established, however, the potential benefits and safety of androgen replacement in older men is much less well developed. At present, replacement therapy in older men is advocated principally for the amelioration of sexual symptoms. This review will seek to explore issues around the pathogenesis, diagnosis, clinical consequences and management of male hypogonadism as it relates to T2DM.
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Affiliation(s)
- Fraser W Gibb
- Edinburgh Centre for Endocrinology and Diabetes, UK.
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Abstract
Male hypogonadism is a clinical syndrome that results from failure to produce physiological concentrations of testosterone, normal amounts of sperm, or both. Hypogonadism may arise from testicular disease (primary hypogonadism) or dysfunction of the hypothalamic-pituitary unit (secondary hypogonadism). Clinical presentations vary dependent on the time of onset of androgen deficiency, whether the defect is in testosterone production or spermatogenesis, associated genetic factors, or history of androgen therapy. The clinical diagnosis of hypogonadism is made on the basis of signs and symptoms consistent with androgen deficiency and low morning testosterone concentrations in serum on multiple occasions. Several testosterone-replacement therapies are approved for treatment and should be selected according to the patient's preference, cost, availability, and formulation-specific properties. Contraindications to testosterone-replacement therapy include prostate and breast cancers, uncontrolled congestive heart failure, severe lower-urinary-tract symptoms, and erythrocytosis. Treatment should be monitored for benefits and adverse effects.
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Affiliation(s)
- Shehzad Basaria
- Section on Men's Health, Aging and Metabolism, Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Lunenfeld B, Mskhalaya G, Kalinchenko S, Tishova Y. Recommendations on the diagnosis, treatment and monitoring of late-onset hypogonadism in men - a suggested update. Aging Male 2013; 16:143-50. [PMID: 24188520 DOI: 10.3109/13685538.2013.853731] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Recommendations on the diagnosis, treatment and monitoring of late-onset hypogonadism (LOH) in men were first published by ISSAM in 2002 In 2005, and, in 2008, updated recommendations were published in the International Journal of Andrology, the Journal of Andrology, the Aging Male and European Urology. Towards discussions at the next ISSAM/ESSAM meeting in Moscow, 29 November 2013, we suggest the following update.
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Affiliation(s)
- Bruno Lunenfeld
- Faculty of Life Sciences, Bar-Ilan University , Ramat Gan, Tel-Aviv , Israel
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Buvat J, Maggi M, Guay A, Torres LO. Testosterone Deficiency in Men: Systematic Review and Standard Operating Procedures for Diagnosis and Treatment. J Sex Med 2013; 10:245-84. [DOI: 10.1111/j.1743-6109.2012.02783.x] [Citation(s) in RCA: 186] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Abstract
CONTEXT Symptoms and signs consistent with androgen deficiency and low testosterone levels are recognized frequently in clinical practice. Recent population-based epidemiological studies indicate that low testosterone levels in men are associated with increased morbidity and mortality. The clinician must be able to counsel patients to help them determine whether testosterone replacement therapy is appropriate for them. EVIDENCE ACQUISITION The authors have conducted a literature search in PubMed, and we have reviewed references in the multiple systematic reviews and meta-analyses that have been published on this topic. EVIDENCE SYNTHESIS We have attempted to provide the reader with an appreciation of the evidence that can be used to support the diagnosis of androgen deficiency, the efficacy of treatment, the potential risks of treatment, the therapeutic options, and the recommendations for monitoring treatment. CONCLUSIONS We think that published clinical experience justifies testosterone replacement therapy in males who have not initiated puberty by age 14 and in males with low testosterone levels due to classical diseases of the hypothalamic-pituitary-gonadal axis. The benefit:risk ratio is less certain in older men and in those with chronic diseases associated with low testosterone levels. The decision to treat in this setting is much more controversial because there are few large clinical trials that have demonstrated efficacy and no large clinical trials that have determined potential risks of increasing the incidence of clinical prostate cancers or cardiovascular events. We provide a critical review of the evidence that supports treatment and potential risks and ways to reduce the risks if the physician and patient elect testosterone replacement.
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Affiliation(s)
- Glenn R Cunningham
- Baylor College of Medicine and St. Luke's Episcopal Hospital, Houston, Texas 77030, USA.
