Question of the week # 287

287) A 38 year old caucasian man  is seen in the office due to decreased libido and energy. His past medical history is significant for testicular cancer diagnosed 1 year ago and was treated with radical orchiectomy of left testicle and chemotherapy. He denies smoking tobacco but admits using Marijuana on a daily basis for the past few months. His family history is unremarkable.  Physical examination  reveals gynecomastia and absent left testicle. Body mass index is 24.  His routine laboratory investigations including complete blood count are within normal limits. Serum total testosterone level is reduced and Serum LH concentration is elevated. The patient is started on Testosterone replacement therapy with a testosterone skin gel. Which of the following is the most appropriate step in follow up care of  this patient after starting testosterone therapy?

A) Digital Rectal exam and Serum PSA level at one year

B) Hematocrit at 6 months and then, every year

C) DEXA scan at one year

D) Serum Testosterone level at 6 months

E) Serum LH at one month.

12 Responses

  1. B. Hematocrit at 6 months and then, every year. You’re screening for polycythemia. Increased RBC mass mas increase likelihood of thromboembolic events.

  2. Or D, the obvious – just to ensure that his levels improve.

  3. io think its a because increase level of testosterone can cause prostate cancer or hyperplasia

  4. I will go for D. Check Testosterone levels at 6 months.

  5. E.. We need to check the responce, how much the LH going to the normal level. Always testosterone in blood is going to be normal o high on blood, because he is in Testosterone therapy. Increase level of testosterona cause prostata cancer or hyperplasia? no, only if we use for long period of time and….other risk factors. The most important risk factor for cancer, any cancer, is the age. Anybody has seeing a prostata cancer adenocarcinoma in a child? even with the most high level of testosterone. Of course we can see cancer at early age, lekemia, lymphomas, others, but gen mutation are involved in those cancers more than anythings.

  6. bbb

  7. C -deXa at 1 year most of the other monitorin like hct and testestrone level are every 3 ,6 months then every year .PSA 3,6 month then individualized. The correct from the list is C= DeXa

  8. The Task Force recommends evaluating the patient 3 to 6 months after treatment initiation and then annually to assess whether symptoms have responded to treatment and whether the patient is suffering any adverse effects, and to check compliance. (1 | +OOO)

    The Task Force suggests monitoring testosterone levels 3 to 6 months after initiation of testosterone therapy. The Task Force suggests aiming at achieving serum testosterone levels during treatment in the mid-normal range. In men receiving testosterone enanthate or cypionate, the Task Force suggests aiming for testosterone levels between 400 and 700 ng/dl one week after the injection. (2 | ++OO)

    The Task Force recommends determining hematocrit at baseline, at 3 to 6 months, and then annually. If hematocrit is >54%, stop therapy until hematocrit decreases to a safe level, evaluate the patient for hypoxia and sleep apnea, and reinitiate therapy at a reduced dose. (1 | +OOO)

    The Task Force suggests repeating bone mineral density of the lumbar spine, femoral neck, and hip after 1 to 2 years of testosterone therapy in hypogonadal men with osteoporosis or low trauma fracture. (2 | +OOO)

    In men 40 years of age or older who have a baseline PSA >0.6 ng/ml, the Task Force recommends digital examination of the prostate and PSA measurement before initiating treatment, at 3 to 6 months, and then in accordance with evidence-based guidelines for prostate cancer screening, depending on the age and race of the patient. (1 | +OOO)

    The Task Force recommends that clinicians obtain urological consultation if there is: (1 | +OOO)

    An increase in serum or plasma PSA concentration greater than 1.4 ng/ml within any 12-month period of testosterone treatment.
    A PSA velocity of more than 0.4 ng/ml·yr using the PSA level after 6 months of testosterone administration as the reference. PSA velocity should be used only if there are longitudinal PSA data for more than 2 years.
    Detection of a prostatic abnormality on digital rectal examination.
    American Urological Association/International Prostate Symptom Score >19.
    The Task Force recommends evaluation for symptoms and signs of formulation-specific adverse events at each visit: (1 | +OOO)

    Injectable testosterone esters: Inquire about fluctuations in mood or libido, and cough after injection, and evaluate hematocrit to detect excessive erythrocytosis, especially in older patients.
    Testosterone patch: Look for signs of skin reaction at the application site.
    Testosterone gels: Advise patients to cover the application site with clothing and wash the skin before having skin-to-skin contact, because gels leave a residue of testosterone on the skin that can be transferred to a woman or child who comes in close contact.
    Buccal testosterone tablets: Inquire about alterations in taste and examine gums and oral mucosa for irritation.
    Answer D) confirm the testosterone level first and then check for the side effect.

  9. E) The pt presents with decreased libido due to hypogonadism from the cancer treatment (evidenced in the question by Serum total testosterone level is reduced and Serum LH concentration is elevated). To treat the hypogonadism testosterone therapy is started, the best way to know if the hyponadism is responsive to teatment is to test for LH in a month (more like how you want to test TSH for hypothyroidism instead of T4)

  10.  Patients who are treated with testosterone should be monitored to determine that normal serum testosterone concentrations are being achieved. Monitoring should be done two to three months after initiation of treatment and after changing a dose. When the dose appears to be stable, monitoring every 6 to 12 months should suffice. They should also be monitored for undesirable effects.

  11. D

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