1 / 96

Module 2

Module 2. Male hypogonadism. Approval Number : G.MKT.GM.MH.04.2018.0513. Module 2: Male hypogonadism. Definition. Several international societies have proposed definitions of hypogonadism. EAU , European Association of Urology

gillette
Download Presentation

Module 2

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Module 2 Male hypogonadism Approval Number: G.MKT.GM.MH.04.2018.0513

  2. Module 2: Male hypogonadism Definition

  3. Several international societies have proposed definitions of hypogonadism EAU, European Association of Urology 1.Dohle GR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/2.Bhasin S et al. J ClinEndocrinolMetab. 2010;95(6):2536–59.

  4. Several international societies have proposed definitions of hypogonadism (2) ISSAM, International Society for the Study of the Aging Male LunenfeldB et al. Aging Male. 2015;18(1):5–15.

  5. Several international societies have proposed definitions of hypogonadism (3) ICSM, International Consultation for Sexual Medicine; SHBG, sex hormone-binding globulin; TD, testosterone deficiency Khera M et al. J Sex Med. 2016;13(12):1787–804.

  6. Several international societies have proposed definitions of hypogonadism (4) ISSM, International Society for Sexual Medicine; TD, testosterone deficiency Dean JD et al. J Sex Med. 2015;12(8):1660–86.

  7. Module 2: Male hypogonadism Classification and etiology

  8. Classification of male hypogonadism Primary hypogonadism Testis Nieschlag Secondary hypogonadism Hypothalamus Pituitary gland Target organ androgen insensitivity/ resistance • Androgen receptor defect • 5α-reductase deficiency • Aromatase deficiency Target tissuesfortestosterone,DHT and estradiol DHT, dihydrotestosterone BhasinS et al. J ClinEndocrinolMetab. 2010;95(6):2536–59;Nieschlag E et al. Andrology: Male reproductive health and dysfunction, 3rd edition, Springer, 2010.

  9. Classification of male hypogonadism (2) Hypothalamus Pituitary gland • Normaltestosterone • Normal hypothalamic-pituitary-testicular function No hypogonadism LH LH LH GnRH Testis FSH + FSH FSH • Low testosterone • Testicular failurewith elevatedgonadotropin secretion Primary GnRH + • Low testosterone • Hypothalamic-pituitaryfailurewith decreasedgonadotropin secretion Secondary FSH, follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone Dohle GR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/;Hayes F et al. Hypogonadotropic hypogonadism (Hh) and gonadotropin therapy. Endotext. South Dartmouth (MA); 2013.

  10. Classification of male hypogonadism (3) • Low testosterone • Combined testicular and hypothalamic-pituitary failure, leading to variable gonadotropin secretion LH Mixed1 (adult-onset,1 functional2) LH FSH FSH • Normal testosterone • Elevated LH secretionElevated SHBG secretion(lower free testosterone) • Associated predominantlywith physical symptoms Compensated3 (subclinical) GnRH + FSH, follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone;SHBG, sex hormone-binding globulin 1.DohleGR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/2. Grossmann M & Matsumoto AM. J ClinEndocrinolMetab. 2017;102(3):1067–75.3.Tajar A et al. J ClinEndocrinolMetab. 2010;95(4):1810–8.

  11. Hypogonadism can have avariety of underlying causes Hypogonadism Testicular causes Hypophyseal causes Primary Secondary Functional hypogonadism Target organ resistance Hypothalamic causes • Maldescended or ectopic testes • Klinefelter syndrome • Testicular tumors • Orchitis • Congenital oracquired anorchia • Testicular atrophy/dysgenesis • Hyperprolactinemia • Hypopituitarism • Pituitary tumors • Isolated/idiopathic hypogonadotropic hypogonadism • Kallmann syndrome • Secondary GnRH deficiency • Prader-(Labhart)-Willi syndrome • Feminization due to androgen resistance or 5α-reductase deficiency • Estrogen deficit due to aromatase deficiency GnRH, gonadotropin-releasing hormone DohleGR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/ The most frequently observed causes of hypogonadism are isolated/idiopathic hypogonadotrophic hypogonadism, hypopituitarism, Klinefelter syndrome and functional hypogonadism

