Surveillance of testosterone substitution therapy

The physiological effects of testosterone (Mooradian et al. 1987) can be used for monitoring the efficacy of testosterone substitution therapy. Since therapy aims at replacing the testosterone endogeneously lacking and since physiological serum concentrations are well known, serum testosterone levels also provide a good parameter for therapy surveillance. Guidelines for monitoring testosterone therapy in general have been issued by WHO (1992) and, with special focus on the ageing male, by others (Bhasin and Buckwalter 2001; Bhasin etal. 2003; Morales and Lunenfeld 2002; National Institute on Ageing 2001) and should be referred to for more details. Behaviour and mood

The patient's general well-being is a good parameter to monitor the effectiveness of replacement therapy. Under sufficient testosterone replacement the patient feels physically and mentally active, vigorous, alert and in good spirits; too low testosterone levels will be accompanied by lethargy, inactivity anddepressed mood (Burris etal. 1992; Wang etal. 1996; Zitzmann and Nieschlag 2001). Sexuality

The presence and frequency of sexual thoughts and fantasies correlate with appropriate testosterone substitution, while loss of libido and sexual desire are a sign of subnormal testosterone values. Spontaneous erections such as those during sleep will not occur if testosterone replacement is inadequate; however, erections due to visual erotic stimuli maybe present even with low testosterone levels. The frequency of ejaculations and sexual intercourse correlate with serum testosterone levels in the normal to subnormal range. Therefore, detailed psychological exploration or a diary on sexual activity are useful adjuncts in assessing testosterone substitution. For objective evaluation of psychosexual effects weekly questionnaires on sexual thoughts and fantasies, sexual interest and desire, satisfaction with sexuality, frequency of erections and number of morning erections and ejaculations may be used (Lee et al. 2003). These clinical experiences are substantiated by studies on androgen replacement in hypogonadal men (Bals-Pratsch et al. 1988; Behre et al. 1992; Burris etal. 1992; Carani etal. 1992; Clopper etal. 1993; Cunningham etal. 1990; Jain etal. 2000; Morales etal. 1997), and by findings in normal men treated with GnRH analogues (Bagatell etal. 1994; Behre etal. 1994a; Buena etal. 1993) and in contraceptive trials (see Chapter 23).

Priapism has been reported to occur in individual cases at the beginning of testosterone substitution (Endres et al. 1987; Ruch and Jenny 1989; Zelissen and Stricker 1988). This is an extremely rare effect; in our own experience of 35 years of substitution therapy only one case is recollected. Decreasing the testosterone dose is the rational consequence, but intervention by aspirating blood from the corpora cavernosa may be acutely necessary.

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