HDL, high density lipoprotein; PSA, prostate speci c antigen; SHBG, sex hormone-binding globulin in .NET

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Table 184 Synopsis of testosterone therapy Indications for testosterone supplementation Clinical symptoms Psychologic symptoms: Irritability, depression, nervousness, anxiety, discouragement, lack of energy Somatovegetative symptoms: Joint/muscle complaints, sweating, hot ushes, sleep disturbances, increased need for sleep, deterioration in well-being, weakness, fatigue, exhaustion Sexual symptoms: Erectile dysfunction, decreased libido, decreased ejaculate volume, decreased orgasmic intensity Laboratory tests Total testosterone: Calculated free testosterone: Bioavailable testosterone: SHBG <23 ng/mL (<8 nml/L): T therapy mandatory Between this level and 35 ng/mL or 12 nmol/L a trial of T therapy is also justi ed <52 pg/mL (<180 pml/L): T therapy mandatory Between this level and 72 pg/mL or 180 pmol/L a trial is also justi ed <075 ng/mL >50 60 nmol/L may be associated with a decrease in bioavailable testosterone
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Contraindications History of prostate or breast cancer PSA elevation (>4 ng/mL) Warning: hypogonadal men with PSA levels of 25 to 4 ng/mL may also be at risk for prostate cancer! PSA increase >050 ng/mL/year for at least 2 years Symptomatic benign prostate hyperplasia with severe clinical symptoms Polycythemia/polyglobulism, hypercoagulability Sleep apnea syndrome Severe left cardiac insuf ciency Poorly controlled severe hypertension Uncontrolled hyperprolactinemia Possible bene ts of T therapy (marked in less than 40 years old hypogonal males, less constant and ample over 40) Body composition: Muscle mass, fat mass, especially abdominal and visceral fat Bone: Bone mineral density, prevention of osteoporosis Blood: Red blood cell count, anemia and resulting fatigue Physical functions: Muscle strength, energy, weakness, fatigue Psychic functions: Spatial cognition and memory, energy, irritability and depression Sexuality: Sexual desire, arousal, erections, volume of ejaculate Possible side effects of T therapy Prostate: PSA increase but mostly within normal range Prostate enlargement but mostly within normal range Rarely prostate cancer Possible HDL cholesterol In case of overdosing: Polycythemia with hematocrit and risk of thrombosis Fluid retention with risk of: Reinforcement of high blood pressure Decompensation of cardiac insuf ciency Sleep apnea syndrome with possible reinforcement of hematocrit, blood viscosity and risk of thrombosis Testes volume, spermatogenesis and fertility, till azoospermia In case of overdosing aggression, excessive excitement Size of prolactinoma with possible headache, visual complications, and hypopituitarism Stimulation of breast cancer Gynecomastia
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Metabolic and cardiovascular:
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Sleep disturbances: Testes, fertility: Psychic functions: Stimulation of diseases sensitive to estrogens (due to aromatization into estradiol):
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HDL, high density lipoprotein; PSA, prostate speci c antigen; SHBG, sex hormone-binding globulin
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Hormones, Metabolism, Aging, and Men s Health
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Hypogonadal male Young
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Fig 184 Algorithm for androgen therapy in a man presenting with low testosterone DRE, digital rectal examination; hCG, human chorionic gonadotropin; PSA, prostate-speci c antigen; SARM, selective androgen recepor modulator; T, testosterone
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Therapy inducing endogenous T production: hCG or clomifene
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Early follow up T,PSA, DRE, hematocrit, lipids Follow-up: T, + after age 40 PSA, DRE,
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Observation, exercise, and/or alternative therapy, eg SARMs, osteoporosis therapies,etc
Long-term follow-up T, PSA, DRE
and erectile function in hypogonadal ED patients [221]
Human chorionic gonadotropin
Human chorionic gonadotropin (hCG) has the same biologic activity as LH, but a longer half-life One injection of 5000 IU stimulates T secretion for three to ve days on condition that the Leydig cells are responsive
low T who do not have these symptoms but may bene t from androgen therapy [18] Testosterone monotherapy may correct sexual dysfunction caused by hypogonadism, but absence of an adequate response after appropriate therapy may require further evaluation to exclude associated co-morbidities, such as those causing vasculogenic or neurogenic ED [222]
Summary of recommendations Recommendations for screening and therapy
Currently there is no basis for androgen therapy in older men, unless they have overt androgen de ciency with symptoms and low testosterone [2] Testosterone levels needed for normal sexual function may vary between individuals Some men may have normal sexual function even if their T levels fall into the age-adjusted lower normal range [221] However, in patients with ED and/or hypoactive sexual desire, T testing is recommended to screen for hypogonadism T therapy is appropriate when clinical indications and biochemical evidence of hypogonadism exist [168,222] In men with ED, determining T levels only in case of either low sexual desire or abnormal physical examination overlooks many patients with