A 70-year-old man seeks advice regarding testosterone replacement therapy. The patient recently married a younger woman and has been reading reports in the news media regarding the therapy's potential benefits. He has diminished sexual desire and moderate erectile dysfunction that responds to sildenafil. The patient rarely has a morning erection. His ability to perform endurance exercise at a high level is significantly lower than it was 10 years ago. Other medical problems include hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia (American Urological Association score of 10) , and hyperlipidemia. There is no family history of prostate cancer.
Blood pressure is 134/88 mm Hg and pulse is 84/min. BMI is 30 kg/m². Neck circumference is 20 in (51 cm) . Cardiovascular, pulmonary, abdominal, and extremity examinations are normal. The testes appear normal for age. Digital rectal examination shows a symmetrical prostate that is mildly enlarged.
Laboratory results are as follows:
Which of the following is the best advice regarding testosterone replacement for this patient?

Question

A 70-year-old man seeks advice regarding testosterone replacement therapy. The patient recently married a younger woman and has been reading reports in the news media regarding the therapy's potential benefits. He has diminished sexual desire and moderate erectile dysfunction that responds to sildenafil. The patient rarely has a morning erection. His ability to perform endurance exercise at a high level is significantly lower than it was 10 years ago. Other medical problems include hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia (American Urological Association score of 10) , and hyperlipidemia. There is no family history of prostate cancer.
Blood pressure is 134/88 mm Hg and pulse is 84/min. BMI is 30 kg/m². Neck circumference is 20 in (51 cm) . Cardiovascular, pulmonary, abdominal, and extremity examinations are normal. The testes appear normal for age. Digital rectal examination shows a symmetrical prostate that is mildly enlarged.
Laboratory results are as follows:

Which of the following is the best advice regarding testosterone replacement for this patient?

Quizplus · Accepted Answer

Testosterone replacement therapy (TRT) should be considered only in men with clinically significant androgen deficiency (eg, low libido, erectile dysfunction, loss of body hair, gynecomastia, decreased bone density, testicular atrophy) and an unequivocally low morning serum testosterone level (eg, <200-300 ng/dL, depending on the reference). Nonspecific symptoms (eg, fatigue, weakness, weight changes) do not usually respond to TRT and do not warrant testing or treatment in most cases. Testosterone levels show significant variability; if the initial testosterone level is low, it should be confirmed on repeat testing. In addition, providers should consider measuring free testosterone levels, as variations in the levels of sex hormone-binding globulin, which may be decreased in certain conditions (eg, obesity, diabetes), can cause misleading total testosterone results. Contraindications to TRT include breast or prostate cancer, polycythemia, severe lower urinary tract symptoms (ie, American Urological Association score >19), unstable heart failure, PSA >4 ng/mL (>3 ng/mL in high-risk patients), and untreated obstructive sleep apnea (OSA). This patient has an elevated hematocrit, hypertension, obesity, and a large neck circumference, which together suggest possible OSA. TRT can worsen OSA and exacerbate erythrocytosis, with a possible increased risk of venous thromboembolism. The patient also has multiple risk factors for cardiovascular disease, and some evidence suggests that TRT may increase this risk. As a result, the risks likely outweigh the benefits of TRT in this patient (Choice C). In addition, TRT is indicated for specific disorders of gonadal function (eg, chemotherapy-induced hypogonadism), but TRT for age-related declines in serum testosterone is considered an off-label use. (Choice A) FSH and LH help to distinguish primary (elevated LH and FSH) from secondary (low or normal FSH and LH) hypogonadism. However, this patient's mildly low testosterone level should be confirmed on repeat testing prior to further evaluation. (Choice B) A PSA level and digital prostate examination are recommended to screen for prostate cancer prior to initiation of TRT in men age >50 (or age >40 with a family history of prostate cancer). This patient's PSA is normal for his age; additional testing is not needed at this time (Choice D) Although erectile dysfunction is a significant symptom in men with hypogonadism, TRT has shown inconsistent benefits in the treatment of erectile dysfunction in older men. Phosphodiesterase inhibitors (eg, sildenafil) are more likely to be effective. Educational objective: Testosterone replacement therapy should be considered only in men with clinically significant androgen deficiency (eg, low libido, erectile dysfunction, loss of body hair, gynecomastia, decreased bone density, testicular atrophy) and an unequivocally low morning serum testosterone level confirmed on repeat testing. Careful pretreatment evaluation is recommended to identify patients with a favorable risk:benefit ratio. __________ References: Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/20525905)

A 70-Year-Old Man Seeks Advice Regarding Testosterone Replacement Therapy