Case of the Month: Testosterone Therapy in Men with Hypogonadism: An Endocrine Society Clinical Practice Guideline Educational Activity

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Clinical Vignette

A 58-year-old moderately obese man is concerned that his erections are weak and insufficient to have satisfactory intercourse despite normal sexual desire. He also feels that his energy level is very low and has been worsening over the last 3 years. He has type 2 diabetes mellitus, coronary artery disease with stable angina, hypertension, and hypercholesterolemia. Current medications include metformin, hydrochlorothiazide, lisinopril, metoprolol, isosorbide mononitrate, and atorvastatin.

On physical examination, he is a plethoric, obese man with a mildly depressed mood. Blood pressure is 138/83 mm Hg. His height is 73.5 in (186.7 cm), and weight is 265 lb (120.2 kg) (BMI = 34.5 kg/m2). He has normal axillary and pubic hair. You palpate 2.5-cm, nontender breast tissue bilaterally. There are no striae on his abdomen, but you observe that he has prominent abdominal adiposity. He has normal-sized testes, 20 mL bilaterally. On examination of his extremities, he has 1+ ankle edema and no dorsalis pedis pulses bilaterally. Neurologic examination shows reduced vibratory sensation, but intact sensation to 10-g monofilament.

Laboratory test results (8 AM):

  • Hematocrit = 46% (41%-50%) (SI: 0.46 [0.41-0.51])
  • Fasting glucose = 178 mg/dL (70-99 mg/dL) (SI: 9.9 mmol/L [3.9-5.5 mmol/L])
  • Creatinine = 1.2 mg/dL (0.7-1.3 mg/dL) (SI: 106.1 µmol/L [61.9-114.9 µmol/L])
  • Estimated glomerular filtration rate = 75 mL/min per 1.73 m2 (>60 mL/min per 1.73 m2)
  • Hemoglobin A1c = 7.7% (4.0%-5.6%) (61 mmol/mol [20-38 mmol/mol])
  • Total testosterone = 250 ng/dL (300-900 ng/dL) (SI: 8.7 nmol/L [10.4-31.2 nmol/L])

 

Which of the following laboratory tests should you order next?

  1. Direct free testosterone measurement by immunoassay
  2. Serum LH measurement
  3. Calculated free testosterone level by equilibrium dialysis
  4. Serum prolactin measurement
  5. No further testing is necessary


SEE CORRECT ANSWER AND EXPLANATION

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