Hypogonadism resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Elsaiey, MBBCH [2]

Overview

Hypogonadism is a disorder of the reproductive system which results in lack of function of the gonads (ovaries or testes). Hypogonadism is caused by several conditions which may be congenitalacquiredgenetic, or malignancies. Hypogonadism may be classified on the basis of etiology and the site causing the defect into primary or secondary hypogonadism. Primary hypogonadism results from defect in the gonads themselves and it has a high level of the gonadotropin hormones FSH and LH. Secondary hypogonadism indicates a defect in the pituitary gland or the hypothalamus and presents with a low level of the gonadotropin releasing hormoneFSH, and LH. Hypogonadism is also associated with low level of testosterone hormone, especially in the males. Genetic mutations that can cause hypogonadism include ANOS 1, SOX10SEMA3A, IL17RD and FEZF1. Other genes include KISS, GNRNH, and PROK. Hypogonadism must be differentiated from diseases that cause delayed puberty or infertility. The prevalence of hypogonadism is estimated to be 38,700 per 100,000 individual aging 45 years. The incidence of hypogonadism is 1230 per 100,000 persons. Hypogonadism affects men more than women and its prevalence increases with age. Hypogonadism has many risk factors like dyslipidemiaobesitymalignancies and alcohol intake. Screening may be done for men patients who present with erectile dysfunctioninfertilityHIV patients and young patients with osteoporosis. If left untreated, patients with hypogonadism will end up with infertility and rheumatic autoimmune diseases. Hypogonadism can cause complications like gynecomastia and delay of puberty in the prepubertal patients. It can also cause depression and cardiovascular stroke in the adults. Hypogonadism usually has a good prognosis with the proper treatment. Patients with hypogonadism usually present with loss of the secondary sexual characteristics. Male patients present with infertility, loss of libido, and erectile dysfunction. Female patients present with amenorrhea and no pubic hair. Lab diagnosis reveals low testosterone levels, variable FSH and LH levels according to the cause of hypogonadism whether primary or secondary. The mainstay of treatment for hypogonadism is testosterone replacement therapy and it can be administrated through different regimens injectedtransdermal or buccal. In females, estrogen replacement is helpful besides testosterone.

Causes

Life Threatening Causes

Common Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of hypogonadism according the the endocrine society guidelines.

 
 
 
Identify the symptoms that increase the possibility of hypogonadism

Most common symptoms:
❑Decrease of libido
❑Erectile dysfunction
❑Decreased size of testes
❑Sweating
❑Gynecomastia
❑Muscle loss and decreased bone density
❑Infertility
❑Loss of body hair
Less common symptoms:
❑Headaches
❑Visual loss
❑Galactorrhea
❑Anorexia nervosa
❑Fatigue and weakness
❑Loss of energy
❑Depression
❑Sleeping disturbances

❑Decreased work performance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure the level of the total testosterone
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Low level
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat measuring the morning level of the testosterone
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Still low
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure the level of the FSH and LH to detect the cause
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low level of FSH and LH
 
High level of FSH and LH
 

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Patients with hypogonadism are treated mainly with sex hormones replacement. Sex hormones will help in retaining the secondary sexual characteristics for both genders. They will also help in maintaining normal bone density and muscle mass. The main medical therapy in males will be testosterone replacement. In the females, estrogen replacement is important besides testosterone.[1]

Medical therapy for men

Testosterone replacement therapy

Type of testosterone drug Administrative doses Adverse effects
Testosterone (Injection)
Testosterone (Transdermal)[3] Transdermal testosterone may be accompanied with the following skin reactions:[4]
Testosterone (Buccal)

Medical therapy for women

Estrogen replacement therapy

Do's

  • The content in this section is in bullet points.

Don'ts

  • The content in this section is in bullet points.

References

  1. Petak SM, Nankin HR, Spark RF, Swerdloff RS, Rodriguez-Rigau LJ, American Association of Clinical Endocrinologists (2002). "American Association of Clinical Endocrinologists Medical Guidelines for clinical practice for the evaluation and treatment of hypogonadism in adult male patients--2002 update.". Endocr Pract. 8 (6): 440–56. PMID 15260010. 
  2. Bhasin S, Cunningham GR, Hayes FJ, Matsumoto AM, Snyder PJ, Swerdloff RS; et al. (2010). "Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline.". J Clin Endocrinol Metab. 95 (6): 2536–59. PMID 20525905. doi:10.1210/jc.2009-2354. 
  3. Wang C, Swerdloff RS, Iranmanesh A, Dobs A, Snyder PJ, Cunningham G; et al. (2000). "Transdermal testosterone gel improves sexual function, mood, muscle strength, and body composition parameters in hypogonadal men.". J Clin Endocrinol Metab. 85 (8): 2839–53. PMID 10946892. doi:10.1210/jcem.85.8.6747. 
  4. Jordan WP (1997). "Allergy and topical irritation associated with transdermal testosterone administration: a comparison of scrotal and nonscrotal transdermal systems.". Am J Contact Dermat. 8 (2): 108–13. PMID 9153333. 
  5. North American Menopause Society (2005). "The role of testosterone therapy in postmenopausal women: position statement of The North American Menopause Society.". Menopause. 12 (5): 496–511; quiz 649. PMID 16145303. doi:10.1097/01.gme.0000177709.65944.b0. 



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