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One size does not fit all when treating hypogonadism
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A 55-year-old white male presented for an initial evaluation of erectile dysfunction.
He noticed his first bout of erectile dysfunction (ED), along with low libido, approximately 2 years before the visit. Total testosterone was reported to be in the low 200s at the time; however, erectile function improved after supplementation of vitamins D and B by his primary care physician.
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The patient began to notice ED again 3 months before the visit. It responded to Tadalafil (Cialis, Lilly) 20 mg, as needed, and he was no longer complaining of ED after using the medication three times at 2 weeks before the visit. He reported average libido but was concerned whether the ED may return. As an orthodox Jew, the patient observes a period of abstinence 2 weeks every month for religious reasons.
He shaves once a day; went through puberty at age 11 years; denied changes in body hair, a history of fracture or gynecomastia and reported intentional weight loss of 18 lb during the past year due to dietary changes.
His cardiovascular risk factors included male gender. His Sexual Health Inventory for Men (SHIM) score was 17 of 25.
Medications include:
- Cholestyramine (Questran oral).
- Cholecalciferol, vitamin D3 (vitamin D, 2,000 unit, oral caplet).
- Vitamin B complex (oral).
- Multivitamin (oral).
Other medical history consisted of cholecystectomy, appendectomy, tonsillectomy, rosacea, migraine headaches and volvulus of the short bowel. He never smoked cigarettes, rarely drinks alcohol and works as a lawyer. His family history is unremarkable.
Pertinent physical exam revealed: blood pressure 114 mm Hg/74 mm Hg, pulse 72, height 1.753 m (5' 9"), weight 74.1 kg (163 lb 8 oz). No gynecomastia; phallus normal in shape and size; normal male-pattern hair distribution and testicular size approximately 18 mL bilaterally. His skin was warm and dry, and his facial and perinasal efflorescence was consistent with rosacea.
His labs revealed:
- Total testosterone: 278 ng/dL.
- Free testosterone: 3.5 ng/dL.
- Luteinizing hormone: 4 mIU/mL.
- Follicle-stimulating hormone: 3.4 mIU/mL.
- Estradiol: 11.4 pg/mL.
- Prolactin: 3.9 ng/mL.
Additionally, an MRI of the pituitary was read as normal.
The patient was diagnosed with idiopathic secondary hypogonadism and started on 5 g testosterone (Testim gel, Auxilium Pharmaceuticals) applied to skin daily. Three days later, he called to report improved energy level, libido and erectile function. However, he was concerned because his rabbi advised him that he was not allowed to apply gel on the holy Sabbath and Jewish holidays for religious reasons.
Based on this restriction, which treatment option is the least likely to be acceptable to this patient?
A. Striant buccal system (Actient Pharmaceuticals) 30 mg every 12 hours, applied to the upper gum.
B. Androderm (Watson Labs) 4 g patch, applied to skin daily.
C. AndroGel 1% (Abbott) 5 g, applied to skin daily.
D. Testosterone cypionate 80 mg, weekly intramuscular injection.
E. Testopel (Slate Pharmaceuticals) 75 mg, subcutaneous insertion of six pellets every 4 months.
CASE DISCUSSION:
Answer: C
This patient was advised not to use a gel, even in its therapeutic role, based on the concept of memahek (the act of spreading or smoothing). This rule leads many observant Jews to avoid cosmetics and lotions on Jewish holidays and Shabbat. Although exceptions are obviously made for severe or acute illnesses, this patient’s rabbi felt that testosterone supplementation for hypogonadism was not in that category. Rather than have a religious argument, I chose to work around it. This case highlights the tremendous arsenal we now have at our disposal to successfully treat male hypogonadism. With the exception of AndroGel, all these options were acceptable to the patient. In the end, the patient’s preference was to stay on Testim 6 days a week and to apply an Androderm patch 4 g on Jewish holidays and Saturdays.
Ronald Tamler, MD, PhD, MBA, is clinical director of the Mount Sinai Diabetes Center in New York. He is also an Endocrine Today Editorial Board member.
Disclosure: Dr. Tamler reports that he has received research support from Abbott.