How to recognize late-onset hypogonadism in men with sexual dysfunction

Sexual Medicine and Andrology Unit, Department of Clinical Physiopathology, University of Florence, Florence 50139, Italy.
Asian Journal of Andrology (Impact Factor: 2.53). 03/2012; 14(2):251-9. DOI: 10.1038/aja.2011.138
Source: PubMed

ABSTRACT Late-onset hypogonadism (LOH) has been considered the most common form of male hypogonadism with a prevalence of approximately 1 in 100 men. Diagnosis of LOH should be made in symptomatic men with unequivocally low serum testosterone (T) levels. However, its clinical presentation is often insidious and difficult to recognize because it is characterized by nonspecific symptoms that make differential diagnosis with physiological ageing problematic. Sexual dysfunction is the most important determinant for medical consultation and the most specific symptom associated with low T. We therefore analysed a consecutive series of 1734 subjects who attended our unit for sexual dysfunction to investigate the associations between low T (different thresholds), sexual parameters, medical history data (delayed puberty, pituitary disease or cryptorchidism) and their physical exam results. Metabolic parameters, in particular waist circumference, display the greatest accuracy in detecting low T. We found that only the association of several symptoms and signs could significantly raise the clinical suspicion of low T. Structured inventories, which cluster together symptoms and signs of hypogonadism, can help clinicians suspect androgen deficiency. In particular, structured interviews, such as ANDROTEST, have been demonstrated to have a greater accuracy when compared to self reported questionnaires in detecting low T levels.

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    • "The association between decreased TT and accumulation of visceral fat is well-known and has been extensively described in recent reviews, also by our group.672930 Essentially, it is a bidirectional association, with hypogonadism facilitating the accumulation of abdominal adiposity2829303132333435 and weight loss resulting in a substantial rise in T levels.36 "
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    ABSTRACT: Erectile dysfunction (ED) is a frequent complication of obesity. The aim of this review is to critically analyze the framework of obesity and ED, dissecting the connections between the two pathological entities. Current clinical evidence shows that obesity, and in particular central obesity, is associated with both arteriogenic ED and reduced testosterone (T) levels. It is conceivable that obesity-associated hypogonadism and increased cardiovascular risk might partially justify the higher prevalence of ED in overweight and obese individuals. Conversely, the psychological disturbances related to obesity do not seem to play a major role in the pathogenesis of obesity-related ED. However, both clinical and preclinical data show that the association between ED and visceral fat accumulation is independent from known obesity-associated comorbidities. Therefore, how visceral fat could impair penile microcirculation still remains unknown. This point is particularly relevant since central obesity in ED subjects categorizes individuals at high cardiovascular risk, especially in the youngest ones. The presence of ED in obese subjects might help healthcare professionals in convincing them to initiate a virtuous cycle, where the correction of sexual dysfunction will be the reward for improved lifestyle behavior. Unsatisfying sexual activity represents a meaningful, straightforward motivation for consulting healthcare professionals, who, in turn, should take advantage of the opportunity to encourage obese patients to treat, besides ED, the underlying unfavorable conditions, thus not only restoring erectile function, but also overall health.
    Asian Journal of Andrology 03/2014; 16(4). DOI:10.4103/1008-682X.126386 · 2.53 Impact Factor
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    • "In contrast to the general population, we recently reported that in subjects with sexual dysfunction, the presence of sexual symptoms does not help raise the suspicion of hypogonadism among clinicians, because of lack of specificity, in particular when a severe form of hypogonadism is considered.54,55 Other clinical signs, such as increased waist circumference, might help, but only the clustering of several symptoms and signs, as reported in specific structured interviews such as ANDROTEST, result in a reliable screener for this condition.55 "
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    ABSTRACT: Late-onset hypogonadism (LOH) is a syndromic condition that has a well-recognized association with sexual and reproductive failure. LOH is frequently associated with chronic conditions including cardiovascular diseases (CVD), obesity, osteoporosis, HIV infection, renal failure, and obstructive pulmonary diseases. Despite this evidence, in patients with these conditions, LOH is still only rarely investigated and testosterone replacement therapy (TRT) rarely considered. In this paper, we critically reviewed the available evidence on LOH treatment focusing on possible risks and benefits. Medical therapy of LOH should be individualized depending on the etiology of the disease and the patient's expectations. The fear of prostate cancer and the risk of erythrocytosis probably represent the main limitations of TRT in aging men. However, TRT in healthy older men in near physiological doses does not appear to incur serious adverse events, although regular monitoring of prostate-specific antigen and hematocrit levels is required. Available evidence also suggests that TRT might ameliorate central obesity and glycometabolic control in patients with metabolic syndrome and type 2 diabetes. In addition, TRT has been associated with an increase in bone mineral density in men with osteoporosis, with an improvement in lean body mass in subjects with human immunodeficiency virus infection or chronic obstructive pulmonary disease, as well as with peripheral oxygenation in patients with chronic kidney diseases. Despite this evidence, however, it should be recognized that the results of these trials were heterogeneous and limited by small sample sizes. Hence, further research is required regarding the long-term benefits and adverse effects of TRT in LOH.
    08/2013; 31(2):103-125. DOI:10.5534/wjmh.2013.31.2.103
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    ABSTRACT: INTRODUCTION: Since the phenotype and clinical need of the hypogonadal individuals changes dramatically over time, versatile therapies are needed. AREAS COVERED: The authors review the available evidence on possible therapies. EXPERT OPINION: In the case of primary hypogonadism starting early in life, substitution with testosterone (T) is the only choice. For secondary congenital hypogonadism, we recommend starting with gonadotrophins to allow the testes to reach pubertal size. Thereafter, T replacement therapy can be administered until fertility is desired. At that time, gonadotrophins should be employed until fathering occurs. Antiestrogens are an alternative, however, their efficacy has not been adequately tested. In the presence of increased estrogen production symptoms (breast tenderness and gynecomastia), a short-term trial with non-aromatizable androgens (dihydrotestosterone mesterolone or oxandrolone) could be advisable. However, after a few months of therapy, switching to other aromatizable preparations is recommended, to prevent bone loss. When prostate safety is concerned, the use of steroidal or non-steroidal selective androgen receptor modulators that are less susceptible to 5α reduction might be advisable. An attractive possibility is the combined use of testosterone with 5α inhibitors. Theoretically, also estrogen receptor-beta ligands could be employed, however the development of these compounds, although promising, is still in its infancy.
    Expert Opinion on Emerging Drugs 05/2012; 17(2):239-59. DOI:10.1517/14728214.2012.683411 · 3.28 Impact Factor
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