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Testosterone is the androgenic hormone primarily responsible for normal growth and development of male sex and reproductive organs, including the penis, testicles, scrotum, prostate, and seminal vesicles. Testosterone facilitates the development of secondary male sex characteristics such as musculature, bone mass, fat distribution, hair patterns, laryngeal enlargement, and vocal chord thickening. Additionally, normal testosterone levels maintain energy level, healthy mood, fertility, and sexual desire.
Testosterone production declines with age. Testosterone deficiency (TD) may result from disease or damage to the hypothalamus or pituitary gland, or from the testicles themselves. This condition is known as hypogonadism. Depending on age, insufficient testosterone production can lead to abnormalities in muscle and bone development, underdeveloped genitalia, and diminished virility.
The testes produce testosterone regulated by a complex chain of signals that begins in the brain. This chain is called the hypothalamic-pituitary-gonadal axis. The hypothalamus secretes gonadotropin-releasing hormone (GnRH) to the pituitary gland in carefully timed pulses (bursts), which triggers the secretion of leutenizing hormone (LH) from the pituitary gland. Leutenizing hormone stimulates the Leydig cells of the testes to produce testosterone. Normally, the testes produce 4–7 milligrams (mg) of testosterone daily.
Hypogonadsim is classified by the location of its cause along the hypothalamic-pituitary-gonadal axis:
Disease, injury, surgery, and drug side effects can cause hypogonadism and testosterone deficiency.
Hypogonadism may be congenital or acquired depending on the nature of the underlying condition.
Congenital causes include the following:
Acquired causes include the following:
Congenital hypogonadism is generally characterized by underdeveloped genitalia (testes that do not descend into the scrotum) and, occasionally, undeterminable genitalia.
Hypogonadism developed near puberty can result in gynecomastia (enlargement of breast tissue), sparse or absent pubic and body hair, and underdeveloped penis, testes, and muscle.
Adult men may experience diminished libido, erectile dysfunction, muscle weakness, loss of body hair, depression, and other mood disorders.
Treatment involves hormone replacement therapy. The method of delivery is determined by age and duration of deficiency.
Treatment for adults is aimed at maintaining secondary sex characteristics, improving energy, strength, mood, and feelings of well-being, and preventing bone degeneration. Modes of delivery include transdermal or intramuscular injection.
Transdermal delivery (through the skin) with a testosterone patch or gel is becoming the most common method of treatment for testosterone deficiency in adults. It establishes and maintains adequate serum levels in as many as 92% of men treated, without causing significant side effects.
INTRAMUSCULAR INJECTION (IM)
Intramuscular injection (IM) is used less frequently because it is associated with erratic testosterone levels. The primary adverse effect associated with injected testosterone involves fluctuating mood, energy level, and libido caused by testosterone levels that rise rapidly upon injection and then fall too low before the next dose.
One of the long-term treatment options is the insertion of subcutaneous pellets called Testopel®. This is done with a short 3 minute procedure in the office every 4 months for most patients.