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Wylie K, Rees M, Hackett G, Anderson R, Bouloux PM, Cust M, Goldmeier D, Kell P, Terry T, Trinick T, Wu F. Androgens, health and sexuality in women and men. HUM FERTIL 2010; 13:277-97. [DOI: 10.3109/14647273.2010.530966] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Wylie K, Rees M, Hackett G, Anderson R, Bouloux PM, Cust M, Goldmeier D, Kell P, Terry T, Trinick T, Wu F. Androgens, health and sexuality in women and men. Maturitas 2010; 67:275-89. [DOI: 10.1016/j.maturitas.2010.07.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 07/20/2010] [Indexed: 01/23/2023]
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Hugh Jones T. 'What should I do with a 60-year old man with a slightly low serum total testosterone concentration and normal levels of serum gonadotrophins'? Clin Endocrinol (Oxf) 2010; 72:584-8. [PMID: 19878210 DOI: 10.1111/j.1365-2265.2009.03737.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The fundamental question in assessing an older man with a slightly low total testosterone and normal gonadotrophin levels is to determine whether or not he has clinical hypogonadism. Hypogonadism is defined as a clinical syndrome complex, which comprises both symptoms as well as biochemical testosterone deficiency. As symptoms are nonspecific and there are no clear cut-off values for testosterone levels this invariably leads to a clinical dilemma. International guidelines have been published which provide recommendations to aid the clinician in making a diagnosis. Late-onset hypogonadism, the preferred terminology for age-related hypogonadism, can only be made once other causes have been excluded. Evidence shows that low testosterone levels are associated with several common male conditions including erectile dysfunction, osteoporosis and diabetes. Short-term studies have shown benefits of testosterone replacement therapy (TRT) on body composition, bone metabolism, insulin resistance, sexual function and quality of life. Recommendations give clear advice on safety monitoring, specifically in relation to prostate health. If a diagnosis of hypogonadism is made with borderline testosterone levels then a 3-month trial of TRT can be considered. The diagnosis of hypogonadism associated with borderline testosterone levels and the decision to treat should only be made by an experienced clinician.
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Affiliation(s)
- T Hugh Jones
- Robert Hague Centre for Diabetes and Endocrinology, Barnsley Hospital, Barnsley and Academic Unit of Diabetes, Endocrinology and Metabolism, School of Medicine and Biomedical Sciences, University of Sheffield, Sheffield, UK.
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Wang C, Nieschlag E, Swerdloff RS, Behre H, Hellstrom WJ, Gooren LJ, Kaufman JM, Legros JJ, Lunenfeld B, Morales A, Morley JE, Schulman C, Thompson IM, Weidner W, Wu FCW. ISA, ISSAM, EAU, EAA and ASA recommendations: investigation, treatment and monitoring of late-onset hypogonadism in males. Aging Male 2009; 12:5-12. [PMID: 18763169 DOI: 10.1080/13685530802389628] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Christina Wang
- Division of Endocrinology, Department of Medicine, Harbor-UCLA Medical Center and Los Angeles BioMedical Research Institute, Torrance, CA 90509, USA.
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Wang C, Nieschlag E, Swerdloff R, Behre HM, Hellstrom WJ, Gooren LJ, Kaufman JM, Legros JJ, Lunenfeld B, Morales A, Morley JE, Schulman C, Thompson IM, Weidner W, Wu FCW. Investigation, treatment and monitoring of late-onset hypogonadism in males. ACTA ACUST UNITED AC 2009; 32:1-10. [DOI: 10.1111/j.1365-2605.2008.00924.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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21
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Wang C, Nieschlag E, Swerdloff R, Behre HM, Hellstrom WJ, Gooren LJ, Kaufman JM, Legros JJ, Lunenfeld B, Morales A, Morley JE, Schulman C, Thompson IM, Weidner W, Wu FC. Investigation, Treatment, and Monitoring of Late-Onset Hypogonadism in Males: ISA, ISSAM, EAU, EAA, and ASA Recommendations. Eur Urol 2009; 55:121-30. [DOI: 10.1016/j.eururo.2008.08.033] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Accepted: 08/07/2008] [Indexed: 01/28/2023]
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Wang C, Nieschlag E, Swerdloff R, Behre HM, Hellstrom WJ, Gooren LJ, Kaufman JM, Legros JJ, Lunenfeld B, Morales A, Morley JE, Schulman C, Thompson IM, Weidner W, Wu FCW. ISA, ISSAM, EAU, EAA and ASA recommendations: investigation, treatment and monitoring of late-onset hypogonadism in males. Int J Impot Res 2008; 21:1-8. [PMID: 18923415 DOI: 10.1038/ijir.2008.41] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The new ISA, ISSAM, EAU, EAA and ASA recommendations on the investigation, treatment and monitoring of late-onset hypogonadism in males provide updated evidence-based information for clinicians who diagnose and treat patients with adult onset, age related testosterone deficiency.
