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31 year old male presenting
in early 2001 with a 2 year history of fatigue, low
mood and irritability, poor concentration at work and
some decline in short-term memory. He has had problems
with weight control since puberty and since that time
has had problems with sweating. He has experienced night
sweats on occasions. His libido had been poor for over
2 years and his early morning erections were infrequent
(once in seven days). On the occasions when he had early
morning erections they were of poor rigidity. He has
not suffered from erectile dysfunction associated with
sexual activity or masturbation and was having intercourse
once a month with his current partner. He performed
masturbation approximately once every day or two days.
He felt that he had aged, feeling much older than his
years and was suffering from moderate aches and pains
in his lower limbs and back.
He had a right undescended
testicle from birth which was removed when he was 21,
a prosthesis being inserted post-surgically. He believes
he had an episode of orchitis aged 21. He has suffered
from chronic backache and has had 2 prolapsed intervertebral
discs. He has a past history of depression diagnosed
by his general practitioner for which he takes fluoxetine
20 mg daily.
He had undergone fertility
investigation 18 months previously at which point it
was noted his sperm count was 5m/ml with 30% motility.
It was also noticed that his plasma testosterone level
was 5.5 nmol/L, the gonadotrophins and prolactin being
normal. Twelve months ago a urologist treated him with
testosterone patches (5m per day) with resulting improvements
in early morning erections, mood and libido. He noticed
some lessening of beneficial effect 6 weeks after application
of the patches and a repeat plasma testosterone level
during patch treatment revealed a level of 8nmol/L.
He was advised to increase the dose to 2 patches per
day but again noticed a fall off in effect after 8 weeks
of patch use. He had not used testosterone for 1 week
prior to this present consultation.
He has never smoked, does
not take recreational drugs but does drink approximately
30 units of alcohol per week.
Examination revealed a weight
of 108kg and a height of 187 cm giving a body mass index
of 30 (overweight). The blood pressure was 148 / 85
mmHg seated. The pulse was 88 beats per minute and regular.
The remainder of the cardiovascular examination was
normal. He had a small degree of gynaecomastia, a small
left testicle and a prosthesis on the right. Secondary
sexual characteristics were present and hair distribution
was normal if slightly sparse.
Investigations revealed a
morning plasma testosterone level of 8.3 nmol/L, SHBG
14 nmol/L, follicle stimulating hormone (FSH) level
of 14.1 IU/L, luteinising hormone (LH) level of 8.1
IU/L, oestradiol level of 242 pmol/L. Thyroid function
and the prolactin levels were normal. The prostate specific
antigen (PSA) level was 0.45 ng/ml. The blood chemistry
investigations were normal except for an elevated fasting
total cholesterol (6.56 mmol/L), LDL-cholesterol (3.83
mmol/L), triglyceride level ((3.3mmol/L). Haematology
was normal. The haemaglobin was 16.4 g/dl, red cell
count 5.48 x 10-12 /L, haematocrit 0.47.
Urinalysis was normal except for a trace of protein
in the urine.
He was informed as to the
consequences of testosterone treatment particularly
the effects on spermatogenesis. Informed consent to
treatment was obtained and he was treated with testosterone
implanted pellets 1600 mg to the right buttock under
local anaesthesia.
He was reviewed one month
later. Fatigue, mood concentration and memory had improved
markedly. Libido and early morning erections had improved.
He was experiencing early morning erections most mornings
and rigidity was improved. Frequency of intercourse
had increased to 3 times per month. Masturbation frequency
remained the same. Feelings of ageing had decreased
as had his general aches and pains.
Examination showed a reduction
in weight of 2 kg. The blood pressure was 145 / 85 mmHg
seated and the pulse was 90 beats per minute and regular.
Investigations revealed a
plasma testosterone level of 32 nmol/L, SHBG 10 nmol/L,
FSH <0.7 IU/L, LH <0.2 IU/L, oestradiol level
of 410 pmol/L, PSA level of 0.79 ng/ml. The fasting
total cholesterol level was 6.08 mmol/L, LDL-cholesterol
3.28 mmol/L, and triglyceride level 4.24 mmol/L. The
haemaglobin had increased to 17.5 g/dl, the red cell
count to 6.05 x 10-12 /L and the haematocrit
to 0.526. The urinalysis was normal.
This man with acquired primary
hypogonadism has been successfully treated to date by
implanted testosterone pellets. There have been increases
in haemaglobin, red cell count and haematocrit as expected.
The PSA level has increased marginally and the total
and LDL-cholesterol levels have decreased fractionally.
Subjectively his symptoms have improved. He will continue
to be treated and monitored on a bi-annual basis.
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