  12. Hypo-thalamic • Hypo-thalamic • Testicular • Hypo-physeal • Causes of hypogonadism • Target organ-related • Secondary to diseases and exogenous toxins

  13. Hypothalamic causes of hypogonadism Isolated/idiopathic hypogonadotropic hypogonadism and Kallmann syndrome Phenotype ofKallmann syndrome FSH, follicle-stimulating hormone;GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone Nieschlag E et al. Andrology: Male reproductive health and dysfunction, 3rd edition, Springer, 2010. Isolated/idiopathic hypogonadotropic hypogonadism is a genetic disordercaused by insufficient secretion of GnRH from the hypothalamus • LH and FSH are not produced by the pituitary gland, so neither androgen synthesis nor spermatogenesis are stimulated in the testes • In Kallmann syndrome, a related genetic disorder that occurs in ~1:10,000 males, patients also have anosmia (loss of senseof smell) for aromatic substances e.g. coffee or perfume and may have other physical abnormalities e.g. impaired hearing orcleft palate

  14. Hypothalamic causes of hypogonadism Delayed puberty Phenotype ofdelayed puberty CDGP, constitutional delay of growth and puberty; GnRH, gonadotropin-releasing hormone Nieschlag E et al. Andrology: Male reproductive health and dysfunction, 3rd edition, Springer, 2010. Definition: onset of puberty (gonadarche) later than the average age for individuals of the same gender and ethnicity • Generally, the onset of puberty is at ~14 years The most common cause of delayed puberty(occurring in up to 1:40 males) is CDGP, in which individual fluctuations in maturation of the hypothalamus delay the initiation of pulsatile GnRH secretion CDGP is an extreme functional variant of the onset of normal puberty;once puberty begins, development is usually normal and ends in complete sexual maturity and normal fertility

  15. Hypothalamic causes of hypogonadism Delayed puberty caused by CDGP does not require treatment • LH and FSH raised • Testosterone reduced Primary hypogonadism Assess gonadotropin and testosterone levels • LH, FSH and testosterone reduced Secondary hypogonadism Open epiphyseal platein boy aged 16 years CDGP, constitutional delay of growth and puberty;FSH, follicle-stimulating hormone; LH, luteinizing hormone Nieschlag E et al. Andrology: Male reproductive health and dysfunction, 3rd edition, Springer, 2010. It is important to distinguish between CDGP and primary or secondaryhypogonadism for prognosis and management: • CDGP should not be treated – puberty will start spontaneously • However, if the patient is experiencingpsychological pressure because of theirchild-like appearance, short-termtestosterone therapy can be administered • This should not begin before 14 yearsof age, because testosterone can causepremature closure of the epiphyseal lines,resulting in reduced stature

  16. Hypothalamic causes of hypogonadism Other conditions are associatedwith hypothalamic hypogonadism FSH, follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone Nieschlag E et al. Andrology: Male reproductive health and dysfunction, 3rd edition, Springer, 2010. • Prader–(Labhart)–Willi syndrome • Genetic disorder associated with mutations and abnormal expression of a cluster of genes on chromosome 15 • Affects ~1:10,000 individuals, causing a congenital disturbance of GnRH secretion • Pubertal boys with this condition display a specific form of combined secondary (low LH and testosterone) and primary hypogonadism (low inhibin B and high FSH) • Anorexia nervosa is associated with low testosterone and gonadotropin levels and poor responses to GnRH stimulation • Less common conditions include isolated LH (Pasqualini syndrome) or FSH deficiency, which are exceptionally rare forms of isolated/idiopathic hypogonadotropic hypogonadism, and GnRH deficiency

  17. Hypo-thalamic • Testicular • Hypo-physeal Hypo-physeal • Causes of hypogonadism • Target organ-related • Secondary to diseases and exogenous toxins

