Testosterone Replacement Jonathan Insel,MD,FACE
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1 Testosterone Replacement 2015 Jonathan Insel,MD,FACE
2 Sometimes life has a way of neutering us.
3 NN 74 YO RETIRED SURGEON c/o BREAST SWELLING 30s MUMPS ORCHITIS ; UNABLE TO FATHER KIDS ETOH : 6 COCKTAILS A DAY DON T MIND BEING AN OLD MAN, BUT DAMN IF I WANT TO TURN INTO AN OLD WOMAN
4 FINDINGS GYNECOMASTIA (3-4cm.) SMALL TESTES TESTOSTERONE 342 ( ) LH 57.5 (6-30) LFTS: Nl.
5 REST OF THE STORY RX.: DEPOTESTOSTERONE mg./mos. GYNECOMASTIA MELTED AWAY INCREASED POTENCY AND PEP WIFE ACCOMPANIED PATIENT TO OFFICE: IT S LIKE A MIRACLE
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7 Normal Physiology
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9 Causes of Primary Hypogonadism Kleinfelter s (47 XXY) Infection-Mumps orchitis Vanishing testis Trauma Radiation
10 Testes:the most accessible endocrine gland Primary Hypogonadism: Normal
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12 Causes of Secondary Hypogonadism Pituitary tumors Empty sella Opiates Kallman s syndrome Hemochromatosis HIV
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14 Causes of Mixed Primary and Secondary Hypogonadism Aging Obesity/ Type 2 DM Renal failure Steroids COPD Cirrhosis
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16 WEIGHT LOSS l
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19 Making the Diagnosis AM (prior 10 AM) Fasting Testosterone <300 ng/dl x2 Free Testosterone <50 pg/ml LH,FSH ( before initiation of testosterone Rx) Prolactin MRI Pituitary if 2 nd hypogonadism: severe 2 nd Hypogonadism (T<150) elevated prolactin panhypopituitarism mass effect: visual field loss, headaches 3 rd /6 th nerve palsy
20 Why Free Testosterone? SHBG Aging SHBG Obesity Cirrhosis HyperT4
21 A 52 yo obese male complains of erectile dysfunction. Normal libido. AM testosterone: 267 ( ) The next step would be to : 1. Calculate or measure a free testosterone. 2. Refer to a medical weight loss program. 3. Stratify coronary risk. 4. Provide a sample of Cialis,Levitra, or Viagra. 5. Consider all of the above.
22 64 YO RETIRED INTERNIST ERECTILE DYSFUNCTION RECENTLY REMARRIED ( I FIND HER VERY EXCITING ) BUT UNABLE TO CONSUMMATE MARRIAGE TRIAL ANDROGENS AND PSYCHOTHERAPY FAILED
23 Making the diagnosis
24 FINDINGS SLIGHT GYNECOMASTIA NL. TESTICULAR VOLUME NL.CARDIOVASCULAR AND NEURO. EXAM LAB: TESTOSTERONE 530
25 THE REST OF THE STORY LAB : PROLACTIN 332 CT : PITUITARY MACROADENOMA RX.: BROMOCRIPTINE 2.5mg.bid 2 wks. later his young wife accompanied patient to office visit: HE HAS BECOME A STUD PROLACTIN : 3.9
26 Free Testosterone LH/FSH Diagnosis Primary Hypogonadism Nl. Compensated Primary Secondary Hypogonadism Low Nl. Combined hypogonadism
27 T Testosterone undecanoate injections q 6 weeks
28 37 yo male c/o fatigue Testosterone 275 Placed on Testosterone Inquires about fertility
29 Testosterone Rx. : Male contraceptive-reduces spermatogenesis If man with secondary hypogonadism desires fertility : Mild 2 nd hypogonadism-clomiphene, 50 mg 3 times a week. (augments LH/FSH ) Severe 2 nd hypogonadism-hcg : units SQ/IM 3 times a week
30 Patients for whom testosterone contraindicated Very High risk: Metastatic prostate cancer Breast cancer Moderate to high risk: Unevaluated prostatic nodule PSA >4 (>3 for men at high risk for prostate cancer) HCT>50 Severe urinary outlet obstructive symtoms Uncontrolled CHF Potential risk: Clotting disorders-thrombophilia (Factor 5 Leidin) Elderly
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32 Benefits of Testosterone replacement in the elderly Reduces frailty Improves energy,libido,bone density? Reduces cardiovascular events
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34 Risks in the elderly? Increases cardiovascular events Unmask prostate cancer (50% men have histological prostate cancer) Aggravate urinary outlet obstruction Polycythemia? Increase DVT risk ONLY TREAT IF CLEARLY HYPOGONADAL
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36 Testosterone -? Cardiovascular Risk Retrospective studies: conflicting data? Increase risk in individuals who have preexisting CAD In one small prospective study (Tom trial) events occurred in the first few months of exposure and more frequent at higher Testosterone levels
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39 Testosterone Rx.: Prostate Ca Stress Test BASELINE AND F/U PSA BASELINE AND F/U DRE Increase PSA > 1.4 ng PSA > 4 ng PSA velocity >.4 ng/year over 2 years
40 Adverse Events and Testosterone Levels T X Do not overtreat older men
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42 Testosterone should be prescribed only after the diagnosis and cause of hypogonadism has been clearly established and with proper surveillance after testosterone initiated.
43
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