Internal Medicine

0521779407-09 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:13

Hypogonadism in Men 785

■Hypogonadism may be manifestation of serious underlying disease:

pituitary tumor or HIV infection

specific therapy

■All testosterone formulations can correct androgen deficiency; var-

ious formulations differ in pharmacokinetics

■Initiate testosterone replacement therapy:

➣IM testosterone enanthate or cypionate: inexpensive and

effective; results in fluctuating testosterone levels and need for

frequent injections

➣Nongenital transdermal systems: easy to use, mimic diurnal

rhythm of testosterone secretion; causes skin reactions

➣Scrotal testosterone patch: must shave scrotal skin for good adhe-

sion

➣Testosterone gel: easy to apply; dosing flexibility; potential for

transfer of testosterone to female partner or child

■17-alpha-methyl testosterone should not be used for androgen

replacement because of risk of liver toxicity

➣Androgen supplementation contraindications:

Prostate or breast cancer

Baseline PSA≥4 ng/mL or a palpable abnormality in prostate

without urologic evaluation to rule out prostate cancer

Benign prostatic hypertrophy with severe symptoms

Baseline hematocrit >52%

Severe sleep apnea

■Side Effects

➣Acne, oiliness of skin, breast tenderness, gynecomastia, erythro-

cytosis, induction or worsening of sleep apnea

follow-up

■During testosterone replacement:

➣Measure PSA, perform digital rectal exam, evaluate symptoms of

benign prostatic hypertrophy using IPSS or AUA questionnaires

at baseline, 3, 6, & 12 mo, then annually

➣Inquire about symptoms of sleep apnea and measure

hemoglobin at baseline, 3, 6, & 12 mo, then annually

➣General health evaluation at baseline, then annually

complications and prognosis

■Patients with androgen deficiency need lifelong replacement and

monitoring

■Replacement therapy does not adversely affect serum lipids