Etiology of Hypogonadism
Low Serum testosterone levels (levels than 300ng/dl) characterize. Also, some specific signs and symptoms characterize hypogonadism. Some of the symptoms of postpubertal hypogonadism include;
sexual dysfunction which manifests by libido reduction, diminished penile sensation, erectile dysfunction, a decrease of ejaculate with orgasm, and diminished penile sensation.
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Reduced energy, stamina and vitality.
A depressed mood.
Cognitive difficulties which manifest through difficulty in concentrating.
Increased irritability.
Hot flushes especially during the acute onset.
Some of the signs of hypogonadism include oligospermia or azoospermia, sarcopenia, anemia, bone density reduction, abdominal adiposity and regression or the complete absence of secondary sexual characteristics. Hypogonadism may manifest either as primary hypogonadism (serum testosterone level is low despite high follicle stimulating hormone and luteinizing hormone levels) or secondary hypogonadism (levels of luteinizing hormone, follicle stimulating hormone or testosterone are low). Hypogonadism is associated with some conditions which include diabetes mellitus, cancer, liver cirrhosis, Cushing syndrome, sickle cell anemia, morbid obesity, hyperthyroidism/hypothyroidism among others (Seftel, 2006).
Pathophysiology
Testosterone affects various bodily functions including sexual function, body composition and cognitive functions. Low testosterone levels affect sexual functions more especially libido levels while leading to an increase in fat-free and lean tissue mass. Language functions and cognitive functions are affected by low testosterone levels. At an advanced age, there is usually in bone mass density, is associated with the decreasing levels of testosterone (Seftel, 2006).
Epidemiology
Hypogonadism is known to occur in men aged 45 years and above mostly. Currently, more than four million men are affected, and despite the high prevalence, only 5% of the affected individuals acquire treatment. It is expected the current trends of increasing aging population will result in a rise in the incidence of hypogonadism. This is because testosterone levels in serum decrease with advancing age. Also, the prevalence of hypogonadism is high in men who are diagnosed with type II diabetes (Seftel, 2006).
Diagnostic Criteria
In most instances, aging male patients present with low testosterone (Jones, 2012). The patient in this case study is 45 years old, and therefore his age could be playing a role in the diagnosis. Moreover, early morning serum testosterone tests are used to confirm the diagnosis. For older men, the decrease in testosterone levels occurs at 25-20% with 24 hours. In addition to this, personal background used to confirm the diagnosis is diminished intellectual capacity, low libido, osteoporosis, lethargy, depression, as well as loss of muscle strength and mass. Though FSH and LH are used to confirm the diagnosis further, this is not a requirement for this particular patient.
Goals of Drug Therapy
The goal of drug therapy in hypogonadism which is testosterone replacement therapy (TRT) is an increase in testosterone levels to a mid-normal level, in addition to alleviating the hypogonadism symptom. Moreover, drug therapy should seek to improve mood and cognition levels.
4. Prescription
PRIMARY CARE CLINIC
KEISER UNIVERSITY SCHOOL OF NURSING
Date: 1/8/19
Patient Name: Sir Jonathan Birthdate:
2/24/74
Name of Medication: Testosterone cypionate injection 100mg injection (Depo-testosterone)
SIG: Administer 100mg every two weeks
# dispensed: 1 10ml vial
Refill Every week
Signature:
Mechanism of Action of Depo-Testosterone
Depo-testosterone binds and activates the androgen receptor; this can happen directly, or cytoplasmic enzyme 5α-reductase can convert the drug to 5α-dihydrotestosterone (DHT) which binds to the receptor more strongly. The drug-receptor complex formed moves into the cell nucleus after undergoing structural changes and thereby binds to chromosomal DNA's specific nucleotide sequences. Certain genes’ transcription activity is influenced by hormone response elements (the binding areas in the nucleotide sequence) hence producing androgenic activity (DrugBank, n.d.).
“ Watch outs” for Testosterone: Adverse Effects, Drug Interactions and Contraindications
Some of the adverse effects associated with testosterone are myocardial infarction and stroke, suppression of clotting factors, jaundice, nausea, gynecomastia, acne, seborrhea, male pattern blindness, hirsutism, oligospermia, increased occurrences of penile erections, hypersensitivity, venous thromboembolism and polycythemia. Testosterone also leads to decreased libido, depression, anxiety and headaches. Androgens are known to increase sensitivity to oral anticoagulants. Moreover, if concurrently administered with oxyphenbutazone, there may be elevated serum levels of the drug. Testosterone decreases blood glucose in diabetic patients and hence glucose requirements. Some of the contraindications for testosterone include male patient breast cancer, polycythemia vera, high cholesterol, diabetes, stroke, enlarged prostate, high blood pressure, lung embolism, chronic lung disease, and kidney disease.
Patient Education
Patient education that I will give to the patient will involve; the reasons for prescribing THT which is used to treat hypogonadism. Besides, I will advise the patient to watch out for potential side effects including thromboembolism signs and symptoms as well as the symptoms for other side effects. I will also ask the patient to contact a physician in case of skin color changes, fatigue, irregular breathing and prolonged erection. Finally, I will educate the patient on how to perform self-administration, and then advise the patient to check out for color changes or particulates before injection of the drug. To dissolve the crystals, I will advise the patient to warm in hands (Seftel, 2016).
Monitoring Patient for Medication effectiveness
To monitor the effectiveness of testosterone; various parameters will be monitored. These include prostate-specific antigen (PSA), and prostate digital rectal examination (Seal, 2017). These procedures will be conducted every three months, and testosterone levels will be measured every two months after the initiation of the therapy. Baseline hematocrit value will be checked after every three months. Finally, lumbar spine or femoral neck will be measured for bone mineral density annually (Bebb, 2011). Also, it is essential to observe symptom response, to the drug.
Clinical Guidelines
A clinical practice guideline that supports my treatment decision for this case study is the updated clinical practice guideline on testosterone therapy that was developed by the Endocrine Society in 2018. According to data from large randomized clinical trials, the society cited that there have been improvements in testosterone measurements in men undergoing TRT (Schad, 2018).
References
Bebb, R. A. (2011). Testosterone deficiency: Practical guidelines for diagnosis and treatment. BC Medical Journal , 53 (9), 474-479. Retrieved from https://www.bcmj.org/articles/testosterone-deficiency-practical-guidelines-diagnosis-and-treatment
DrugBank. (n.d.). Testosterone cypionate - DrugBank. Retrieved from https://www.drugbank.ca/drugs/DB13943
Jones, H. (2012). Diagnosis of hypogonadism: symptoms, signs, tests, and guidelines. OEL Testosterone Deficiency in Men , 21-34. doi:10.1093/med/9780199651672.003.0003
Schad, V. (2018, March 21). Updated Clinical Practice Guidelines on Testosterone Therapy in Men With Hypogonadism. Retrieved from https://www.endocrinologyadvisor.com/androgen-and-reproductive-disorders/updated-guidelines-on-testosterone-therapy-in-men-with-hypogonadism/article/752762/
Seal, L. J. (2017). Male hypogonadism and testosterone replacement therapy. Medicine , 45 (9), 532-537. doi:10.1016/j.mpmed.2017.06.009
Seftel, A. (2006). Male hypogonadism. Part II: etiology, pathophysiology and diagnosis. International Journal of Impotence Research , 18 (3), 223-228. doi:10.1038/sj.ijir.3901365
Seftel, A. D. (2016). Re: Screening and Monitoring in Men Prescribed Testosterone Therapy in the U.S., 2001-2010. The Journal of Urology , 195 (2), 440-443. doi:10.1016/j.juro.2015.10.105
