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Travison TG, Araujo AB, O'Donnell AB, Kupelian V, McKinlay JB. A population-level decline in serum testosterone levels in American men. J Clin Endocrinol Metab. 2007;92:196-202. Abstract
Mulligan T, Frick MF, Zuraw QC, Stemhagen A, McWhirter C. Prevalence of hypogonadism in males aged at least 45 years: the HIM study. Int J Clin Pract. 2006;60:762-769. Abstract
Litman HJ, Bhasin S, Link CL, Araujo AB, McKinlay JB. Serum androgen levels in black, Hispanic, and white men. J Clin Endocrinol Metab. 2006;91:4326-4334. Abstract
Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2006;91:1995-2010. Abstract
Wang C, Nieschlag E, Swerdloff R, et al. Investigation, treatment and monitoring of late-onset hypogonadism in males: ISA, ISSAM, EAU, EAA and ASA recommendations. Eur J Endocrinol. 2008;159:507-514. Abstract
Araujo AB, McGraw SA, Conor M, et al. Development and Validation of a New Screening Instrument to Assess Symptoms of Androgen Deficiency. Program and abstracts of the 6th World Congress of The Aging Male; February 2008; Tampa, Florida. Poster presentation.
Traish AM, Guay A, Feeley R, Saad F. The dark side of testosterone deficiency: I. Metabolic syndrome and erectile dysfunction. J Androl. 2009;30:10-22. Abstract
Traish AM, Saad F, Guay A. The dark side of testosterone deficiency: II. Type 2 diabetes and insulin resistance. J Androl. 2009;30:23-32. Abstract
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Heidler S, Temml C, Broessner C, et al. Is the metabolic syndrome an independent risk factor for erectile dysfunction? J Urol. 2007;177:651-654.
Kupelian V, Hayes FJ, Link CL, Rosen R, McKinlay JB. Inverse association of testosterone and the metabolic syndrome in men is consistent across race and ethnic groups. J Clin Endocrinol Metab. 2008;93:3403-3410. Abstract
Dhindsa S, Prabhakar S, Sethi M, et al. Frequent occurrence of hypogonadotropic hypogonadism in type 2 diabetes. J Clin Endocrinol Metab. 2004;89:5462-5468. Abstract
Kapoor D, Aldred H, Clark S, Channer KS, Jones TH. Clinical and biochemical assessment of hypogonadism in men with type 2 diabetes: correlations with bioavailable testosterone and visceral adiposity. Diabetes Care. 2007;30:911-917. Abstract
Chen RY, Wittert GA, Andrews GR. Relative androgen deficiency in relation to obesity and metabolic status in older men. Diabetes Obes Metab. 2006;8:429-435. Abstract
Basaria S, Dobs AS. Testosterone making an entry into the cardiometabolic world. Circulation. 2007;116:2658-2661. Abstract
Traish AM, Saad F, Feeley RJ, Guay AT. The dark side of testosterone deficiency: III. Cardiovascular disease. J Androl. 2009;20:477-494.
Rosano GM, Sheiban I, Massaro R, et al. Low testosterone levels are associated with coronary artery disease in male patients with angina. Int J Impot Res. 2007;19:176-182. Abstract
Khaw KT, Dowsett M, Folkerd E, et al. Endogenous testosterone and mortality due to all causes, cardiovascular disease, and cancer in men: European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) Prospective Population Study. Circulation. 2007;116:2694-2701. Abstract
Shores MM, Matsumoto AM, Sloan KL, Kivlahan DR. Low serum testosterone and mortality in male veterans. Arch Intern Med. 2006;166:1660-1665. Abstract
Laughlin GA, Barrett-Connor E, Bergstrom J. Low serum testosterone and mortality in older men. J Clin Endocrinol Metab. 2008;93:68-75. Abstract
Nieschlag E, Swerdloff R, Behre HM, et al; International Society of Andrology (ISA); International Society for the Study of the Aging Male (ISSAM); European Association of Urology (EAU). Investigation, treatment and monitoring of late-onset hypogonadism in males. ISA, ISSAM, and EAU recommendations. Eur Urol. 2005;48:1-4. Abstract
Vermeulen A, Verdonck L, Kaufman JM. A critical evaluation of simple methods for the estimation of free testosterone in serum. J Clin Endocrinol Metab. 1999;84:3666-3672. Abstract
Kopp HP, Festa A, Krugluger W, Schernthaner G. Low levels of sex-hormone-binding globulin predict insulin requirement in patients with gestational diabetes mellitus. Exp Clin Endocrinol Diabetes. 2001;109:365-369. Abstract
Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Male Reproduction and Urology. Androgen deficiency in the aging male. Fertil Steril. 2008;90(5 Suppl):S83-S87.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2006;29 Suppl 1:S43-S48. Abstract
Kapoor D, Goodwin E, Channer KS, Jones TH. Testosterone replacement therapy improves insulin resistance, glycaemic control, visceral adiposity and hypercholesterolaemia in hypogonadal men with type 2 diabetes. Eur J Endocrinol. 2006;154:899-906. Abstract
Kapoor D, Clarke S, Stanworth R, Channer KS, Jones TH. The effect of testosterone replacement therapy on adipocytokines and C-reactive protein in hypogonadal men with type 2 diabetes. Eur J Endocrinol. 2007;156:595-602. Abstract
Allan CA, Strauss BJ, Burger HG, Forbes EA, McLachlan RI. Testosterone therapy prevents gain in visceral adipose tissue and loss of skeletal muscle in nonobese aging men. J Clin Endocrinol Metab. 2008;93:139-146. Abstract
National Cholesterol Education Program. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): Final Report. Circulation. 2002;106:3143-421. Abstract
Grundy SM, Cleeman JI, Bairey Merz N, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation. 2004;110:227-239. Abstract
Saltzman EA, Guay AT, Jacobson J. Improvement in erectile function in men with organic erectile dysfunction by correction of elevated cholesterol levels: a clinical observation. J Urol. 2004;172:255-258. Abstract
Grossmann M, Thomas MC, Panagiotopoulos S, et al. Low testosterone levels are common and associated with insulin resistance in men with diabetes. J Clin Endocrinol Metab. 2008;93:1834-1840. Abstract
Carruthers M. Time for international action on treating testosterone deficiency syndrome. Aging Male. 2009;12:21-28. Abstract
Gooren LJ, Behre HM, Saad F, Frank A, Schwerdt S. Diagnosing and treating testosterone deficiency in different parts of the world. Results from global market research. Aging Male. 2007;10:173-181. Abstract
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Szmulewitz R, Mohile S, Posadas E, et al. A randomized phase 1 study of testosterone replacement for patients with low-risk castration-resistant prostate cancer. Eur Urol. 2009 Feb 27. [Epub ahead of print]
Stattin P, Lumme S, Tenkanen L, et al. High levels of circulating testosterone are not associated with increased prostate cancer risk: a pooled prospective study. Int J Cancer. 2004;108:418-424. Abstract
Calof OM, Singh AB, Lee ML, et al. Adverse events associated with testosterone replacement in middle-aged and older men: a meta-analysis of randomized, placebo-controlled trials. J Gerontol A Biol Sci Med Sci. 2005;60:1451-1457. Abstract
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Coward RM, Simhan J, Carson CC 3rd. Prostate-specific antigen changes and prostate cancer in hypogonadal men treated with testosterone replacement therapy. BJU Int. 2009;103:1179-1183. Abstract
Shabsigh R, Crawford ED, Nehra A, Slawin KM. Testosterone therapy in hypogonadal men and potential prostate cancer risk: a systematic review. Int J Impot Res. 2009;21:9-23. Abstract
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Author(s)

