Transcript Management of Ureteral Calculi American Urological Association

Hugo H Davila, MD
Urology Center
St. Joseph Hospital
Objective
Objective:
My objective is to update the guidelines for the evaluation and treatment
of androgen deficiency syndromes in adult men published previously in
2006.
1. The Endocrine Society Clinical Practice Guideline 2010
2. Prostate-Specific Antigen, Best Practice Statement: 2009. American Urological
Association.
3. Guideline for the Management of Clinically Localized Prostate Cancer 2007.
American Urological Association.
4. Campbell-Walsh Urology 10TH Edition . chapter 29 – Androgen Deficiency in
the Aging Male.
Agenda
 Diagnosis of Hypogonadism
 Symptoms
 Labs
 Testosterone Replacement Therapy (TRT)
 Indications
 Benefits
 Formulation
• Contraindications
• Prostate Cancer and TRT
• PSA and TRT
• Adverse Effect
• Monitoring men in TRT
• Androgen-Deprivation Therapy (ADT) in Prostate Cancer and
Cardiovascular Risk.
Diagnosis of Hypogonadism?
Men with consistent symptoms
and signs and unequivocally low
serum testosterone levels.
Testosterone Replacement
Step 1
What are those symptoms and Signs?
More specific symptoms and signs
Incomplete or delayed sexual development, eunuchoidism
Reduced sexual desire (libido) and activity
Decreased spontaneous erections
Breast discomfort, gynecomastia
Loss of body (axillary and pubic) hair, reduced shaving
Very small (especially 5 ml) or shrinking testes
Inability to father children, low or zero sperm count
Height loss, low trauma fracture, low bone mineral density
Hot flushes, sweats
Other less specific symptoms and signs
Decreased energy, motivation, initiative, and self-confidence
Feeling sad or blue, depressed mood, dysthymia
Poor concentration and memory
Sleep disturbance, increased sleepiness
Mild anemia (normochromic, normocytic, in the female
range)
Reduced muscle bulk and strength
Increased body fat, body mass index
Diminished physical or work performance
Testosterone Replacement
Step 2
What is next?
Measurement of morning total testosterone
level by a reliable assay (mass spectrometry) as the initial
diagnostic test.
Confirmation of the diagnosis by repeating
measurement of total testosterone.
Evaluation of androgen deficiency should not be made during an
acute or subacute illness.
Testosterone Replacement
Step 2
How low is low?
The lower limit of the normal range for young
men, i.e. approximately 300 ng/dl (10.4
nmol/liter), with a greater likelihood of
having symptoms below this threshold than
above it.
Men with consistent symptoms
and signs and unequivocally low
serum testosterone levels.
Low TT Predict the development of
Metabolic Synd and Diabetes
Population-based cohort study: 11 years follow up
N= 702
TT <450 ng/dl
After 11 years 45% of those men developed MS and DM
Diabetes care. Vol 27.2004. 1036-1041
Definition of Metabolic syndrome
NHLBI and WHO need >3 of the following
Obesity waist circumference >94cm (40 in)
Triglycerides mg/dl
>150
HDL mg/dl
<40
BP mmHg
>130/85
Glucose mg/dl
>110
Metabolic syndrome
Hypogonadism and ED are commonly treated
Associated with metabolic syndrome, type 2 diabetes
and CVD, these condition are clearly linked to
increase mortality and morbidity.
Metabolic syndrome may be considered a risk factor
for ED.
ED may be considered a risk factor for CVD
Low TT and CHF
CHF is a complex multistep Disease
Disrupt the endocrine and metabolic system
Impaired exercise capacity and fatigue
Associated with Low testosterone levels
25% of hypogonal men have CHF
Aukrust P, et al. J Am Coll Cardiol 2009;54(10)928-929.
Diagnosis of Hypogonadism?
Testosterone Replacement
Step 2
What is Total Testosterone?
Serum total testosterone =SHBG bound (40-50%)+ Free T (2%) +
Albumin bound (48%)
Most of the circulating testosterone is bound to SHBG and to albumin.
Only 2% of circulating testosterone is unbound or “free.”
The term “bioavailable testosterone” refers to free testosterone plus
testosterone bound loosely to albumin
Testosterone Replacement
Step 3
Do I need any other test?
Measurement of free or bioavailable testosterone
level, using an accurate and reliable assay, in some
men in whom total testosterone concentrations are
near the lower limit of the normal range and in
whom alterations of SHBG are suspected.
