Late Onset Hypogonadism and its management.pptx

precise slides on Late on sent Hypogonadism(male Andropause) and its management

1. Late onset Hypogonadism AAU,Department of surgery,urology division Moderator ; Dr.Admasu (consultant urologist) Abiy T. PGY-4 9/3/2024 1

2. contents Introduction Epidemiology Physiology of testosterone Role of testosterone in male sexual and reproductive health Classification and causes of male hypogonadism Clinical and features and Evaluation Treatment of male hypogonadism Safety and follow-up in hypogonadism management References 9/3/2024 2

3. introduction Male Hypogonadism ( aka Testosterone deficiency)- refers to a decrease in either or both of the two major functions of the testes: sperm production and testosterone production Androgens play a crucial role in the development and maintenance of male reproductive and sexual functions, body composition, erythropoiesis, muscle and bone health, and cognitive functions Late-onset hypogonadism (LOH) is a clinical condition in ageing men, Persistent specific symptoms and Biochemical evidence of testosterone deficiency(in absence of structural causes) 9/3/2024 3

4. Epidemiology The prevalence of LOH increases with age Incidence 12 per 1000 cases people per year the incidence of symptomatic hypogonadism varies between 2.1 and 5.7 %, in men aged b/n 40-79 years High prevalence of LOH within specific populations, Obesity , Type 2 diabetes (T2DM), Metabolic syndrome ( MetS ), Cardiovascular diseases (CVD), Chronic obstructive pulmonary disease (COPD), Renal disease and cancer Klinefelter syndrome ,(47 , XXY), is the most prevalent genetic cause of primary hypogonadism . 9/3/2024 4

5. Brief on Physiology of TT Biosynthesis Regulation Circulation and transport High affinity -Sex-Hormone-Binding-Globulin(SHBG)- 60-70% of TT Lower affinity, ( albumin, α-1 acid glycoprotein and corticosteroid-binding protein) only 1-2 % of testosterone remains non protein bound Degradation and excretion 9/3/2024 5

6. Role of testosterone in male sexual and reproductive health S exual development and maturation Sexual function Body composition, Erythropoiesis , Muscle and bone health , Cognitive functions 9/3/2024 6

7. Classification/ etiology Functional or Classical(organic) Can be Primary or Secondary Congenital or Acquired 9/3/2024 7

8. 9/3/2024 8

9. Clinical features P oses several challenges as symptoms are non-specific Fatigue , Decreased energy, Sexual impairment Drug history that potentially interfere HPG axis Hx of recent Acute illness Any comorbidity Surgery hx -cryptorchidism/hypospadias Several self-reported questionnaires or structural interviews have been developed for screening of hypogonadism - low specificity are not recommended Screen only in symptomatic patients* 9/3/2024 9

10. Evaluation P/E- Waist circumference,BMI Gynecomastia Testicular size, varicoceles DRE 9/3/2024 10

11. investigation CBC-HCT tT -<12ng/ dL (3.5 ng/mL) fT <6.5ng/ dL (< 225 pmol /L) SHBG level if Indicated PSA(age b/n 40-70) Serum LH and Serum FSH Serum prolactin Serum Pituitary hormone determination Brain MRI 9/3/2024 11

12. Testosterone assays Reliable assay Morning measurement Circadian variation Influenced by food intake Acute illness Confirmatory two or more occasions measurement 9/3/2024 12

13. Diagnosis Signs and symptoms consistent with hypogonadism , coupled with Biochemical evidence of low morning TT on two or more occasions, measured with a reliable assay. 9/3/2024 13

14. Treatment of LOH Patients with symptomatic hypogonadism (total testosterone < 12 nmol /L) without specific contraindications. 9/3/2024 14

15. Choice of treatment A-Lifestyle factors Functional hypogonadism is frequently associated with obesity and metabolic disorders Weight loss Physical exercise Low calorie diet Only small rise in TT Bariatric Surgery Combination with TT Withdraw drugs that halt testosterone production Treat comorbidities B-Medications Testosterone Anti-oestrogens . Gonadotropins C- T reat organic causes 9/3/2024 15

16. Testosterone preparations Several preparations available No direct comparisons available Choice should be based on the Clinical situation, Formulation availability, and Patient needs and expectations Gels and long-acting injectable testosterone undecanoate -optimal safety profiles . TT gels first line for high risk pts 9/3/2024 16

17. 9/3/2024 17

18. Testosterone therapy outcomes Sexual dysfunction First line in pts with milder ED Pt with severe hypogonadism benefit more and presence of metabolic S.with or without DM decreased magnitude of improvement ?Combination with PDEI=severe form of ED Body composition and metabolic profile TT-found to decrease waist circumference, body weight and BMI, with these effects more predominant after 12 months of treatment Improve Body composition and insulin resistance. 9/3/2024 18

19. continued…, Mood and cognition Depressive symptoms and cognitive impairment are less likely responds can improve milder depressive symptoms in hypogonadal men. Use conventional medical Rx Bone Strong r/n b/n hypogonadism and bone loss and osteoporosis Shown to increase BMD, No sufficient data show TT decrease bone fracture risk. Use conventional medical Rx Vitality and physical strength Despite well established role of T on stimulating muscle growth and strength no significant role in older men with physical limitations Don’t give to enhance solely physical activity 9/3/2024 19

20. Safety of hypogonadism management Hypogonadism and fertility issues Use Gonadotropins to maintain T level and spermatogenesis Male breast cancer Active or treated disease-no information available-C/I for TT LUTS/BPH No grounds to discourage TT except in severe LUTS(IPSS>19) Improvement in storage LUTS, but no difference in Qmax , residual volume, PSA level Prostatic ca Not increased risk of Pca in TT Treated/ pt on active surveillance Pca -Risk of recurrence and progression has not yet been established Restrict to Low risk Pca with tPSA <0.01ng/mL 9/3/2024 20

21. Continued…., Cardiovascular disease Whether or not LOH is a cause or a consequence of atherosclerosis has not been clearly determined No CV increased Risk with TT therapy Don’t start TT for period of three to six months in patients with a history of cardiovascular events Cardiac failure TT C/I in severe CHF Untreated Hypogonadism increase Readmission and Mortality rate in chronic HF Treat with careful follow up with clinical, TT and Hct assessment Erythrocytosis Most common Adverse effect Hct Increase Up to 54% no AE Mildly higher incidence of Venous thromboembolism esp in pts with Congenital thrombophilia Rx-lower dose, change formulations,Venesection No need to stop TT therapy In pts high risk for polycythemia Obstructive Sleep Apnoea No evidence that TT therapy result in onset or Worsening 9/3/2024 21

22. Follow up TT improves sexual symptoms as early as 3 months Components Clinical Biochemical Imaging 9/3/2024 22

23. summary LOH significantly affects QoL of aging men LOH diagnosed with specific clinical signs and symptoms supported by biochemical evidences Screen pt for LOH only in symptomatic pts Do not use testosterone therapy in eugonadal men. Discuss with patients about formulations of TT Discuss the benefits of the treatment with patient in details All men with testosterone deficiency should be counseled regarding lifestyle modifications - 9/3/2024 23

24. References 1-Campbell and Walsh Urology Alan 12th ed ,2021 2-EAU-Guidelines-on-Sexual-and-Reproductive-Health-2024. 3-Up-To-Date online 4- Mulhall JP, Trost LW, Brannigan RE et al: Evaluation and management of testosterone deficiency: AUA guideline. J Urol 2018;  200:  423 9/3/2024 24

25. ? Our Experience 9/3/2024 25

26. Thank you! 9/3/2024 26