This article serves as a primer for primary care NPs, based on current guidelines, to provide evidence-based care for men with hypogonadism, offering an overview of etiology, clinical presentation, diagnostic criteria, and treatment options.
Key Findings
Background
Hypogonadism is characterized by inadequate testosterone production and requires confirmed low testosterone levels plus clinical symptoms for diagnosis.
Diagnosis requires two morning fasting total testosterone measurements below the normal range, typically defined as less than 300 ng/dL
Symptoms include decreased libido, erectile dysfunction, fatigue, decreased muscle mass, increased body fat, mood changes, and decreased bone density
Primary hypogonadism originates from testicular failure, while secondary hypogonadism results from hypothalamic or pituitary dysfunction
Testing should be performed between 7 AM and 11 AM when testosterone levels are at their peak
Methods
Multiple testosterone replacement therapy formulations are available, each with distinct administration routes, dosing schedules, and clinical considerations.
Available formulations include intramuscular injections (testosterone cypionate and enanthate), transdermal gels and patches, buccal systems, subcutaneous pellets, and intranasal gel
Intramuscular testosterone cypionate is typically dosed at 100-200 mg every 1-2 weeks
Transdermal gels are applied daily and carry a risk of transference to others through skin contact
Subcutaneous pellets are inserted every 3-6 months and offer the advantage of sustained hormone delivery without daily administration
Results
TRT carries several contraindications and potential adverse effects that primary care NPs must monitor.
Absolute contraindications include prostate cancer, breast cancer, elevated hematocrit greater than 54%, and untreated severe obstructive sleep apnea
TRT suppresses the hypothalamic-pituitary-gonadal axis, resulting in reduced sperm production and potential infertility
Polycythemia is a significant risk, requiring monitoring of hematocrit levels at baseline and periodically during treatment
Other potential adverse effects include acne, oily skin, fluid retention, gynecomastia, and mood changes
Results
Laboratory monitoring at defined intervals is recommended for men receiving testosterone replacement therapy.
Total testosterone levels should be measured 3-6 months after initiating therapy and then annually once stable
Hematocrit should be checked at baseline, at 3-6 months, and then annually
Prostate-specific antigen (PSA) and digital rectal exam should be performed at baseline and monitored per guidelines
Bone mineral density testing is recommended for men with osteoporosis or low-trauma fractures
Discussion
Primary care nurse practitioners play an essential role in identifying, diagnosing, and managing hypogonadism in men.
NPs must distinguish between primary and secondary hypogonadism, as treatment approaches differ
A thorough history and physical examination including assessment of testicular size, body hair distribution, and gynecomastia are essential components of evaluation
NPs should assess for modifiable contributing factors such as obesity, metabolic syndrome, type 2 diabetes, and medication use before initiating TRT
Referral to endocrinology or urology may be warranted for complex cases or when secondary hypogonadism is suspected
Gallegos J. (2024). Testosterone replacement therapy for hypogonadism: A primer for primary care.. The Nurse practitioner. https://doi.org/10.1097/01.NPR.0000000000000210