1. Diagnostic approaches for LOH: Biochemical and laboratory aspects
Paul PIETTE, PharmD
Senior Research Fellow
Clinique Antoine Depage - Belgium
Sydney 2014, October 25th

2. Definition of LOH, or aged-related Testosterone Deficiency Syndrome (TDS)
TDS is a clinical AND biochemical syndrome associated with advancing age, age-related comorbidities and deterioration in general health status, characterized by symptom AND a deficiency in serum testosterone levels.
It may adversely affect the function of multiple organ systems with a significant deterioration of the QOL, including alterations of sexual function
Wang C, Nieschlag E et al. Aging Male 2008; 1-8.

3. Definition of Testosterone Deficiency (TD)
It results from abnormalities at several levels of the pituitary-hypothalamic-testicular axis: at the testis level (primary TD), pituitary or hypothalamic level (secondary or tertiary TD) or both.
It may also result from a decrease in testosterone activity due to
a decrease in T bioavailability ( increase in SHBG)
or a decrease in androgens receptor sensitivity

4. Primary Androgen Effects
Facial hair appears and acne may develop
Larynx enlarges and voice deepens
Axillary hair appears
Musculature develops
Pubic hair grows
Penis, seminal vesicles and prostate enlarge
Puberty / virilization
Sexual function and behavior
Build protein
Metabolic activities
Virilization – the development of secondary sexual male characteristics
Primary androgen effects include primary & secondary sexual characteristics:
Primary sexual characteristics: enlargement of penis, scrotum, testes and prostate
Secondary sexual characteristics: pubic hair, increased muscular development, facial hair, etc.

5. Late Onset of Hypogonadism (LOH)
or (Partial) Androgen Deficiency by the Aging Male (PADAM)
or Testosterone Deficiency Syndrome (TDS)
LOH = a biological evidence …
Progressive decrease of total testosterone with age… (1,2)
…more evident for bioavailable testosterone (1,2)
(increase of SHBG with age) (2)
Decrease
of total and bioavailable testosterone blood levels
with age by 810 men
from 24 to 90 years (2)
(1) Lejeune H. Déficit androgénique lié à l’âge. Andrologie 2001;11(4):
(2) Ferrini RL et al. Sex Hormones and Age : a cross-selectional Study of Testosterone and Estradiol and Their Bioavailable Fraction in Community-dwelling Men. Am J Epidemiol 1998;147:750-4.

6. Normal TT with decreased free T Normal free T with low TT
Dissociation between total testosterone (TT) and bioavailable testosterone values (due to SHBG)
SHBG increase
Normal TT with decreased free T
SHBG decrease
Normal free T with low TT
Aging male
Obesity
Hyperthyroidism
Hypothyroidism
Estrogens
Androgens
Hepatic diseases
cirrhosis
Insulin resistance
Hyperinsulinism
Antiepileptics
Hyperprolactinemia
tamoxifen
GH, acromegaly
Steroids, hypercorticism

7. Testosterone assay Assay Advantages Disadvantages
TT: Liq Chromatography/
Mass Spectrometry (LC/MS)
Most accurate, especially for low value
Expensive
Not always available
TT: RIA, or chemoluminescence
Lesser expensive
Largely available
Lesser accurate,
especially for low value
Bioavailable T: after precipitation by NH4OH
Active T measure: Free T 1-2% % T bound to albumin
Expensive,
Time consuming
Some errors
Free T: dialysis at equilibrium
GOLD STANDARD
The most accurate
cFree T: cFT (calculated from TT and SHBG)
Good correlation with dialysis; Lesser expensive
Require accurate TT assay (MS) and SHBG
Free T: assay with analog
Only a low % of free T det NOT RECOMMENDED!

