genitourinary disorders
Male Hypogonadism
Treatment of Male Hypogonadism
Testosteronereplacement therapy Gonadotropin replacement therapy for restoration of fertility due to secondary hypogonadism Treatment is directed toward providing adequate androgen replacement conveniently and safely. Although patients with primary hypogonadism may not become fertile with any endocrine therapy, patients with secondary hypogonadism often become fertile with gonadotropin therapy.Testosteroneformulations discussed here are those available in the US. Other formulations may be available in other countries. replacement therapy alone may be used to treat secondary hypogonadism. Treatment of secondary hypogonadism in boys with gonadotropin replacement therapy (see Treatment of infertility due to hypogonadism ) usually stimulates androgen production as well as spermatogenesis. TRT can be used for young males who Have no signs of puberty Are near age 15 Have had secondary hypogonadism excluded They may be given long-actingtestosteroneenanthate 50 mg IM once/month for 4 to 8 months. These low doses cause some virilization without restricting adult height. Older adolescents withtestosteronedeficiency receive long-actingtestosteroneenanthate ortestosteronecypionate at a dose that is increased gradually over 18 to 24 months from 50 to 100 to 200 mg IM every 1 to 2 weeks. Transcutaneous gel may also be used, although it is more expensive; it could possibly be transferred to others during intimate contact. It is reasonable to convert older adolescents totestosteronegel preparations at adult dosages when their IM dosage has reached the equivalent of 100 to 200 mg every 2 weeks. deficiency may benefit from replacement therapy. Treatment slows the course of osteopenia, muscle loss, vasomotor instability, Libido , Options for replacement therapy include: a new oral form oftestosteroneundecanoate taken twice daily Testosteronegel 1% or 1.62% (5 to 10 g of gel daily to deliver 5 to 10 mg oftestosteronedaily) Transdermal axillary solution (60 mg once a day) A buccal mucosal lozenge (30 mg twice a day) Transdermaltestosteronepatch (4 mg once day) A nasal formulation (one spray of 5.5 mg in each nostril 3 times a day) Subcutaneoustestosteroneimplants (75 mg/pellet) given as 4 to 6 units placed every 3 to 6 months IMtestosteroneenanthate or cypionate (100 mg every 7 days or 200 mg every 10 to 14 days); available for self-injection Testosteronegel maintains physiologic blood levels more consistently than other treatments, but IM or patch systems are sometimes preferred because of their lower cost. Oral formulations are unpredictably absorbed. Potential adverse effects oftestosteroneand its analogs include Secondary Erythrocytosis (particularly in men over age 50 receiving IM Venous thromboembolism unrelated to erythrocytosis Acne Vulgaris None Gynecomastia None Sperm Disorders None to physiologic levels is not thought to cause new prostate cancer or accelerate growth or spread of localized prostate cancer. TRT is thought to have a minimal effect on serum prostate-specific antigen (PSA) levels in men with Benign Prostatic Hyperplasia (BPH) and in men with treated prostate cancer. However, product inserts do state that TRT is contraindicated in men with Men taking supplementaltestosteroneshould be monitored periodically. Hematocrit (Hct), PSA, andtestosteronelevels should be measured quarterly during the first year of TRT and semiannually thereafter. Digital rectal examination should be offered at the same times. If Hct is≥54%, thetestosteronedose should be reduced. Significant increases in PSA level should prompt consideration of prostate biopsy in men who would otherwise be candidates for prostate cancer diagnosis and treatment. Overview of Infertility has many possible causes other than hypogonadism. Infertility due to primary hypogonadism (elevated FSH) does not respond to hormonal therapy. Men with primary hypogonadism occasionally have a few intratesticular sperm that can be harvested with various microsurgical techniques and used to fertilize an egg by assisted reproductive technique (eg, Infertility due to secondary hypogonadism usually responds to gonadotropin replacement therapy. Other symptoms of secondary hypogonadism also respond well totestosteronereplacement therapy. If secondary hypogonadism results from pituitary disease, gonadotropin replacement therapy usually is successful. Therapy begins with replacement of luteinizing hormone (LH) and recombinant follicle-stimulating hormone (FSH). Luteinizing hormone replacement is initiated usinghuman chorionic gonadotropin(hCG) (eg, at doses of 1500 IU subcutaneous 3 times a week), with dose adjustments based on subsequent hormone levels. FSH replacement, which is expensive, uses human menotropic gonadotropin (hMG) or human recombinant FSH (eg, at doses of 75-150 IU 3 times a week). Doses may be adjusted based on the results of periodic testing with semen analysis and levels of serum FSH, LH, andtestosterone. Once an adequate sperm count is achieved, FSH can be stopped and hCG monotherapy continued. Most men who have secondary hypogonadism due to a hypothalamic defect (eg, idiopathic hypogonadotropic hypogonadism, Selective Pituitary Hormone Deficiencies ) become fertile with treatment despite sperm counts that are low (eg, 