Introduction: Symptomatic hypogonadism affects 56% of men aged 3079 years and is associated with increased morbidity and mortality. There are currently no trust guidelines for the diagnostic workup of these patients.
Methods: Retrospective analysis was performed of diagnosis and assessment of adult men with low serum total testosterone (TT) and compared with clinical practice guidelines of The Endocrine Society. We identified all patients with TT below normal range (<9.9 nmol/l) carried out at the trust between July and November 2010 and excluded patients with known hypogonadism or prostate cancer. First 50 cases were evaluated in detail. Investigation results were retrieved using electronic records and clinic letters.
Results: In total, 247 cases with low TT were identified. Among 50 patients (mean age 63, range 3494 years) 84% (42/50) had a valid indication for measurement. Mean time (±S.D.) of measurement was 11:18am±142 min. Fifty-eight per cent (29/50) had a confirmatory repeat measurement, 42% (21/50) had sex hormone-binding globulin measured and 52% (26/50) had gonadotropins measured, of which 69.2% (18/26) were low/normal and 26.9% (7/26) were high. Of those with low/normal gonadotropins, 50% (9/18) had complete pituitary function testing (cortisol, prolactin, free thyroxine). Testosterone replacement therapy was commenced in 44% (22/50). Pre-treatment, 45.5% (10/22) had PSA, 27.3% (6/22) had liver function, and 27.3% (6/22) had haematocrit measured. Within six months after starting treatment, 86.4% (19/22) were reviewed in clinic, 63.6% (14/22) had repeat TT and 50% (11/22) had repeat haematocrit.
Conclusion: There are pitfalls in our current practice in both diagnosis and assessment of hypogonadism. Morning TT is measured later than recommended and often not repeated, resulting in potential over-diagnosis. Lack of gonadotropin measurement has serious implications for missing potential aetiology. Pre-treatment assessment and treatment monitoring must be improved to ensure patient safety. We are currently writing trust guidelines to address these issues.