  18. Hypophyseal causes of hypogonadism Hypophyseal hypogonadism is caused by defects in pituitary function Hyper-prolactinemia1 Hypo-pituitarism1 • Hyperprolactinemia describes any non-physiological increase in prolactin • Serum concentrations >20–25 ng/mL (400–500 mU/L) are pathological2 • Prolactin reduces hypothalamic GnRH secretion, leading to hypogonadism • Hyperprolactinemia is most commonly caused by prolactinomas(prolactin-secreting pituitary adenomas), but it can also be drug-induced (dopamine antagonists) or caused by chronic renal failure or hypothryoidism • Due to hypophyseal insufficiency (a deficiency of one or more pituitary hormones) • Most common cause: tumors/metastases of the pituitary and hypophyseal stalk • Prolactinomasare the most numerous, followed by endocrine-inactive adenomas, and more rarely, growth hormone-producing adenomas/other tumors • Other causes: trauma, infection, hemochromatosis and vascular disorders GnRH, gonadotropin-releasing hormone 1. Nieschlag E et al. Andrology: Male reproductive health and dysfunction, 3rd edition, Springer, 2010.2. Majumdar A & Mangal NS. J Hum Reprod Sci. 2013;6(3):168–75. • With hypophyseal hypogonadism, no increase is seen in gonadotropin secretion after GnRH pump testing, unlike with hypothalamic hypogonadism1 • Common causes of hypophyseal hypogonadism include:

  19. Hypo-thalamic Testicular Testicular Hypo-physeal Causes of hypogonadism Target organ-related Secondary to diseases and exogenous toxins

  20. Testicular causes of hypogonadism Primary hypogonadism is causedby defects in testicular function Nieschlag E et al. Andrology: Male reproductive health and dysfunction, 3rd edition, Springer, 2010. • The testes are bi-functional organs, producing both androgens and sperm • Hypogonadism may therefore manifest as reduced androgen production and/or disturbed spermatogenesis • Disorders of the testes resultin primary hypogonadism, typically characterized by increased gonadotropin and reduced testosterone secretion

  21. Testicular causes of hypogonadism Klinefelter syndrome Phenotype ofKlinefelter syndrome Nieschlag E et al. Andrology: Male reproductive health and dysfunction, 3rd edition, Springer, 2010. • Klinefeltersyndrome is a congenital abnormality of chromosome number that in ~80% of cases has the karyotype of 47,XXY • It is the most common form of male hypogonadism (prevalence: 0.2% or 1:500) • Clinically, Klinefelter syndrome is characterizedin the adult by the combination of small, firmtestes, infertility, gynecomastia and symptomsof androgen deficiency • The signs of Klinefelter syndrome are almost unnoticeable in childhood, and only become apparent after puberty • Occasionally, prepubertal boys affected with the condition are referred for testicular maldescentor long-leggedness

  22. Hypo-thalamic Testicular Hypo-physeal Causes of hypogonadism Target organ-related Target organ-related Secondary to diseases and exogenous toxins

  23. Target organ-related causes of hypogonadism Target organ-related causesof hypogonadism DHT, dihydrotestosterone Nieschlag E et al. Andrology: Male reproductive health and dysfunction, 3rd edition, Springer, 2010. • Hypogonadism can be caused by disorders in which testicular function is intact, but there is impaired action of androgens (testosterone, anti-Müllerian hormone, DHT) and/or estrogens (estradiol) in their target organs • This is due to either: • Defects or mutations in the corresponding tissue-specific androgen and estrogen receptors (androgen insensitivityor estrogen resistance, respectively) • Aberrant 5-reductase activity (e.g. as in perineoscrotal hypospadias with pseudovagina) • Deficient aromatase activity (estrogen deficiency)

  24. Hypo-thalamic Testicular Hypo-physeal Causes of hypogonadism Target organ-related Secondary to diseases and exogenous toxins Secondary to diseases and exogenous toxins

  25. Secondary causes of hypogonadism Secondary causes of hypogonadism AIDS, acquired immunodeficiency syndrome; COPD, chronic obstructive pulmonary disease; HIV, human immunodeficiency virus 1. Grossmann M & Matsumoto AM. J ClinEndocrinolMetab. 2017;102(3):1067–75. 2.Tajar A et al. J ClinEndocrinolMetab. 2010;95(4):1810–8.3.DohleGR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/ 4.Nieschlag E et al. Andrology: Male reproductive health and dysfunction, 3rd edition, Springer, 2010. • Many systemic conditions and exogenous factors are associated withlow testosterone levels and impairment of testicular or sexual function • Obesityis the most-common cause and predictor in middle-aged and older men1,2

