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Tired of love
This patient was initially introduced in a past issue of Endocrine Today, and we are following him again for his next challenge.
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This 46-year-old man was diagnosed with secondary hypothyroidism in the setting of panhypopituitarism and an empty sella. In a second case challenge, we identified an elevated serum testosterone level from a compromised blood draw. He is now returning for follow-up and is presenting the next challenge.
To recapitulate, he had been diagnosed with adrenal insufficiency four years ago after loss of consciousness and admission to the hospital for hyponatremia. The patient started noticing erectile dysfunction, as well as testicular shrinkage, hot flashes and loss of body hair about one year ago and was started on testosterone gel, prednisone and later levothyroxine. Labs were drawn before this visit. The patient is accompanied by his wife.
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Since his diagnosis and adequate treatment, the patient has been feeling much better. However, he describes flu-like symptoms and episodes of profound fatigue that used to occur approximately once per week. He noticed that symptoms would typically occur the day after engaging in relations with his wife, and he has remained free of symptoms since they ceased relations eight weeks before the visit. He describes good libido, mild erectile dysfunction and is not using a phosphodiesterase type 5 inhibitor. His weight has been stable since an initial weight loss of 50 lb at the time of diagnosis with adrenal insufficiency. The couple is unhappy that sexual relations have ceased completely.
Other medical history includes ulcerative colitis (quiescent), peptic ulcer disease, scabies, sinusitis and removal of anal fissure.
Medications include: mesalamine; prednisone 5 g in the morning and 2.5 g at night; testosterone gel 5 g daily (AndroGel 1%, Solvay Pharmaceuticals) and levothyroxine 75 mcg daily.
The patient has no known drug allergies, is married and is not trying for children. He denies use of tobacco, alcohol or recreational drugs.
Physical exam is unremarkable, unless indicated otherwise: blood pressure 122/82 mm Hg, pulse 68, weight 199 lb; no gynecomastia; phallus normal in shape and size; decreased urogenital hair in female pattern distribution; testicles small at about 5 mL bilaterally.
Labs indicate: total testosterone 835 ng/dL; thyroid-stimulating hormone 0.24 mIU/L (low); free T4 0.8 ng/dL (normal); and insulin-like growth factor I 103 ng/mL.
What is the next best step to help this patient with fatigue and self-prescribed celibacy?
A. Advise the couple to continue the current regimen of abstinence because it is working and the patient has no further symptoms.
B. Start growth hormone supplementation.
C. Advise the patient to take sildenafil (Viagra, Pfizer) 100 mg, as needed.
D. Advise the patient to take 1 mg prednisone one hour before anticipated relations.
E. Increase the patient’s transdermal testosterone dose to 7.5 g daily.
CASE DISCUSSION:
Answer: D
This is a man with panhypopituitarism who, in general, is doing well on supplementation with glucocorticoids, thyroid hormone and testosterone. All of these levels appear to be appropriate, and the total testosterone level is even on the high side. A dose increase to 7.5 g would therefore be the wrong answer (E). However, the lack of sexual relations is clearly weighing on the couple, and abstinence appears to be a hard choice for both (A). The patient only describes mild erectile dysfunction when engaging in relations. Although he was offered sildenafil, it does not address the actual problem, which is the profound fatigue and flu-like symptoms the day after relations (C). GH supplementation has been shown to be useful in patients with panhypopituitarism, and this patient clearly would qualify for treatment with GH. Although the treatment was discussed at this visit, it would not address the couple’s primary concern either (B).
In the end, I felt that he was so taxed by engaging in vigorous sexual relations with his wife that I recommended prednisone 1 mg, as needed, one hour before anticipated relations. Three weeks later, I received an e-mail from the patient that confirmed improved well-being the day after having relations whenever he took an additional 1 mg of prednisone. When the patient returned for follow-up and we were going over his medication list, I noticed that he was taking the additional 1 mg virtually every day.
His wife’s smile answered all questions.
Ronald Tamler, MD, PhD, MBA, is Assistant Professor in the Division of Endocrinology at Mount Sinai School of Medicine, N.Y.