U.S. Endocrine Society (ES) published a clinical practice guideline on testosterone therapy in men with hypogonadism, and Endocrine Society of Australia (ESA) a position statement on management of male hypogonadism. Both emphasise the importance of diagnosing men who are androgen deficient due to organic (classical or pathological) hypogonadism arising from disorders of the hypothalamus, pituitary or testes, who assuredly benefit from testosterone therapy. Both recognise that men with an intact gonadal axis may have low testosterone concentrations, for instance older men or men with obesity or other medical comorbidities. ES guidelines classify such symptomatic men as having organic (advanced age) or functional (obesity, medical comorbidities) hypogonadism, giving an option for testosterone therapy as a shared decision between clinicians and individual patients. ESA did not recommend testosterone therapy in these men. ES offers a reference range for total testosterone established in young men, while ESA cites age-standardised reference ranges. ES recommends using free testosterone as well as total testosterone to identify men with hypogonadism in conditions where sex hormone-binding globulin (SHBG) is altered, or when total testosterone is borderline. ESA recommends confirmatory biochemical testing with total testosterone, recognising that this may be lower than expected if SHBG concentrations are low. Both emphasise the importance of identifying pre-existing prostate and cardiovascular disease prior to initiating testosterone therapy, with ES providing specific recommendations for PSA measurement, deferring testosterone therapy after major cardiovascular events and indications for pituitary imaging. These contrasting approaches highlight gaps in the evidence base where individualised patient management is required. This article is protected by copyright. All rights reserved.
Clinical endocrinology. 2018 Oct 25 [Epub ahead of print]
Bu B Yeap, Frederick C W Wu
University of Western Australia, Perth, Western Australia 6009, and Endocrinologist, Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western, Australia, 6150., Emeritus Professor of Medicine and Endocrinology, Division of Endocrinology, Diabetes& Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, M13 9WL, United Kingdom.