Endocrine Society of Australia position statement on male hypogonadism (part 1): assessment and indications for testosterone therapy

Abstract

Key points and recommendations are:Pathological hypogonadism arises due to diseases of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism) or testes (hypergonadotropic hypogonadism). It is a clinical diagnosis with a pathological basis, confirmed by hormone assays.Hormonal assessment is based on measurement of circulating testosterone, luteinising hormone (LH) and follicle-stimulating hormone (FSH) concentrations. Measurement of sex hormone-binding globulin levels can be informative, but use of calculated free testosterone is not recommended for clinical decision making.Testosterone replacement therapy is warranted in men with pathological hypogonadism, regardless of age.Currently, there are limited data from high-quality randomised controlled trials with clinically meaningful outcomes to justify testosterone treatment in older men, usually with chronic disease, who have low circulating testosterone levels but without hypothalamic, pituitary or testicular disease.Obesity, metabolic syndrome and type 2 diabetes are associated with lowering of circulating testosterone level, but without elevation of LH and FSH levels. Whether these are non-specific consequences of non-reproductive disorders or a correctable deficiency state is unknown, but clear evidence for efficacy and safety of testosterone therapy in this setting is lacking.Glucocorticoid and opioid use is associated with possibly reversible reductions in circulating testosterone level, without elevation of LH and FSH levels. Where continuation of glucocorticoid or opioid therapy is necessary, review by an endocrinologist may be warranted.Changes in management as result of the position statement: Men with pathological hypogonadism should be identified and considered for testosterone therapy, while further research is needed to clarify whether there is a role for testosterone in these other settings.

Clinical practice update on testosterone therapy for male hypogonadism: Contrasting perspectives to optimize care

“…30 In this respect, ES and ESA recommendations concur. 2 Managing the obesity, may also have additional health benefits. 1 ESA recommends that obese men who may have reduced testosterone concentrations be encouraged to lose weight using a combination of diet and exercise.…”

“…2 Thus, total testosterone concentrations may be low in men with low SHBG concentrations for example in the presence of obesity and insulin resistance (or exogenous androgens), without being indicative of androgen deficiency particularly when LH and FSH are normal. 2 Thus, total testosterone concentrations may be low in men with low SHBG concentrations for example in the presence of obesity and insulin resistance (or exogenous androgens), without being indicative of androgen deficiency particularly when LH and FSH are normal.…”

“…ES lists systemic illness, sleep disorders, end-stage renal disease, liver, heart and lung failure as causes of functional hypogonadism with elements of primary and secondary hypogonadism coexisting in many cases (Figure 2). Endocrine Society of Australia notes that in men (of any age) with intrinsically normal hypothalamo-pituitary-testicular (HPT) axis function, systemic illness and accumulation of comorbidities including renal, cardiac, inflammatory and mental health disorders, are associated with reduced testosterone concentrations 2. ES further states that the paucity of RCT data on efficacy or safety of T therapy precludes a general recommendation for T therapy in patients with chronic diseases (including severe obesity).…”

Testosterone Treatment and Cardiovascular and Venous Thromboembolism Risk: What is ‘New’?

“…In line with these data, reports in the scientific and lay press significantly halted the enthusiasm on androgen boosting, suggesting that TTh does increase CV risk. Accordingly, the FDA11 and the Australian Endocrinology Society14 stressed the lack of conclusive data on the benefits and safety of T medications in ageing men. In addition, the FDA has mandated pharmaceutical companies that market patented T delivery systems to conduct a placebo-controlled trial that is powered to address potential CV events 19.…”

Thromboembolism Peaking 3 Months after Starting Testosterone Therapy: Testosterone–Thrombophilia Interactions

“…Testosterone has been approved in the USA since the 1950s as hormone replacement therapy (HRT) for male hypogonadism,1 and its use has been carefully evaluated 2 3. Ultimately the risk/benefit ratio of testosterone therapy (TT) can optimally be better defined by a placebo-controlled clinical trial, comparable to the Women’s Health Initiative trials,4 which were required to resolve conflicting epidemiological and clinical data.…”