How to recognize late-onset hypogonadism in men with sexual dysfunction

Abstract

Late-onset hypogonadism (LOH) has been considered the most common form of male hypogonadism with a prevalence of approximately 1 in 100 men. Diagnosis of LOH should be made in symptomatic men with unequivocally low serum testosterone (T) levels. However, its clinical presentation is often insidious and difficult to recognize because it is characterized by nonspecific symptoms that make differential diagnosis with physiological ageing problematic. Sexual dysfunction is the most important determinant for medical consultation and the most specific symptom associated with low T. We therefore analysed a consecutive series of 1734 subjects who attended our unit for sexual dysfunction to investigate the associations between low T (different thresholds), sexual parameters, medical history data (delayed puberty, pituitary disease or cryptorchidism) and their physical exam results. Metabolic parameters, in particular waist circumference, display the greatest accuracy in detecting low T. We found that only the association of several symptoms and signs could significantly raise the clinical suspicion of low T. Structured inventories, which cluster together symptoms and signs of hypogonadism, can help clinicians suspect androgen deficiency. In particular, structured interviews, such as ANDROTEST, have been demonstrated to have a greater accuracy when compared to self reported questionnaires in detecting low T levels. Keywords: late-onset hypogonadism (LOH); male hypogonadism; testosterone; sexual dysfunction INTRODUCTIONThe testis (the male gonad) continuously produces sex steroids (mostly testosterone (T)) and sperm soon after the onset of puberty. Testis activity is regulated by intratesticular factors (including T) and by extratesticular trophic factors released from the pituitary (i.e., gonadotropin luteinizing hormone (LH) and follicle-stimulating hormone (FSH)), which are strictly regulated by the hypothalamic peptide gonadotropin-releasing hormone (GnRH). Male hypogonadism is a failure in testis activity that is classically considered to be a partial or total communication breakdown among the hypothalamus, the pituitary and the testis itself. Current definitions of hypogonadism rely on T deficiency more than abnormal sperm production, but from a conceptual point of view, both factors contribute to testicular function and dysfunction.

Factors affecting spermatogenesis upon gonadotropin‐replacement therapy: a meta‐analytic study

“…However, the present metaanalysis failed to find any significant association between testis volume and sperm concentration or any difference in patients with lower or higher testis volume. It should be considered that a small testis volume is a clinical feature of both pre-and post-pubertal onset HHG (Corona et al, 2012b;Basaria, 2014), however, reflecting different scenarios. Whereas the volume decrease of a post-pubertal testis is the result of an arrest/failure of its spermatogenetic functions, the Figure 8 Cumulative rates (with 95% confidence interval) of appearance of at least one spermatozoa in the semen upon GnRH therapy, overall and according to different possible predictors.…”

Topical Testosterone Gel for the Treatment of Male Hypogonadism

“…In 1734 subjects, the associations between low T and sexual function were studied. 7 Of interest, waist circumference displayed the greatest accuracy in predicting low total T levels. 7 Structured inventories assessing symptoms and clinical signs are often used to better define clinical hypogonadism.…”

“…7 Of interest, waist circumference displayed the greatest accuracy in predicting low total T levels. 7 Structured inventories assessing symptoms and clinical signs are often used to better define clinical hypogonadism. Structured interviews such as the ANDROTEST, a 12-item tool initially validated for the screening of androgen deficiency in patients with SD have been demonstrated to have a greater accuracy when compared to self reported questionnaires in detecting low T levels.…”

“…Structured interviews such as the ANDROTEST, a 12-item tool initially validated for the screening of androgen deficiency in patients with SD have been demonstrated to have a greater accuracy when compared to self reported questionnaires in detecting low T levels. 7,10 Patients with a pathological test (ie, a score . 8) showed a higher prevalence of hypogonadism with related signs such as reduced testis volume and depressive symptoms.…”

“…1 LOH is characterized by T deficiency in aging men, accompanied by clinical symptoms that negatively affect quality of life and might lead to multiple organ system involvement associated with low T. The prevalence of LOH is approximately 1 in 100 adult men. 7,9 Diagnosis of LOH is based on symptomatic men with low serum T levels (total T levels , 300 ng/dL and free T , 5 ng/dL). The clinical presentation is often insidious and might be underrecognized because of nonspecific symptoms.…”