Practical management of testosterone deficiency: The primary care perspective

Description

Dr Coxon gives a primary care perspective of hypogonadism, pointing out the low priority of identifying, diagnosing and providing care for men with testosterone deficiency. Besides lack of knowledge among general practitioners about how to make the diagnosis of hypogonadism, another reason is that Men’s Health does not get many financial incentives, like Women’s Health does.

Dr Coxon shows data on the high prevalence of hypogonadism and highlights the importance of screening for low testosterone, especially in men with obesity, metabolic syndrome and type 2 diabetes. When making the diagnosis of hypogonadism, physicians need to be aware that laboratory reference ranges vary considerably. Therefore, instead of relying on laboratory reference ranges, diagnostic testosterone thresholds or “action levels” should be used. For example, a patient may have a total testosterone level of 8.7 nmol/L and the laboratory references range may be 6.68 - 25.7 nmol/L. If unaware of the diagnostic testosterone thresholds, physicians may deem this patient to have a “normal” testosterone level because it is “within range”. Therefore, knowledge of diagnostic testosterone thresholds is crucial.

A guideline for diagnostic testosterone thresholds is as follows:

  • Total testosterone level <8 nmol/L (231 ng/dL) or free testosterone <180 pmol/L:
    • Usually requires testosterone therapy
  • Total testosterone level >12 nmol/L (346 ng/dL) or free testosterone >225 pmol/L:
    • Does not require testosterone therapy
  • Total testosterone 8-12 nmol/L (231 – 346 ng/dL) or free testosterone 180-225 pmol/L:
    • A trial of testosterone therapy for a minimum of 6 months recommended

Dr Coxon emphasizes the importance of informing patients that different symptoms improve at different time points during testosterone therapy. While mental health improvements – such as mood, sexual desire and quality of life - occur relatively fast within 3-6 weeks, improvement in erections/ejaculations may require 6 months or longer. Improvement in body composition (reduced fat mass and increased muscle mass) may take at least 1 year or longer. Therefore, it is critical that the therapeutic trial is of sufficient duration – at minimum 6 months - for improvements to be achieved. Another critical factor for successful testosterone therapy is adherence to treatment.

Patients should also be informed that testosterone therapy will likely be needed for life, because when testosterone therapy is stopped there is reversal of benefits.

Dr Coxon presents results from the REVITALISE audit, which assessed the prevalence of type 2 diabetes and erectile dysfunction or who were potentially at risk of erectile dysfunction and/or testosterone deficiency in 43,633 men across 13 practices in the UK.1 It also investigated how often erectile dysfunction and testosterone deficiency was discussed. It was found that 40 % of men with type 2 diabetes have hypogonadism (testosterone levels < 12nmol/L), and 34% of diabetic men were not asked about sexual function. In most men with diagnosed erectile dysfunction, testosterone had not been measured in the last 2 years. Critically, among men with type 2 diabetes who had testosterone levels < 12 nmol/L and < 8 nmol/L, only 27% and 32% were receiving testosterone therapy. Among non-diabetic men who had testosterone levels < 12 nmol/L and < 8 nmol/L, only 7% and 9% were receiving testosterone therapy.

Findings from REVITALISE highlight the need to improve the clinical management of men with and without type 2 diabetes who are potentially at risk of erectile dysfunction or low testosterone or both. Despite the well-documented relationship between type 2 diabetes, erectile dysfunction and low testosterone, a substantial number of men with type 2 diabetes were not assessed for either condition, meaning a valuable opportunity to diagnose and to potentially improve the overall health of this group was missed. Also, only a minority of men with low testosterone levels were receiving testosterone therapy, which suggests that more continuing educational efforts are needed to make physicians aware of hypogonadism, how to make the diagnosis and how to effectively and safely treat this large group of suffering men.


 

Speakers

Dr Jonny Coxon BM BCh MA MD MRCS MRCGP FECSM

Dr Jonny Coxon BM BCh MA MD MRCS MRCGP FECSM
GP Partner
Specialty Doctor: Urology & Gender Identity
Brighton, UK

References

  • David J, Edwards D, Wright P. REVITALISE audit: Erectile dysfunction and testosterone review in primary care. Diabetes & Primary Care. 2017;19:67–72. Return to content