Male hypogonadism (Low Testosterone)

What is male hypogonadism?
Testosterone is the primary male hormone that is produced by the testes and is responsible for the male secondary sex characteristics, such as facial and body hair, pubic hair, muscle mass, and deepening of the voice. Testosterone is also responsible for maintaining normal sexual function (sex drive and erections)and fertility (sperm production). Hypogonadism results when testosterone levels fall below the normal range either due to lack of testicular stimulation by pituitary hormones or due to intrinsic testicular problems. Hypogonadism becomes more common as you get older.

What are the symptoms of hypogonadism?
• Low sex drive/loss of interest in sex
• Difficulty getting and keeping an erection
• Infertility
• Hot flushes, sweating
• Loss of hair
• Decreased muscle bulk and /or strength
• Fatigue
• Depressed mood

What causes male hypogonadism?
Male hypogonadism can be either primary (problem within the testes) or secondary (resulting from lack of stimulation of the testes due to defective pituitary or hypothalamic function).
Common causes for primary hypogonadism include:
• Genetic conditions such as Klinefelter syndrome
• Testicular infection (mumps] or injury (trauma, castration, radiation, or chemotherapy)
Common causes for secondary hypogonadism include:
• Pituitary or hypothalamic tumors or diseases
• High prolactin levels
• Rare genetic conditions such as IHH/KS (see above)
• Medications such as opiate pain medications
In some cases, the cause could be multi-factorial and can involve both primary and secondary mechanisms.

How is hypogonadism diagnosed?
• Detailed medical history including family history
• General physical exam including an examination of testicles
• Blood tests to check for evidence of low testosterone (levels below reference range for hospital laboratory) and other hormonal abnormalities (e.g. high prolactin, LH, FSH, thyroid hormone levels)
• Additional tests to establish the cause of the hypogonadism (e.g. genetic tests, MRI Brain etc)

How is male hypogonadism treated?
Once hypogonadism is confirmed, your doctor may prescribe testosterone therapy to alleviate your symptoms. Your doctor will discuss the different testosterone options available (gels, patches, and injections) and identify the best method of therapy suited to your needs.. In patients with secondary hypogonadism, infertility can be treated with gonadotropin injections.

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What is Gynecomastia?
Gynecomastia is the growth of breast tissue in boys or in men resulting in enlarged breasts. It can sometimes be painful/tender and results from an imbalance between testosterone and estrogen. In the vast majority of cases, the breast growth is benign. Gynecomastia is often a normal finding in newborns and in boys going through puberty and in both cases, it usually resolves without any treatment. Persistent gynecomastia in boys and new gynecomastia in adults usually requires medical evaluation.

What are the common causes of gynecomastia?
• Exposure to mother’s estrogen causes transient gynecomastia in newborns
• In pubertal boys, hormonal imbalance between testosterone and estrogen produced by the testes causes transient gynecomastia
• In adults over 50, persistent gynecomastia may result from hormonal changes and body fat changes that are normally associated with ageing
• Conditions resulting in low testosterone levels (see hypogonadism section)
• Medications that block or interfere with testosterone such as treatments for prostate cancer, chemotherapy treatments, ketoconazole, illicit drugs, certain anti-depressants, excessive alcohol intake and blood pressure medication
• Relative excess of estrogen due to conditions such as chronic liver disease, overactive thyroid gland, chronic renal failure, starvation followed by re-feeding etc.
• Rarely, excess estrogen may be produced from tumors in the testes or adrenal glands
• In many cases, no cause may be actually found (idiopathic)

How will Gynecomastia be evaluated?
• Detailed medical history including family history
• General physical exam including an examination of your breasts and testicles
• Blood tests to check for evidence of hormonal abnormalities (e.g. low testosterone, high prolactin, high estrogen, thyroid hormone levels) and to check your liver and kidneys
• Imaging tests such as ultrasound of the breast, testes
• Mammography and/or needle aspiration of breast to exclude tumors

How will Gynecomastia be treated?
• In newborns and pubertal boys no treatment may be necessary. Similarly, in adult males in whom the condition is long-standing and asymptomatic, no treatment may be needed.
• If treatment is required, the options depend on how long the gynecomastia has been present. An estrogen blocker such as tamoxifen can be used if symptoms have been present for less than 6 months, while surgery is the treatment of choice if the gynecomastia is long standing.
• Any other underlying condition causing gynecomastia may require treatment (e.g. hypogonadism treatment; treatment of thyroid, liver or kidney problems, removal of testicular mass etc)

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Erectile Dysfunction

What is Erectile Dysfunction?
Erectile dysfunction (ED) is one of the most common health problems to affect men as they get older. It is defined as the inability to get and/or maintain an erection adequate for sexual relations. Normal erectile function requires blood to flow to the penis and stay there until orgasm. ED can happen at any age, but is more common in men older than 65. Manymen may experience ED on occasion, so it is only if the problem persists that it requires medical attention.

What are the common causes of ED?
• Medical conditions that prevent blood flow to the penis through narrowing or damage to blood vessels through a process called atherosclerosis e.g. diabetes, obesity, smoking, high blood pressure and high cholesterol.
• Hormonal imbalances such as low testosterone levels or high prolactin levels
• Certain medications such as antidepressants and drugs used to treat high blood pressure
• Damage to the nerves supplying the penis due to diabetes, stroke, pelvic or prostatic surgery, spinal cord injuries
• Psychiatric conditions such as depression, anxiety disorders as well as relationship problems with the sexual partner

How will ED be evaluated?
• Detailed medical history
o General physical exam including an examination of your penis and testicleBlood tests to check for evidence of hormonal abnormalities (e.g. low testosterone, high prolactin), diabetes (glucose), lipid abnormalities (cholesterol) etc.
• Sometimes, additional psychiatric/psychological evaluation may also be needed

How is ED treated?
Your doctor will discuss treatment options with you, which may include:
• Oral medications that improve ED by increasing blood flow to the penis
• Medications that can be injected into the penis or vacuum
• Testosterone replacement therapy: Testosterone replacement therapy may be prescribed if you have low testosterone. Therapy options include testosterone replacement therapies in the forms of gels, patches, and injections.
• Psychological causes of ED may require counseling, either individually or as a couple with therapist who specializes in sexual dysfunction.
• Depression or anxiety disorders may also need treatment.

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