Late-onset Hypogonadism

What is Late-onset Hypogonadism?

Hypogonadism means reduction in testosterone production.. Late-onset hypogonadism occurs at some point during the life of a man who had a normal puberty growth and normal development of all secondary gender features. Symptomatology of this type of hypogonadism is usually milder than hypogonadism that occurs during childhood and progresses gradually. It seems that mean values of testosterone levels slowly reduce. This starts from the age of 40 or even earlier; the mechanism is not yet fully clear. It is estimated that about 7% of men aged 40-60 y.o. suffer from hypogonadism, 22% of men aged 60-80 y.o and 36% of men  aged 80-100 y.o. 

What are the symptoms of Late-onset Hypogonadism?

Signs and symptoms in late-onset hypogonadism are:

  • Hypoactive (low) sexual desire
  • Erectile dysfunction
  • Muscle mass loss
  • Bone mass loss
  • Depressive thoughts
  • Fatigue
  • Body hair loss
  • Hot flashes

To check symptoms on your own, you can fill in a special questionnaire used worldwide, the ADAM questionnaire. Symptoms in men of middle/advanced age are non-specific. Hormonal screening is necessary for excluding other diseases that could also manifest the same symptoms. 

Is Preventive Screening necessary?

Screening does not have to be done on a routine check-up basis. Only if you have several of the above symptoms, will your physician recommend you to perform specific tests.

When is there need for therapy?

The aim of the therapy is to normalize testosterone levels in the body and treat symptoms. Indications for therapy are:

  • Sexual dysfunction with low testosterone levels
  • Bone mass loss
  • When having several of the hypogonadism symptoms that are mentioned above

Are there contra-indications for the treatment of Hypogonadism?

Testosterone Replacement Therapy should not be administered in cases of:

  • prostate cancer  (it can be administered only after radical prostatectomy and only if recommended by the Urologist )
  • PSA  > 4 ng/ml
  • breast cancer
  • severe sleep apnea episodes 
  • Hematocrit > 50%
  • severe symptoms from the urinary tract due to bening prostatic hyperplasia (for evaluating urinary symptoms, you can fill in a special questionnaire, the IPSS questionnaire).

How is Testosterone administered?

There are quite many testosterone agents which differ in their formulation and route of administration (injections, tablets, transdermal patches). The therapy is always performed under medical guidance every 3 months. More specifically, there are:

  • Testosterone injections -Testosterone is injected intramuscularly every 10-14 weeks. It is a safe and effective therapeutic method. 
  • Transdermal agents - These come in the form of gel or skin patches. They supply the body with  normal testosterone levels for 24 hours. Common side-effect is topical skin irritation  at the site of application. Also, the patient should take some precautions so that other people are not exposed to testosterone with personal contact.   
  • Subcutaneous implants. These grafts are placed under the skin and supply the body with stable testosterone levels for a long period of time (5-7months). The greatest disadvantage of this method is the risk  for graft infection and rejection, which amounts to 10% of  patients with implants. 
  • Oral tablets/ Sublingual tablets. Their use has been limited since they do not offer stable testosterone levels.

Are there risks from Testosterone Replacement Therapy?

The highest risk is when testosterone is taken by men who do not have hypogonadism problem. In this case, testosterone is used as an anabolic, and its major side-effect is gradual testicular atrophy and  infertility.

Other risks related to testosterone administration are referred to specific groups of population and are listed below:

  • Male breast cancer. Testosterone administration is contra-indicated for men suffering from breast cancer. Yet, there is no medical evidence supporting that testosterone may cause breast cancer.
  • Prostate cancer. Testosterone therapy is absolutely contra-indicated for patients with prostate cancer even though it seems that its administration does not cause cancer. However, screening of prostate should always take place both before and during testosterone administration. 
  • Cardiovascular diseases. Testosterone therapy does not seem to be related to the occurrence of cardiovascular events. However, the therapy is contraindicated for patients who suffer from severe heart failure and high hematocrit.  
  • Obstructive sleep apnea. There is an ongoing debate about whether testosterone administration is involved in  the occurrence or aggravation of apneas.