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TESTOSTERONE DEFICIENCY & TREATMENT


What are Male Hormones?
Causes of low Testosterone
Indications of treatment
Side Effects & Precautions

What are Male Hormones:  Males have following male hormones namely testosterone, androstenidione, dehydrotestosterone & dehdroepiandrostenidione in the body. These male hormones are either produced from testis or adrenal glands.The testosterone is produced in testis by leydig cells. The secretion of testosterone is under control of L.H. & F.S.H. & Gonadotropin releasing hormones, Thyroid hormone & growth hormone. Additionally any significant & prolong diseases of other body organs also decreases the formation of various male hormones. After production from testis it circulates in blood in two forms, most of it remains bound to genital hormone binding globulin, which works as store for testosterone. Very small percentage of total testosterone remains free in blood circulation this free testosterone is active hormone. It binds with various tissues of the body as hair of face leading to development of beard & moustache, with pennis tissue leading to its enlargement of pennis & erection, with body muscles leading to enlargement of body muscle i. e. muscular body typical of men. It also works on genital centers in brain (hypothalamus) leading to normal genitaldesire. There are many conditions in which the protein which binds the testosterone (i.e. genital hormone binding globulin) concentration increases leading to increase in total testosterone concentration but free testosterone concentration decreases. Thus overall free testosterone decreases leading to less effect of testosterone on body. Testosterone also has many effects on testis functions leading to improvement in spermatogenesis.  Thus there are many factors which may either decrease the testosterone production in the body or decrease its effectiveness. To complicate the matter further there are certain condition in which even if every aspects of testosterone is normal, there may be less male hormone receptor.

Causes of Low Testosterone: The various causes for low testosterone are:

Hypogonadotropichypogonadism: (hypothalamic or pituitarydeficiencies)
 Idiopathic GnRH deficiency, Kallman syndrome, Hypogonadism, Hypothyroidism, hyperprolactinemia, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome , Hypothalamic deficiency, pituitary hypoplasia, Trauma, post surgical, postorradiation, Tumor (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, tuberculosis, fugal infection, hemochromatosis),Autoimmune hypophysitis, drug-induced hyperprolactinemia, Untreated   endocrinopathies, Uncontrolled  Diabetes mellitus,  Chronic Glucorticoid excess, Hypopituitarism, Cushing disease, Addison diseases multiple pituitary hormone deficiencies, Idiopathic pan-hypopituitarism, Pituitary dysgenesis, Space-occupying lesions, cranial irradiation, CNS chemotherapy, inflammation, Infiltrative or destructive processes (autoimmune, hemosiderosis)

Hyperogonadotropic hypogonadism:

Testicular failure, development defect, drugs, trauma, congenital defect, congenital adrenal hyperplasia, Chromosomal defect, testosterone hormone biosynthetic defect, Mumps orchitis leading to testicular atrophy,Primary testicular defect-disorders of testicular differentiation or inborn errors of testosterone synthesis, Klinefelter syndrome, Other X polysomies (i.e. XXXXY, XXXY) Rainbow syndrome

Andropause (for detail information read andropause webpage of this website)

Delayed or Absent Puberty due to various cause (for detail information read Absent genital development webpage of this website)

Investigation & Diagnosis: For diagnosis of cause of low testosterone following tests are required:

Complete male hormone profile: This profile includes all the male hormone tests, which affects testicular development, growth & other genital organ development as well as genital functions.

Thyroid test
Semen analysis
SHBG
Ultrasound of testis
Biochemistry tests

Then we do test for functional capacity of testis  in this we inject single injection of gonadotropin as intramuscular injection then we measure  the rise in concentration of serum total testosterone. This test confirms whether testis has capacity to function normally or not. 

Chromosomal analysis is done to see the genetic structure of testis, because there are many chromosome disorders lead to hypogonadism. 

Gene tests for various genetic disorders

Capacity of generation of active testosterone end product i.e. DHT is tested. This DHT generation test is abnormal in some cases of hypogonadism. 

Tests to locate testis as ultrasonography or C.T. Scan abdomen is needed if testis is not palpable. 

Serum inhibin is tested which tells that whether hypogonadism is temporary or permanent. 

Serum Iron, T.I.B.C. & ferritin concentration tested for hypogonadism due to hemochromatosis.

