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Multidisciplinary Insights Into the Assessment

, Diagnosis, and Management of Hypogonadism

Baseline assessments should include a DRE and blood tests to measure PSA and hemoglobin or hematocrit. Voiding symptoms can be assessed by obtaining a history or using an instrument such as the International Prostatic Symptom Scale. Patients should be questioned regarding symptoms of sleep apnea. If the PSA level is >4.0 ng/mL or the DRE finding is abnormal, a prostate biopsy should be performed.1,22

At follow-up, urinary symptoms and the presence or exacerbation of sleep apnea or gynecomastia should be monitored. Because increased testosterone levels appear to stimulate erythropoiesis, hemoglobin or hematocrit should be monitored during

therapy.1,22 The risk of erythrocytosis appears to vary with the type of testosterone formulation.1

DRE should be repeated at follow-up visits. If the PSA level is >4.0 ng/mL or increases by 1.0 ng/mL in 1 year, a prostate biopsy should be performed or the patient should be referred to a urologist.1,22 For increases in PSA levels of 0.7 to 0.9 ng/mL in 1 year, the PSA measurement should be repeated in 3 to 6 months, and a biopsy should be performed if a further increase is detected.1

Guidelines have been established by several organizations with regard to monitoring during testosterone treatment. Similar in nature and intent, these guidelines are provided in Table 8.1,22,24,31

X

X

Goal is to restore serum testosterone to mid-normal range

X

X

X

X

Biopsy if abnormal at baseline and if abnormal during treatment

Testosterone level

X

PSA level

X

DRE findings

X

Table 8. A. Monitoring During Testosterone Therapy B. International Society of Andrology, International Society for the Study of the Aging Male, and European Association of Urology Recommendations C. American Association of Clinical Endocrinologists Recommendations1,22,24,31

X

Baseline

1-2 Mo

3-6 Mo

Annually

X

XX

X

A.

Parameter

Symptom assessment

Test Frequency

Goal/Comments

Evaluate whether symptoms have responded to treatment or if there are adverse effects

X

X

X

X

X

X

X

X

Breast examination findings

X

Hematocrit level

X

Sleep apnea

X

Voiding, IPSS score

X

DEXA findings

X

Detect gynecomastia; mammograms only as indicated

If hematocrit is >54%, stop therapy until hematocrit decreases to a safe level

Ask about fatigue during the day and disordered sleep

Every 2-5 y if testosterone score is <-2.0 at baseline

B.

Parameter DRE, PSA, hematologic assessments in men aged >45 y

Baseline Quarterly for the first 12 mo Yearly thereafter

Test Frequency

Bone density

Every 2 y if abnormal at baseline

C.

Side effects

Parameter

Test Frequency Every 3-4 mo for the first year

Testosterone levels Injectables Gels Patches

Midpoint between injections Timing of measurement not important Measure 4-8 h after application

Prostate examination and prostate-related symptom evaluation

Every 6-12 mo

PSA

Every 12 mo

Hematocrit

Every 6 mo for the first 18 mo and yearly thereafter if stable and normal; decrease or discontinue testosterone therapy if hematocrit increases to >50%

Lipid profile

Baseline, every 6-12 mo, yearly thereafter

DEXA, dual-energy x-ray absorptiometry; DRE, digital rectal examination; IPSS, International Prostate Symptom Scale; PSA, prostate-specific antigen.

13

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