8. LOH can be defined by the presence of at last three sexual symptoms associated with a total testosterone level of less than 11 nmol/L (320 ng/dL) and a free testosterone level of less than 220 pmol/L (64 pg/mL)
Wu F et al. N Engl J Med 2010; /NEJMoa

9. Identification and Prevalence of Symptoms Related to Testosterone in the Training Set
Wu F et al. N Engl J Med 2010; /NEJMoa

10. Summary
Presence of three sexual symptoms combined with a total testosterone level of less than 11 nmol/L (320 ng/dL) and a free testosterone level of less than 220 pmol/liter (64 pg/mL) can be considered the minimum criteria for the diagnosis of late-onset hypogonadism in aging men.
There is a substantial overlap between late-onset hypogonadism and nonspecific symptoms of aging.
The application of these new criteria can guard against the excessive diagnosis of hypogonadism and curb the injudicious use of testosterone therapy in older men.
Wu F et al. N Engl J Med 2010; /NEJMoa

11. Hypogonadism: Testosterone Cut-Off Values
2008: ISA, ISSAM, EAU, EAA and ASA
Substitution required with levels of
TT < 230 ng/dL (8 nmol/L)
If TT = 230 – 346 ng/dL (8-12 nmol/L)
…Test FT
FT < 6.5 ng/dL (225 pmol/L) supportive for substitution
Test LH if T below lower limit and prolactin if T < 150 ng/dL (5.2 nmol/L)
2010: US Endocrine Society
Substitution may be required with levels below
TT= ng/dL ( nmol/L) (depending low limit lab value)
and/or
FT = ng/dL (170 – 310 pmol/L)
Use the lower limit of the normal range established in the reference laboratory T
Test LH, FSH if T levels are below or at the lower limit
2012: EAU guidelines
Indications for TRT with levels below
TT= 350 ng/dL (12,1 nmol/L)
FT= 7 ng/dL (243 pmol/L)
The 2008 recommendations from the ISA, ISSAM, EAU, EAA and ASA:
General agreement that TT levels >12 nmol/l (346 ng/dl) do not require substitution.
There is consensus that TT levels <8 nmol/l (231 ng/d) will usually benefit from substitution.
FT levels of <225 pmol/l (65 pg/ml) can provide supportive evidence for substitution.
If TT levels 8-12 nmol/l, repeat measurement of TT with SHBG to calculate FT, or FT can be measured vy equilibrium dialysis.
Measure LH to assist in differentiation between primary and secondary hypogonadism, and prolactin if T <5.2 nmol/l (150 ng/dl) or when secondary hypogonadism is suspected.
The 2006 recommendations from the US Endocrine Society:
In some laboratories : TT = 300 ng/dl (10.4 nmol/liter)
FT = 50 pg/dl (0.17 nmol/liter)
Use the lower limit of normal range for healthy young men established in the reference laboratory.
Perform if LH, FSH testing, if testosterone levels are below or at the lower limit of normal
2012 NEW EAU guidelines: Indications for TRT with levels below TT=12,1 noml/L of FT= 243 pmol/L
Wang C, Nieschlag E et al.
Aging Male 2008; 1-8.
Bhasin S, Cunningham GR et al.
J Clin Endocrin Metab. 2010; 95:
Dohle GR et al.
EAU Guidelines on Male Hypogonadism

12. Summary of five Hypogonadism Prevalence Studies
BLSA, 2001
MMAS, 2005
HIM, 2006
BACH, 2007
EMAS, 2010
No of patients
890
1691
2165
1475
3369
Age
22-91 yrs (mean 53.8)
40-69 yrs
≥ 45 yrs (mean 60.5)
30-79 yrs (mean 47.3)
40-79yrs (means 59,7)
TT and FT levels
TT <325ng/dl
TT <200 ng/dl x 2
TT <300 ng/dl x 1
TTl < 300 ng/dl and FT < 5 ng/dl
TT<320 ng/dl and FT<6.4 ng/dl
Symptoms evaluation No
ADAM
Questions
Prevalence of hypogonadism
Defined by TT
50s = 12%
60s = 19%
70s = 28%
80s = 49%
and symptoms
Baseline = 6%
Follow-up =12.3%
38.7%
Defined by TT and symptoms
5.6% (18.4% in 70s)
Defined by TT, FT and presence of at least three sexual symptoms
2.1% (5.1% in 70-79yrs)
Harman SM, Metter EJ et al. JCEM 2001; 86: Araujo AB, O’Donnell AB et al. JCEM 2004; 89: Mulligan T, Frick MF et al. Int J Clin Pract. 2006; 60:762-9.
Araujo AB, Esche GR et al. JCEM 2007; 92:
Wu F , Tajar A et al. NEJM 2010; 363(2):

