Male hypogonadism or Testosterone Deficiency Syndrome

At Tulane Urology Garden District Urology clinic, we provide comprehensive men’s health services through our group of highly qualified and fellowship-trained andrologists. We provide services for all types of male sexual dysfunctions, including: premature ejaculation, anejaculation (absence of ejaculation), anorgasmia (absence of orgasm), erectile dysfunction, Peyronie’s disease (abnormal curvature of the erect penis), and male hypogonadism (low testosterone levels).
Testosterone, the major androgenic hormone in men, is of special importance throughout all of a man’s life stages; in-utero, testosterone stimulates the development of male reproductive and genital organs, and the elevated levels of testosterone at puberty cause significant changes, leading to adulthood. Testosterone is mainly produced by the testicles under the control of hormones secreted by glands in the brain (hypothalamus and pituitary), with a very small amount secreted by the adrenal glands.
Testosterone plays an important role throughout a man’s adult life. It is directly related to the maintenance of normal male sexual function in terms of normal levels of sexual desire and erectile function, lean muscle mass, level of energy, cognitive function, and good mood. In other words, a normal testosterone level is vital for male well being, mentally, physically, psychologically, and sexually. An inevitable change with aging is decreased levels of testosterone (hypogonadism), which may affect a man’s health and function at multiple levels.

There two major types of male hypogonadism: primary and secondary.

Primary male hypogonadism occurs when the testicles do not produce enough testosterone. This could be secondary to undescended testicles, testicular injury due to an infection, trauma or surgery, or due to cancer treatment with chemotherapy and/or radiation.

Secondary male hypogonadism results from insufficient brain stimulation that allows the testes to make testosterone. The hypothalamus- produced gonadotropin hormone stimulates the pituitary to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The LH, in turn, stimulates the testicles to produce testosterone. However, factors such as aging, obesity, AIDS/HIV, brain and pituitary tumours, and severe illness and physical stress (major surgery) may impede this process.

According the American Urology Association (AUA) 2018 testosterone deficiency guidelines, male hypogonadism is defined as total testosterone level less than 300 ng/dl on two different readings (both done in the morning, as this is when daily testosterone levels are highest), along with one or more of the following physical symptoms and signs: reduced energy, reduced endurance, diminished work or physical performance, loss of body hair, reduced beard growth, fatigue, reduced lean muscle mass, obesity. Cognitive symptoms and signs include: depression, reduced motivation, poor concentration and memory, irritability, reduced sex drive, and diminished erectile function. Some of these symptoms can be attributed to other conditions like, thyroid gland disorders, depression, and diabetes; therefore it is imperative that all patients undergo a thorough medical assessment, with documented laboratory results of low testosterone, prior to considering testosterone replacement therapy (TRT), which restores normal testosterone levels and aims to alleviate the above-mentioned symptoms.
At Tulane Urology, we perform a comprehensive medical assessment, consisting of focused medical/urological history and a physical examination. The history component focuses on testosterone deficiency symptoms. We also ask about family history of prostate cancer, previously detected or treated prostate cancer, most recent PSA level (prostate specific antigen, if available), and pertinent medical history, including: cardiovascular diseases, high blood pressure, blood clots, strokes, and obstructive sleep apnea. The physical examination focuses on secondary sexual characteristics: male hair distribution, degree of sexual maturation of genitalia, and size of the testicles. We also check for the development of male breast tissue (gynecomastia) and routinely perform a digital rectal examination to assess the prostate gland.
The laboratory assessment includes baseline PSA, CBC (complete blood count), and two separate morning total testosterone readings (below 300 ng/dl is considered subnormal).
Once a diagnosis of testosterone deficiency is confirmed based on symptoms and a low testosterone level, we counsel patients about options to replace the testosterone deficient levels; this discussion consists of potential benefits, possible side effects, and a follow-up plan.
The benefits of TRT are improved general energy levels, as well as improved cognitive and sexual functions.
Possible side effects of TRT may include: acne, osteoporosis, polycythaemia (increased amount of red blood cells which makes the blood more viscous), increased risk of thromboembolic events (e.g., deep vein thrombosis, pulmonary embolism and strokes), and, according to the FDA, a possible increased chance of prostate cancer and/or major cardiac event (heart attack). However, the AUA and SMSNA (Sexual Society of North America) both agree that the current evidence from available medical studies do not indicate that TRT increases the risk of developing prostate cancer or heart attack. The relationship is best described as “unsure” for the time being; furthermore, some studies suggest the opposite: that men with low testosterone are actually at a higher risk of developing heart attacks.
Men with low testosterone who wish to father children or have a history of male factor infertility need to be counseled that TRT could lower their sperm counts, and prolonged duration of TRT can result in irreversible changes to the sperm-producing cells in the testicles, leading to testicular atrophy (loss of volume).