Testosterone Replacement
Step 3
What are the conditions that affects SHBG?
Conditions associated with decreased SHBG concentrations
Moderate obesity
Nephrotic syndrome
Hypothyroidism
Use of glucocorticoids, progestins, and androgenic steroids
Acromegaly
Diabetes mellitus
Conditions associated with increased SHBG concentrations
Aging
Hepatic cirrhosis and hepatitis
Hyperthyroidism
Use of anticonvulsants
Use of estrogens
HIV disease
Recommendations
Testosterone Replacement
Recommendation 1
Avoid treatment in men without unequivocally low
testosterone levels and symptoms.
Testosterone Replacement
Recommendation 2
Avoid labeling men with low testosterone levels
due
To:
1. SHBG abnormalities.
2. Natural variations in testosterone levels.
3. Transient disorders as requiring testosterone
therapy.
Do we need any other tests?
Testosterone Replacement
Sometimes,
Step 4
What are those additional tests?
If Total Testosterone <150 ng/dl
LH, FSH, Prolactin and MRI of the sella Turcica
If testicular Vol<6ml (small testes)
Karyotype (Klinefelter syndrome)
Infertility
2 semen analyses
Bone mineral density by using dual-energy x-ray absorptiometry (DEXA) scanning in men with
severe androgen deficiency or low trauma fracture
Note: I recommend measurement of serum LH and FSH levels to distinguish between primary
(testicular) and secondary (pituitary-hypothalamic) hypogonadism.
Testosterone Replacement
Recommendation 3
The diagnostic strategy places a relatively higher
value on detecting conditions (e.g. pituitary
neoplasia or other treatable pituitary disorders) for
which effective treatment or counseling is
available.
Do we need to screen the general
population for hypogonadism?
Testosterone Replacement
NO,
The benefits and adverse
consequences of long term
testosterone therapy in
asymptomatic men with presumed
hypogonadism remain unclear.
Can We measure Testosterone Level in
patients with other medical problems?
Testosterone Replacement
Yes,
Patients in whom there is high prevalence of low testosterone
Levels:
•Sellar mass, radiation to the sellar region, or other diseases of
the sellar region
•Treatment with medications that affect testosterone
production or metabolism, such as glucocorticoids and
opioids
•HIV-associated weight loss
•End-stage renal disease and maintenance hemodialysis
•Moderate to severe chronic obstructive lung disease
•Infertility
•Osteoporosis or low trauma fracture, especially in a young man
•Type 2 diabetes mellitus
Testosterone Replacement
Long-acting opioid analgesics suppress the
hypothalamic-pituitary gonadal axis in men,
produce symptomatic androgen deficiency (up to
74%), and are associated with increased risk of
osteoporosis.
Testosterone Replacement
Androgen deprivation therapy using GnRH
analogs in men with prostate cancer has emerged
as an important cause of therapeutically induced
androgen deficiency that is associated with
increased risk of sexual dysfunction, fatigue,
fractures, cardiovascular disease, and diabetes.
What about symptoms
Questionnaires?
Testosterone Replacement
There is limited information about the
performance properties of case-detection
instruments that rely on self report, namely:
•Androgen Deficiency in Aging Males .
•the Aging Males’ Symptoms Rating Scale.
•Massachusetts Male Aging Study
Questionnaire
Testosterone Replacement
Recommendation 4
The recommendation in favor of measurement
testosterone levels in those conditions in which
there is a high prevalence of low testosterone levels
Agenda
 Diagnosis of Hypogonadism
 Symptoms
 Labs
 Testosterone Replacement Therapy (TRT)
 Indications
 Benefits
 Formulation
• Contraindications
• Prostate Cancer and TRT
• PSA and TRT
• Adverse Effect
• Monitoring men in TRT
• Androgen-Deprivation Therapy (ADT) in Prostate Cancer and
Cardiovascular Risk.
Testosterone Replacement
Indications/contraindications for TRT
•Testosterone therapy for symptomatic men
with classical androgen deficiency syndromes
and low TT
•Avoid testosterone therapy in patients with
breast or prostate cancer.
Testosterone Replacement
What are the benefits of TRT?
Testosterone therapy of hypogonadal men is
associated with improvements in:
1. Overall sexual activity, frequency of sexual thoughts
2. Increase in the frequency and duration of nighttime
erections
3. Increases hair growth.
4. Increases fat-free mass and muscle strength
5. Increases bone mineral density
6. May improves the positive and reduces the negative
aspects of mood
7.