13. Results of the HIM Study
Crude prevalence rate of low T (<300 ng/ml ) was 38.7%
Odds of having a low T or being treated for low T are:
2.4 x higher, if obese
2.1 x higher, if diabetic
1.8 x higher, if hypertensive
1.5 x higher, if hyperlipidemic
Medical Conditions associated with Hypogonadism
Obesity
Diabetes
Hypertension
Hyperlipidemia
The prevalence of hypogonadism was 38.7% in men aged ≥ 45 years presenting to primary care offices. Obesity, diabetes, hypertension and hyperlipidemia were medical conditions associated with hypogonadism.
Mulligan T, Frick MF et al.
Int J Clin Pract. 2006; 60:

14. Co-Morbidities Occur More Often (p<0
Co-Morbidities Occur More Often (p<0.001) in Hypogonadal Men (HIM Study)
Data from 2165 men aged ≦45yrs seen in primary care practice
OR = 1.84
(1.53–2.22)
OR = 1.47
(1.23–1.76)
OR = 2.09
(1.70–2.58)
OR = 2.38
( )*
Percentage (%)
OR = 1.40
( )
The HIM study found that men with hypogonadism were significantly (p<0.001) more likely to have medical co-morbidities, such as hypertension, hyperlipidaemia, diabetes and obesity, than eugonadal men.
Int J Clin Pract Jul;60(7):762-9.
Prevalence of hypogonadism in males aged at least 45 years: the HIM study.
Mulligan T, Frick MF, Zuraw QC, Stemhagen A, McWhirter C.
The Hypogonadism in Males study estimated the prevalence of hypogonadism [total testosterone (TT) < 300 ng/dl] in men aged > or = 45 years visiting primary care practices in the United States. A blood sample was obtained between 8 am and noon and assayed for TT, free testosterone (FT) and bioavailable testosterone (BAT). Common symptoms of hypogonadism, comorbid conditions, demographics and reason for visit were recorded. Of 2162 patients, 836 were hypogonadal, with 80 receiving testosterone. Crude prevalence rate of hypogonadism was 38.7%. Similar trends were observed for FT and BAT. Among men not receiving testosterone, 756 (36.3%) were hypogonadal; odds ratios for having hypogonadism were significantly higher in men with hypertension (1.84), hyperlipidaemia (1.47), diabetes (2.09), obesity (2.38), prostate disease (1.29) and asthma or chronic obstructive pulmonary disease (1.40) than in men without these conditions. The prevalence of hypogonadism was 38.7% in men aged > or = 45 years presenting to primary care offices.
* Body mass index ≥ 25 kg/m2
Conditions
Adapted from Mulligan T, Frick MF et al.
Int J Clin Pract. 2006; 60:

15. ISA, ISSAM, EUA, EAA, ASA Recommendation 8
ISA, ISSAM, EUA, EAA, ASA Recommendation 8.1 on Testosterone and Obesity, Metabolic Syndrome and Type 2 Diabetes
Many of the components of the metabolic syndrome (obesity, hypertension, dyslipidemia, impaired glucose regulation and insulin resistance) are also present in hypogonadal men.
“Serum T should be measured in men with Type 2 diabetes mellitus with symptoms suggestive of T deficiency”
Wang C, Nieschlag E et al. Aging Male 2008; 1-8.

16. Clinical Features of Late Onset hypogonadism
Physical
Decreased muscle mass and strength
Increased body fat
Decreased bone mineral density and osteoporosis
Psychological
Decreased vitality
Decreased mood
Sexual
Decrease in frequency of morning erections
Decreased libido
Erectile dysfunction
In 2008, recommendations for the investigation, treatment and monitoring of late onset hypogonadism were on published by the International Society of Andrology (ISA), the International Society for the Study of the Aging Male (ISSAM), the European Urology Association (EUA), the European Academy of Andrology (EAA) and the American Society of Andrology (ASA).
Demographic data clearly demonstrate that the percent of population in the older age group is increasing. Androgen deficiency in the aging male has become a topic of increasing interest and debate throughout the world. Cross-sectional and longitudinal data indicate that testosterone falls aggressively with age and that a significant percentage of men over the age of 60 years have serum testosterone levels that are below the lower limits of young adult (aged years) men.
Low libido is cited as the symptom most frequently associated with hypogonadism, whilst others include erectile dysfunction, decreased muscle mass and strength, increased body fat, decreased bone mineral density and osteoporosis, decreased vitality and depressed mood. None of these symptoms are specific to the low androgen state but may raise suspicion of testosterone deficiency. One or more of these symptoms must be corroborated with a low serum testosterone level.
Wu FC et al. N Engl J Med 2010; 363(2):
Wang C, Nieschlag E et al. Aging Male 2008; 1-8

