This activity has been designed to meet the educational needs of physicians, nurse practitioners, and physician assistants who work in the Department of Veterans Affairs.
Male hypogonadism has been found to be more common than was previously recognized and more likely to be prevalent among VA patients than among the general population. As testosterone replacement therapy (TRT) is commonly used to treat this condition, VA practitioners should have a comprehensive understanding of the diagnosis and treatment of older men with adult-onset hypogonadism, and the benefits and risks associated with TRT.
Upon completion of this activity, participants will be able to:
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This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). The Postgraduate Institute for Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Postgraduate Institute for Medicine designates this educational activity for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
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and acceptance of continuing education credit for this activity, please consult your professional licensing board.
This activity is designed to be completed within the time designated on the title page; physicians should claim only those
credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the
activity online during the valid credit period that is noted on the title page.
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A number of testosterone replacement modalities are in use in the United States. Each has a unique profile that may determine its appropriateness for your patient.
A 76-year-old man with primary testicular failure secondary to war trauma sustained 40 years ago reports dissatisfaction with his testosterone replacement therapy (TRT). For many years, he has been using testosterone enanthate (TE) 200 mg IM every 2 weeks. He was doing relatively well with the treatment until recently, after his wife passed away. Now he is bothered by the mood swings and the lethargy that he feels shortly before his next injection is due. Although these symptoms are not new, he says he has recently been feeling low and is, therefore, more sensitive to them.
The patient recalls that, while using TE, he had a healthy libido despite some erectile dysfunction. He is, however, no longer interested in continuing the treatment for this goal.
He has no problem voiding, reports no excessive daytime sleepiness, and has no history of fractures or height loss, though he has never had a dual energy X-ray absorptiometry (DEXA) bone scan.
Past medical history includes dyslipidemia, for which he is currently taking simvastatin 20 mg daily. In addition, he takes aspirin 81 mg daily to lower his risk of clot-related events. A cardiac catheterization performed within the past few years showed some blockage.
Recent blood work reveals the following levels: hemoglobin (Hb), 16.2 g/dL (normal, 13.8 to 17.2); hematocrit (Hct), 49.2% (normal, 42% to 52%); low-density lipoprotein (LDL) cholesterol, 65 mg/dL (normal, less than 100 mg/dL); high-density lipoprotein (HDL) cholesterol, 52 mg/dL (normal, above 40 mg/dL); triglycerides, 104 mg/dL (normal, less than 150 mg/dL); prostate-specific antigen (PSA), 0.8 ng/mL (normal, below 4 ng/mL); total testosterone, 369 ng/dL (normal, 280 to 800 ng/dL); luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, undetectable (normal, 2 to 12 mIU/mL and 1 to 12 mIU/mL, respectively). He also has been told he has elevated blood glucose levels and has, therefore, reduced his carbohydrate intake and lost some weight.
On physical exam, the patient appears to be healthy and in no distress. His vital signs are within the normal range. He has a nontender, Tanner stage II gynecomastia on the left side, which he says developed recently. Genitourinary examination reveals no palpable testis in the left scrotal sack, and an atrophic right testis measuring approximately 7 mL. Digital rectal exam (DRE) reveals a nonenlarged prostate with no nodules. Body hair, virilization, and all other aspects of his physical examination are normal.
How do we evaluate and manage this patient's treatment?
The ideal TRT would be one that mimics the normal physiologic state and is safe, efficient, and easy to use. A number of TRT modalities are in current use, many of which have been approved for use in the United States (Table 1).[1] Each has a unique profile that may influence its acceptability to the specific patient.