  26. Secondary causes of hypogonadism Functional hypogonadism is closely linked to obesity and underlying conditions HPT, hypothalamic–pituitary–testicular Grossmann M & Matsumoto AM. J ClinEndocrinolMetab. 2017;102(3):1067–75. • Many middle-aged and older (age ≥50 years) men, especially those who are obese and/or have underlying conditions, present with clinical features of organic androgen deficiency and modestly (or occasionally severely) low testosterone levels, yet they do not have recognizable intrinsic structural HPT pathology • Increasing evidence suggests that in these men, low testosterone is due to functional HPT axis suppression, caused by excess adiposity, comorbid illness and/oruse of medications such as opioids or glucocorticoids

  27. Secondary causes of hypogonadism Functional hypogonadism is closely linked to obesity and underlying conditions (2) Total testosterone increase (nmol/L) Diet/exercise Bariatric surgery Body weight loss (% of total) BMI, body mass index Grossmann M & Matsumoto AM. J ClinEndocrinolMetab. 2017;102(3):1067–75. • Obesity is the strongest risk factor associated with low testosterone levels in middle-aged and older men • In large, prospective, observational studies, weight gain and presence of underlying conditionsare consistently associated with an acceleratedage-related decline in testosterone levels • Weight loss can lead to testosterone increasesin obese men

  28. Hypogonadism: testosterone levelsnaturally decline with age Men with hypogonadism (%) Age (years) Rhoden EL & Morgentaler A. N Engl J Med. 2004;350(5):482–92.

  29. Hypogonadism/TDS: mechanism of down-regulation of testosterone levels Increased sensitivity totestosterone Hypothalamus Testosterone Reduced LHRH SHBG Pituitary gland Serum SHBG levels increase with age, decreasing the amount of bioactive free testosterone Testosterone Reduced LH SHBG Testicular andhypophyseal-hypothalamic insufficiency prevents an increase in testosterone secretion from the testis Testis LH, luteinizing hormone;LHRH, luteinizing hormone-releasing hormone; SHBG, sex hormone-binding globulin; TDS, testosterone deficiency syndrome Nieschlag E et al. Andrology: Male reproductive health and dysfunction, 3rd edition, Springer, 2010.

  30. Module 2: Male hypogonadism Epidemiology

  31. Epidemiology of hypogonadism/TDS HIM study1 (N=2,126) Men aged ≥45 years (total testosterone <300 ng/mL) Crude prevalence: 38.7% BLSA2 (N=890) Prevalence rates (total testosterone <325 ng/dL) were 12%, 19%, 28% and 49% in men in their 50s, 60s, 70s and 80s, respectively BACH study3 (N=1,475) Men aged 30–79 years Incidence of symptomaticandrogen deficiency*: 5.6% MMAS4 (N=1,691) Men aged 40–70 years with total testosterone <200 ng/dL and ≥3 clinical features of androgen deficiency Prevalence: 12.3% The prevalence/incidence of hypogonadism/TDS is high; however, estimates differ according to the definition used *Defined as low total (<300 ng/dL) and free (<5 ng/dL) testosterone plus low libido, erectile dysfunction, osteoporosisor fracture, or ≥2 of the following: sleep disturbance, depressed mood, lethargy or diminished physical performanceBACH, Boston Area Community Health; BLSA, Baltimore Longitudinal Study of Aging; HIM, Hypogonadism in Males;MMAS, Massachusetts Male Aging Study; TDS, testosterone deficiency syndrome 1. Mulligan T et al. Int J ClinPract. 2006;60(7):762–9.2. Harman SM et al. J ClinEndocrinolMetab. 2001;86(2):724–31.3.Araujo AB et al. J ClinEndocrinolMetab. 2007;92(11):4241–7. 4. Araujo AB et al. J ClinEndocrinolMetab. 2004:89(12); 5920–6.