Options for TRT:

Testosterone-sparing options: For men who want to preserve spermatogenesis or for men with a history of fertility problems, the indirect stimulation of the testicles to produce more testosterone naturally can be medically induced by off-label medications such as B-hCG and clomiphene sulphate.
If fertility is not a concern, there are a number of FDA-approved forms of TRT; these include topical testosterone gel for daily use, injectable options (every1-2 weeks), or testosterone pellets implanted under the skin every 3-6 months. Patients can choose from this wide range of options; every option has pros and cons that are discussed in clinic with each patient.
Follow-up regimens generally consist of clinic visits every 6-12 months to assess improvement of symptoms with up-to-date lab tests of PSA, CBC, and testosterone, in addition to a digital rectal examination of the prostate.
This is a general overview of adult male hypogonadism, including the causes, signs and symptoms, medical assessment, treatment options, and follow up. Every case is assessed individually, and a treatment plan is devised through shared decision-making based on the patient’s needs, expectations, and medical assessment. We always address any other associated urological issues, such as lower urinary tract symptoms and erectile dysfunction, to ensure a holistic-care approach to improve the patient’s overall quality of life.
If you have any of the above symptoms, call our office for an appointment. We advise patients to avoid taking unverified over-the-counter or internet-based men’s health products, as well as self-administered TRT without consulting a qualified medical source, as these alternative methods can be harmful to one’s health.

Dosing Profiles of Available Testosterone Formulations (as of AUA 2018 guidelines)
Drug Name	Brand Name	Delivery System	Dose	Starting Dose	Dose Range	Application Site	Monitoring
Topical
1% gel	Testim®	5g Tube	50mg/tube	50mg	50- 100mg	Shoulders, upper arms	T within 4 weeks
1% gel	Vogelxo®	5g Tube 5g Packet 5g Pump	50mg/tube 50mg packet 12.25mg/actuation	50mg 50mg 4 actuations	50- 100mg	Shoulders, upper arms	T within 4 weeks
1% gel	Androgel®	Packet Pump	50mg 12.25mg/actuation	50mg 4 actuations	50- 100mg	Shoulders, upper arms	T within 4 weeks
1.62% gel	Androgel®	Packet Pump	40.5mg packet 20.25mg/actuation	40.5mg 2 actuations	20.25- 81mg	Shoulders, upper arms	T within 4 weeks
2% gel pump	Fortesta®	Pump	10mg/actuation	4 actuations	10- 70mg	Thigh	T within 4 weeks
2% solution	Axiron®	Pump	30mg/actuation	2 actuations	30- 120mg	Axilla	T within 4 weeks
Patch	Androderm®	Patch	2 or 4mg/patch	4mg	2-6mg	Back,upper arms,or thighs	T within 4 weeks

Intramuscular
T cypionate	*	Injection (1 and 10mL vials)	100 mg	50- 200mg every 7-14days	Gluteal muscle or lateral upper thigh	After cycle 4
T enanthate	*	Injection (5mL vials)	100 mg	50- 200mg every 7-14 days	Gluteal muscle or lateral upper thigh	After cycle 4
T undecanoate	Aveed®	Injection– (750mg/3mL)	750mg (single dose)	750mg injection at weeks 0, 4, and every 10 weeks thereafter	Gluteal muscle	After cycle 4

Pellets
Testosterone	Testopel®	Pellet	75mg/pellet	10 pellets	6 -12 pellets every 3 to 4 months	Subcutaneous (buttock, flank)	1 and 3 months after first pellet insertion
T: testosterone *Available under multiple brand names

References:
1.Adult-onset hypogonadism. Khera M, Broderick GA, Carson CC 3rd, Dobs AS, Faraday MM, Goldstein I,Hakim LS, Hellstrom WJ, Kacker R, Köhler TS, Mills JN, Miner M, Sadeghi-Nejad H, Seftel AD, Sharlip ID, Winters SJ, Burnett AL.MayoClinProc.2016.Jul;91(7):908-26.doi:10.1016/j.mayocp.2016.04.022.Epub 2016 Jun 21. Review. PMID: 27343020

2.Pharmacotherapy for Erectile Dysfunction: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015).Hatzimouratidis K, Salonia A, Adaikan G, Buvat J, Carrier S, El-Meliegy A, McCullough A, Torres LO, Khera M. J Sex Med. 2016 Apr;13(4):465-88. doi: 10.1016/j.jsxm.2016.01.016. Epub 2016 Mar 25.

3.Testosterone therapy improves erectile function and libido in hypogonadal men. Rizk PJ, Kohn TP, Pastuszak AW, Khera M.Curr Opin Urol .2017 Nov;27(6):511-515. doi:10.1097/MOU.0000000000000442.

4. Evaluation and Management of Testosterone Deficiency, AUA guidelines 2018, http://www.auanet.org/guidelines/testosterone-deficiency-(2018).