Hormonal Evaluation and Treatment

Abstract

Hypogonadism is a problem that has been known about for millennia, both as an endocrine disease and as an age-related phenomenon. Normal aging results in changes in androgen status and alterations in feedback sensitivities, decline in synthetic capacity, changes in serum availability, aging of responder cells, and interaction with other hormone and regulatory systems (e.g., dihydroepiandrosterone, growth hormone, melatonin, leptin). There are significant variations in how hypogonadism develops in terms of timing, the systems involved, and the extent of the changes. Genetic factors may play a part in these variations. The clinical picture can include alterations in bone mass, energy level and motivation, erectile function, fat mass, hair and skin, hematocrit, low- and high-density lipoprotein, cholesterol, leptin production, mood and cognition, muscle mass, quality of life, sexual desire, sleep, spatial cognition, vasomotor status (hot flushes), and insulin sensitivity. The biochemical diagnosis is made by measuring the total serum testosterone levels, however, in the obese and the elderly, the levels of sex-hormone binding globulin increase, reducing the metabolically active component. The optimal measure is a bioavailable testosterone. Treatment is reserved for men with symptomatic hypogonadism (a combination of clinical and biochemical abnormalities) and is directed at restoring normality. Injections and oral testosterone formulations (non-methylated) are available but transdermal preparations, notably gels, are often preferred by patients for their steady levels. A 3-mo trial may be indicated in borderline cases. The presence of either prostate or breast carcinoma is an absolute contraindication. At present, it is not thought that testosterone supplementation is responsible for carcinogenesis. All treatment should be adequately monitored for adverse effects.