madman
Super Moderator
Organic male hypogonadism due to irreversible hypothalamic–pituitary–testicular (HPT) pathology is easily diagnosed and treated with testosterone-replacement therapy. However, controversy surrounds the global practice of prescribing testosterone to symptomatic men with low testosterone and non-gonadal factors reducing healthstatus, such as obesity, type 2 diabetes, and ageing (ie, functional hypogonadism), but without identifiable HPT axis pathology. Health optimisation remains the gold-standard management strategy. Nevertheless, in the last decade large clinical trials and an individual patient data meta-analysis of smaller clinical trials confirmed that testosterone therapy induces modest, yet statistically significant, improvements in sexual function without increasing short-term to medium-term cardiovascular or prostate cancer risks in men with functional hypogonadism. Although testosterone improves bone mineral density and insulin sensitivity in these men, trials from the last decade suggest insufficient evidence to determine the safety and effectiveness of use of this hormone for the prevention of fractures or type 2 diabetes. This Review discusses the pathogenesis and diagnosis of male hypogonadism and appraises the evidence underpinning the management of this condition.
Introduction
*This Review draws upon authors’ experience from diverse health-care settings, to summarise our understanding of pathophysiology, presentation, diagnostic criteria, and management of male hypogonadism. Furthermore,a dedicated section on diagnostic and management controversies aims to highlight areas of uncertainty and provides a balanced approach for clinicians to support affected men.
Physiology of HPT axis
Pathophysiology and classification of male hypogonadism
-Organic hypogonadism
-Functional hypogonadism and late-onset hypogonadism
-Association of male hypogonadism with cardiovascular risk factors and outcomes
Epidemiology
Diagnosis
Clinical assessment
Laboratory testing and imaging
Diagnostic challenges
Management
Efficacy of testosterone
Controversies on testosterone
Conclusions
Male hypogonadism encompasses a diverse group of congenital and acquired conditions either due to intrinsic pathology in the HPT axis or reversible suppression. Clinical presentation depends on the time of onset. Absence of secondary sexual characteristics is the hallmark of prepubertal male hypogonadism. Diagnosis of organic male hypogonadism should be mostly straightforward due to convincing clinical presentation and biochemistry, but even so, very few older men with primary testicular failure are being identified and treated considering the anticipated prevalence of this condition. Management with testosterone also does not pose any controversies. The increasing number of men presenting with functional hypogonadism poses diagnostic challenges due to subtle clinical features and controversies in diagnostic serum testosterone cut-offs. Similarly, treating the underlying risk factors such as obesity supersedes testosterone use, though the evidence suggests medium-term cardiovascular safety and modest symptomatic benefits of testosterone treatment in this group of men. For these men, lifestyle change represents a more holistic and globally effective treatment across multiple parameters.
Introduction
*This Review draws upon authors’ experience from diverse health-care settings, to summarise our understanding of pathophysiology, presentation, diagnostic criteria, and management of male hypogonadism. Furthermore,a dedicated section on diagnostic and management controversies aims to highlight areas of uncertainty and provides a balanced approach for clinicians to support affected men.
Physiology of HPT axis
Pathophysiology and classification of male hypogonadism
-Organic hypogonadism
-Functional hypogonadism and late-onset hypogonadism
-Association of male hypogonadism with cardiovascular risk factors and outcomes
Epidemiology
Diagnosis
Clinical assessment
Laboratory testing and imaging
Diagnostic challenges
Management
Efficacy of testosterone
Controversies on testosterone
Conclusions
Male hypogonadism encompasses a diverse group of congenital and acquired conditions either due to intrinsic pathology in the HPT axis or reversible suppression. Clinical presentation depends on the time of onset. Absence of secondary sexual characteristics is the hallmark of prepubertal male hypogonadism. Diagnosis of organic male hypogonadism should be mostly straightforward due to convincing clinical presentation and biochemistry, but even so, very few older men with primary testicular failure are being identified and treated considering the anticipated prevalence of this condition. Management with testosterone also does not pose any controversies. The increasing number of men presenting with functional hypogonadism poses diagnostic challenges due to subtle clinical features and controversies in diagnostic serum testosterone cut-offs. Similarly, treating the underlying risk factors such as obesity supersedes testosterone use, though the evidence suggests medium-term cardiovascular safety and modest symptomatic benefits of testosterone treatment in this group of men. For these men, lifestyle change represents a more holistic and globally effective treatment across multiple parameters.