Data on the impact of testosterone replacement on insulin
sensitivity have yielded conflicting results.
TRT in men with Sexual Dysfunction
Recommendation #5
•TRT in men with low testosterone levels and low libido to
improve libido
•TRT men with ED who have low testosterone levels after
evaluation of underlying causes of ED and consideration of
established therapies for ED.
Note: A decision to treat older men depends on the physician’s and
the patient’s assessment of risks and benefits and costs.
TRT in Older Men with Low
Testosterone
Recommendation #6
We recommend against a general policy of offering TRT to
all older men with low testosterone levels.
But
TRT in Older Men with Low
Testosterone
•Several studies demonstrate that serum total and free
testosterone concentrations in men fall with increasing
age
•By the eighth decade, according to one study, 30% of men
had total testosterone values in the hypogonadal range, and
50% had low free testosterone values .
•Note: Depending on the severity of clinical manifestations,
some panelists favored treating symptomatic older men
with a testosterone level below the lower limit of normal for
healthy young men 280–300 ng/dl , others favored a level
less than 200 ng/dl.
Testosterone Replacement
•Bone mineral density
The panel did not find any trials reporting the
effect of testosterone on bone fractures.
•Body composition
TRT was associated with a significantly greater
increase in lean body mass (LBM) (2.7
kg; 95% CI, 1.6, 3.7) and a greater reduction in fat
mass(2.0 kg; 95% CI, 3.1, 0.8) than placebo.
Testosterone Replacement
•Muscle strength and physical function
TRT was associated with a greater improvement in grip
strength than placebo. Most of the studies included
men who had no functional limitations and used
measures of physical function that had a low ceiling.
•Sexual function
Two placebo-controlled trials yielded imprecise results
regarding the effect of testosterone on overall sexual
satisfaction.
Interval from manifestation of ED to initial
atherosclerotic cardiovascular event.
•Atherosclerotic cardiovascular event subsequent to
manifestation of ED
•5-10 years after ED onset 37% will have CV event.
•20-25% of men with low testosterone present with
ED
•ED onset 20-40 yo is associated 7 fold increase in
risk for a CV in the next 7-10 years
Chew KK et al, J Sex Med. 2010.7.192-202.
Testosterone Replacement
•Quality of life
The results were inconsistent across trials and
imprecise.
•Depression
The effects of testosterone therapy on depression have
been inconsistent across trials.
•Cognition
Three placebo-controlled, randomized trials, reported
imprecise effects on several dimensions of cognition,
none of which was significant after pooling.
Testosterone Replacement
•HIV-infected men with weight loss
Clinicians should consider short-term TRT as an
adjunctive therapy in HIV-infected men with low
testosterone levels and weight loss to promote
weight maintenance and gains in LBM and muscle
strength.
Testosterone Replacement
•Glucocorticoid-treated men
We suggest that clinicians offer TRT to men
receiving high doses of glucocorticoids who have
low testosterone levels to promote preservation of
LBM and bone mineral density.
Agenda
 Diagnosis of Hypogonadism
 Symptoms
 Labs
 Testosterone Replacement Therapy (TRT)
 Indications
 Benefits
 Formulation
• Contraindications
• Prostate Cancer and TRT
• PSA and TRT
• Adverse Effect
• Androgen-Deprivation Therapy (ADT) in Prostate Cancer and
Cardiovascular Risk.
• Monitoring men in TRT
Testosterone Replacement
Clinical Pharmacology TRT
•T enanthete or Cypionate Injections
150-200 mg IM every 2 wk or 75-100mg/wk
Advantages: Correct symptoms, inexpensive,
self-administered
Disadvantages: IM injection, peaks and valleys
in serum T.
Testosterone Replacement
Clinical Pharmacology TRT
•Testosterone Gel (Androgel 1.6%, Fortesta 2%,
Axiron, Testim 1%)
Androgel = Arm
Fortesta = Upper Thigh
Axiron = Axilla
5-10 g T gel containing 50-100mg T QDay
Advantages: Correct symptoms, flexibility, ease of
application, good skin tolerability
Disadvantages: Potential of transfer, skin
irritation in some PT, moderately high DHT
levels.
Testosterone Gel
•Testosterone Gel
Single center, randomized, double-blinded placebocontrolled study.
