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Mr B presented in May 1999
when he was 52 years of age. He had noticed a dramatic
increase in weight over the previous 2 years from 127
kg to 159 kg. He had always been obese, as at the age
of 30 he weighed 117 kg. He was however at that time
a national squash player. In addition to his sudden
weight gain, he had also noted profound tiredness and
lethargy, a decline in his short-term memory, a diminution
in early morning erection frequency with a recent cessation,
a reduction in libido and sexually related erections
over the previous 6 to 12 months. He had not had sexual
intercourse in the 6 months prior to the consultation.
He had also noticed excessive sweating at night and
a decline in mood and general wellbeing. He had led
a sedentary lifestyle except for walking his dog 200
to 400 meters each day.
He had had mumps at the age
of 14 but could not recall any testicular involvement.
He had suffered from low back pain for the previous
15 years and had suffered a right knee injury several
years ago for which he had received cortisone injections
intrarticularly. He had been prescribed a salbutamol
inhaler by his general practitioner for his wheezy chest.
He had been a non-smoker
and drank between 2 and 4 units of alcohol per week.
At consultation, the examination
revealed a weight of 167 kg and height of 1.77 m with
a calculated BMI of 53. His blood pressure was 142/78
mmHg (seated) and the pulse was 86 beats per minute
and regular. Testes were small, but not atropic. Investigations
revealed a total plasma testosterone of 5.6 nmol/L and
a sex hormone binding globulin (SHBG) level of 20 nmol/L.
The total thyroxin and thyroid stimulating hormone levels
were within normal limits (74 nmol/L and 1.99 mIU/L
respectively). The prolactin level was within normal
limits (146 mIU/L). The haemoglobin, haematocrit and
red cell count levels were within normal limits (13.8
g/dL, 41.9 and 4.72 x 10-12 /L respectively),
however all were at the lower end of their respective
ranges. The fasting total cholesterol was 7.33 mmol/L
and triglyceride level 5.91mmol/L. The remainder of
the biochemistry and haematology profiles were normal.
A random glucose was normal at 6.4 mmol/L. The prostate
specific antigen level was 6.45 ng/ml with a free to
total ratio of 17%. As it was decided to treat his hypogonadism
a trans-rectal ultrasound of the prostate was undertaken
with biopsy. The results showed a slightly enlarged
gland with a volume of 44 ml and some mild benign hypertrophic
hyperplasia. The biopsy confirmed the latter and there
was no evidence of malignancy or high grade PIN from
eight sample sites.
Informed consent was obtained
and Mr B underwent testosterone replacement therapy
with implanted testosterone pellets to the buttock region
at a dose of 2200 mg. He was followed up 8 weeks post
implant when his testosterone was 21.8 nmol/L and SHBG
20 nmol/L. His symptoms improved dramatically thereafter
with an absence of fatigue and tiredness, an improvement
in short-term memory and concentration, no depressive
symptoms or irritability, a return of libido, early
morning erections and erections associated with sexual
activity. He resumed sexual activity and was having
intercourse approximately 3 times per month. He continues
to be treated on a six monthly basis with testosterone
pellet implants at doses of between 1800 and 2200 mg.
Such doses maintain his plasma testosterone level within
the normal range.
His most recent results from
March 2001 revealed a six-month post-implant plasma
testosterone level of 8.4 nmol/L and SHBG of 20 nmol/L.
Thyroid stimulating hormone was 2.1 mIU/L. The haemoglobin,
haematocrit and red cell counts were 15.3 g/dL, 45.8
and 5.16 x 10-12 /L respectively. The fasting
total cholesterol was 6.16 mmol/L and the triglyceride
level was 3.87 mmol/L. The total PSA was 5.24 ng/ml
with a free to total ratio of 9%. Other blood test results
were within normal limits, however the fasting glucose
level was on this occasion 7.5 mmol/L. On previous occasions
it had been within the normal range. His weight remains
problematic at 154 kg (down from 167kg in 1999). The
blood pressure remains within the normal range at 152/86
mmHg and the pulse at 63 beats per minute. He was treated
on this occasion with testosterone pellets implanted
into the buttock at a dose of 2000 mg and will be reviewed
in 6 months.
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