Hypogonadism: Causes, Cures, And Concerns-—A Pharmacist's Perspective
Robert Moye, PharmD, BCPS, EMT*
Although oral contraceptives may have started the sexual revolution in the 1960s, sildenafil is considered by some to be a catalyst for a second sexual revolution in the late 1990s. The now famous phosphodiesterase inhibitor was not only the first effective oral agent for erectile dysfunction (ED), it also became a reason for many men to raise the topic of sexual dysfunction with their physicians.1 One can scarcely watch the evening news or a televised sporting event without viewing direct-to-consumer advertisements for this class of agents. This change in social awareness, attitudes, and behavior toward sexuality has provided clinicians the opportunity to evaluate many patients they previously would likely not have seen. In assessing patients with ED, it's not uncommon for physicians to discover widely recognized underlying disease states, such as diabetes and peripheral vascular disease. However, in some cases, the cause of sexual dysfunction may be hypogonadism, a largely underdetected, and yet one of the most common, endocrinologic disorders in existence.2
This clinical syndrome affects 2 to 4 million men in the United States and becomes progressively prevalent with age.3-5 The increasing life expectancy, in addition to certain associated conditions, are expected to further raise the incidence of male hypogonadism.6 Although the basic need to stay young and vital in the winter of life has drawn much attention to the effects of hypo-gonadism, fairly recent statistics indicate that only 5% of affected men receive treatment.6 The reasons for undertreatment are numerous but, essentially, it appears that a lack of awareness about the disease among patients, physicians, and other healthcare providers may be largely responsible for underdetection or underdiagnosis. And, basically, we cannot treat what we cannot identify. That's where pharmacists have the clear potential to make a real difference. Looking at some of the elaborate pharmacy disease state management and counseling programs set up for major disease states, such as diabetes, asthma, and hypertension, it can be said with certain confidence that pharmacists have come a long way since the days of "count, lick, and pour." From performing routine blood pressure and glucose measurements to administering vaccines, and providing timely drug information, pharmacists have evolved from simply dispensers of medication to therapeutic experts who are involved in multiple aspects of patient care.
Now with increasing focus on identifying and treating many age-related conditions that were once dismissed as just "a part of getting old," pharmacists are finding themselves in a position where they can help detect many previously underdiagnosed illnesses—like hypogonadism—and make appropriate referrals to other healthcare providers. This condition not only affects a patient's quality of life, but it may also be associated with very real adverse health outcomes, such as osteoporosis and anemia. With today's patients being more health conscious, and thus more forthcoming in talking about personal symptoms, a pharmacist who is vigilant and a good listener may have a tremendous impact on identifying at-risk males. And, it doesn't have to end there. There are multiple drug-related issues inherent to diagnosis and management of hypogonadism. Having access to medication profiles, pharmacists can easily review a patient's profile and assess it for drugs that can negatively affect testosterone levels. Pharmacists can also instruct patients on the correct use of various testosterone dosage forms, some of which can be quite complex to administer.
In an effort to involve more healthcare professionals in identifying and managing patients with hypogonadism, this issue of University of Tennessee Advanced Studies in Pharmacy is dedicated to educating pharmacists on the major clinical aspects of this multifactorial condition. Abe Morgentaler, MD, offers insights into the prevalence, diagnosis, and physiologic aspects of hypogonadism. A practicing urologist at Men's Health Boston, Dr Morgentaler discusses the challenges of detecting hypogonadism in older males, pointing out the subtle nature of disease progression in this age group. It's not uncommon for testosterone-dependent physical features, such as muscle mass, beard, and genital development, to be maintained long after the onset of testicular failure. He emphasizes the need for clinicians to be familiar with not only the obvious physical manifestations of hypogonadism, such as sexual dysfunction, but also with subtle, nonspecific symptoms (ie, fatigue, depression, and sleep disturbances).
Narinder Duggal, BSc (Pharm), CGP, BCPP, MD, FRCPC, FASCP, explains the intricate workings of the hypothalamic-pituitary complex and how to discern between primary and secondary hypogonadism. Dr Duggal, who is both an internist and clinical pharmacologist at the Liberty Bay Internal Medicine Center in Poulsbo, Washington, also focuses on common conditions that are important to recognize as either potential causes or consequences of hypogonadism, including type 2 diabetes mellitus, chronic obstructive pulmonary disease, rheumatoid arthritis, cancer, cardiovascular disease, prostate disease, AIDS, morbid obesity, and depressive disorders. In his section on a phenomenon known as "relative hypogonadism," he points out the importance of looking beyond the numbers and recognizing that normal testosterone levels should be individualized for each patient. Dr Duggal also participated in a clinician interview, in which he responds to questions regarding the challenges of detection and treatment of hypogonadism, in addition to some therapeutic concerns that physicians, as well as patients, may raise.
In reviewing the management of hypogonadism, Eric A. Wright, PharmD, BCPS, addresses the different clinical features and administration nuances of the various dosage forms of testosterone. Dr Wright, associate professor at Wilkes University in Pennsylvania, provides a discussion on the benefits of testosterone, such as improvements in sexual function, mood and energy, and bone mineral density. He also conveys the potential risks associated with therapy, including fluid retention, hypertension, and sleep apnea. A practical monitoring strategy that involves close watch of hypo-gonadal symptoms and product-specific side effects is essential for evaluating the effectiveness and safety of therapy.
Having proven their ability to positively affect patient outcomes in several major disease states, pharmacists can undoubtedly increase their clinical value, in addition to improve patients' quality of life, by getting more involved in the management of previously uncommon age-related conditions, such as hypogonadism. The times are always changing. In medicine, it's important to change with the times.
1. Morgentaler A. A 66-year-old man with sexual dysfunction. JAMA. 2004;291:2994-3003.
2. Darby E, Anawalt BD. Male hypogonadism : an update on diagnosis and treatment. Treat Endocrinol. 2005;4:293-309.
3. Morley JE, Kaiser FE, Perry HM, et al. Longitudinal changes in testosterone, LH and FSH in healthy older men. Metabolism. 1997;46:410-413.
4. Harman SM, Metter EJ, Tobin JD, et al. Longitudinal effects of aging on serum total and free testosterone levels in healthy men: Baltimore Longitudinal Study of Aging. J Clin Endocrinol Metabol. 2001;86:724-731.
5. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2006;91:1995-2010.
6. Seftel AD. Male hypogonadism. Part I: epidemiology of hypogonadism. Int J Impot Res. 2006;18:115-120.
* Education/Training Coordinator and Pharmacist Specialist, Department of Pharmacy,
Assistant Professor, UT College of Pharmacy, University of Tennessee Medical Center, Knoxville, Tennessee
Address all correspondance to: Robert Moye, PharmD, BCPS, EMT, Education/Training Coordinator and Pharmacist Specialist, Department of Pharmacy, Assistant Professor, UT College of Pharmacy, University of Tennessee Medical Center, Knoxville, Tennessee 37996
The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.