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Hormone balance at the ballet barre
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A 66-year-old man is referred for hypogonadism by his primary care doctor. He complains of decreased libido, complete erectile dysfunction, fatigue and weight gain for more than 10 years. His symptoms worsened after a procedure involving the prostate approximately 1 year before the visit. The patient was told that he had low testosterone several years ago, but was never treated for hypogonadism.
He has recently undergone cervical spine surgery for spinal stenosis and is taking opioids for pain.
Ronald Tamler
The patient shaves once a day, entered puberty at approximately age 12 years; no changes in body hair, not complaining of gynecomastia.
The patient is not trying for children, never tried testosterone therapy, denies anabolic steroid use and tried sildenafil for erectile dysfunction treatment in the remote past with good results.
Lifestyle includes a “high-protein” diet, in general, and no regular exercise other than dancing as part of his work as a ballet instructor.
Medical history includes: chronic hepatitis C, hypothyroidism, gastroesophageal reflux disease, herpes simplex virus infection, hypertension, depression, gout, insomnia, shortness of breath, myelopathy, heart murmur, remote history of alcohol abuse, erectile dysfunction and cervical herniated disc.
He has no known allergies and is single. The patient has never smoked, drinks about seven alcoholic beverages per week and has no history of recreational drug use. Family history is remarkable for stroke in the father and heart attack in the mother.
Outpatient prescriptions include:
- Furosemide 20-mg twice daily;
- Hydromorphone 2-mg every 4 hours as needed for pain;
- Fentanyl 12-mcg/hour patch, one patch to skin every 72 hours;
- Lidocaine 5% (700 mg/patch) patch, one patch to (right lower back) every morning;
- Valacyclovir 1-g tablet twice daily;
- Zolpidem 5 mg nightly as needed;
- Levothyroxine 50 mcg, eight tablets per week;
- Nebivolol (Bystolic, Forest Labs) 40 mg daily;
- Ranitidine 150 mg twice daily;
- Amlodipine 5 mg daily;
- Duloxetine (Cymbalta, Eli Lilly) 60 mg daily;
- Allopurinol 300 mg daily;
- Alfuzosin 10 mg daily;
- Aspirin 81 mg daily;
- Acetaminophen/codeine (300 mg/30 mg) four times daily as needed.
The patient has a blood pressure of 111 mm Hg/65 mm Hg, pulse 67, height 5’3”, weight 77 kg (approximately 171 lb). Estimated BMI is 30.36.
The patient has mild gynecomastia, phallus is normal in shape and size, normal male-pattern pubic hair distribution, testicular size approximately 20 mL R, 25 mL L. Rectal exam: normal sphincter tone, small soft prostate, no palpable nodules. There are fresh scars at the nape of the neck and suprasternal after recent spinal surgery.
The patient brings in a recent lab report with a total testosterone of 222 ng/dL (drawn in the afternoon).
A morning hormone profile after tapering off opioid medications shows: total testosterone low at 200 ng/dL, free testosterone low at 38 pg/mL, luteinizing hormone at 6.3 mIU/mL, follicle-stimulating hormone at 5.8 mIU/mL, estradiol at 30 pg/mL, dehydroepiandrosterone sulfate (DHEA-S) low at 21 mg/dL, TSH elevated at 5.8 mIU/L, free T4 at 0.9 ng/dL, prolactin at 13 ng/mL, IGF-I low at 84 ng/mL, prostrate-specific antigen at 0.8 mg/dL.
Case Discussion
The levothyroxine dose is adjusted. Which of the following should be considered as the best initial step to restore the patient’s gonadal function?
A. DHEA over-the-counter 25 mg twice a day
B. Testopel (Slate Pharmaceuticals) 75 mg, eight pellets implanted (subcutaneously) every 4 months
C. Androderm (Watson Pharmaceuticals) 4-mg patch applied to skin daily
D. Human chorionic gonadotropin (hCG) 1,500 IU injected intramuscularly twice a week
E. AndroGel (AbbVie) 1%, 5 g applied to skin daily
Answer: A
Patients should not be assessed for hypogonadism in acute stress situations because testosterone levels may be temporarily suppressed, especially when patients are in pain and are requiring opiates. I asked the patient to get a morning sex hormone profile a month after the visit, when he was off pain medication.
Testopel, Androderm and AndroGel are examples of testosterone supplementation products and would not restore the patient’s own gonadal function. HCG would promote the patient’s own testicular function, but can be cumbersome to administer. DHEA is a precursor for testosterone. Its circulating sulfate is representative of DHEA status. Occasionally, I find that patients presenting for hypogonadism have low DHEA-S levels — this can be due to a variety of reasons, and merits further adrenal and testicular workup. In the meantime, DHEA supplementation in these rare cases may boost the patient’s testosterone levels. It is available OTC as an oral preparation at relatively low cost.However, one has to consider that nutritional supplements are not as tightly regulated as medications and may contain impurities or less than the advertised amount of the main ingredient.
In this case, the patient’s testosterone almost doubled, to 388 ng/dL, with a DHEA-S level at 287 mg/dL (a bit higher than the normal range), along with good improvement in energy level and libido. While one could also interpret this result as a testosterone rebound after recovering from the stress of surgery and opioid treatment, his reported low testosterone results from over the years make that explanation less likely.