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The Clinical Picture of Adult Male Hypogonadism: A Case-Based Approach

  • Authors: Andre T. Guay, MD, FACP, FACE; Abdulmaged M Traish, MBA, PhD
  • CME Released: 10/14/2009
  • Valid for credit through: 10/14/2010
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Target Audience and Goal Statement

This activity is intended for urologists, primary care physicians, and other healthcare professionals involved in the management of men with hypogonadism.

The goal of this activity is to teach participants about the diagnosis and treatment of hypogonadism in men.

Upon completion of this activity, participants will be able to:

  1. Describe signs and symptoms of male hypogonadism and appropriate diagnostic approach based on clinical symptoms and laboratory tests
  2. Evaluate currently approved therapies for hypogonadism, and design an individualized treatment regimen in conjunction with treatment for diabetes, cardiovascular disease, and other comorbid conditions
  3. Recognize that male hypogonadism is frequently underdiagnosed, misdiagnosed, or underreported due to several factors, including lack of understanding of the relationship between hypogonadism and comorbid chronic illnesses
  4. Demonstrate how the appropriate management of hypogonadism and any comorbid conditions can improve a patient's physical and emotional well-being and sexual function


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  • Andre T. Guay, MD, FACP, FACE

    Clinical Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts; Director, Center for Sexual Function, Lahey Clinic Northshore, Peabody, Massachusetts


    Disclosure: Andre T. Guay, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant to: Solvay Pharmaceuticals, Inc.; Auxilium Pharmaceuticals, Inc.; Indevus Pharmaceuticals, Inc.; Endo Pharmaceuticals; Bayer HealthCare Pharmaceuticals
    Served as a speaker or a member of a speakers bureau for: Auxilium Pharmaceuticals, Inc.; Boehringer Ingelheim Pharmaceuticals, Inc.

  • Abdulmaged M Traish, MBA, PhD

    Professor, Departments of Biochemistry and Urology, Boston University School of Medicine, Boston, Massachusetts


    Disclosure: Abdulmaged M. Traish, PhD, MBA, has disclosed no relevant financial relationships.


  • Anne E. Zitron, PhD

    Freelance Medical Writer


    Disclosure: Anne E. Zitron, PhD, has disclosed no relevant financial relationships.


  • David Danar, MD

    Scientific Director, MedscapeCME


    Disclosure: David Danar, MD, has disclosed that he owns a small quantity of stock in Pfizer Inc.

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The Clinical Picture of Adult Male Hypogonadism: A Case-Based Approach

Authors: Andre T. Guay, MD, FACP, FACE; Abdulmaged M Traish, MBA, PhDFaculty and Disclosures

CME Released: 10/14/2009

Valid for credit through: 10/14/2010


The following test-and-teach case is an educational activity modeled on the interactive grand rounds approach. The questions within the activity are designed to test your current knowledge. After each question, you will be able to see whether you answered correctly and will then read evidence-based information that supports the most appropriate answer choice. Please note that these questions are designed to challenge you; you will not be penalized for answering the questions incorrectly. At the end of the case, there will be a short post-test assessment based on material covered in the activity.


In the United States, approximately 37% of men over the age of 57 years experience erectile dysfunction (ED), and about 28% experience decreased sexual interest (libido).[1] ED and decreased libido have been linked to reductions in testosterone levels.[2] Testosterone levels, bioavailable testosterone, and free testosterone decrease with increasing age,[2,3] and the percentage of men with total testosterone levels in the hypogonadal range increases progressively with increasing age (Figure 1).[4] There are no racial differences in testosterone levels among white, black, and Hispanic men.[5]

The Endocrine Society defined hypogonadism in men as "a clinical syndrome resulting from failure of the testis to produce physiological levels of testosterone (androgen deficiency) and normal numbers of spermatozoa due to disruption of one or more levels of the hypothalamic-pituitary-gonadal (HPG) axis."[6] The presence of a clinical picture of testosterone deficiency and borderline serum testosterone levels may warrant a short trial of testosterone replacement therapy (TRT).[7] For brevity's sake, we will be limiting the discussion to testosterone deficiency only. Over 39% of men older than age 45 years who are seen for primary care medical appointments experience hypogonadism,[4] and it is estimated that by 2025, 6.5 million American men age 30-79 will experience symptomatic androgen deficiency.[2] Thus, accurate assessment, diagnosis, and treatment are growing healthcare needs.

Figure 1. Age-specific prevalence of hypogonadism for enrolled patients. Enrolled patients were men age 45 and older (n = 2165); hypogonadism was defined as total testosterone < 300 ng/dL. From Mulligan T, et al. Int J Clin Pract. 2006;60:762-769.[4] Republished with permission.

Signs and Symptoms of Male Hypogonadism