Transcript SUNYIT Teaching Day 2014 - Iris Gonzalo-Sowle MS, RN

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Iris Gonzalo-Sowle, BS, RN-BC, ONC, FNP-S
Denise Richard, BSN, FNP-S
* Identify the prevalence of hypogonadism
* Identify the risk factors associated with hypogonadism
* Identify the signs and symptoms of hypogonadism
* Discuss the barriers that prevent men from seeking medical
treatment for hypogonadism
* Identify treatment options available for medical management of
hypogonadism
* Discuss risks and benefits of current treatment options
* Discuss contraindications of testosterone replacement therapy
* Review potential side effects of testosterone replacement
therapy
* Discuss key teaching points to cover to ensure safe use of
testosterone replacement therapy
* Implement safety strategies to prevent the misuse of
testosterone replacement
*
No commercial support
was received for this
educational activity.
Primary
* Serum testosterone concentration and/or the
sperm count are below normal and the serum
LH and/or FSH concentrations are above
normal
Secondary
* Serum testosterone concentration and/or the
sperm count are subnormal and the serum LH
and/or FSH concentrations are normal or
reduced
*
(Snyder, 2013)
* Hypothalamus produces gonadotropin releasing
hormone (GnRH) which stimulates pituitary to
produce follicle stimulating hormone and
luteinizing hormone.
* Luteinizing hormone stimulates the testes to
produce testosterone.
* Primary hypogonadism (primary testicular
failure) originates from problem in testes.
* Secondary hypogonadism indicates problem in
hypothalamus or pituitary gland which are
what signals testicles to produce testosterone.
*
(Domino,2014)
PRIMARY
HYPOGONADISM
* Klinefelter syndrome
* Undescended testicles
* Mumps orchitis
* Hemochromatosis
* Testicular injury
* Cancer treatment
SECONDARY
HYPOGONADISM
* Kallmann syndrome
* Pituitary disorders
* Inflammatory disease
* HIV
* Medications
* Obesity
* Normal aging
*
(Snyder, 2013)
*2-4 million men are currently affected
*12.3 cases per every 1,000 in the
United States
*481,000 new cases annually in men
between the ages of 40-69
*
(Domino, 2014)
* Obesity
* Type II Diabetes Mellitus
* COPD
* Medications that affect testosterone production or
metabolism
* Stress
* Trauma
* Infection
* Radiation therapy
* Tumors (testes, pituitary, hypothalamus)
* Chemotherapy
* Inflammatory disease
* Exposure to environmental endocrine modulators
*
(Domino, 2014)
* Absence or regression of
secondary characteristics
* Anemia
* Muscle wasting
* Reduced bone mass or
bone mineral density
(osteoporosis)
* Abdominal adiposity
* Gynecomastia
* Sexual dysfunction
* Reduced libido
* Reduced energy and
stamina
* Depressed mood
* Irritability
* Difficulty concentrating
* Hot flushes
* Decreased body hair
*
(McDermott, 2009)
* Puberty (sexual development)
* Past or present major illnesses and nutritional
deficiency
* Treatment with medications that might affect
testosterone levels, such as strong opiate pain
medications (e.g. methadone) and strong steroid
anti-inflammatory drugs (e.g. prednisone)
* Sexual problems
* Any major life events that have occurred
* Family history of similar problems
* Recent changes in body features and breasts
* Damage to or shrinkage of the testicles
*
* Amount of body hair (underarm and pubic hair)
* Presence of breast enlargement or tenderness
* Size and softness of the testicles
* Penis size
*
SERUM TESTOSTERONE CONCENTRATION
* Most important single diagnostic test for male
hypogonadism
* Normal range 300-800ng/dl
* Draw lab test at 8:00 am
* Illness, malnutrition, and certain medications
can reduce testosterone temporarily, so testing
may need to be postponed
* Abnormal levels should be repeated to confirm
true deficiency
*
* Semen analysis
* Hormonal/Genetic testing
* MRI of Pituitary (to rule out adenoma)
* Testicular biopsy (rarely provides information
that is useful)
*
TREATMENT: Depends on the cause and whether
fertility is a concern.
* Testicular failure: Hormone replacement restores
sexual function, muscle strength, and prevents bone
loss. Patients note an increase in energy, sexual
drive, and feel better about themselves.
* Pituitary problem: Pituitary hormones can be used
to stimulate sperm production and restore fertility.
Testosterone replacement therapy can be used if
fertility isn’t an issue.
* Pituitary tumor: May require surgery, medication,
or radiation.
*
(Bhasin et al., 2006)
*Restore sexual function, libido, well being,
and behavior
*Produce and maintain virilization
*Increase muscle strength
*Optimize bone density and prevent
osteoporosis
*In elderly men, possibly normalize growth
hormone levels
*
(Snyder, 2013)
* Injections-safe and effective. Given approximately every 1-2
weeks. Some physicians choose to only give the injection in
the office (due to risk of misuse).
* Patches- (Androderm) applied nightly. Important to rotate
sites to prevent skin reactions. Do not apply to scrotom.
