madman
Super Moderator
The British Society for Sexual Medicine Guidelines on Male Adult Testosterone Deficiency, With Statements for Practice (2023)
Geoffrey Hackett, Michael Kirby, Rowland W. Rees, T. Hugh Jones, Asif Muneer, Mark Livingston, Nick Ossei-Gerning, Janine David, Jeff Foster, Philip A. Kalra, Sudarshan Ramachandran
Testosterone deficiency (TD) is an increasingly common problem with significant health implications, but its diagnosis and management can be challenging. A multi-disciplinary panel from BSSM reviewed the available literature on TD and provide evidence-based statements for clinical practice. Evidence was derived from Medline, EMBASE, and Cochrane searches on hypogonadism, testosterone therapy (T Therapy), and cardiovascular safety from May 2017 to September 2022. This revealed 1,714 articles, including 52 clinical trials and 32 placebo-controlled randomized controlled trials. A total of twenty-five statements are provided, relating to five key areas: screening, diagnosis, initiating T Therapy, benefits and risks of T Therapy, and follow-up. Seven statements are supported by level 1 evidence, eight by level 2, five by level 3, and five by level 4. Recent studies have demonstrated that low levels of testosterone in men are associated with an increased risk of incident type 2 diabetes mellitus, worse outcomes in chronic kidney disease, and COVID-19 infection with increased all-cause mortality, along with significant quality of life implications. These guidelines should help practitioners effectively diagnose and manage primary and age-related TD.
INTRODUCTION
Testosterone is the principal androgen in men. The term ‘testosterone deficiency (TD)’ is used throughout, in preference to hypogonadism, which refers to under activity of both the endocrine and reproductive function of the testes. TD is a well-established and significant medical condition [1,2]. Testosterone is essential for the development and maintenance of secondary male characteristics [3]. When testosterone levels fall, patients may experience physical, psychological, and metabolic effects, which can compromise their cardiovascular, metabolic, and general health, well-being, sexuality, and fertility [4,5].
These statements have been developed for UK practice and aim to address the widespread media and scientific concerns over the appropriate treatment of men with TD with testosterone therapy (T Therapy).
*DEFINITION AND TERMINOLOGY
*EPIDEMIOLOGY
*BASIC PHYSIOLOGY
*AETIOLOGY
*SUBCLINICAL (COMPENSATED) TD (HYPOGONADISM)
*PRESCRIBED OPIATE MEDICATIONS
*POST FINASTERIDE SYNDROME
*CLINICAL DIAGNOSIS OF TD
*SIGNS, SYMPTOMS, AND COMORBIDITIES
*LIFESTYLE CHANGE AND TESTOSTERONE LEVELS
*ORAL SUPPLEMENTS
*THE RATIONALE FOR T THERAPY
*TESTOSTERONE AND FERTILITY
*THE BENEFITS OF T THERAPY IN MEN WITH TD
*POSSIBLE INCREASED CARDIOVASCULAR RISK WITH T THERAPY
*STUDIES SUGGESTING DECREASED CARDIOVASCULAR RISK WITH T THERAPY
*FINDINGS FROM META-ANALYSES
*T THERAPY AND RISK OF PCA
*ROUTINE MEASUREMENT OF TESTOSTERONE
*HISTORY TAKING AND QUESTIONNAIRES
*PHYSICAL EXAMINATION
*DIGITAL RECTAL EXAMINATION
*LABORATORY DIAGNOSIS
*THRESHOLDS FOR T THERAPY
*TESTOSTERONE THERAPY
*THE IMPORTANCE OF CO-ADMINISTRATION OF DAILY PDE5 INHIBITORS IN HYPOGONADISM
*ALTERNATIVES FOR MEN WITH HYPOGONADISM WHO DESIRE FUTURE FERTILITY
*CARDIOVASCULAR RISK AND TESTOSTERONE THERAPY
*ADVERSE EFFECTS OF T THERAPY
*CONTRAINDICATIONS TO T THERAPY
*FOLLOW-UP AND MONITORING
*BSSM POSITION STATEMENT ON COVID-19 INFECTION
CONCLUSION
TD is a well-established and significant medical condition, encompassing somatic, sexual, and psychological effects. It is also associated with an increased risk of type 2 diabetes and cardiovascular and all-cause mortality. Clearly defined clinical symptoms, especially ED, loss of morning erections, and reduced sexual desire should prompt swift evaluation of these, together with modification of underlying risk factors, and further investigations performed where appropriate.
In order to identify individuals who should be screened for TD, consideration should be given to routinely asking men if they have any sexual concerns, particularly those at high risk. These include men with diabetes, osteoporosis/fragility fractures, CVD, CKD, anemia, ED, depression, COVID-19 infection, and those on long-term opiate/oral glucocorticoid therapy
T Therapy is evidence-based, effective, and safe, and evidence suggests that treatment-related sustained normalization of serum testosterone levels is associated with reduced morbidity and mortality.
However, whilst the multiple benefits of T Therapy are highly relevant to the patient, they are often underestimated by specialist physicians focused on specific outcomes related to their particular discipline. Because sexual dysfunction is often multi-faceted in nature, the treatment of men with sexual desire, arousal, and ejaculation problems should be individualized and may include T Therapy, erectogenic agents, and psychosexual therapy.
