madman
Super Moderator
European Academy of Andrology (EAA) guidelines* on investigation, treatment and monitoring of functional hypogonadism in males
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Abstract
Background. Evidence regarding functional hypogonadism, previously referred to as “late-onset” hypogonadism (LOH), has increased substantially during the last 10 year.
Objective. To update the European Academy of Andrology (EAA) guidelines on functional hypogonadism.
Methods. Expert group of Academicians appointed by the EAA generated a series of consensus recommendations according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system.
Results. The diagnosis of functional hypogonadism should be based on both the presence of clinical symptoms supported by repeatedly low morning fasting serum total testosterone (T) measured with a well-validated assay, after exclusion of organic causes of hypogonadism. Lifestyle changes and weight reduction should be the first approach in all overweight and obese men. Whenever possible, withdrawal/modification of drugs potentially interfering with T production should be advised. Testosterone Replacement Therapy (TRT) is contra-indicated in men with untreated prostate or breast cancer, as well as severe heart failure. Severe low urinary tract symptoms and haematocrit >48-50% represent relative contraindications for TRT. Prostate specific antigen (PSA) and digital rectal examination (DRE) of the prostate should be undertaken in men>40 years of age before initiating TRT to exclude occult prostate cancer. Transdermal T should be preferred for initiation of TRT whereas gonadotrophin therapy is only recommended when fertility is desired in men with secondary hypogonadism. TRT is able to improve sexual function in hypogonadal men. Other potential positive outcomes of TRT remain uncertain and controversial.
Conclusion.TRT can reliably improve global sexual function in men with hypogonadism in the short term. Long-term clinical benefits, and safety of TRT in functional hypogonadism, remain to be fully documented. Clinicians should therefore explicitly discuss the uncertainties and benefits of TRT and engage them in shared management decision-making.
Conclusions
Functional hypogonadism is a relatively new clinical diagnosis that is still not universally recognized or accepted. T concentrations decline gradually with age, but the clinical significance of low T in ageing men remains unclear. This presents a difficult challenge to clinicians who are charged with confirming a genuine diagnosis of (functional) hypogonadism amongst a plethora of relatively non-specific symptoms (of which sexual symptoms show the strongest association with T deficiency). This is compounded by the fact that T concentrations in functional hypogonadism are commonly found in the borderline (8-12 nmol/L) rather than the unequivocally pathological range (<6 nmol/L). In this situation, fT measurement can be helpful in resolving borderline cases. It is important to recognize the roles of obesity and co-morbidity as well as medications in aggravating the natural age-related T decline, with the important implication of potential reversibility. Thus TRT, more often than not, initiated as a therapeutic trial, should not be continued if there is no clinical improvement. Moreover, the diagnosis and changing requirements/priorities of the patient should be reviewed regularly, especially of those in advanced age whose risk and benefit balance may shift with time. The present recommendations for or against treatment are substantially influenced by the fact that real clinical benefits and safety (especially in the longer-term) of TRT have not been fully documented. Furthermore, due to its potential reversibility, no data are currently available to recommend the appropriate duration of TRT in individual patients with functional hypogonadism. It is clear that this is an evolving area of clinical practice that requires much more clinical research efforts. The relative abundance of negative rather than positive recommendations (which may not always be definitive) in these guidelines reflects a dearth of high-level evidence. In the meantime, clinicians dealing with individual patients with possible functional hypogonadism should be prepared to explicitly discuss the uncertainties of the potential risks and benefits of TRT from current evidence and engage them in shared management decision-making.
Error - Cookies Turned Off
Abstract
Background. Evidence regarding functional hypogonadism, previously referred to as “late-onset” hypogonadism (LOH), has increased substantially during the last 10 year.
Objective. To update the European Academy of Andrology (EAA) guidelines on functional hypogonadism.
Methods. Expert group of Academicians appointed by the EAA generated a series of consensus recommendations according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system.
Results. The diagnosis of functional hypogonadism should be based on both the presence of clinical symptoms supported by repeatedly low morning fasting serum total testosterone (T) measured with a well-validated assay, after exclusion of organic causes of hypogonadism. Lifestyle changes and weight reduction should be the first approach in all overweight and obese men. Whenever possible, withdrawal/modification of drugs potentially interfering with T production should be advised. Testosterone Replacement Therapy (TRT) is contra-indicated in men with untreated prostate or breast cancer, as well as severe heart failure. Severe low urinary tract symptoms and haematocrit >48-50% represent relative contraindications for TRT. Prostate specific antigen (PSA) and digital rectal examination (DRE) of the prostate should be undertaken in men>40 years of age before initiating TRT to exclude occult prostate cancer. Transdermal T should be preferred for initiation of TRT whereas gonadotrophin therapy is only recommended when fertility is desired in men with secondary hypogonadism. TRT is able to improve sexual function in hypogonadal men. Other potential positive outcomes of TRT remain uncertain and controversial.
Conclusion.TRT can reliably improve global sexual function in men with hypogonadism in the short term. Long-term clinical benefits, and safety of TRT in functional hypogonadism, remain to be fully documented. Clinicians should therefore explicitly discuss the uncertainties and benefits of TRT and engage them in shared management decision-making.
Conclusions
Functional hypogonadism is a relatively new clinical diagnosis that is still not universally recognized or accepted. T concentrations decline gradually with age, but the clinical significance of low T in ageing men remains unclear. This presents a difficult challenge to clinicians who are charged with confirming a genuine diagnosis of (functional) hypogonadism amongst a plethora of relatively non-specific symptoms (of which sexual symptoms show the strongest association with T deficiency). This is compounded by the fact that T concentrations in functional hypogonadism are commonly found in the borderline (8-12 nmol/L) rather than the unequivocally pathological range (<6 nmol/L). In this situation, fT measurement can be helpful in resolving borderline cases. It is important to recognize the roles of obesity and co-morbidity as well as medications in aggravating the natural age-related T decline, with the important implication of potential reversibility. Thus TRT, more often than not, initiated as a therapeutic trial, should not be continued if there is no clinical improvement. Moreover, the diagnosis and changing requirements/priorities of the patient should be reviewed regularly, especially of those in advanced age whose risk and benefit balance may shift with time. The present recommendations for or against treatment are substantially influenced by the fact that real clinical benefits and safety (especially in the longer-term) of TRT have not been fully documented. Furthermore, due to its potential reversibility, no data are currently available to recommend the appropriate duration of TRT in individual patients with functional hypogonadism. It is clear that this is an evolving area of clinical practice that requires much more clinical research efforts. The relative abundance of negative rather than positive recommendations (which may not always be definitive) in these guidelines reflects a dearth of high-level evidence. In the meantime, clinicians dealing with individual patients with possible functional hypogonadism should be prepared to explicitly discuss the uncertainties of the potential risks and benefits of TRT from current evidence and engage them in shared management decision-making.
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