Combined Pituitary hormone tests are performed when suspecting pituitary disorder. 

Molecular genetic studies done in some special cases. 

Serum estrogen increased whenever testicular function decreased. 

Serum DHT is low in some conditions when generation of dihydrotestosterone is decreased. 

Assessment of androgen receptor

Dynamic tests as HCG test

Response to antiestrogen & gonadotropin releasing hormone tests. 

Other tests which may be required depending on likelihood on any of the above causes. 

Tests may show low testosterone. L.H. & F.S.H. may be decreased or increased. Thyroid test may show low free T3 & free T4 & TSH may be increased or decreased. Similarly prolactin hormone may be low or high. But for interpretation of all above tests one need to be expert of hormone diseases with good experience. Based on above test result diagnosis of cause of low testosterone is made.  Once the cause is found treatment becomes very simple. 

 Treatment of Testosterone deficiency: The various treatments for testosterone deficiency include:

Indications for male hormone testosterone therapy are testosterone replacement in male hormone deficiency cases, in males with less beard & moustache, delayed puberty & absent puberty & for enlargement of small pennis or micro pennis. It is also very effective in patients with low genital desire & erection problem. People also use these for improvement of body muscle & athletic performance, for gain in height but for this indication it should be used under specialist observation.Other uses are treatment of anemia, male osteoporosis, replacement in women with loss of desire for genital & replacement therapy in ageing males i.e. ADAM i.e. Androgen deficiency of ageing male. For weight & muscle gain in wasted conditions

1) Male Hormone Replacement: Treatment with male hormone testosterone is one of the modes of treatment of male hormone testosterone deficiency. It is available as oral tablets, skiin patch, skiin gels or injection is given with very good results.

The various preparation of testosterone & route of administration are: 

a)     Oral preparation that is available in capsule form. It needs to be given one to three capsules daily.

These have no side effects. 

b) Transdermal Testosterone given as testosterone gel preparations.  It need to be applied any part of skiin once a day.

It is very effective & has no side effects. 

c).  Transdermal Testosterone scrotal patch are also available which are very effective even if used in small doses

. It is very effective & has no side effects.

d)   Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & better

genital organ secondary genital character development.  It is used as one tablet daily to be kept under the tongue for few minutes. It has no side effect and it is very very effective.

e)   Local application of D.H.T. gel available as Andractim gel is a new preparation for male hormone replacement. 

f)  Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given intramuscular

injections every 10 to 14 days.

g) Long acting testosterone as testosterone bucilate given once in 4 months.

h)   Testosterones implants are now available which once injected remain effective for up to six months.


2) Gonadotropin therapy is also very effective in low testosterone. This has no side effects with very good results. After start of treatment testosterone level start rising in three months time. With in one year time testosterone value becomes normal in blood circulation. Testis  function also normalizes in most patients. Later testis starts producing normal level of male hormone testosterone.  Once testosterone production normalizes in turn it leads to better production of semen also. The normalization of testosterone values leads to reversal of all symptoms of testosterone deficiency. Thus all the symptoms normalizes. Bone strength recovers. Testosterone treatment is harmless if given by expert in hormone in proper doses. Thus almost all patient are cure in one-year time. 


2) Gonadotropin Releasing hormone therapy is effective in many cases of testosterone deficiency even when gonadotropin therapy has failed in normalizing testicular function & testosterone level.

3) Growth hormone therapy in many cases where somatrop deficiency is found.

4) Growth Factor, Mineral & Micronutrient Therapy 


NOTE: Many times testosterone deficiency is temporary. In these cases after correct diagnosis we can permanently cure the testosterone deficiency in short time. In these patient with in one-year patient achieves normal testosterone & testicular function. offending drugs cure the problem. 

In some long-term treatment with androgen as testosterone is required.

Side Effects: It has no side effects if given in proper disease and in-patients when it is really indicated. This it is absolutely safe.

Anabolic steroid drugs are those drugs, which are derived from male hormone & used for improving body muscles & weight. If they are given under supervision of hormone specialist they are safe. But many boys take it for developing body muscle or by sports person in wrong dosing or without any medical supervision. This should not be used without doctor’s supervision. Thus it should be taken  under doctor’s supervision.

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