Bone mass

Hypogonadism is associated with decreased bone density by increased bone resorption and decreased mineralization, resulting in premature osteoporosis and increased risk of fractures (see Chapter 7). Testosterone replacement in hypogonadal patients results in an increase in bone density (Behre etal. 1997b; Leifke etal. 1998; Devogelaer et al. 1992; Zitzmann et al. 2002b) (Fig. 13.2). Since estrogens

2300 -2200 2100 -

to iE 2000

CO o

CA 1900H

1800 -1700 -1600 -1500

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S 1900

1800 1700 1600 -1500 -

10 20 30 40 50 60 70 80 90 Age (years) Fig. 13.2 Bone density as measured by phalangeal ultrasonographic osteodensitometry in 224 eugonadal men (squares), 156 hypogonadal patients (open circles) and 141 testosterone-substituted patients (closed circles) (modified from Zitzmann etal. 2002b).

play an important role in bone metabolism and structure it is important that the testosterone preparation used for substitution can be converted to estrogens, as is the case with natural testosterone.

Only advanced changes in bone density can be recognized by usual X-ray. For monitoring early signs of inadequate bone density different methods are available, e.g. dual photon absorptiometry (DPA), dual energy X-ray absorptiometry (DEXA) or quantitative computer tomography of the lumbar spine (QCT) or the peripheral quantitative computer tomography of radial or tibial bone (pQCT). These methods are characterized by high accuracy and reproducibility, but are relatively time consuming and expensive. For routine surveillance of hypogonadal patients sonographic osteodensitometry appears to be sufficient to monitor the effects of testosterone therapy (Zitzmann etal. 2002b). In hypogonadal patients results from osteosonography of the phalanges agree well with those from QCT of the vertebrae so that we use this method routinely and subject patients to osteosonography on an annual basis for routine surveillance.

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