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Affiliation(s)
- C Wang
- Division of Endocrinology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509, USA.
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23
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Abstract
PURPOSE Despite the well-established role of testosterone in enhancing libido, its exact contribution to erections in men remains unclear. The main objectives of this review are to clarify the role of testosterone in erectile function and evaluate its therapeutic value in men with erectile dysfunction (ED). METHODS Review of the relevant literature (English, French, and Spanish) from 1939 to June 2005 was conducted using data sources from MEDLINE, endocrinology text books, and hand searching of cross-references from original articles and reviews. Clinical trials, animal studies, case reports, reviews, and guidelines of major associations were included. RESULTS Animal and preliminary human studies suggest that testosterone may facilitate erection by acting as vasodilator of the penile arterioles and cavernous sinusoids. Following castration, most, but not all, men had partial or complete loss of erection. Hypogonadism is not a common finding in ED, occurring in about 5% of cases, and in general, there is lack of association between serum testosterone levels, when present in normal or moderately low levels, and erectile function. Most trials using testosterone for treatment of ED in hypogonadal men suffer from methodological problems and report inconsistent results, but overall, suggest that testosterone may be superior to placebo. Erectile function is more likely to improve with testosterone therapy in patients with severe degrees of hypogonadism. Testosterone treatment may ameliorate the response to the phosphodiesterase 5 (PDE5) inhibitors in hypogonadal men and men with low-normal serum testosterone. Repeated measurement of morning serum total testosterone is a fairly accurate and easy method to evaluate androgenecity, but measurement of free or bioavailable testosterone is recommended in conditions that alter the levels of sex-hormone-binding globulin (SHBG), such as in the elderly and in obesity. CONCLUSIONS Available data suggest that in most men circulating levels of testosterone, well below the normal range, are essential for normal erection and that higher levels of serum testosterone may not have major impact on erectile function. Screening for hypogonadism in all men with ED is necessary to identify cases of severe hypogonadism and some cases of mild to moderate hypogonadism, who may benefit from testosterone treatment.
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Affiliation(s)
- Nasser Mikhail
- Endocrinology Division, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, Calif 91342, USA.
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Affiliation(s)
- S Basaria
- Division of Endocrinology, Department of Medicine, Johns Hopkins University School of Medicine, Bayview Medical Center, Baltimore, MD 21224, USA.
