Testing times with testosterone- a review of testosterone regimens in a 43 year old man.
Mhairi Bolland and Hannah Barnsley, Sagen Zac-Varghese, Jeremy Cox.
Mr SF, a 43yr old man presented to the endocrine clinic for a review of his treatment for pituitary insufficiency. He had been diagnosed with a cystic pituitary macroprolactinoma causing panhypopituitarism. This had been picked up at the age of 39 when Mr SF was undergoing a colonoscopy for his ulcerative colitis and was found to have no pubic or axillary hair prompting an endocrine referral.
His medications included levothyroxine, hydrocortisone and testosterone gel.
He was dissatisfied with the testosterone regimen (1 sachet testogel daily), still experiencing deficiency symptoms such as erectile dysfunction, but also complaining of features consistent with overtreatment including increased libido and difficulty in managing aggression. This had caused difficulties at work.
Testosterone gels are usually an effective treatment for testosterone replacement. In this case, the patient admitted to irregular compliance, then compensating by taking 5-6 sachets prior to seeing his partner. A previous testosterone day curve on tostran 40 mg per day had shown low morning levels of testosterone, but supraphysiological levels 6 hours later of 51.6 nmol/l. In order to regain some control over his level of replacement, we suggested 3 monthly injections of testosterone (Nebido 1g IM).
Lessons learned from this case are:
1- Testosterone gels may not have an even time-couse of action.
2- Compliance may cause further loss of stability of action and possible adverse effects of temporary excess of testosterone should be considered.
3- Increased surveillance may be necessary for such patients.