  32. HIM study: prevalence of hypogonadism/TDS increases with age Men with hypogonadism (%) Age (years) N=2,162 men aged ≥45 years visiting US primary care practicesHIM, Hypogonadism in Males; TDS, testosterone deficiency syndrome Mulligan T et al. Int J ClinPract. 2006;60(7):762–9.

  33. BLSA study: prevalence of hypogonadism/TDS increases with age Men with hypogonadism (%) n= 18 201 279 332 350 251 94 20–29 30–39 40–49 50–59 60–69 70–79 ≥80 Age (years) *Tetosterone/SHBG ratio: <0.153 nmol/nmolBLSA, Baltimore Longitudinal Study of Aging; SHBG, sex hormone-binding globulin; TDS, testosterone deficiency syndrome Harman SM et al. J ClinEndocrinolMetab. 2001;86(2):724–31.

  34. The daily pattern of male testosterone production is attenuated with age Testosterone concentration (ng/mL) Younger men Older men 08:00 12:00 16:00 20:00 24:00 04:00 08:00 Time (h) LH, luteinizing hormone Bremner WJ et al. J ClinEndocrinolMetab. 1983;56(6):1278–81; O’Donnell L et al. Endocrinology of the male reproductive system and spermatogenesis. Endotext. South Dartmouth (MA); 2017. The testes’ capacity to secrete testosterone declines in ageing men, because of a reduced ability to respond to LH pulses

  35. Age-related changes in serum testosterone and SHBG concentrations Serum concentrations Age (years) SHBG, sex hormone-binding globulin Comhaire FH. Eur Urol. 2000;38(6):655–62.

  36. Age-related changes in serum testosterone and SHBG concentrations (2) Free testosterone(nmol/L) SHBG(10-8mol/L) Total testosterone(nmol/L) Serum concentrations 8 25 7 20 6 15 5 10 5 Age (years) SHBG, sex hormone-binding globulin Vermeulen A. Ann Med. 1993;25(6):531–4.

  37. Module 2: Male hypogonadism Clinical signs and symptoms

  38. Symptoms and signs suggestiveof male hypogonadism – Most common symptom/sign in aging men DohleGR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/ • Male hypogonadism is associated with a wide range of symptoms and signs, some of which are more suggestiveof hypogonadism than others

  39. Erectile dysfunction is associatedwith male hypogonadism Patients (%) n=521 men with EDED, erectile dysfunction Guay A et al. J Androl. 2001;22(5):793–7.

  40. Physical and metabolic symptomsand signs of male hypogonadism HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol 1.BhasinS et al. J ClinEndocrinolMetab. 2010;95(6):2536–59. 2.Tajar A et al. J ClinEndocrinolMetab. 2010;95(4):1810–8. 3.Giannoulis MG et al. Endocr Rev. 2012;33(3):314–77. Physical • Often, there are no obvious physical signs; may include decreased muscle mass, loss of body hair, abdominal obesity, gynecomastia and/or small testes (occasionally)1 • Obesity is the single most-powerful predictor of low testosterone2 Metabolic and other Reduction in HDL-C and increase in LDL-C3 Impaired glucose metabolism3 Increase in total body fat (change in lean:fat ratio)3 Osteopenia Osteoporosis3 Reduction in red cell volume

  41. Clinical consequences of hypogonadism are determined by age of onset and severity Androgen deficiency in utero • Absence of androgens or androgen deficiency during sexual differentiation (between the 9th and 14th week of pregnancy) leads to intersexuality with incomplete or no masculinization of the external genitalia • Lack of or insufficient testosterone exposure in the later phase of development (up to about the 24th week of pregnancy) can also cause malpositioningof the testes and an abnormally small penis (micropenis) Dohle GR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/

  42. Clinical consequences of hypogonadism are determined by age of onset and severity (2) Androgen deficiency during puberty • When testosterone deficiency occurs before puberty, virilizationwill not start, resulting in the typical syndrome of eunuchoidism; once the body has taken on eunuchoidproportions, the process is irreversible Dohle GR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/

