A 25-year-old man comes to the office due to decreased libido, fatigue, and weight gain. For the last few months, the patient has been unable to attain a satisfactory erection during intercourse with his girlfriend. He has had no headaches, blurred vision, fever, nausea, or vomiting. The patient has had no significant prior medical problems and takes no prescription medications but does take several over-the-counter supplements to boost his metabolism. He does not use alcohol, tobacco, or illicit drugs. His mother was treated for non-Hodgkin lymphoma, and his father has no major medical problems. Blood pressure is 130/70 mm Hg and pulse is 56/min. The patient appears fit and well-built with no significant abnormalities noted on examination. Laboratory results are as follows: Which of the following is the most appropriate next step in management?

Question

A 25-year-old man comes to the office due to decreased libido, fatigue, and weight gain.  For the last few months, the patient has been unable to attain a satisfactory erection during intercourse with his girlfriend.  He has had no headaches, blurred vision, fever, nausea, or vomiting.  The patient has had no significant prior medical problems and takes no prescription medications but does take several over-the-counter supplements to boost his metabolism.  He does not use alcohol, tobacco, or illicit drugs.  His mother was treated for non-Hodgkin lymphoma, and his father has no major medical problems.  Blood pressure is 130/70 mm Hg and pulse is 56/min.  The patient appears fit and well-built with no significant abnormalities noted on examination.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

Explanation: 11ec2b69_beab_e75b_8f63_2b2c4f6f5619_MD0005_00 This patient has symptomatic hypogonadism with a low serum testosterone and inappropriately low gonadotropin (FSH, LH) levels. In light of his erythrocytosis and use of over-the-counter supplements, this raises concern for abuse of androgen-anabolic steroids (AAS). AAS are available by mail order and are commonly abused by athletes and others wishing to improve muscle mass, athletic performance, and physical appearance. Formulations include injectable testosterone, oral/injectable anabolic steroids, androgen precursors (eg, androstenedione, dehydroepiandrosterone), and selective androgen receptor modulators. AAS cause decreased production of endogenous testosterone via suppression of gonadotropins (ie, FSH, LH). With chronic use, testicular atrophy may be seen. Some AAS (eg, stanozolol) can also cause hepatotoxicity. Testosterone levels usually recover in weeks to months after discontinuation, but chronic AAS abuse can lead to prolonged and even permanent suppression of endogenous testosterone production. (Choice A) AAS can cause erythrocytosis associated with increased erythropoietin production and suppression of the iron regulatory protein hepcidin. Although endurance athletes may abuse erythropoietin, leading to erythrocytosis, this would not cause hypogonadism. (Choice B) Hereditary hemochromatosis can cause erythrocytosis, elevated serum transaminase levels, and central hypogonadism. However, symptoms typically develop at age ~40 (due to total iron accumulation), most patients with significant disease have hyperpigmentation, and symptoms (eg, arthralgias) are typically present for years prior to diagnosis. (Choice C) Although this patient's thyroid function studies resemble central hypothyroidism (low T4, inappropriately normal TSH), AAS causes a similar pattern due to reduced synthesis of thyroxine-binding globulin. Patients are metabolically euthyroid, and free T4 is normal. MRI is not recommended as incidental pituitary abnormalities are common and could instigate additional unnecessary tests. (Choice D) Testosterone therapy in this patient is likely to worsen the suppression of endogenous testosterone production. Educational objective: Abuse of androgen-anabolic steroids can cause decreased production of endogenous testosterone, leading to symptomatic hypogonadism. Testosterone levels usually recover in weeks to months after discontinuation, but chronic abuse can cause prolonged or permanent suppression of endogenous testosterone production. References: Androgen abuse in the community. (http://www.ncbi.nlm.nih.gov/pubmed/19373082) Anabolic steroid-induced hypogonadism: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/24636400)

A 25-Year-Old Man Comes to the Office Due to Decreased