Page 16 - Journal of Special Operations Medicine - Fall 2015

Evaluation for Testosterone Deficiency

Robert Grumbo, MD, FAAFP; David Haight, MD

ABSTRACT
There has been a recent increase in the number of Oper- examination, he notes that he is having a harder time
ators presenting to clinics for evaluation of possible low physically keeping up with the rest of his team. He
testosterone. In response, USASOC recently released an works out regularly, but he does not have the energy he
Androgen Deficiency Clinical Practice Guideline (CPG) used to have in the gym. Despite getting 6 to 7 hours of
to help guide providers through the initial evaluation sleep per night, he just does not feel like he has enough
and treatment of patients. The diagnosis of hypogonad- energy during the day to keep up with his work require-
ism is based on consistent signs and symptoms of andro- ments. He also notes that he has intermittent problems
gen deficiency and unequivocally low serum testosterone with maintaining an erection despite having a strong
(below 300ng/dL). Testosterone levels can change for a libido. He is concerned that he has a low testosterone
variety of reasons and an adequate evaluation requires level and wants to be evaluated.
multiple laboratory tests over a period of time. If a di-
agnosis of hypogonadism is confirmed, differentiating Patient presentations such as this are becoming more
between primary and secondary hypogonadism can help common in the Special Operations community. Opera-
guide further care. Testosterone replacement therapy tors are often competitive by nature and will go to ex-
options are available, but careful monitoring for side- tremes to make themselves faster, stronger, and better.
effects is required. Controversy still exists surrounding Androgen deficiency, sometimes referred to as “low T”
the safety of testosterone replacement therapy, and re- or “low testosterone,” is rare in the Active Duty age
ferral to endocrinology should strongly be considered range, but recent direct-to-consumer advertising sug-
before initiating treatment. gests that many younger individuals might have a tes-
tosterone deficiency that can derail their hard work.
Keywords: testosterone, deficiency; hypogonadism; “low T” As a result, many more Operators are presenting to
clinics to be evaluated for low testosterone. USASOC
recently released an CPG in October 2014 to help pro-
viders with an evaluation that is often not straightfor-
Introduction
ward (Figure 1). The diagnosis of androgen deficiency
1
Testosterone deficiency has become an increasingly requires consistent signs and symptoms of androgen
common concern in our patient population. With jobs deficiency and unequivocally low serum testosterone
that require peak performance in demanding environ- levels. 1,2
ments, it is no surprise that patients are presenting to
clinics to be evaluated for testosterone deficiency. It is Hypogonadism in men is defined as a clinical syndrome
important for providers to be able to address patients’ that results from failure of the testes to produce physi-
concerns with a thorough evaluation based on a broad ological levels of testosterone (androgen deficiency) and
understanding of the pathophysiology involved with the normal number of spermatozoa due to disruption of
this disease process. Fortunately, there are well-written one or more levels of the hypothalamic-pituitary-gonadal
guidelines that can help guide providers through this axis. Depending on where the disruption occurs, the
1,2
process. A better understanding of testosterone defi- hypogonadism can be either primary or secondary. Pri-
ciency is necessary to make this important diagnosis in mary hypogonadism is defined as a failure of the testes to
some patients, while also avoiding overdiagnosing other produce adequate levels of testosterone despite adequate
patients without true pathology. levels of gonadotropins. Secondary hypogonadism oc-
curs when the hypothalamus or pituitary fail to produce
adequate levels of gonadotropins to stimulate the testes
Case Presentation: Fatigue
to produce testosterone. Whether the man has primary
A 38-year-old Operator presents to sick call with a chief or secondary hypogonadism, the end result is insufficient
complaint of fatigue for the past 6 months. During the testosterone resulting in a variety of clinical symptoms.

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