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25
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Leder BZ, Rohrer JL, Rubin SD, Gallo J, Longcope C. Effects of aromatase inhibition in elderly men with low or borderline-low serum testosterone levels. J Clin Endocrinol Metab 2004; 89:1174-80. [PMID: 15001605 DOI: 10.1210/jc.2003-031467] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
As men age, serum testosterone levels decrease, a factor that may contribute to some aspects of age-related physiological deterioration. Although androgen replacement has been shown to have beneficial effects in frankly hypogonadal men, its use in elderly men with borderline hypogonadism is controversial. Furthermore, current testosterone replacement methods have important limitations. We investigated the ability of the orally administered aromatase inhibitor, anastrozole, to increase endogenous testosterone production in 37 elderly men (aged 62-74 yr) with screening serum testosterone levels less than 350 ng/dl. Subjects were randomized in a double-blind fashion to the following 12-wk oral regimens: group 1: anastrozole 1 mg daily (n = 12); group 2: anastrozole 1 mg twice weekly (n = 11); and group 3: placebo daily (n = 14). Hormone levels, quality of life (MOS Short-Form Health Survey), sexual function (International Index of Erectile Function), benign prostate hyperplasia severity (American Urological Association Symptom Index Score), prostate-specific antigen, and measures of safety were compared among groups. Mean +/- SD bioavailable testosterone increased from 99 +/- 31 to 207 +/- 65 ng/dl in group 1 and from 115 +/- 37 to 178 +/- 55 ng/dl in group 2 (P < 0.001 vs. placebo for both groups and P = 0.054 group 1 vs. group 2). Total testosterone levels increased from 343 +/- 61 to 572 +/- 139 ng/dl in group 1 and from 397 +/- 106 to 520 +/- 91 ng/dl in group 2 (P < 0.001 vs. placebo for both groups and P = 0.012 group 1 vs. group 2). Serum estradiol levels decreased from 26 +/- 8 to 17 +/- 6 pg/ml in group 1 and from 27 +/- 8 to 17 +/- 5 pg/ml in group 2 (P < 0.001 vs. placebo for both groups and P = NS group 1 vs. group 2). Serum LH levels increased from 5.1 +/- 4.8 to 7.9 +/- 6.5 U/liter and from 4.1 +/- 1.6 to 7.2 +/- 2.8 U/liter in groups 1 and 2, respectively (P = 0.007 group 1 vs. placebo, P = 0.003 group 2 vs. placebo, and P = NS group 1 vs. group 2). Scores for hematocrit, MOS Short-Form Health Survey, International Index of Erectile Function, and American Urological Association Symptom Index Score did not change. Serum prostate-specific antigen levels increased in group 2 only (1.7 +/- 1.0 to 2.2 +/- 1.5 ng/ml, P = 0.031, compared with placebo). These data demonstrate that aromatase inhibition increases serum bioavailable and total testosterone levels to the youthful normal range in older men with mild hypogonadism. Serum estradiol levels decrease modestly but remain within the normal male range. The physiological consequences of these changes remain to be determined.
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Affiliation(s)
- Benjamin Z Leder
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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26
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Abstract
The interpretation of the total serum testosterone concentration is problematic because it is related directly to the serum SHBG concentration.Frequently, an estimate of the serum free testosterone concentration is obtained to better assess the clinical status of the patient. We reviewed five methods for the determination of free testosterone or a surrogate test/index and the problems with these methods. The calculated free testosterone or BAT (highly positively correlated) are recommended as the preferred tests to assess biologically-active testosterone, although interlaboratory values may differ because standards are not available. The controversies in evaluating gonadal function are illustrated by the andropause (elevated SHBG) and obese men (decreased SHBG).
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Affiliation(s)
- Ronald J Elin
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine, 512 South Hancock Street, #203, Louisville, KY 40202, USA.
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27
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Affiliation(s)
- Elie P Elovic
- TBI Research Laboratory, Kessler Medical Rehabilitation Research and Education Corporation, 1199 Pleasant Valley Way, West Orange, NJ 07052, USA
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28
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Rhoden EL, Estrada C, Levine L, Morgentaler A. The value of pituitary magnetic resonance imaging in men with hypogonadism. J Urol 2003; 170:795-8. [PMID: 12913700 DOI: 10.1097/01.ju.0000082960.84075.54] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We assessed the usefulness of magnetic resonance imaging (MRI) of the brain in the evaluation of hypogonadal men with a variety of endocrine patterns. MATERIALS AND METHODS A total of 51 men with low levels of total testosterone (TT) or free testosterone (FT) underwent MRI. Erectile dysfunction and/or decreased libido were present in 43 (84.3%) of cases and infertility in 8 (15.7%). Serum prolactin (PRL) was obtained in all cases. Low levels of TT and FT were defined as less than 300 and 1.5 ng/dl, respectively. Markedly low levels of TT were defined as less than 200 ng/dl. RESULTS In 38 of 51 (74.5%) men the MRI was normal. A small pituitary gland (the partially empty sella syndrome) was noted in 9 (17.6%) cases and microadenoma was noted in 4 (7.8%). Prolactin levels were greater than twice the upper limit of normal in 3 of 4 (75%) cases of adenoma, and low FT was noted in all 4 cases. An additional case of adenoma was identified in a man with markedly decreased TT and normal PRL. All men with adenoma presented with the combination of erectile dysfunction and decreased libido. Among men without adenomas the highest PRL value was always less than twice the upper limit of normal. Overall, only 1 of 17 men with markedly decreased TT (less than 200 ng/dl) demonstrated adenoma. None of the 17 men with low luteinizing hormone with low TT or FT had an adenoma or pituitary/hypothalamic mass. CONCLUSIONS The likelihood of identifying pituitary adenoma by MRI is high if PRL levels are more than twice the upper limit of normal. Medically significant abnormalities are identified in only a small percentage of hypogonadal men with low luteinizing hormone or if TT levels are markedly decreased. The decision to obtain MRI in these latter cases should be based on individual circumstances.
