Good treatment for testosterone deficiency begins with a correct diagnosis
Source / Disclosures
Source: Healio interview
Disclosures: Nagalli does not report any relevant financial information.
Testosterone deficiency – defined by the American Urological Association as a testosterone level of 300 ng / dL or less – occurs in up to 39% of middle-aged and older American men, data in Translational andrology and urology show.
Although interest in the disease is increasing among medical professionals, understanding is not, experts said.
“Testosterone testing and prescriptions have almost tripled in recent years,” wrote the authors of the American Urological Association’s 2018 Guidelines on Testosterone Deficiency. “However, it is clear from clinical practice that there are a lot of men using testosterone without a clear indication.”
Shivaraj Nagalli, MD, FACP, an internist at Shelby Baptist Medical Center in Alabaster, Alabama, said in an interview that testosterone deficiency is one of the “most misunderstood topics” among primary care physicians and internists.
As part of Men’s Health Month, we asked Nagalli to discuss common misconceptions regarding testosterone deficiency, disease risk factors, treatments and more.
Healio primary care: What are the common misconceptions about testosterone deficiency among internists, family physicians, and primary care physicians?
Nagalli: The first misconception is that single random screening is indicated for men aged 65 and over. However, the ACP and the European Society of Endocrinology advise against routine screening for hypogonadism in asymptomatic men.
A second misconception is that all men who have low testosterone need testosterone treatment. It’s important to remember that as men get older, testosterone levels gradually decline by 1-2% each year. This is why routine screening is not recommended and why not all patients with low testosterone need treatment.
Testosterone deficiency may be due to a problem with the testes (primary hypogonadism) or elsewhere to secondary hypogonadism.
Regardless of the type, symptoms of hypogonadism such as fatigue, low energy levels and insomnia are not exclusive to testosterone deficiency. Therefore, the most common causes of these symptoms should be ruled out before moving on to testosterone replacement. It’s also important to note that testosterone levels fluctuate throughout the day and peak around 8 a.m. Therefore, it is best to measure these levels between 8 a.m. and 10 a.m. Additionally, since oral glucose can alter testosterone levels, patients should fast before these levels are checked.
Healio primary care: What are some of the risk factors for testosterone deficiency?
Nagalli: Obesity, chronic alcoholism, as well as chronic use of opioids, anabolic steroids and gonadotropin releasing hormone analogues are some of the risk factors for low testosterone levels. Testicular torsion, testicular trauma, and a history of radiation therapy to the pelvis can also lead to testosterone deficiency.
Healio primary care: Are there certain foods that contribute to testosterone deficiency? Which? How strong is the association?
Nagalli: There is little evidence to suggest that foods such as tofu and other soy products, processed foods, licorice, and those containing polyunsaturated fats decrease testosterone levels, as does chronic alcohol consumption and of opioids. Additionally, fried foods were associated with low testosterone levels in a study of patients with chronic kidney disease.
Healio primary care: What medical condition (s) are men with testosterone deficiency more at risk of developing?
Nagalli: Low testosterone levels can lead to low energy levels, decreased libido and muscle mass, low impact trauma fractures, gynecomastia, and loss of axillary and pubic hair. Poor concentration and poor memory as well as insomnia are also possible. When the testosterone deficiency is due to primary hypogonadism, infertility may also be present.
Healio primary care: How should doctors treat testosterone deficiency in primary care? What are the risks associated with the treatment?
Nagalli: Management begins by confirming the diagnosis and assessing its cause.
First, primary care physicians must assess the clinical significance of low testosterone levels. Are the patients symptomatic? Does the patient have a constellation of symptoms, such as decreased libido and muscle mass, low impact trauma fractures, gynecomastia, axillary and pubic hair loss? Once testosterone deficiency is confirmed, the next step is to check LH, FSH and prolactin levels and refer patients to an endocrinologist. These patients will also need an MRI of the brain to look for prolactinoma.
Lifestyle modifications are recommended to help treat testosterone deficiency. Additionally, testosterone can be replaced by transdermal pathways (eg, testosterone gels) and parenteral routes (eg, testosterone enanthate or testosterone cypionate). The choice of treatment depends on patient preferences, costs and insurance coverage.
Once a pharmaceutical approach has been chosen, an assessment of the continued need for that drug should be performed frequently. Testosterone levels should be checked every 2 to 3 months until they stabilize, with the goal of reaching about half between 300 ng / dL and 900 ng / dL for all men except those who are older. In older patients, a little lower than half is more appropriate due to the risks associated with testosterone replacement.
The use of testosterone substitutes is associated with risks of hypercoagulability, thromboembolism, CVD (myocardial infarction / exacerbation of heart failure) and prostate cancer. There is also the risk of suppressing spermatogenesis.
Healio primary care: What is the CPA’s position on testosterone therapy? How do the guidelines of other medical societies differ? How can physicians reconcile these differences?
Nagalli: The PCA suggests that men with age-related low testosterone may experience slight improvements in sexual and erectile function with testosterone replacement and therefore this treatment may be considered. However, he does not recommend prescribing testosterone for men with less specific symptoms such as energy, vitality, physical function, or cognition.
The Endocrine Society suggests offering testosterone on an individualized basis to older men who have symptoms and signs suggesting testosterone deficiency and who have consistently and unequivocally serum testosterone levels after an explicit discussion of the risks and potential benefits.
The selection of candidates for testosterone treatment should be individualized for each patient by assessing the risks of testosterone replacement through an in-depth discussion between prescribing physicians and their patients.
Anaïssie J, et al. Translate Androl Urol. 2017; doi: 10.21037 / tau.2016.11.16.
Mulhall JP, et al. J Urol. 2018; doi: 10.1016 / j.juro.2018.03.115.
Health care unit. June is Men’s Health Month. https://www.unicityhealthcare.com/mens-health-month-bringing-awareness-mens-health-issues-month-june/. Accessed June 18, 2021.
Urology Care Foundation. Men’s Health Month. https://www.urologyhealth.org/media-center/mens-health-month. Accessed June 18, 2021.