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Male Hypogonadism: Signs and symptoms



Male Hypogonadism: Signs and symptoms
Male hypogonadism is defined as the failure of the testes to produce androgen, sperm, or both. Although the disorder is exceedingly common, its exact prevalence is uncertain.
Testosterone production declines with advancing age; 20% of men older than 60 years and 30% to 40% of men older than 80 years have serum testosterone levels that would be subnormal in their younger adult male counterparts. This apparent physiologic decline in circulating androgen levels is compounded in frequency by permanent disorders of the hypothalamic-pituitary-gonadal axis (see later). These include the transient deficiency states associated with acute stressful illnesses, such as surgery and myocardial infarction, and the more chronic deficiency states associated with wasting illnesses, such as cancer and acquired immunodeficiency syndrome.

Male factor infertility is probably responsible for one third of the 10% to 15% of couples who are unable to conceive within 1 year of unprotected intercourse. Most of these male-associated cases result from diminished, absent, or faulty spermatogenesis. In addition to abnormal sperm production, other conditions, including obstructive ductal disease, epididymal hostility, immunologic disorders, and erectile or ejaculatory dysfunction should be considered. Finally, because combined female-male infertility is common, and fertility as well as psychological well-being are ultimate goals, both partners must be assessed from the outset.
Treatment

Androgen replacement therapy is relatively straightforward; see Box 4 for testosterone preparations currently available in the United States. Typically, the depot esters are administered by the deep intramuscular route once every 2 weeks at a dose of 200 mg in adults. A usual dosage for the transdermal or the buccal preparations results in the systemic absorption of 2.5 to 10 mg daily. If the parenteral route is chosen, patients should and can be taught to self inject. The major disadvantage with the parenteral route is that testosterone levels exhibit a saw-toothed pattern, with high-normal or supranormal levels on days 2 to 4 and low-normal or borderline low trough values before the next injection. Mood, sense of well-being, and libido may vary accordingly in some individuals. Dosages may be adjusted by aiming for midnormal (400 to 600 ng/dL) testosterone levels after 1 week or at the low end (250 to 350 ng/dL) just before the next injection is due at 2 weeks. Values are stable within a few days or weeks of the skin patch, gel, or newer buccal preparation. It must be ascertained that the preparation was actually used on the day the sample was drawn; again, a value in the midnormal range (400 to 600 ng/dL) is the goal. Although comparable testosterone levels are reached by the patch and the gels, skin reactions at the application site are much more common with the patch. Also, the buccal preparation is difficult for patients to get used to. Alkylated oral androgens should be viewed as potentially hepatotoxic and should not be used.