>65 yo men (N=274)
6 months Test gel 50 mg
TT levels= 500-700 ng/dl
Effect on: Muscle mass and strength, QoL
Results
Improved muscle mass, physical function and QoL
Sriniva-Smankar et al. J Clin Endocrino Metab, 2010; 409-420
Testosterone Replacement
Clinical Pharmacology TRT
•T Pellets
3-6 pellets implanted SC, 3-6 months
Advantages: Correct symptoms.
Disadvantages: Require surgical incision,
pellets may extrude spontaneously.
Testosterone Replacement
Clinical Pharmacology TRT
•T Patch (Androderm)
1-2 patches, 5-10mg Testosterone
Advantages: Correct symptoms, easy
application.
Disadvantages: Serum T in the low normal
range, skin irritation at the application site.
Testosterone Replacement
Clinical Pharmacology TRT
•T Tablets (Striant)
30mg bioadhesive tablets BID, serum T peak
after 1 month.
Advantages: Correct symptoms.
Disadvantages: Gum-related adverse events in
16% of treated men.
Agenda
 Diagnosis of Hypogonadism
 Symptoms
 Labs
 Testosterone Replacement Therapy (TRT)
 Indications
 Benefits
 Formulation
• Contraindications
• Prostate Cancer and TRT
• PSA and TRT
• Adverse Effect
• Androgen-Deprivation Therapy (ADT) in Prostate Cancer and
Cardiovascular Risk.
• Monitoring men in TRT
Prostate Cancer and TRT
Prostate Cancer and TRT
•Clinicians should assess prostate cancer risk in men being
considered for testosterone therapy: Family history, Race, PSA and
digital rectal exam (DRE).
•Avoid testosterone therapy without further urological
evaluation in patients with palpable prostate nodule or
induration
•Avoid testosterone therapy if PSA is greater than 4 ng/ml or
PSA greater than 3 ng/ml in men at high risk of prostate cancer,
such as African-Americans or men with first-degree relatives
with prostate cancer.
PSA and TRT
Prostate Cancer and TRT
In men 40 yr of age or older who have a baseline PSA
greater than 0.6 ng/ml:
Digital examination of the prostate.
PSA measurement before initiating treatment, at 3 to
6 months.
PSA and TRT
•Obtain urological consultation if there is:
An increase in serum PSA concentration >1.4 ng/ml
within any 12-month period of TRT.
PSA velocity > 0.4 ng/ml yr after 6 months of TRT
(only applicable if PSA data are available for a period
exceeding 2 yr).
Abnormal digital rectal examination.
AUA/IPSS of 19.
Prostate Cancer Risk and TRT
Prostate Cancer and TRT
We suggest estimating prostate cancer risk using the prostate cancer
risk calculator
http://deb.uthscsa.edu/URORiskCalc/Pages/calcs.jsp
Takes into consideration:
Age, ethnicity, PSA.
Findings of digital rectal examination.
Family history.
The use of a 5a- reductase inhibitor.
Prior biopsy history.
Can I start my patients on TRT after
prostate cancer treatments?
TRT After Prostate Cancer
Treatment
Prostate Cancer and TRT
Organ-confined prostate cancer
Who have undergone radical prostatectomy.
Have been disease-free 2 or more years
Who have undetectable PSA levels
May be considered for testosterone replacement on an
individualized basis.
Note: The lack of data from randomized trials precludes a
general recommendation.
Contraindications for TRT
Contraindications for TRT
Avoid testosterone therapy in patients
With:
Hematocrit above 50%.
Untreated severe obstructive sleep apnea.
Severe lower urinary tract symptoms (AUA/
IPSS > 19).
Uncontrolled or poorly controlled heart
failure.
In those desiring fertility.
Agenda
 Diagnosis of Hypogonadism
 Symptoms
 Labs
 Testosterone Replacement Therapy (TRT)
 Indications
 Benefits
 Formulation
• Contraindications
• Prostate Cancer and TRT
• PSA and TRT
• Adverse Effect
• Androgen-Deprivation Therapy (ADT) in Prostate Cancer and
Cardiovascular Risk.
• Monitoring men in TRT
Adverse Effect of TRT
Adverse Effect of TRT
37 randomized controlled testosterone
trials were reviewed:
Increases in hemoglobin.
Increase hematocrit.
Increase PSA.
Decrease in high-density lipoprotein (HDL)
Gynecomastia (breast exam)
Adverse Effect of TRT
Adverse Effect of TRT
Not different among testosterone- and
placebo-treated men:
•Overall mortality.
