1. Late-onset Hypogonadism (LOH) 41st Annual General Practitioner Study Day 28th January 2012 Dr. Eoin O’Sullivan Consultant Endocrinologist Bon Secours Cork

2. LOH definition Combination of low serum testosterone (T)
Early morning (pre 11am)
Ideally fasting
Repeated on 2nd occasion
In absence of illness
Lower cut-offs proposed from nmol/l
SHBG if obese; free testosterone not recommended
and clinical symptoms
Reduced libido and ED most common
Signs of hypogonadism
Osteoporosis
Less specific symptoms: fatigue, depression, diminished physical performance

3. LOH diagnosis
Endocrine Society Guidelines 2010

4. Endocrine causes of LOH
Secondary hypogonadism
Low/inappropriately normal LH and FSH
Headaches/visual disturbance
T <5.2nmol/l
Check TFTs, Prolactin, iron studies (±early morning cortisol,IGF1)
±MRI pituitary
Primary hypogonadism
Klinefelters (karyotyope)

5. Evidence for TRT
Placebo-controlled RCTs shows moderate effect on libido but minimal if any effect on ED
No placebo-controlled RCTs on effect on QOL, mood, etc

6. Contra-indications to T therapy
Prostate/breast ca
?High-risk of prostate ca (PSA>4 or >3 if high risk; ES)
Severe LUTS (ES)
Haematocrit >52%(ISA)/>50%(ES)
Untreated OSA
Untreated CCF
Fertility desired

7. Testosterone treatment options
Gel (Testogel, Testim)
IM (Nebido)
Buccal (Striant)
Patches (Andropatch)

8. T treatment monitoring
3-6 month trial to assess response
3, 6, 12 monthly, then annual assessment for prostate ca with DRE and PSA
Hb 3, 6, 12 monthly then annually
Serum T at 3, 6, 12 months aiming for mid-normal range

9. LOH summary Difficult to define/diagnose
Poor evidence for treatment benefit
Potential for harm with testosterone treatment