| Mr
H initially consulted in 1998 at the age of 44. He complained
of a 12-month history of a reduction in libido and a decline
in nocturnal and early morning erections. He had noticed
that erections associated with sexual activity were not
of good quality and he had difficulty achieving an erection
for penetration. Once achieved however erectile maintenance
was satisfactory. He had also noticed an increase in tiredness
and fatigue and a decline in ambition associated with
work. He continues to work in a stressful corporate environment.
He had become increasingly irritable over the 12-month
period and had gained 7 kg in weight in 3 years and had
lost physical fitness and stamina. He had also experienced
night sweats on an occasional basis.
He had surgery for varicose
veins on both legs in the past and believed his blood
pressure had been slightly elevated. He had had mumps
as a child.
He had never smoked and drank
approximately 30 units of alcohol a week, but had previously
been a heavy drinker consuming up to double this quantity
per week. He was not on any medication at the time of
the consultation.
Examination revealed him
to be overweight. His weight was 104 kg and height 1.83m.
Blood pressure was 140/96 mmHg (seated) and the pulse
was 76 beats per minute and regular.
Investigations revealed a
morning plasma testosterone of 12 nmol/L and a sex hormone
binding globulin (SHBG) level of 15 nmol/L. The prostate
specific antigen (PSA) was 1.0 ug/L. The prolactin level
was within normal limits. The haemoglobin, haematocrit
and red cell count were all within normal limits (15
g/dL, 44.9 and 5.0 x 10-12/L respectively).
The total cholesterol was 5.04 mmol/L and triglyceride
level 2.11 mmol/L.
Informed consent to treatment
with testosterone replacement therapy was obtained.
He was treated with testosterone pellets implanted into
the gluteal region at a dose initially of 1800 mg. At
follow up 8 weeks post-implantation, the plasma testosterone
level was 28 nmol/L and the SHBG 19 nmol/L. He had noticed
a marked improvement in fatigue and tiredness as well
as libido. He no longer experienced night sweats and
said he had a better sense of wellbeing and felt more
assured. Since then he has received testosterone by
implantation on a bi-annual basis at doses of between
1600 mg and 2000 mg. His erectile functioning has improved
and he has had a full return of nocturnal and early
morning erections. He has no erectile problems during
sexual activity now and is having intercourse approximately
4 times per month. He is occasionally fatigued and experiences
occasional night sweats during the weeks prior to his
next treatment when he also notices his early morning
erections wane.
The most recent blood tests
results prior to testosterone replacement for April
2001 showed the following: plasma testosterone 20.3
nmol/L, SHBG 15 nmol/L, follicle stimulating hormone
,0.7 IU/L, luteinizing hormone <0.2 IU/L, total PSA
1.29 ng/ml, total cholesterol 4.41 mmol/L, triglycerides
1.88 mmol/ L, haemoglobin 17.2 g/dL, haematocrit 0.5,
red cell count 5.46 x10-12/L. Other haematological,
biochemical results were within the normal ranges. The
urinalysis was normal. The plasma oestradiol level which
had not been measured previously was 53 pmol/L.
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