How to recognise and treat testosterone deficiency

Testosterone deficiency (TD) may be more common than you think. TD may occur as young as 30 years old and increases with age to an incidence as high as 18% in 70–79 year-old group.1

Classical forms of TD include conditions such as Klinefelter’s syndrome, the most common genetic reproductive disorder in men.² It may be recognised by a failure to progress through puberty, behavioural problems in adolescence, small, firm testes of <4 mL, gynaecomastia, lack of body hair, and infertility, among other symptoms.² To assist diagnosis, the testes can be measured using an orchidometer (pictured).

An orchidometer is used to assess testicular volume. Available from Andrology Australia.

TD and ageing

TD is also associated with ageing, so it’s a concern for the wider population of men as well. In fact, serum total testosterone declines by 1% a year, starting in the late 30s.²

The problem is that diagnosis can be difficult because symptoms may be subtle – unless you actively look for it, testosterone deficiency can go unnoticed.²

So what should we look for when uncovering TD in older men? As well as medical history, diagnosis is based on the identification of clinical features and is confirmed with biochemical assays. Conditions that commonly occur concomitantly with TD can also alert us to the possibility of an androgen deficiency.

Patient history

The following aspects should alert you to the possibility of TD:³

A history of delayed puberty
Pituitary disorders
Infertility
Haemochromatosis
Gynaecomastia
Surgery or torsion or trauma to the testes
Osteoporosis
Fractures
Treatment for cancer

Clinical features in adult-onset TD

Men affected by TD as they age may display physical, psychological and sexual symptoms.

Physical symptoms include:^3-5

Gynaecomastia
Increased fatigue
Sleep disturbances
Decreased lean body mass, muscle mass and strength
Increased visceral fat
Reduced beard or body hair growth
Hot flushes and sweats
Anaemia
Decreased bone mineral density resulting in osteopaenia, osteoporosis and increased risk of bone fractures

Psychological symptoms include:^4,5

Diminished energy, sense of vitality or sense of wellbeing
Depressed mood
Irritability
Impaired cognition

Sexual symptoms include:^4,5

Diminished libido
Erectile dysfunction
- Diminished erectile quality and frequency
- Fewer nocturnal erections
Difficulty achieving orgasm
Diminished intensity and experience of orgasm
Diminished sexual penile sensation

The 17 questions of the Aging Male Symptom Scale (AMSS) questionnaire can be used to assess the likelihood of testosterone deficiency and investigate the degree of impairment.⁶ A downloadable, interactive version is available online at http://www.bayermenshealth.com.au/

Laboratory assessment

In men aged 40 and over, testosterone deficiency is confirmed by testosterone levels of <8 nmol/L, or 8–15 nmol/L with high luteinising hormone (>1.5 x upper limit of the eugonadal reference range for young men).⁷ Guidelines recommend taking two morning samples of serum total testosterone on two different days.⁷

Comorbidities that may indicate TD

TD often occurs with other conditions, with obese men clearly at risk.⁸ In addition, all men presenting with erectile dysfunction should be evaluated for testosterone deficiency.⁹

Other conditions that may alert us to the presence of TD include diabetes, hypertension, hyperlipidaemia, COPD and prostate disease.⁸

Treating TD

The goal of treatment is to maintain physiological testosterone levels.⁹There are several testosterone therapies available, including patches, capsules, short-acting injectables, long-acting injectables, which are delivered every three months, such as testosterone undecanoate (Reandron^® 1000), subcutaneous implants, and daily testosterone gels (Testogel^®).

References

Araujo AB, Esche GR, Kupelian V, O’Donnell AB, Travison TG, Williams RE, et al. Prevalence of symptomatic androgen deficiency in men. J Clin Endrocrinol Metab. 2007; 92(11): 4241-7.
Andrology Australia. GP Summary Guide 4: Androgen Deficiency [online]. April 2007 [cited 10 December 2008]. Available from URL: http://www.andrologyaustralia.org
Andrology Australia. GP Summary Guide 3: Examination of male genitals and secondary sexual characteristics [online]. January 2007 [cited 10 December 2008]. Available from URL: http://www.andrologyaustralia.org
Rhoden EL, Morgentaler A. Risks of testosterone-replacement therapy and recommendations for monitoring. N Engl J Med. 2004; 350(5): 482-92.
Nieschlag E, Swerdloff R, Behre HM, Gooren LJ, Kaufman JM, Legros JJ, et al. Investigation, treatment, and monitoring of late-onset hypogonadism in males: ISA, ISSAM, and EAU recommendations. J Androl. 2006; 27(2): 135-7.
ZEG Berlin. Aging Males Symptoms Scale [online]. 2008 [cited 10 December 2008]. Available from URL: http://www.aging-males-symptoms-scale.info
Pharmaceutical Benefits Schedule [online]. Australian Government Department of Health and Ageing. 1 December 2008 [cited 10 December 2008]. Available from URL: http://www.pbs.gov.au
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(7): 762-9.
Conway AJ, Handelsman DJ, Lording DW, Stuckey B, Zajac JD. Use, misuse and abuse of androgens. The Endocrine Society of Australia consensus guidelines for androgen prescribing. Med J Aust. 2000; 172(5): 220-4.