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Affiliation(s)
- Ernani Luis Rhoden
- Division of Urology, Beth Israel Deaconess Medical Center, Men's Health Boston, One Brookline Place, Suite 624, Brookline, MA 02445, USA
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29
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Abstract
The endocrine system has a major role in erections in normal men and it can also be a cause of significant morbidity. The relationship between serum testosterone measurement and erectile function is complex. Androgen treatment should certainly be considered in patients without prostate cancer but with a clinical picture that suggests a relevant contribution of hypogonadism to the ED. Other, nondiabetic, endocrine abnormalities may need to be considered in the management or the patient with ED.
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Affiliation(s)
- Jeremy P W Heaton
- Queen's University and Kingston General Hospital, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
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30
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Matsumoto AM. Andropause: clinical implications of the decline in serum testosterone levels with aging in men. J Gerontol A Biol Sci Med Sci 2002; 57:M76-99. [PMID: 11818427 DOI: 10.1093/gerona/57.2.m76] [Citation(s) in RCA: 274] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Alvin M Matsumoto
- Department of Medicine, Division of Gerontology and Geriatric Medicine, Population Center for Research in Reproduction, University of Washington School of Medicine, Seattle, WA, USA.
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31
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Abstract
The introduction of new oral therapies has completely changed the diagnostic and therapeutic approach to erectile dysfunction. A panel of experts in this field have developed guidelines for clinical evaluation and treatment based on the review of available scientific information.
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Affiliation(s)
- Eric Wespes
- Hôpital Civil de Charleroi, Urology Department, Belgium
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Lundberg P, Ertekin C, Ghezzi A, Swash M, Vodusek D. Neurosexology. Guidelines for Neurologists. European Federation of Neurological Societies Task Force on Neurosexology*. Eur J Neurol 2001. [DOI: 10.1046/j.1468-1331.2001.0080s3002.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Winters SJ, Kelley DE, Goodpaster B. The analog free testosterone assay: are the results in men clinically useful? Clin Chem 1998. [DOI: 10.1093/clinchem/44.10.2178] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AbstractMen with low testosterone concentrations are usually hypogonadal. However, because variations in the testosterone transport protein, sex hormone-binding globulin (SHBG), directly influence the total testosterone concentration, confirmation of a low testosterone with a measurement of free testosterone or “bioavailable” testosterone (BAT) is recommended. In the present study, we examined the relationship of SHBG with free testosterone (Coat-A-Count assay, Diagnostic Products) and with BAT in men (n = 29) and women (n = 28) who participated in a study of the metabolic determinants of body composition. As expected, total testosterone was strongly positively correlated with SHBG among men (r = 0.68; P <0.01). Although the BAT was independent of SHBG in men (r = 0.02), SHBG was an important predictor of free testosterone (r = 0. 62; P <0.01). In contrast, in women serum concentrations of total testosterone (r = −0.26; P = 0.17), free testosterone (r = −0.30; P = 0.17), and BAT (r = −0.46; P = 0.013) all tended to be lower with increasing SHBG. Free testosterone was nearly perfectly positively correlated with total testosterone (r = 0.97) in men, among whom free testosterone represented a relatively constant percentage of the total testosterone (0.5–0.65%), and the percentage of free testosterone was unrelated to SHBG. Thus the Coat-A-Count free testosterone concentration in men, like the total testosterone concentration, is determined in part by plasma SHBG. Accordingly, androgen deficiency may be misclassified with this assay in men with low SHBG. Moreover, the previous findings of reduced free testosterone concentrations with hypertension or hyperinsulinemia or as a risk factor for developing type 2 diabetes, conditions in which SHBG is reduced, may have been methodology-related.
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