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Normal LH or FSH levels with low testosterone suggest primary defects in the hypothalamus and/or the pituitary (secondary hypogonadism). In secondary hypogonadism (hypogonadotropic hypogonadism), defects in the hypothalamus or pituitary result in low testosterone levels because of insufficient stimulation of the Leydig cells. If the total testosterone level is normal in the aging male presenting signs of hypogonadism, the clinician can measure free testosterone or measure SHBG and calculate bioavailable testosterone.9
In particular, research has questioned the validity of commonly administered assays of free testosterone by radioimmunoassay. A position statement by the Endocrine Society expressed dissatisfaction with most assays for total, free, and bioavailable testosterone. Hypogonadism is often discovered during the evaluation of delayed puberty, but ordinary delay, which eventually results in normal pubertal development, wherein reproductive function is termed constitutional delay. Contrast with a young woman or teen, who would have hypogonadism rather than menopause.
Large randomised trials using men with and without cardiovascular disease and with cardiovascular end-points are needed to better assess the consequences of testosterone treatment on cardiovascular risk (36). Human observational studies, however, have shown no associations between high testosterone levels and coronary artery disease, and testosterone has been shown to dilate the coronary arteries both in vitro and in vivo. In fact, the increased risk of cardiovascular disease in males compared with females has been taken to imply a role for testosterone (or oestrogen) in the disease. It is not yet understood whether the low testosterone levels are a consequence of the disease, are connected with the disease’s aetiology, or are one of the causes of the disease. As discussed below, a measurement of low testosterone in a patient should be reconfirmed at a later stage before considering treatment. A subject can have low testosterone levels, but can also have no clinically significant symptomatology.
Some patients show parallel variations in breast tenderness, sexual activity, emotional stability (anger or depression) and general well-being (fatigue) as the testosterone levels change over time. We therefore recommend that you should consider free testosterone or BAT measurements in all men other than healthy lean young men (whose SHBG levels are presumably normal and whose measured total testosterone concentration is reliable). SHBG levels are easily affected by many conditions, so total testosterone measurements can therefore be misleading indicators of hypogonadism. The clinical practice guidelines by the Endocrine Society (2) and the AACE (3) suggest that physicians should measure the testosterone levels of men with any of the symptoms and signs outlined in Table 5. However, studies of testosterone therapy in men with osteoporosis are limited and none have used fractures as an end-point; so although there is significant evidence of an association between hypogonadism and osteoporosis, there is no established causal link between the two. The withdrawal of testosterone therapy in hypogonadal patients that had been stabilised on this therapy leads to an increase in insulin resistance within 2 weeks and prior to significant weight gain (59).
In addition, if you are planning fertility, you should not use testosterone therapy. There are many different types of testosterone therapy. These should be addressed before testosterone therapy is contemplated. This might include additional blood tests, and sometimes imaging such as a pituitary MRI.
The signs and symptoms depend on the stage at which the patient presents with hypogonadism in relation to sexual maturity. It is also known as hypogonadotrophic hypogonadism due to low levels of LH and FSH resulting in decreased testosterone production. Secondary hypogonadism occurs when signalling to the testis is unable to stimulate sufficient testosterone production and is caused by conditions affecting the function of the hypothalamus and/or pituitary gland.

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