  43. Clinical consequences of hypogonadism are determined by age of onset and severity (3) Androgen deficiency during adulthood • With onset after puberty, the clinical picture of hypogonadism can vary widely • Body proportions, penis size and pitch of voicedo not change • However, body and facial hair dwindle and shavingneed not be carried out as frequently • The chief clinical signs are decreased sexual potency, loss of libido and infertility Dohle GR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/

  44. Module 2: Male hypogonadism Diagnosis

  45. Patient selection COPD, chronic obstructive pulmonary disease; HIV, human immunodeficiency virus; TDS, testosterone deficiency syndrome Dohle GR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/ • Diagnosis of male hypogonadism is based on persistent signs and symptoms of androgen deficiency, plus consistently low serum testosterone concentrations • Assessment of TDS should also be considered in men with underlying conditions or who are receiving treatments that are commonly associated with male hypogonadism

  46. Special guidance for overweight orobese men with suspected hypogonadism AACE, American Association of Clinical Endocrinologists; ACE, American College of Endocrinology; BMI, body mass index Garvey WT et al. EndocrPract. 2016;22 Suppl 3:1–203.

  47. History-taking and physical examination of adult men with suspected hypogonadism Dean JD et al. J Sex Med. 2015;12(8):1660–86; Dohle GR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/; Lunenfeld B et al. Aging Male. 2015;18(1):5–15;Petak SM et al. EndocrPract. 2002;8(6):439–56.

  48. Clinical assessment of male hypogonadism The most widely accepted diagnostic parametersfor male hypogonadism are serum total testosterone and free testosterone1–3 Clinical assessment of testosterone deficiency syndrome includes symptoms and biochemical confirmation with low circulating testosterone concentrations1–3 1.Bhasin S et al. J ClinEndocrinolMetab. 2010;95(6):2536–59. 2.Dean JD et al. J Sex Med. 2015;12(8):1660–86.3.Lunenfeld B et al. Aging Male. 2015;18(1):5–15.

  49. Testosterone level cut-offs Total T<8 nmol/L (231 ng/dL) or Free T<180 pmol/L (5.2 ng/dL) Total T8–12 nmol/L (231–346 ng/dL) or Free T180–225 pmol/L (5.2–6.5 ng/dL) Total T >12 nmol/L (346 ng/dL) or Free T>225 pmol/L (6.5 ng/dL) TDS likely TTh indicated TDS possible, consider TTh(if presence of bothersome symptoms and/or elevated SHBG) TDS unlikely Consider TTh* There is no universally accepted lower limit of ‘normal’ for testosterone level, and it is unclear whether geographically different thresholds depend on ethnic differences or the clinician’s perception1,2 However, there is general agreement that:1–6 *Consider TTh in individual cases, based on total T concentrations/symptoms and low calculated free T concentrations6SHBG, sex hormone-binding globulin; T, testosterone; TDS, testosterone deficiency syndrome; TTh, testosterone therapy 1.Nieschlag E et al. J Androl. 2006;27(2):135–7. 2. Dean JD et al. J Sex Med. 2015;12(8):1660–86.3.Dohle GR et al. EAU guidelines on male hypogonadism. 2017. http://uroweb.org/guideline/male-hypogonadism/4.Lunenfeld B et al. Aging Male. 2015;18(1):5–15. 5. Hackett G et al. Int J ClinPract. 2017;71(3–4):e12901.6.Traish AM et al. Am J Med. 2011;124(7):578–87.

  50. Biochemical examination of adult men with suspected hypogonadism Basic hormonal examinations for male hypogonadism include assessment of testosterone, LH and FSH • Testosterone reveals the endocrine activity of the testes • LH and FSH are indicators of pituitary function and allow etiological assessment of hypogonadism Increased gonadotropins indicate primary hypogonadism Decreased gonadotropins in combination with decreased testosterone suggest secondary hypogonadism Other hormonal assays and baseline tests may include SHBG, hematocrit and lipid profile FSH, folllicle-stimulating hormone; LH, luteinizing hormone; SHBG, sex hormone-binding globulin BhasinS et al. J ClinEndocrinolMetab. 2010;95(6):2536–59; PetakSM et al. EndocrPract. 2002;8(6):439–56.

More Related