•Cardiovascular event rates.
•Systolic and diastolic blood pressure.
Agenda
 Diagnosis of Hypogonadism
 Symptoms
 Labs
 Testosterone Replacement Therapy (TRT)
 Indications
 Benefits
 Formulation
• Contraindications
• Prostate Cancer and TRT
• PSA and TRT
• Adverse Effect
• Monitoring men in TRT
• Androgen-Deprivation Therapy (ADT) in Prostate Cancer and
Cardiovascular Risk.
Monitoring Men Receiving TRT
•
Evaluate the patient 3 to 6 months after treatment
initiation
1. Testosterone Injection: T level midway between
injections = 400-700ng/dl.
2. Transdermal Gel: assess testosterone level any time
after patient has been on treatment for at least 1 wk;
adjust dose to achieve serum testosterone level in the
mid-normal range.
3. Testosterone pellets: measure testosterone levels at
the end of the dosing interval. Adjust the number
of pellets and/or the dosing interval to achieve serum
testosterone levels in the normal range.
Monitoring Men Receiving TRT
• Hematocrit at baseline, at 3 to 6 months, and then
annually.
If hematocrit is >54%, stop therapy until hematocrit
decreases to a safe level; evaluate the patient for
hypoxia and sleep apnea; reinitiate therapy with a
reduced dose.
• Measure bone mineral density of lumbar spine and/or
femoral neck after 1–2 yr of testosterone therapy in
hypogonadal men with osteoporosis or low trauma
fracture, consistent with regional standard of care.
Monitoring Men Receiving TRT
•Evaluate formulation-specific adverse effects at each visit:
Injectable testosterone (enanthate, cypionate, and undecanoate):
ask about fluctuations in mood or libido, and rarely cough.
Testosterone gels: advise patients to cover the application sites with a
shirt and to wash the skin with soap and water before having skin-toskin contact, can be transferred to a woman or child who might come
in close contact. T levels are maintained when the application site is
washed 4–6 h after application of the testosterone gel.
Testosterone pellets: look for signs of infection, fibrosis, or pellet
extrusion.
Agenda
 Diagnosis of Hypogonadism
 Symptoms
 Labs
 Testosterone Replacement Therapy (TRT)
 Indications
 Benefits
 Formulation
• Contraindications
• Prostate Cancer and TRT
• PSA and TRT
• Adverse Effect
• Monitoring men in TRT
• Androgen-Deprivation Therapy (ADT) in Prostate Cancer and
Cardiovascular Risk.
Androgen-Deprivation Therapy in Prostate Cancer and
Cardiovascular Risk
A Science Advisory From the American Heart Association, American
Cancer Society, and American Urological Association
Endorsed by the American Society for Radiation Oncology
Androgen-Deprivation Therapy in Prostate
Cancer and Cardiovascular Risk
There is a substantial amount of data
demonstrating that ADT adversely affects
traditional cardiovascular risk factors:
Including serum lipoproteins.
Insulin sensitivity.
Obesity.
Androgen-Deprivation Therapy in Prostate
Cancer and Cardiovascular Risk
•Despite the metabolic effects of ADT and the
possible increased cardiovascular risk.
•There is no clear indication for patients
for whom ADT is believed to be beneficial to
be referred to:
Internists, endocrinologists, or cardiologists
for evaluation before initiation of ADT
Androgen-Deprivation Therapy in Prostate
Cancer and Cardiovascular Risk
Given the metabolic effects of ADT, it is
advisable that patients in whom ADT is
initiated be referred to their primary care
physician for periodic follow-up
evaluation
Androgen-Deprivation Therapy in Prostate
Cancer and Cardiovascular Risk
The American Heart Association and
other expert organizations, recommend,
when appropriate:
•Lipid-lowering therapy.
•Antihypertensive therapy.
•Glucose lowering therapy.
•Antiplatelet therapy.
Agenda
 Diagnosis of Hypogonadism
 Symptoms
 Labs
 Testosterone Replacement Therapy (TRT)
 Indications
 Benefits
 Formulation
• Contraindications
• Prostate Cancer and TRT
• PSA and TRT
• Adverse Effect
• Monitoring men in TRT
• Androgen-Deprivation Therapy (ADT) in Prostate Cancer and
Cardiovascular Risk.
Take Home Message
Take Home Message
Recommendation 1: Definition
•Hypogonadism is a clinical and biochemical syndrome associated with advancing age
and characterized by symptoms and a deficiency in serum T levels.
