💡 TLDR Primary Care - Deep Dive (#055)

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TLDR Primary Care #055

Sep 13, 2023

In This Issue:

✅ Summarized Male Hypogonadism guidelines

🧠 Review the common signs and symptoms of Male Hypogonadism

⭐ Review the updated options for testosterone replacement

📈 And more!

💡 Deep Dive: Male Hypogonadism

In-depth review of key recent guidelines

This week, we'll explore the latest clinical guidelines on Male Hypogonadism, a condition affecting a substantial portion of the male population. Male hypogonadism typically occurs when the testes produce insufficient levels of testosterone, leading to a range of symptoms and potential health implications. It's estimated that around 4 to 5 million men in the United States experience some form of hypogonadism.

Male hypogonadism often manifests with symptoms such as fatigue, reduced libido, erectile dysfunction, muscle weakness, and mood disturbances. Effective management strategies encompass hormone replacement therapy, lifestyle modifications, and regular monitoring of hormone levels to gauge treatment progress.

Guidelines on the evaluation and management of male hypogonadism are from the European Association of Urology (EAU 2023), the Italian Society of Endocrinology (SIE/SIAMS 2022), and the American Urological Association (AUA/SMSNA 2022), among others.

For a full review of male hypogonadism guidelines, head over to Pathway. We’ll cover some key takeaways below (with the recommendation strength in parentheses).

1) Screening and Diagnosis:

Obtain screening for late-onset hypogonadism only in symptomatic patients, including in T2DM. (A)
Do not use structured interviews or self-reported questionnaires for systematic screening for late-onset hypogonadism because of their low specificity. (D)
Obtain screening for testosterone deficiency in all patients with:
- consistent and multiple signs of testosterone deficiency (B)
- erectile dysfunction, loss of spontaneous erections, or low sexual desire (A)
- T2DM, BMI > 30 kg/m², or waist circumference > 102 cm (B)
- long-term opioid, antipsychotic, or anticonvulsant use. (B)

2) Diagnostic Investigations:

Use a total testosterone value of 12 nmol/L (3.5 ng/mL) as a reliable threshold to diagnose late-onset hypogonadism. (A)
Obtain measurement of total testosterone in the morning (7-11 a.m.) and in the fasting state with a reliable laboratory assay. (A)
Repeat total testosterone on at least two separate occasions when < 12 nmol/L and before initiating testosterone therapy. (A)
Obtain measurement of LH and FSH serum levels to differentiate between primary and secondary hypogonadism. (A)
View a value of LH ≥ 9.4 IU/L in the presence of low total or calculated free testosterone as suggestive of primary hypogonadism. Consider measuring follicle-stimulating hormone to differentiate between primary and secondary hypogonadism if LH concentration is < 9.4 IU/L. (B)
Obtain pituitary MRI in patients with secondary hypogonadism, with elevated prolactin levels or specific symptoms of a pituitary mass and/or presence of other anterior pituitary hormone deficiencies. (A)
Obtain pituitary MRI in patients with severe secondary hypogonadism (total testosterone < 6 nmol/L). (B)
Elicit a family history to exclude VTE before initiating testosterone therapy. (A)
Treat comorbidities before initiating testosterone therapy. Treat patients with preexisting cardiovascular, VTE, or chronic cardiac failure requiring testosterone therapy with caution, by careful clinical monitoring and regular measurement of hematocrit (not exceeding 54%) and testosterone levels. (B)

⭐ Landmark Trial Alert

Is testosterone therapy safe in patients with hypogonadism with regard to CVD death?

TRAVERSE - NEJM June 2023

3) Medical Management of Male Hypogonadism:

Withdraw concomitant drugs likely to impair testosterone production, when possible. (B)
Treat organic causes of hypogonadism (such as pituitary masses and hyperprolactinemia) when indicated. (A)
Initiate testosterone replacement therapy in patients with hypogonadism to restore serum testosterone concentration to the average normal range for young males. (B)
Initiate a combination of PDE5 inhibitors and testosterone therapy in more severe forms of erectile dysfunction. (B)
Do not initiate testosterone therapy to reduce weight, enhance the cardiometabolic status, and improve cognitive vitality and physical strength in aging males. (D)
Restrict testosterone replacement therapy to patients with a low risk for recurrent prostate cancer (preoperative PSA < 10 ng/mL, Gleason score < 7, cT1-2a), and initiate treatment after at least 1 year of follow-up with PSA level < 0.01 ng/mL. (B)
Aim to target a total testosterone level of 15-30 nmol/L to achieve optimal response. (B)
Offer testosterone gels rather than long-acting depot administration when starting initial treatment, thus allowing adjustment or discontinuation of therapy in case of treatment-related adverse effects. (B)
Advise lifestyle improvements and weight reduction in patients with hypogonadism. (B)
Monitor testosterone and hematocrit at 3, 6, and 12 months after initiation of testosterone therapy and annually thereafter. (A)
Discontinue testosterone therapy and perform phlebotomy in case of hematocrit level > 54%. Re-introduce testosterone therapy at a lower dose once the hematocrit has normalized, and consider switching to topical testosterone preparations. (A)

4) High Yield Testosterone Deficiency Guidelines from the AAFP:

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Warm regards,

- The Pathway Team