Hypogonidism Slide

slidekit-hypogonadism

Causes of low testosterone

There are three different categories of hypogonadism, depending on the organs or organ systems responsible:

Primary hypogonadism, where the defect lies in the testes – The testes may be malfunctioning as a result of an accident or surgery. Inflammation of the testes and a number of other diseases can also lead to impaired testosterone production in the testes.

Secondary hypogonadism, where the defect lies in the hypothalamic-pituitary system – Hormones produced by the hypothalamus and the pituitary stimulate testosterone production by the testes. If insufficient amounts of these hormones are present the testes are unable to function properly. The hypothalamus-pituitary-testes system can be impaired by being underweight, a pituitary tumour and certain diseases, drugs and toxins.

Age-related testosterone deficiency, also known as late-onset hypogonadism (LOH) – In men, there is a slow but steady decline in blood levels of testosterone with increasing age. This often results in a vicious circle. On one hand complex ageing processes lead to the development of a testosterone deficiency. A general age-related deterioration in health as a result of disease is often an additional factor in this development. On the other hand, the developing testosterone deficiency itself has a negative effect on health and contributes to ageing processes.

 

Why do I need to know about testosterone?

estosterone deficiency has serious health consequences. It can put men at higher risk of:

Metabolic syndrome and diabetes
The increase in visceral fat in the man’s abdomen is linked to a decline in testosterone levels. This extra fat increases the risk of not only diabetes, but also metabolic syndrome (increased levels of total and ‘bad’ cholesterol, insulin resistance and high blood glucose).

Cardiovascular disease
Studies have shown that the lower the levels of testosterone, the higher the risk of cardiovascular disease and promotes a number of cardiovascular risk factors. Lower levels of testosterone can also lead to a decrease in elasticity in the walls of the arteries; this is associated with an increase in blood pressure. Healthy levels of testosterone have been linked to lower risk of heart attacks and healthier cholesterol levels.

Contraindications

Contraindications are conditions or circumstances (e.g. history of previous illness) in which the use of a certain drug or medical procedure is not allowed or only with special medical supervision.

Testosterone treatment is contraindicated in patients with diagnosed cancer of the prostate. Testosterone therapy does not lead to the development of prostate cancer. However, as prostate cancer is sex-hormone dependent, testosterone could stimulate the growth of an already existing tumor.

Breast cancer, which is very rare in men, is also a contraindication for testosterone therapy

Efficacy of testosterone treatment

The efficacy of testosterone therapy has been proven in testosterone deficiency.

Effects of treatment:

• Improvement in libido and erections
• Mental and physical wellbeing and performance are considerably increased. Many patients report positive effects on general mood, self-esteem and vitality
• has a virilising (masculinising) effect on the secondary sex characteristics (body and pubic hair, beard growth)
• Body shape and proportions become masculine again. Muscle mass and muscle strength increase, fat decreases
• Long-term therapy leads to an increase in bone density. The risk of osteoporosis-related fractures is reduced
• Improved production of red blood cells
• There is preliminary evidence that testosterone therapy may prevent the development of cardiovascular disease.

Testosterone has a wide margin of safety. Even after prolonged use of high doses, serious side-effects are rare. In some cases, testosterone therapy cannot be used due to pre-existing medical conditions. This is what doctors refer to as contraindications.

Treatment with testosterone must be individually tailored to the patient’s age and current needs. Monitoring of the treatment is carried out regularly to assess progress.

The aim of testosterone therapy is to achieve blood testosterone levels appropriate for the patient’s age. The only case in which other forms of treatment may be necessary is if there is a desire for fertility. These treatments are performed in centres specialising in reproductive medicine.

Comparing treatment options

Treatment	Advantages	Side-effects & disadvantages
Testosterone injection	Testosterone enanthate: Well established Well tolerated	Produce high blood concentrations of active hormone shortly after the injection and that levels then fall again rapidly, leading to adverse side effects About 20 injections required per year Undesirable for patients who fear needles
	Testosterone undecanoate: Testosterone levels are stable throughout period of duration, hence overcomes the problem of mood fluctuations Only four injections required per year	Undesirable for patients who fear needles
Testosterone patch	Convenient Non-invasive	Visibility Limited skin tolerability (skin irritation)
Testosterone implants	Each pellet lasts four to six months	Invasive, anaesthesia required
Oral testosterone capsules	Convenient Non-invasive	Very short duration of action Action not very reliable Must be taken with high-fat meal for optimal absorption
Testosterone gel	Convenient Non-invasive Not visible Well tolerated Reliable testosterone concentration	Must be applied every day

Treatment options

If a testosterone deficiency is established, testosterone therapy can considerably improve mental and physical wellbeing, sexual satisfaction and quality of life. Diseases resulting from a testosterone deficiency (e.g. osteoporosis) can be prevented. Below are some treatment options available for treating testosterone deficiency.

