Men

Question 1

Men as Patients

Answer 1

• There is gender-related health disparity among men across the lifespan
• Men are less likely to receive annual examinations and health screenings
• The leading causes of death in men are heart disease, cancer, & accidents
• The concept of masculinity begins with socialization at a young age
• –Masculinity directly affects health care and health-care choices

Question 2

Hypogonadism

Answer 2

Affects an estimated 13 million men in the U.S.

Refers to the failure of the testes to produce androgen, sperm, or both

Primary hypogonadism (testicular failure) characterized by low testosterone and elevated gonadotropins

Secondary hypogonadism (hypothalamic-pituitary failure) characterized by low testosterone and low or normal gonadotropins

Question 3

Congenital Hypogonadism

Answer 3

Insufficient amounts of testosterone produced by the gonads

• During puberty, delayed, arrested, or absent testicular growth and delayed secondary sexual characteristic development
• Voice does not deepen, no muscle mass increase, penis and testes do not develop and mature

Question 4

Hypogonadism in Adults

Answer 4

Symptoms:
- Depression, development of male breasts, erectile dysfunction, failure of growth of facial or body hair, increase in body fat, loss of energy, inhibited sexual desire, loss of muscle mass, onset of osteoporosis, shrinking and softening of the testicles

Question 5

Older Men

Answer 5

Testosterone production decreases with age

Spermatogenesis is maintained in the 80s

Testosterone replacement improves muscle strength and body composition in frail elderly men

Question 6

Testosterone Replacement Therapy (TRT)

Answer 6

• TRT restores levels to normal range, improving effects of hypogonadism
• Effects of TRT:
• – Stimulation of erythropoesis, increased bone mass in eugonadal men, long-term benefit of TRT on bone mineral density no known, may improve cognitive functioning, improves insulin sensitivity, no association between TRT & cardiac events, has variable effects on mood, energy, and sense of well-being
• Muscle Mass & Strength
• – May reverse age-dependent body composition changes & associated morbidity
• – Associated with greater improvement in grip strength compared with placebo
• Sexual desire, function, and performance
• – may benefit men with ED caused by hypogonadism; enhanced libido

Question 7

Testosterone: Clinical Use and Dosing

Answer 7

Depot esters 200 mg IM every 2 weeks
- Dosages adjusted to aim for mid-normal (400-600) testosterone levels after 1 week or at the low end (250-350) just before the next injection is due at 2 weeks

Dosage for transdermal or buccal TRT: results in systemic absorption of 2.5 to 10 mg daily
- A testosterone value in the mid-normal range (400-600) is the goal

Nasal gel (Natesto)

Question 8

TRT: Risks and Contraindications

Answer 8

• Erythrocytosis
• – check HGB/HCT levels
• – HGB greater than 17.5 or HCT greater than 54% suggests overtreatment or occasionally abuse
• Prostate cancer risk
• – Digital rectal examination and PSA testing should be done throughout therapy
• Decreased sperm production and infertility
• Boys: acne and gynecomastia
• Adolescents: aggressive behavior; premature closure of the epiphyses

Question 9

TRT: Monitoring

Answer 9

Evaluate efficacy at 3-6 months of therapy

Evaluate testosterone level at 3-6 months from starting therapy
- Goal is mid-normal range

Evaluate Hct/Hgb at 3-6 months, then annually

Evaluate bone mineral density at 1-2 years

Evaluation of PSA levels and digital rectal examination should be performed before beginning therapy and at 3-6 months

Question 10

Erectile Dysfunction (ED)

Answer 10

Treatment include phosphodiesterase type 6 (PDE-5) inhibitors, or TRT

• PDE-5 inhibitors: sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis)
• Potential for fatal hypotension if PDE-5 inhibitors are taken concurrently with nitrates (nitrolgycern)

Not prescribed to patients with acute MI, stroke, arrhythmia in past 6 months

Rare reports of vision and hearing problems

Patient Education critical

Question 11

Benign Prostatic Hyperplasia

Answer 11

Enlarged prostate interferes with urination

Treatment

• Alpha blockers
• 5-alpha-reductase inhibitors
• PDE-5 inhibitors

Question 12

Hair Loss in Men- Rational Drug Selection

Answer 12

Topical Minoxidil

• Applied twice daily to scalp
• If discontinued, hair will shed in 3-4 months

Systemic finasteride

• Type II 5-alpha reductase-specific inhibitor
• Daily treatment with full treatment effect after 6-12 months of use
• Not prescribed to patients with hepatic dysfunction, elevated PSA
• Pregnancy category X
• Need to avoid exposure of partner to semen if planning pregnancy

Question 13

Men Who Have Sex With Men

Answer 13

HIV infection and STIs

• Men who have sex with men often do not use protection
• There are high rates of syphilis among them

Anal cancer

• Incidence of anal cancer is 17 times higher in gay and bisexual than in heterosexual men
• All males should receive HPV vaccine as adolescents

Tobacco abuse: 33% of gay men smoke