Recommendation 2: Clinical Diagnosis
• The diagnosis of hypogonadism requires symptoms and signs suggestive of T
deficiency.
Most common symptom is low libido.
Others include ED, sarcopenia, osteopenia/osteoporosis, increased body fat,
decreased vitality, and low mood.
None of them is specific for T deficiency and must be corroborated with a low T
level.
•Questionnaires such as AMS and ADAM are not recommended for diagnosis of
hypogonadism because of low specificity.
Take Home Message
Recommendation 3: Laboratory Diagnosis
• Patients suspected of low T need a biochemical workup .
Risk factors for hypogonadism in older men include chronic illnesses (diabetes,
chronic obstructive lung disease, and renal and HIV-related diseases), obesity,
metabolic syndrome, and hemochromatosis.
• A sample for T determination should be obtained between 7:00 and 11:00 AM.
The most widely accepted test is serum total T.
• Measurement of free or bioavailable T should be considered when the total T
is not diagnostic, particularly in obese men.
Take Home Message
Recommendation 4: Assessment of Treatment Outcome and Decisions on
Continued Therapy
• Failure to benefit within a reasonable interval (3 months is adequate for sexual
function, others require a longer interval) should result in discontinuation of
treatment. Seeking other causes of symptoms is then mandatory.
Recommendation 5: Body Composition
• T administration improves body composition in hypogonadal men
(decrease fat mass, increase lean body mass).
Recommendation 6: Bone Density and Fracture Rate
• Osteopenia/osteoporosis and fracture prevalence rates are greater in
hypogonadal men. Bone density in hypogonadal men increases under T
treatment.
Take Home Message
Recommendation 7: Testosterone and Sexual Function
• The initial assessment of all men with ED and/or diminished libido should
include determination of serum T.
• Men with ED and/or diminished libido and documented T deficiency are
candidates for therapy.
• There is evidence suggesting therapeutic synergism with combined use of T
and phosphodiesterase-5 inhibitors in hypogonadal men.
Recommendation 8: Testosterone and Obesity, Metabolic Syndrome, and
Type 2 Diabetes
• Several components of the metabolic syndrome are also present in hypogonadal
men.
Take Home Message
Recommendation 9: Carcinoma of the Prostate and Benign Prostatic
Hyperplasia
• There is no conclusive evidence that T therapy increases the risk or carcinoma of
the prostate or benign prostatic hyperplasia.
• Prior to TRT, the risk of carcinoma of the prostate must be assessed using, as a
minimum, direct rectal examination and PSA screening.
• During treatment, patients should be monitored for prostate disease at 3 to 6
months, 12 months, and at least annually thereafter.
• Severe lower urinary tract symptoms (>19 in IPSS) due to benign prostatic
hyperplasia represent a temporary contraindication. After successful treatment of
these symptoms this contraindication is lifted.
• Men successfully treated for prostate carcinoma and suffering from confirmed low T
are potential candidates for TRT after a prudent interval if there is no clinical or
laboratory evidence of residual cancer.
Take Home Message
Recommendation 10: Treatment and Delivery Systems
• Available intramuscular, subdermal, transdermal, oral and buccal preparations of testosterone
are safe and effective.
Recommendation 11: Adverse Effects and Monitoring
• TRT is contraindicated in men with prostate or breast cancer.
• Men with significant erythrocytosis, untreated obstructive sleep apnea, and untreated severe
congestive heart failure should not be treated with T until resolution of the comorbid
condition.
• Erythrocytosis might develop during treatment, especially with injectable preparations. Periodic
hematologic assessment is indicated. Dose adjustments and/or periodic phlebotomy may be
necessary.
Recommendation 12: Age
• Age is not a contraindication to initiate testosterone treatment. Individual assessment of
comorbidities and potential risks versus benefits of treatment is particularly important in elderly
men.
Objective
Objective:
My objective was to update the guidelines for the evaluation and
treatment of androgen deficiency syndromes in adult men published
previously in 2006.
1. The Endocrine Society Clinical Practice Guideline 2010
2. Prostate-Specific Antigen, Best Practice Statement: 2009. American Urological
Association.
3. Guideline for the Management of Clinically Localized Prostate Cancer 2007.
American Urological Association.
4. Campbell-Walsh Urology 10TH Edition . chapter 29 – Androgen Deficiency in
the Aging Male.
Thank you