* Gels-(AndroGel/Testim) rub into skin of lower abdomen,
upper arm or shoulder. Less skin reactions than the patches.
Can’t shower or bathe for several hours after application.
Must avoid skin to skin contact or cover the area until gel is
completely dry. Women and children should avoid contact
with unwashed or unclothed area where gel has been
applied. Gels are flammable and must be dry before going
near an open flame.
*
(Snyder, 2013)
* Buccal tablet: Applied twice daily and adheres
to a depression in the gum above the upper
incisors. Releases testosterone across buccal
mucosa into systemic circulation.
* Testosterone pellet: Three to six 75 mg
testosterone pellets are implanted into
subdermal fat of buttocks, lower abdominal
wall, or thigh with a trocar under sterile
conditions using local anesthesia every three to
six months. Not routinely recommended.
*
(Snyder, 2013)
(Snyder, 2013)
* Misuse/abuse of testosterone amongst
athletes, bodybuilders, weight lifters, and
others to enhance athletic performance or
physique
* Considered a controlled substance in NYS
(class II)
* Prescription cannot be sent electronically
* Paper script required
* No refills allowed
*
Testosterone therapy is contraindicated in:
* Breast or prostate cancer
* Enlarged prostate
* Obstructive sleep apnea (if untreated)
* Class III or IV heart failure
* Smokers (erythrocytosis)
*
(Bhasin et al., 2006)
* Increased PSA
* Mood swings
* High blood pressure
* Skin irritation at site of
* Prostate Cancer
* Erythrocytosis
* Decreased sperm count
* Lower extremity
* Prostatic hyperplasia
* Heart failure
* Blood clots
application
edema
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(McDermott,2009)
Digital rectal exam, PSA, CBC, done prior to
initiation of testosterone therapy in:
*Any man over the age of 50
*Any man over the age of 40 with family
history of Prostate cancer or is African
American
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(Snyder, 2013)
* Testosterone levels and CBC checked every 3
months for first year and then every 6 months if
stable.
* Annual digital rectal exam and PSA for as long as
the patient remains on testosterone replacement
therapy.
* For patients with a history of osteoporosis or past
bone fractures, a bone mineral density testing
(DEXA scan) should be done every one to two years
while receiving testosterone treatment.
*
1. Risk factors for hypogonadism include all of the following except
a)
b)
c)
d)
obesity
age
inflammatory disease
enlarged prostate
2. Serum testosterone levels should be drawn at what time?
a)
b)
c)
d)
5:00 pm
any time
11:00 am
8:00 am
3. Testosterone therapy is contraindicated in:
a)
b)
c)
d)
Class III or IV heart failure
Enlarged prostate
Diabetes
Hypertension
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4. According to current clinical guidelines which tests should be performed prior to the initiation
of testosterone therapy?
a)
b)
c)
d)
CBC and PSA
CBC, COMP and PSA
digital rectal exam, PSA and CBC
digital rectal exam and PSA
5. Side effects of testosterone therapy include all of the following except:
a)
b)
c)
d)
hypotension
elevated PSA level
localized skin irritation
mood swings
6. Which teaching point is not indicated when providing education regarding testosterone gel
application?
a)
b)
c)
Gels are flammable and should be allowed to dry completely before exposure to open flames.
d)
Gel should be applied after bathing or showering.
To reduce the risk of skin irritation gels should be applied to bilateral ankles.
Exposure to skin areas where testosterone gel has been applied should be avoided in women
and children.
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Bhasin, S., Cunningham, G. R., Hayes, F. J., Matsumoto, A. M., Snyder, P.
J.,Swerdloff, R. S., & Montori, V. M. (2006). Testosterone therapy
in adult men with androgen deficiency syndromes: An endocrine
society clinical practice guideline. The Journal of Clinical
Endocrinology & Metabolism, 91(6), 1995-2010
Domino, F. J. (2014). The 5 minute clinical consult. (2nd ed., pp. 12061207). Philadelphia, PA: Lippincott Williams & Wilkins.
Endocrine Society. (2014). Testosterone therapy in men. Retrieved from
http://www.hormone.org/patient-guides/2010/testosteronetherapy-in-men
Jackson, G. (2012). Late onset hypogonadism in males-think of it-act on it.
International Journal of Clinical Practice, 66(2), 115-116.
doi:10.1111/j.1742-1241.2011.02865.x
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McDermott, M. (2009). Endocrine secrets. (5th ed.).
Philadelphia, PA: Mosby Elsevier.
Snyder, P. J. (2013, February 11). Testosterone treatment of
male hypogonadism. Retrieved from
www.uptodate.com.
Snyder, P. J. (2013, January 18). Clinical features and diagnosis
of male hypogonadism. Retrieved from
www.uptodate.com
Vigen, R., O'Donnell, C. I., Baron, A. E., Grunwald, G. K.,
Maddox, T. M., Bradley, S. M., … Ho, P. M. (2013).
Association of testosterone therapy with
mortality, myocardial infarction, and stroke in men
with low testosterone levels. JAMA, 310(17), 18291836. doi: 10.1001/jama.2013.280386
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