Testosterone injection
Intramuscular injection of testosterone is one of the standard forms of therapy.

Injections of testosterone enanthate have been used for more than 50 years and are therefore well established. The injections are given at intervals of two to three weeks. They are generally well tolerated. The disadvantage of these conventional injections are that they produce high blood concentrations of active hormone shortly after the injection and that levels then fall again rapidly. Patients often find that this can lead to fluctuations of mood (feeling of energy and wellbeing shortly after the injection – increasing tiredness as the testosterone levels decline).

A newly developed injectable preparation with testosterone undecanoate overcomes the shortcomings of conventional testosterone injections. Only four injections are required per year. Testosterone levels remain constant. Patients value the consistent, reliable efficacy and the long duration of effect, which mean they are not dependent on having frequent injections. Consequently, testosterone undecanoate is believed to become the standard preparation for long-term treatment.

Testosterone patch
Testosterone patches were the first preparations in which testosterone was delivered to the bloodstream via the skin (transdermally). Two of these patches are affixed to the upper arms, abdomen, shoulders or back every evening. They must be left in place for 24 hours. The disadvantage is the visibility and particularly the limited skin tolerability. In some patients the skin can become irritated (redness, itching).

Testosterone implants
Implants (also called pellets) are amongst the oldest testosterone preparations. They are implanted under the skin of the abdomen in a minor surgical procedure under local anesthesia. Implantation of 3 to 6 pellets ensures gradually declining testosterone levels within the normal range for four to six months. Then new pellets have to be implanted.

Oral testosterone capsules
Testosterone capsules have a very short duration of action (only a few hours). Therefore several capsules have to be taken in the course of the day. In addition, uptake and utilization of the testosterone are influenced by the diet, so the action is not very reliable. Testosterone capsules have to be taken with a high-fat meal for optimal absorption. This poses a problem for obese men since the additional intake of fat will only worsen their obesity and increase related health risks.

Testosterone gel
The patient applies the clear, colourless gel to the skin of the upper arms, shoulders or abdomen himself every morning. The gel is absorbed within a few minutes. After this, the testosterone concentration remains very reliably within the normal range for 24 hours. Most patients tolerate the gel well.

Testosterone in Your Body

An adult male produces about 6mg to 7mg of testosterone per day. The normal blood level of testosterone fluctuates between 12 and 35 nmol/l. The amount of testosterone produced varies during the course of the day and blood levels can be up to 30% higher in the early morning. This is the explanation for morning erections. Testosterone levels are usually at their lowest between 6pm and 10 pm.

Testosterone production declines in the course of a man’s life. On average, testosterone levels begin to decrease gradually after the age of about 35 to 40.

Testosterone production is controlled by the pituitary gland and the hypothalamus (a part of the midbrain). The pituitary hormone LH stimulates the testes to produce testosterone, which is released into the bloodstream. The hormone is thus carried to the different parts of the body where its actions are required.

The bloodstream also carries testosterone to the hypothalamus and the pituitary. These organs continuously register the levels of testosterone in the blood. If enough testosterone has been produced the activity of the hypothalamus and the pituitary is reduced.

The balance of this control system of hypothalamus, pituitary and testes can be influenced by numerous factors, e.g. sensory stimuli such as light and smell, emotions, stress, environmental factors and disease.

Testosterone and You

Testosterone is the most important male sex hormone (androgen). In men, more than 90% of testosterone production takes place in the testes. A considerably smaller amount is produced in the outer layer (cortex) of the adrenal glands.

Testosterone has different functions in different phases of life.

In the unborn child it causes male sexual differentiation while during puberty it is responsible for virilisation (masculinisation).

In the adult male testosterone controls all sexual functions (libido, potency, fertility). In addition, it preserves the typical male build and appearance. It is important for physical health and performance and also has a decisive influence on mood and sensation of wellbeing