INVESTIGATION, TREATMENT AND MONITORING OF LATE ONSET HYPOGONADISM (LOH) IN MALES
Androgen deficiency in the ageing male has become a topic of increasing interest and debate throughout the world. Demographic data demonstrates the increasing percentage of the population that is found in the older age groups. The data also support the concept that testosterone falls progressively with age and that a significant percentage of men over the age of 60 years have serum testosterone levels that are below the lower limits of young adult men (age 20-30 years).
This clinical situation today has a name "Late Onset Hypogonadism" (LOH): a clinical and biochemical syndrome associated with advancing age and characterized by typical symptoms and a deficiency in serum testosterone levels. It may result in significant detriment in the quality of life and adversely affect the function of multiple organ systems.
LOH is a syndrome characterized primarily by:
(1) The easily recognized features of diminished sexual desire (libido) and erectile quality and frequency, particularly nocturnal erections.
(2) Changes in mood with concomitant decreases in intellectual activity, cognitive functions, spatial orientation ability, fatigue, depressed mood and irritability.
(3) Sleep disturbances.
(4) Decrease in lean body mass with associated diminution in muscle volume and strength.
(5) Increase in visceral fat.
(6) Decrease in body hair and skin alterations.
(7) Decreased bone mineral density resulting in osteopenia, osteoporosis and increased risk of bone fractures.
In patients at risk or suspected of hypogonadism in general and LOH in particular, a thorough physical and biochemical work-up is mandatory and, especially, the following biochemical investigations should be done: a serum sample for total testosterone determination and sex hormone binding globulin (SHBG) should be obtained between 07.00 and 11.00 hours. The most widely accepted parameters used to establish the presence of hypogonadism are the measurement of total testosterone and free testosterone calculated from measured total testosterone and SHBG. Preparations of natural testosterone should be used for substitution therapy. Currently available intramuscular, subdermal, transdermal, oral and buccal preparations of testosterone are safe and effective. The treating physician should have sufficient knowledge and adequate understanding of the pharmacokinetics, as well as the advantages and drawbacks, of each preparation. The selection of the preparation should be a joint decision by the patient and the physician. Since the possible development of a contraindication during treatment (especially prostate carcinoma) requires rapid discontinuation of testosterone substitution, short-acting (transdermal, oral, buccal) preparations should be preferred over long-acting (intramuscular, subdermal) depot-preparations in patients with LOH. Digital rectal examination (DRE) and determination of serum prostate-specific antigen (PSA) are mandatory in men over the age of 45 years as baseline measurements of prostate health prior to therapy with testosterone, at quarterly intervals for the first 12 months and yearly thereafter.
European Association of Urology Recommendations 2007
PROF A. NATALI (MD) UROLOGIST-ANDROLOGIST
DIRECTOR OF "URO-ANDROLOGICAL CENTER" DEPARTMENT OF UROLOGY - UNIVERSITY OF FLORENCE - ITALY
DIRECTOR OF "URO-ANDROLOGICAL CENTER LEONARDO DA VINCI" - FLORENCE - ITALY
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