JANINE DAVID: I think there’s a really big problem with the laboratory results in the UK and globally actually, because when we get the level back, it’ll often be the laboratory value rather than the recommended guideline value for low or borderline low testosterone levels. And the difficulty with this is that the GP who was unaware of the guideline levels will probably mark this as normal if the laboratory result is given back as “normal”. They get so many results every day that this will – it’ll come back as a normal result and it will just get filed with the thousands. So, lots of men every day are being missed, having a missed diagnosis of testosterone deficiency or low testosterone because GPs are unaware of borderline, low borderline levels, because the laboratory levels are not concurrent with the guidelines. This is a huge problem.
It’s really important that as GPs, we are open, honest and frank with our patients. And if – I think we need to get a culture of not being concerned about discussing embarrassing issues with men, and we know that men don’t present to the doctor. So, when they do, it’s so vital that we ask them these questions. And, you know, it could really change someone’s life if we bother to say, “Look, lots of people with your symptoms may have a sexual problem. Is this you?” And that can make a huge difference to the rest of their life’s morbidity and even mortality.
I will always screen patients with erectile dysfunction or low libido. However, I will also now check a testosterone level in patients who are tired all the time. So, for example, a workup to a tired-all-the-time presentation, I will now always add a testosterone level. I will check testosterone in osteoporotic men. I will also check in men with chronic anemia of unknown cause. I think it’s really important that as GPs, we think about these things not just the sexual thing—presentations—when we’re checking testosterone levels. Also, of course with obese men, especially if their BMI is over 30, waist circumstance above 102, I’ll always consider checking the testosterone level in them as well.
Okay. I’ll always screen for hypogonadism, low testosterone in patients with erectile dysfunction, and of course loss of libido, loss of sex drive. But I’ll also screen – actually I screen all my diabetic patients for low testosterone. So, if you think half of them are going to have a low testosterone, I actually then ask them retrospectively, “Do you have a sexual problem with erectile dysfunction or loss of sex drive?” I will also screen all osteoporotic men for low testosterone and those with chronic anemia. And I’ll also consider it with obese men, especially if their BMI is over 30, waist circumstance above 102, I will check a testosterone level in them as well.
So, in my obese Type II diabetic patients with a low testosterone, I think you’ve got to remember that these patients are demotivated. They’re tired, they’re anhedonic, they don’t want to do anything. Is it realistic to expect them to go to a gym, to eat well when they can’t be bothered to do anything? I think this is not a realistic expectation. So, I think it’s really important that we treat these patients with testosterone and life style advice initially.
In my patients who’ve got Type II diabetes and are obese, or, in fact, the non-diabetics who are obese and who have got a low testosterone, I think it’s paramount that we educate them that they’re in this for the long term. And when we see them at review, it’s so important to check compliance and reinforce that this is a long-term treatment program. It will take a fair amount of time for their sexual symptoms to improve, but then we’re looking at months rather than years. But to look at the metabolic factors associated, we are looking at years for them to see improvement, and that’s sort of where we’re concerned, the clinician, rather than the patient. The patient wants the sexual improvement, but perhaps we’d prefer the metabolic improvement. So, it’s a negotiation between us and the patient, and it’s so important that we educate them and make sure that they continue taking the treatment in the long term.
Prof. Dr. med. Marija Pfeifer Medical Faculty University of Ljubljana, Slovenia