Until a definitive well-powered long-term study is published, the treatment of TD with T Therapy should be guided by the best available evidence.
Geoffrey Hackett, Michael Kirby, Rowland W. Rees, T. Hugh Jones, Asif Muneer, Mark Livingston, Nick Ossei-Gerning, Janine David, Jeff Foster, Philip A. Kalra, Sudarshan Ramachandran
Testosterone deficiency (TD) is an increasingly common problem with significant health implications, but its diagnosis and management can be challenging. A multi-disciplinary panel from BSSM reviewed the available literature on TD and provide evidence-based statements for clinical practice. Evidence was derived from Medline, EMBASE, and Cochrane searches on hypogonadism, testosterone therapy (T Therapy), and cardiovascular safety from May 2017 to September 2022. This revealed 1,714 articles, including 52 clinical trials and 32 placebo-controlled randomized controlled trials. A total of twenty-five statements are provided, relating to five key areas: screening, diagnosis, initiating T Therapy, benefits and risks of T Therapy, and follow-up. Seven statements are supported by level 1 evidence, eight by level 2, five by level 3, and five by level 4. Recent studies have demonstrated that low levels of testosterone in men are associated with an increased risk of incident type 2 diabetes mellitus, worse outcomes in chronic kidney disease, and COVID-19 infection with increased all-cause mortality, along with significant quality of life implications. These guidelines should help practitioners effectively diagnose and manage primary and age-related TD.
INTRODUCTION
Testosterone is the principal androgen in men. The term ‘testosterone deficiency (TD)’ is used throughout, in preference to hypogonadism, which refers to under activity of both the endocrine and reproductive function of the testes. TD is a well-established and significant medical condition [1,2]. Testosterone is essential for the development and maintenance of secondary male characteristics [3]. When testosterone levels fall, patients may experience physical, psychological, and metabolic effects, which can compromise their cardiovascular, metabolic, and general health, well-being, sexuality, and fertility [4,5].
These statements have been developed for UK practice and aim to address the widespread media and scientific concerns over the appropriate treatment of men with TD with testosterone therapy (T Therapy).
*DEFINITION AND TERMINOLOGY
*EPIDEMIOLOGY
*BASIC PHYSIOLOGY
*AETIOLOGY
*SUBCLINICAL (COMPENSATED) TD (HYPOGONADISM)
*PRESCRIBED OPIATE MEDICATIONS
*POST FINASTERIDE SYNDROME
*CLINICAL DIAGNOSIS OF TD
*SIGNS, SYMPTOMS, AND COMORBIDITIES
*LIFESTYLE CHANGE AND TESTOSTERONE LEVELS
*ORAL SUPPLEMENTS
*THE RATIONALE FOR T THERAPY
*TESTOSTERONE AND FERTILITY
*THE BENEFITS OF T THERAPY IN MEN WITH TD
*POSSIBLE INCREASED CARDIOVASCULAR RISK WITH T THERAPY
*STUDIES SUGGESTING DECREASED CARDIOVASCULAR RISK WITH T THERAPY
*FINDINGS FROM META-ANALYSES
*T THERAPY AND RISK OF PCA
*ROUTINE MEASUREMENT OF TESTOSTERONE
*HISTORY TAKING AND QUESTIONNAIRES
*PHYSICAL EXAMINATION
*DIGITAL RECTAL EXAMINATION
*LABORATORY DIAGNOSIS
*THRESHOLDS FOR T THERAPY
*TESTOSTERONE THERAPY
*THE IMPORTANCE OF CO-ADMINISTRATION OF DAILY PDE5 INHIBITORS IN HYPOGONADISM
*ALTERNATIVES FOR MEN WITH HYPOGONADISM WHO DESIRE FUTURE FERTILITY
*CARDIOVASCULAR RISK AND TESTOSTERONE THERAPY
*ADVERSE EFFECTS OF T THERAPY
*CONTRAINDICATIONS TO T THERAPY
*FOLLOW-UP AND MONITORING
*BSSM POSITION STATEMENT ON COVID-19 INFECTION
CONCLUSION
TD is a well-established and significant medical condition, encompassing somatic, sexual, and psychological effects. It is also associated with an increased risk of type 2 diabetes and cardiovascular and all-cause mortality. Clearly defined clinical symptoms, especially ED, loss of morning erections, and reduced sexual desire should prompt swift evaluation of these, together with modification of underlying risk factors, and further investigations performed where appropriate.
In order to identify individuals who should be screened for TD, consideration should be given to routinely asking men if they have any sexual concerns, particularly those at high risk. These include men with diabetes, osteoporosis/fragility fractures, CVD, CKD, anemia, ED, depression, COVID-19 infection, and those on long-term opiate/oral glucocorticoid therapy
T Therapy is evidence-based, effective, and safe, and evidence suggests that treatment-related sustained normalization of serum testosterone levels is associated with reduced morbidity and mortality.
However, whilst the multiple benefits of T Therapy are highly relevant to the patient, they are often underestimated by specialist physicians focused on specific outcomes related to their particular discipline. Because sexual dysfunction is often multi-faceted in nature, the treatment of men with sexual desire, arousal, and ejaculation problems should be individualized and may include T Therapy, erectogenic agents, and psychosexual therapy.
Until a definitive well-powered long-term study is published, the treatment of TD with T Therapy should be guided by the best available evidence.
