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Heart of the Matter: Hypogonadism Management With Testosterone Therapy

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Allen D. Seftel, MD
Head, Division of Urology
Cooper University Hospital
Professor of Urology
Robert Wood Johnson School of Medicine
Camden, New Jersey

Adrian S. Dobs, MD, MHS
Professor of Medicine and Oncology
Johns Hopkins University School of Medicine
Division of Endocrinology and Metabolism
Baltimore, Maryland

Robert A. Kloner, MD, PhD
Professor of Medicine
Division of Cardiovascular Medicine
Keck School of Medicine of the University of Southern California
Director of Research, Heart Institute
Good Samaritan Hospital
Los Angeles, California

Martin M. Miner, MD
Director, Men's Health Center
Miriam Hospital
Clinical Associate Professor of Family Medicine and Urology
Warren Alpert Medical School of Brown University
Providence, Rhode Island

Urologists, endocrinologists, primary care physicians, and other healthcare professionals interested in the management and treatment of hypogonadism.

Hypogonadism is an underdiagnosed and therefore undertreated condition of men that can be associated with serious comorbid conditions. In light of these facts, screening, recognition, and treatment should be encouraged for any provider seeing men who are at risk.

Extrapolation of 2003 census data suggests that 13.8 million men aged ≥45 years visiting primary care physicians in the United States may have low testosterone levels, yet fewer than 10% of these men are being treated. In the Boston Area Community Health (BACH) survey, only 12.2% of all androgen-deficient men were being treated despite adequate access to healthcare.

Reported prevalences vary among studies depending on the population being studied, the definition of hypogonadism used, and the methodology, however, hypogonadism is becoming increasingly prevalent with the aging of the US population. The overall prevalence of hypogonadism was reported to be 6% at baseline in data from the Massachusetts Male Aging Study (MMAS). Of the 1691 men in that study for whom complete testosterone data were available at baseline, 561 were aged 40 to 49 years, 558 were aged 50 to 59, and 572 were aged 60 to 70. During the follow-up phase (n=1087; mean follow-up interval, 8.8 y; range, 7.0-10.4 y), the overall prevalence doubled to 12.3%. In data from the BACH survey, the reported prevalence of hypogonadism was 5.6% (N=1475; mean age, 47.3 y).

It is critical to recognize the signs and symptoms of hypogonadism prior to choosing appropriate interventions. Hypogonadism is associated with an array of signs and symptoms, many of them subtle and nonspecific, and with several serious comorbid conditions, such as diabetes and osteoporosis. In addition, mounting evidence indicates that low testosterone levels are associated with premature cardiovascular disease, cardiovascular events, and cardiac death, as well as increased all-cause mortality. In a well-designed population-based study of men aged 50 to 91 years (mean, 73.6 y), Laughlin et al found a >40% increased risk of mortality among men in the lowest quartile of total testosterone or bioavailable testosterone compared with the highest quartile. Despite compelling evidence, many clinicians are not aware of the connections between testosterone, comorbid conditions, and overall health.

At the conclusion of this activity, participants should be better able to:
• Define hypogonadism as a significant, chronic medical condition that is associated with obesity, metabolic syndrome, diabetes, dyslipidemia, hypertension, frailty, and cardiovascular disease and may lead to increased morbidity
• Examine current data on the relationship between cardiovascular disease and serum testosterone concentrations demonstrating that a causal relationship has not been established, and recognize that testosterone therapy may be safely initiated
• Determine appropriate therapy to address patient needs by differentiating between testosterone formulations currently available and in development
• Realize that a critical component of the overall health of men is eugonadal testosterone levels

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Annenberg Center for Health Sciences at Eisenhower and CogniMed Inc. The Annenberg Center is accredited by the ACCME to provide continuing medical education for physicians.

The Annenberg Center designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

There is no charge for this activity. Statements of Credit will be provided by mail following activity participation and upon completion and electronic submission of the posttest and evaluation form to CogniMed Inc. A link to the evaluation form is provided upon completion of the activity. Please allow 4 to 6 weeks for the delivery of your statement.

It is the policy of the Annenberg Center to ensure fair balance, independence, objectivity, and scientific rigor in all programming. All faculty and planners participating in sponsored programs are expected to identify and reference off-label product use and disclose any significant relationships with those supporting the activity or any others whose products or services are discussed. The faculty for this activity have disclosed that there may be discussion about the use of products for non–FDA-approved applications.

In accordance with the Accreditation Council for Continuing Medical Education standards, parallel documents from other accrediting bodies, and Annenberg Center policy, the following disclosures have been made:

All staff at the Annenberg Center for Health Sciences at Eisenhower have nothing to disclose.

All staff at CogniMed Inc. have nothing to disclose.

Allen D. Seftel, MD, is a consultant for Auxilium Pharmaceuticals, Inc.; Eli Lilly and Company; Pfizer Inc; Sanofi-Aventis; and Solvay Pharmaceuticals, Inc., and serves on the speakers bureau of Eli Lilly and Company.

Adrian S. Dobs, MD, MHS, receives research support from the National Institutes of Health and Takeda Pharmaceutical Company Limited.

Robert A. Kloner, MD, PhD, has consulted in an unpaid capacity for and has served on the speakers bureau of Pfizer Inc.

Martin M. Miner, MD, receives research support from Auxilium Pharmaceuticals, Inc., and Indevus Pharmaceuticals, Inc. He is a consultant for GlaxoSmithKline/Schering-Plough Corporation and Sanofi-Aventis.

The ideas and opinions presented in this educational activity are those of the faculty and do not necessarily reflect the views of the Annenberg Center and/or its agents. As in all educational activities, we encourage the practitioners to use their own judgment in treating and addressing the needs of each individual patient, taking into account that patient’s unique clinical situation. The Annenberg Center disclaims all liability and cannot be held responsible for any problems that may arise from participating in this activity or following treatment recommendations presented.

This activity will address professional practice gaps in knowledge.

This program may contain discussion of investigational uses of pharmacologic and nonpharmacologic therapies. Individual clinical judgments should be used in all patient care decisions.

This event was not part of the AUA 2011 Annual Meeting.

This activity is an enduring material and consists of a Web posting. Successful completion is achieved by viewing the material, reflecting on its implications in your practice, and completing the assessment component.

The estimated time to complete this activity is 1.5 hours.

This activity was originally released July 22, 2011, and is available for credit through July 22, 2012.

Jointly sponsored by the Annenberg Center for Health Sciences at Eisenhower and CogniMed Inc.

This activity is supported by an independent educational grant provided by Abbott Laboratories, Eli Lilly and Company, and Endo Pharmaceuticals.