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

Disclosures

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

Disclosures

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

Writer(s)

Anne E. Zitron, PhD

Freelance Medical Writer

Disclosures

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

Editor(s)

David Danar, MD

Scientific Director, MedscapeCME

Disclosures

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

CME

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
THIS ACTIVITY HAS EXPIRED
Valid for credit through: 10/14/2010

Start Activity

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:

Describe signs and symptoms of male hypogonadism and appropriate diagnostic approach based on clinical symptoms and laboratory tests
Evaluate currently approved therapies for hypogonadism, and design an individualized treatment regimen in conjunction with treatment for diabetes, cardiovascular disease, and other comorbid conditions
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
Demonstrate how the appropriate management of hypogonadism and any comorbid conditions can improve a patient's physical and emotional well-being and sexual function

Disclosures

Author(s)

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

Disclosures

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

Disclosures

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

Writer(s)

Anne E. Zitron, PhD

Freelance Medical Writer

Disclosures

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

Editor(s)

David Danar, MD

Scientific Director, MedscapeCME

Disclosures

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

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For Physicians

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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.

Introduction

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

Page 1 of 14

CME Information

References

Disclaimer

The material presented here does not necessarily reflect the views of MedscapeCME or companies that support educational programming on www.medscapecme.com. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity.

References

Faculty and Disclosures

Author(s)

Andre T. Guay, MD, FACP, FACE

Abdulmaged M Traish, MBA, PhD

Writer(s)

Anne E. Zitron, PhD

Editor(s)

David Danar, MD

CME

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

Target Audience and Goal Statement

Disclosures

Author(s)

Andre T. Guay, MD, FACP, FACE

Abdulmaged M Traish, MBA, PhD

Writer(s)

Anne E. Zitron, PhD

Editor(s)

David Danar, MD

Accreditation Statements

For Physicians

Instructions for Participation and Credit

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

Introduction

Signs and Symptoms of Male Hypogonadism