17. Diagnosis & Treatment of LOH Patient Selection Algorithm
Clinical symptoms of late-onset hypogonadism
Total testosterone (TT) & SHBG (7 – 11 am)
Low: TT <8nmol/l
Borderline: TT = 8-12nmol/l
Normal: TT>12nmol/L
(<230 ng/dL)
(>346 ng/dL)
Repeated measurement TT + LH, FSH, PRL,
Validation of low T or low free T
Calculate free T
No androgen deficiency Seek other causes
Low or low normal LH, FSH, or PRL significantly elevated
Low free T <225pmol/l
Normal free T >225pmol/l
Elevated LH, FSH
(<6,5 ng/dL)
(>6,5 ng/dL)
Exclusion of contraindications
Elevation of pituitary and hypothalamic function
LH = Lutenizing hormone
FSH = Follicle stimulating hormone
PRL = Prolactin
SHBG = Sex hormone binding globulin
Trial of testosterone
Treatment of the disease, Trial of testosterone
Close monitoring validation of clinical improvement/diagnosis
Wang et al. Aging Male 2009; 12(1): 5-12

18. Diagnosis & Treatment of LOH Patient Selection Algorithm
TT= ng/dL ( nmol/L)
FT = ng/dL (170 – 310 pmol/L
Bhasin S, Cunningham GR et al.
J Clin Endocrin Metab. 2010; 95:

19. Clinical Features in Relation to Testosterone Levels
Total testosterone nmol / l
Patients (n) 74 69
Loss of libido
Loss of vigour
p<0.001 84
Obesity 65
Feeling depresse
Disturbed sleep
Lacking concentration
Diabetes mellitus type 2
p=0.001
p=0.004
p=0.002 67
Hot flushes
Erectile dysfunction
p=0.003 75 20 15
Increasing prevalence of symptoms with decreasing testosterone concentrations 12
> 12 requires no substitution 10
ISA, ISSAM, EAU, EAA and ASA
Recommendations
Zitzmann M, Faber S, Nieschlag E. Association of specific symptoms and metabolic risks with serum testosterone in older men. J Clin Endocrinol Metab 2006; 91:
Overview of symptom specific concentrations of TT levels below which the prevalence of the respective symptom starts to increase, hence, a lack of androgen exerts an influence. 8
< 8 requires substitution
Zitzmann M, Faber S et al. J Clin Endocrinol Metab 2006; 91:

20. Diagnosing Testosterone Deficiency in Different Parts of the World
Physicians’ perception of main symptoms of testosterone deficiency 10 20 30 40 50 60 70 80
Loss of body hair
Loss of muscle mass
Depression
Loss of power
Fatigue
Erectile dysfunction
Lack of libido
Symptoms
Aging Male 2007; 10: Diagnosing and treating testosterone deficiency in different parts of the world. Results from global market research. Gooren LJ, Behre HM, Saad F, Frank A, Schwerdt S.
AIM: This study analysed variations between different regions of the world in diagnosing and treating testosterone (T) deficiency. METHODS: Physicians were interviewed in Germany, Spain and the United Kingdom, in Brazil, in Saudi Arabia and South Korea. Items in the survey: 1) reasons/motivation to use or not to use T; 2) what category of patients would not receive T on the basis of these concerns; 3) concerns about prostate pathology in the decision not to provide T treatment; 4) phosphodiesterase type 5 (PDE-5) inhibitors are efficacious, but T treatment makes a comeback. RESULTS: Between 5% and 10% of consulting patients suffered from T deficiency. The fear to induce prostate cancer appeared very powerful. About 68% of physicians associate the use of T more with risks than benefits, more so in Europe than elsewhere. As a result about 35% of hypogonadal men do not receive treatment. The PDE-5 inhibitors are very prominent in the treatment of erectile dysfunction. Of patients suffering from erectile dysfunction, 18% to 29% have T deficiency which is not always diagnosed and treated. CONCLUSION: World-wide physicians require more education on diagnosing T deficiency, on the role of T in erectile dysfunction and the relative safety of testosterone treatment.
Percentage of physicians (%)
Gooren LJ, Behre HM et al.
Aging Male 2007; 10: