APPROACH TO HYPOGONADAL MEN. Michael S. Irwig, M.D. Director, Center for Andrology Division of Endocrinology & Metabolism
|
|
- Leslie Burke
- 5 years ago
- Views:
Transcription
1 APPROACH TO HYPOGONADAL MEN Michael S. Irwig, M.D. Director, Center for Andrology Division of Endocrinology & Metabolism
2 Disclosures Pharma-Free Presentation
3 My andrology clinic
4 Controversy with Testosterone Endocrine Society s Clinical Practice Guidelines EVIDENCE RECOMMENDATIONS QUALITY High 0 Moderate 0 Low 11 Very Low 21 Bhasin S, et al. J Clin Endocrinol Metab 2010
5 Controversy with Testosterone Endocrine Society s Clinical Practice Guidelines EVIDENCE RECOMMENDATIONS QUALITY High 0 Moderate 0 Low 11 Very Low 21 No distinction between aging and disease-based androgen deficiency due to hypothalamic, pituitary or testicular pathology No cut point for a low testosterone No clear definition of symptomatic Bhasin S, et al. J Clin Endocrinol Metab 2010
6 Controversy with Testosterone September the FDA s Bone, Reproductive and Urologic Drugs Advisory Committee and the Drug Safety and Risk Management Committee voted 20-1 that the indication should be tightened that TRT is NOT indicated for age-related declines in testosterone. We don t really know whether aging-associated low testosterone is in fact a disease at all A. Michael Lincoff, MD, Vice Chairman of cardiovascular medicine, Cleveland Clinic. Internal Medicine News 2014
7 Case # 1 A 48 year old man is referred for consultation regarding management of a low total testosterone of 171 ng/dl ( ) Past medical history: hypertension, hyperlipidemia, prediabetes Medications: olmesartan-hctz, rosuvastatin, vitamin D Vitals: BP 147/77; BMI 31 Physical: normal exam; testes 20 cc bilaterally Normal puberty Married and has fathered 2 children ROS + difficulty maintaining an erection irritability
8 Erectile Dysfunction Assessment Abridged International Index of Erectile Function Short instrument of five questions on a likert scale (1,2,3,4,5) Sum the numbers to get the score 5-7 severe 8-11 moderate mild-moderate mild none Only administer if man has had sexual intercourse in past 6 months; for gay men inquire about sexual practices Rosen RC et al. Int J Impot Res 1999
9 Any other signs or symptoms to inquire about?
10 Signs & Symptoms Associated With a Low Testosterone libido erectile dysfunction regression of secondary sex characteristics osteoporosis muscle strength depression depressed mood lethargy inability to concentrate sleep disturbance irritability decreased interest in activities Second Annual Andropause Consensus Meeting. The Endocrine Society 2001
11 What s a low libido?
12 Sexual Desire (Libido) Dopamine Norepinephrine Oxytocin Serotonin Opioids Endocannabinoids Pfaus J. J Sex Med 2009
13 Androgen Deficiency Boston Area Community Health Survey N = 1,413 men aged 39-79; white, black and Hispanic Low total T < 300 ng/dl; low free T < 5 ng/dl Symptoms: 1 suggestive (ED, low libido, osteo) or 2 non-specific (lethargy, depression, etc) Araujo AB, et al. J Clin Endocrinol Metab 2008
14 Androgen Deficiency Boston Area Community Health Survey N = 1,413 men aged 39-79; white, black and Hispanic Low total T < 300 ng/dl; low free T < 5 ng/dl Symptoms: 1 suggestive (ED, low libido, osteo) or 2 non-specific (lethargy, depression, etc) 28.4 % Araujo AB, et al. J Clin Endocrinol Metab 2008
15 Androgen Deficiency Boston Area Community Health Survey N = 1,413 men aged 39-79; white, black and Hispanic Low total T < 300 ng/dl; low free T < 5 ng/dl Symptoms: 1 suggestive (ED, low libido, osteo) or 2 non-specific (lethargy, depression, etc) 22.3 % Araujo AB, et al. J Clin Endocrinol Metab 2008
16 Androgen Deficiency Boston Area Community Health Survey N = 1,413 men aged 39-79; white, black and Hispanic Low total T < 300 ng/dl; low free T < 5 ng/dl Symptoms: 1 suggestive (ED, low libido, osteo) or 2 non-specific (lethargy, depression, etc) 4.2 % 8.4 % Araujo AB, et al. J Clin Endocrinol Metab 2008
17 Testosterone Levels & Symptoms European Male Aging Study (N=3200 men 40-79) 244 ng/dl 3 sexual symptoms + total testosterone < 317 ng/dl AM full erections Erections (get and keep) Think about sex Symptomatic 1/past month never or sometimes 3 times/month Wu FC, et al. NEJM 2010
18 How many hours do you sleep each night?
19 Testosterone & Sleep ng/dl Leproult R, et al. JAMA 2011
20 Do you snore?
21 Sleep Apnea Screening STOP-BANG Scoring Tool 1) Snoring loudly 2) Tired, fatigued, sleepy during the daytime 3) Has anyone Observed you stop breathing? 4) High blood Pressure 5) BMI > 35 6) Age > 50 7) Neck circumference > 17 in males 8) Male Gender Chung F et al. J Anesthesiology 2008
22 Sleep Apnea Screening STOP-BANG Scoring Tool 1) Snoring loudly 2) Tired, fatigued, sleepy during the daytime 3) Has anyone Observed you stop breathing? 4) High blood Pressure 5) BMI > 35 6) Age > 50 7) Neck circumference > 17 in males 8) Male Gender Sensitivity Specificity PPV NPV AHI > 5 84% 56% 81% 61% AHI > 10 93% 43% 52% 90% AHI > % 37% 31% 100% Chung F et al. J Anesthesiology 2008
23 The patient is concerned about his low T level. What do you do next?
24 Daily Testosterone Variability Spratt DI, et al. Am J Physiol 1988
25 WHAT TEST BEST REFLECTS HIS ANDROGEN STATUS? A) AM total testosterone by LC/MS B) AM bioavailable T or free T by equilibrium dialysis C) AM free T by analog immunoassay D) They are all similar E) Ask the 8 ball
26 Sex Hormone Binding Globulin FREE SHBG ALBUMIN Bioavailable testosterone = free + albumin bound
27 Which is Better: Total or Free? European Male Aging Study (N=3200 men age 40-79) (300 ng/dl) (6.3 ng/dl) Free T regulates LH secretion Antonio L, et al. J Clin Endocrinol Metab 2016
28 Case # 1 Initial labs: total testosterone 171 ng/dl ( ) AM FASTING LABS Total testosterone 212 ng/dl ( ) Bioavailable testosterone 100 ng/dl (95-350) So how do you interpret his T levels?
29 Testosterone and BMI European Male Aging Study (N=3200 men 40-79) Wu FC, et al. J Clin Endocrinol Metab 2008
30 Sex Hormone Binding Globulin Obesity Hypothyroidism Androgens Progestins Glucocorticoids Nephrotic syndrome Aging Hyperthyroidism Androgen deficiency Estrogens Anticonvulsants Hepatic cirrhosis HIV
31 Testosterone is a Prohormone Testosterone aromatase 5 α reductase Estradiol (E2) Dihydrotestosterone (DHT)
32 Do you want to prescribe testosterone therapy? Yes No
33 Case # 1 MY RECOMMENDATIONS Begin an exercise regimen and lose weight (goal weight of lbs) Sleep study to assess for sleep apnea
34 Weight Loss & Testosterone 173 ng/dl 115 ng/dl 58 ng/dl Grossmann M. J Clin Endocrinol Metab 2011
35 Case # 1 FOUR MONTH FOLLOW-UP APPOINTMENT He reports exercising twice a week for an hour (cardio & weights) He gained 7 lbs since the last visit He reports an improvement to his energy, physical functioning, erectile function and marital relationship Referral to a nutritionist SUBSEQUENT PLANS Reassess his testosterone level and HbA1c after he has lost weight
36 Case # 1 Search for reversible causes of ED MEDICATIONS Anticonvulsants: carbamazepine, phenytoin, primidone Antidepressants: amitriptyline, amoxapine, clomipramine, imipramine, nortriptyline, phenelzine, fluoxetine, fluvoxamine, paroxetine, sertraline Antipsychotics: chlorpromazine, haloperidol, thioridazine Barbiturates Benzodiazepines Antihypertensives: atenolol, clonidine, hydralazine, labetalol, methyldopa, metoprolol, propranolol, verapamil Diuretics: amiloride, chlorthalidone, spironolactone, thiazides NSAIDS: naproxen Anticholinergics: atropine, diphenhydramine, scopolamine Antispasmodics: baclofen, hypnotics
37 Case # 2 A 30 year old man is referred by his NP for consultation regarding management of several symptoms over 3-4 years: Decreased libido Nervousness Fatigue Cold intolerance Confusion Insomnia Normal puberty; single and has not attempted to father children He denies any causes of primary or secondary hypogonadism Past medical history: hyperlipidemia Medications: mind & memory supplements (ginkgo, L-carnitine, St. Johns Wort); vitamins A,B,C, D and E; zinc Vitals: BP 148/77; BMI 27 Physical:? gynecomastia; testes 8 cc bilaterally
38 Case # 2 OUTSIDE LABS Total testosterone 367 ng/dl ( ) Free testosterone 73 pg/ml (52-280) Bioavailable T 185 ng/dl ( ) Estradiol 37.6 pg/ml ( ) LH 5.1 ( ) FSH 7.0 ( ) What do you do next?
39 Depression Screening Patient Health Questionnaire 9 (PHQ-9) Over the past 2 weeks, how often have you been bothered by? 1) Little interest or pleasure in doing things 2) Feeling down, depressed, or hopeless 3) Trouble falling or staying asleep, or sleeping too much 4) Feeling tired or having little energy 5) Poor appetite or overeating 6) Feeling bad about yourself or that you are a failure or have let yourself or family down 7) Trouble concentrating on things, such as reading the newspaper or watching TV 8) Moving or speaking so slowly that other people could have noticed 9) Thoughts that you would be better off dead or of hurting yourself in some way 0= not at all 1=several days 2= > half of days 3= nearly every day Kroenke K et al. J Gen Intern Med 2001
40 Depression Screening Patient Health Questionnaire 9 (PHQ-9) Over the past 2 weeks, how often have you been bothered by? 0= not at all 1=several days 2= > half of days 3= nearly every day Sum the scores (range 0-27) Using the mental health professional interview as the criterion standard, a score 10 had a sensitivity of 88% and a specificity of 88% for major depression. Kroenke K et al. J Gen Intern Med 2001
41 Depression Screening Patient Health Questionnaire 9 (PHQ-9) Over the past 2 weeks, how often have you been bothered by? 1) Little interest or pleasure in doing things 2) Feeling down, depressed, or hopeless 3) Trouble falling or staying asleep, or sleeping too much 4) Feeling tired or having little energy 5) Poor appetite or overeating 6) Feeling bad about yourself or that you are a failure or have let yourself or family down 7) Trouble concentrating on things, such as reading the newspaper or watching TV 8) Moving or speaking so slowly that other people could have noticed 9) Thoughts that you would be better off dead or of hurting yourself in some way 0= not at all 1=several days 2= > half of days 3= nearly every day Kroenke K et al. J Gen Intern Med 2001
42 Depression Screening
43 Men with Borderline T Levels Total testosterone levels between ng/dl ( nmol/l) EXERCISE SESSIONS/WEEK N=200 None 51% % 4 22% WEIGHT STATUS Underweight 2% Normal 16% Overweight 39% Obese 43% DEPRESSION AND/OR DEPRESSIVE SYMPTOMS (PHQ 9 10) 56% Westley C, et al. J Sex Med 2015
44 Case # 3 A 40 year old man presents to clinic with complaints of lower energy and libido than normal. He works 2 jobs and has 1 day off a week. Past medical history: unremarkable. Medications: none Vitals & Physical: BP =124/75; BMI 30; otherwise normal exam An afternoon total testosterone by LC/MS done by his general physician was 370 ng/dl [12.8 nmol/l] (normal range ng/dl [12-42 nmol/l]). As it turns out, he had a total testosterone measured two years ago which was 625 ng/dl (21.7 nmol/l). He is concerned that his symptoms correlate with the decline in his testosterone levels. He believes that his testosterone is low for a man his age. He is interested in a trial of testosterone therapy.
45 Case # 3 WHAT DO YOU NEXT? A) Obtain an AM total testosterone by LC/MS B) Obtain an AM fasting bioavailable T and SHBG C) Prescribe 3 month trial of testosterone D) Educate the patient
46 Case # 3 WHAT DO YOU NEXT? A) Obtain an AM total testosterone by LC/MS B) Obtain an AM fasting bioavailable T and SHBG C) Prescribe 3 month trial of testosterone D) Educate the patient DOCTOR (dok ter) Teacher (derived from Latin)
47 Case # 3 WHAT IS THE MEAN TOTAL TESTOSTERONE LEVEL AMONG HEALTHY 40 YEAR OLD MEN? OLDER MEN YOUNGER MEN ng/dl nmol/l
48 Current Philosophy in Medicine
49 Can you recommend a supplement to boost my testosterone? Worldwide spending on nutritional supplements in 2006: $ 60,000,000,000
50 Contamination of Supplements Geyer H, et al. Int J Sports Med 2004
51 Case # 4 A 71 year old retired school bus driver with GERD, type 2 diabetes, & hyperlipidemia is referred for management of a low testosterone. Gradual erectile dysfunction; has not yet tried a PDE5I. Fewer AM erections than in the past His libido is lower than it once was ROS: Medications: fatigue, nocturia aspirin, atorvastatin, metformin, omeprazole, pioglitazone Vitals: BP 142/84, Weight 221 lbs, BMI 32 Physical: unremarkable Labs: AM total testosterone 269 ng/dl ( ) HbA1c 7.3% Repeat testosterone 291 ng/dl ( )
52 So what does this patient want to know?
53 What is a Normal Testosterone? LOW NORMAL HIGH Cut points are arbitrary based on statistical percentiles rather than clinical correlations/evidence Different labs establish their own normal ranges Reference range is often based on lean adult men < 40 years and is usually not age adjusted
54 Proposed Levels of Normal T Massachusetts Male Aging Study REFERENCE RANGE: Using the 2.5% (roughly below 2 SD) of healthy men, the proposed normal lower limit for total testosterone was: Testosterone Age 251 ng/dl ng/dl ng/dl ng/dl Mohr BA, et al. Clin Endocrinol 2005
55 Proposed Levels of Normal T Massachusetts Male Aging Study REFERENCE RANGE: Using the 2.5% (roughly below 2 SD) of healthy men, the proposed normal lower limit for total testosterone was: Testosterone Age 251 ng/dl ng/dl ng/dl ng/dl Mohr BA, et al. Clin Endocrinol 2005
56 Consensus Statement on LOH American Society of Andrology (ASA) European Academy of Andrology (EAA) European Association of Urology (EAU) International Society of Andrology (ISA) Intl. Society for the Study of Aging Male (ISSAM) <230 ng/dl >350 ng/dl <8 nmol/l >12 nmol/l Usually benefits Repeat level No treatment from therapy Wang C, et al. Multiple Andro/Endo/Urology Journals 2008
57 Erectile Dysfunction Fazio L, et al. CMAJ 2004
58 Age is the # 1 Risk Factor for ED National Health and Nutrition Examination Survey (NHANES) (n =2126) ED definition sometimes able or never able TOTAL AGE Selvin E et al. Am J Med 2007
59 Case # 4 My internist wanted me to ask you about testosterone replacement. Are there any cardiovascular risks? A) Very unlikely B) Possible increased risk of small magnitude C) Significant increased risk in men over 65 D) We have no idea. The studies have not been done.
60 Case # 4 My internist wanted me to ask you about testosterone replacement. Are there any cardiovascular risks? A) Very unlikely B) Possible increased risk of small magnitude C) Significant increased risk in men over 65 D) We have no idea. The studies have not been done.
61 Systematic Reviews >75 Testosterone trials 7 Systematic Reviews 1 Review of the Reviews Quality AMSTAR = tool to assess quality of systematic reviews Onasanya O, et al. Lancet Diabetes Endocrinol 2016
62 Systematic Reviews Calof 2005 Haddad 2007 Fernandez- Balsells 2010 Xu 2013 Borst 2014 Corona 2014 # trials Unspec Albert 2016 N (treatment/ controls) CV events (treatment/ controls) Primary estimate (OR RR) Conclusion 651/ / / / / / / /16 14/7 47/30 115/65 131/87 31/20 116/ ( ) No assoc 1.82 ( ) No assoc 0.91 ( ) No assoc 1.54 ( ) Risk 1.28 ( ) No assoc 1.07 ( ) No assoc 1.10 ( ) No assoc Subgroup Analyses Risk with oral T only Risk in first 12 months Onasanya O, et al. Lancet Diabetes Endocrinol 2016
63 Take Home Points Recognize the non-specific nature of most symptoms of male hypogonadism Recognize the limitations of the reference range: it does not tell you what is normal Recognize the limitations of the guidelines given the low quality of most studies Clarify what does low libido represent to the patient Recognize the association between obesity and low SHBG (and total T) Educate men with borderline testosterone levels about mean levels and variability
64 Take Home Messages DO I PRESCRIBE THIS GUY TESTOSTERONE? SLEEP APNEA? OBESITY? ADEQUATE SLEEP? DEPRESSION? MEDICATION SIDE EFFECT?
65 Tool Box for Clinic ITEM Medication side effect Sleep apnea Erectile function Depression TOOL PDR, Lexicomp, Epocrates STOP Bang scoring tool Abridged international index of erectile function PHQ-9
66 Team Approach -- Resources PROBLEM RESOURCES Obesity Nutritionist Commercial weight loss programs Personal trainers Pedometers Depression Sleep apnea Severe erectile dysfunction Therapist, mental health Sleep specialist, CPAP Urology for intracavernosal injections, etc.
67 Questions
MALE HYPOGONADISM: CHOOSING THE APPROPRIATE THERAPY. Michael S. Irwig, M.D. Director, Center for Andrology Division of Endocrinology & Metabolism
MALE HYPOGONADISM: CHOOSING THE APPROPRIATE THERAPY Michael S. Irwig, M.D. Director, Center for Andrology Division of Endocrinology & Metabolism Disclosures Aromatase inhibitors & clomiphene citrate are
More informationTestosterone Therapy in Men with Hypogonadism
Testosterone Therapy in Men with Hypogonadism (Endocrine Society 2018 Guideline) Ngwe Yin, MD Assistant Clinical Professor of Medicine, UCSF Fresno Medical Education Program Disclosures None Objective
More informationHypogonadism 4/27/2018. Male Hypogonadism -- Definition. Epidemiology. Objectives HYPOGONADISM. Men with Hypogonadism. 95% untreated.
Male Hypogonadism -- Definition - Low T, Low Testosterone Hypogonadism -...a clinical syndrome that results from failure of the testes to produce physiological concentrations of testosterone due to pathology
More informationDisclosures. Learning Objectives. Effects of Hormone Therapy on the Metabolic Syndrome and Cardiovascular Disease. None
Effects of Hormone Therapy on the Metabolic Syndrome and Cardiovascular Disease Micol S. Rothman, MD Associate Professor of Medicine Endocrinology, Diabetes and Metabolism Clinical Director Metabolic Bone
More informationBIOCHEMICAL TESTS FOR THE INVESTIGATION OF COMMON ENDOCRINE PROBLEMS IN THE MALE
Authoriser: Moya O Doherty Page 1 of 7 BIOCHEMICAL TESTS FOR THE INVESTIGATION OF COMMON ENDOCRINE PROBLEMS IN THE MALE The purpose of this protocol is to describe common tests used for the investigation
More informationPRISM Bruges June Herman Leliefeld Urologist. The Netherlands
PRISM Bruges 25-26 June 2015 Herman Leliefeld Urologist The Netherlands Guidelines EAU 2015: a rich source of Knowledge! Epidemiology/ Aetiology / Pathology Diagnostic evaluation Disease management Follow-Up
More informationDANA COKER KINGDON, PA
PERSONAL HEALTH HISTORY AGNES KINRA, MD, PA Board Certified in Internal Medicine DANA COKER KINGDON, PA 4104 West 15 th St # 101 Plano, TX 75093 Phone 972-596-0006 Fax 972-596-0904 Name (Last, First, M.I.):
More informationDr. Marc E. Lewis Dr. Meenakshi Aggarwal Anne Dunne, DNP Melinda Sanfilippo, FNP
Thank you for attending your annual health maintenance exam. Depending on your health insurance plan, you may receive preventative benefits for a reduced copay or no copay. We would like to clarify the
More information6/14/2010. GnRH=Gonadotropin-Releasing Hormone.
Male Androgen Replacement Mitchell Sorsby, MD June 19, 2010. QUESTION # 1 Which of the following is not a symptom associated with low T levels? a) decreased libido b) erectile dysfunction c) depression
More informationDr. Marc E. Lewis Dr. Meenakshi Aggarwal Anne Dunne, FNP Melinda Sanfilippo, FNP
Thank you for attending your annual health maintenance exam. Depending on your health insurance plan, you may receive preventative benefits for a reduced copay or no copay. We would like to clarify the
More informationISSM QUICK REFERENCE GUIDE ON TESTOSTERONE DEFICIENCY FOR MEN
International Society for Sexual Medicine - www.issm.info ISSM QUICK REFERENCE GUIDE ON TESTOSTERONE DEFICIENCY FOR MEN Version: September 2015 What is testosterone deficiency? Testosterone deficiency
More informationHow to treat: TRT modalities and formulations
How to treat: TRT modalities and formulations Paul PIETTE, PharmD Senior Research Fellow Clinique Antoine Depage - Belgium ppiette@besins-healthcare.com Bruges 2014, May 15 th Testosterone-replacement
More informationAppendix B: Screening and Assessment Instruments
Appendix B: Screening and Assessment Instruments Appendix B-1: Quick Guide to the Patient Health Questionnaire (PHQ) Purpose. The Patient Health Questionnaire (PHQ) is designed to facilitate the recognition
More informationAnnual Wellness Visit Form 2016
Annual Wellness Visit Form 6 Initial G48/Subsequent G49 (circle one) Subjective: Past Medical History (mark X to confirm and note duration for chronic conditions only) Conditions Yrs Conditions Yrs Others:
More informationINSOMNIA SEVERITY INDEX
Name: Date: INSOMNIA SEVERITY INDEX For each of the items below, please circle the number that most closely corresponds to how you feel. 1. Please rate the CURRENT (i.e. last 2 weeks) severity of your
More informationPATIENT HEALTH QUESTIONNAIRE PHQ-9 FOR DEPRESSION
PATIENT HEALTH QUESTIONNAIRE PHQ-9 FOR DEPRESSION USING PHQ-9 DIAGNOSIS AND SCORE FOR INITIAL TREATMENT SELECTION A depression diagnosis that warrants treatment or treatment change, needs at least one
More informationPoint-Counterpoint: Late Onset Hypogonadism (LOH)
Point-Counterpoint: Late Onset Hypogonadism (LOH) We are Under-diagnosing and Treating Men with LOH LOH is a Non-existent Disease ~ Robert E. Donohue, MD Late Onset Hypogonadism LOH: underdx. & undertx
More informationRecognizing and Managing Testosterone Deficiency
Recognizing and Managing Testosterone Deficiency J. Bruce Redmon, M.D. Professor Division of Endocrinology Departments of Medicine and Urologic Surgery Disclosure Information I have no financial relationships
More informationTo: Our Medicare Patients. Subject: Your Welcome to Medicare Exam
To: Our Medicare Patients Subject: Your Welcome to Medicare Exam Medicare covers a one-time Welcome to Medicare visit. The Welcome to Medicare visit must occur during your first twelve months as a Medicare
More informationPHARMACY INFORMATION:
Patient Name: Date of Birth: Referred by: Reason for Visit: Current psychiatric medications and doses: PHARMACY INFORMATION: Name of Pharmacy: Phone Number: Fax Number: Address: PRIMARY CARE PHYSICIAN
More informationLate onset hypogonadism
Late onset hypogonadism Farrukh Javid Male Menopause Clinical AND biochemical syndrome Testosterone levels decline by 0.4-3% per year after the age of 30, as opposed to the more rapid decline that occurs
More informationProf Dato Dr TAN Hui Meng University of Malaya, Kuala Lumpur University of Pennsylvania, USA
Prof Dato Dr TAN Hui Meng University of Malaya, Kuala Lumpur University of Pennsylvania, USA Prevailing context Increase number of men who are potential candidates for Testosterone Replacement Therapy
More informationWhat Is the Low T Syndrome? Is Testosterone Supplementation Safe?
What Is the Low T Syndrome? Is Testosterone Supplementation Safe? UCSF Osher Mini Medical School March 7, 2018 Dolores Shoback, MD Staff Physician SF-VAMC Professor of Medicine, UCSF No disclosures or
More informationMen Getting Older Will Testosterone Keep Him Young?
Men Getting Older Will Testosterone Keep Him Young? Alvin M. Matsumoto, M.D. Associate Director, GRECC V.A. Puget Sound Health Care System Professor, Department of Medicine Division of Gerontology and
More informationThese questionnaires are used by psychology services to help us understand how people feel. One questionnaire measures how sad people feel.
ADAPTED PHQ-9 & GAD-7 QUESTIONNAIRES How to fill in these questionnaires: These questionnaires are used by psychology services to help us understand how people feel. One questionnaire measures how sad
More informationMedicare Wellness Visit
of Birth: Today s : Medicare Wellness Visit Dear Patient, Your Medicare benefits include an Annual Wellness Visit to assist in preventing illness or detect illness at an early stage. Your Annual Wellness
More informationDepression Assessment and Management. John Kern MD Clinical Professor University of Washington
Depression Assessment and Management John Kern MD Clinical Professor University of Washington Handouts Antidepressant Treatment Flowchart Managing antidepressant nonresponse handouts 2 Diagnosis PHQ-9
More informationSleep History Questionnaire. Sleep Disorders Center Duke University Medical Center. General Information. Age: Sex: F M (select one)
Sleep History Questionnaire Sleep Disorders Center Duke University Medical Center Part I: General Information Name: Address: Date: Phone: Age: Sex: F M (select one) Education (years of school): Occupation:
More informationOutline. Major variables contributing to airway patency/collapse. OSA- Definition
Outline Alicia Gruber Kalamas, MD Associate Clinical Professor of Anesthesia & Perioperative Care University of California, San Francisco September 2011 Definition Pathophysiology Patient Risk Factors
More informationSchodack Internal Medicine and Pediatrics. Annual Physical-Female
Schodack Internal Medicine and Pediatrics Annual Physical-Female Please Fill out this form (or have your caregiver complete it) and discuss with your medical provider. Thank you! Please Mark the preferred
More informationTestosterone Therapy in Men An update
Testosterone Therapy in Men An update SANDEEP DHINDSA Associate Professor of Medicine Director, Division of Endocrinology and Metabolism, Saint Louis University, St. Louis, MO Presenter Disclosure None
More informationEndocrine Update Mary T. Korytkowski MD Division of Endocrinology University of Pittsburgh
Endocrine Update 2016 Mary T. Korytkowski MD Division of Endocrinology University of Pittsburgh Disclosure of Financial Relationships Mary Korytkowski MD Honoraria British Medical Journal Diabetes Research
More informationUpdate on diagnosis and complications of adult and elderly male hypogonadism
Hypoandrogenism in the elderly: to treat or not to treat? 12 th Italian AME Meeting; 6 th joint Meeting with AAC Bari november 10th Update on diagnosis and complications of adult and elderly male hypogonadism
More informationMajor Depressive Disorder Wellness Workbook
Framing Major Depressive Disorder Major Depressive Disorder Wellness Workbook This Workbook belongs to you and you decide how to use it. You decide who to show it to and whether or not you want someone
More informationChapter 1 The State of Male Health What You Don t Know May Kill You
1 The Low T Book A Man s 30 Day Guide To Improve Your Strength Energy Libido & Fitness Chapter 1 The State of Male Health What You Don t Know May Kill You Every Man s Problem! In men the symptoms of testosterone
More informationEvaluation and Treatment of Primary Androgen Deficiency Syndrome in Male Patients
Evaluation and Treatment of Primary Androgen Deficiency Syndrome in Male Patients Jeff Unger, MD Director Chino Medical Group Diabetes and Headache Intervention Center Chino, California January 16, 2008
More informationTESTOSTERONE DEFINITION
DEFINITION A hormone that is a hydroxyl steroid ketone (C19H28O2) produced especially by the testes or made synthetically and that is responsible for inducing and maintaining male secondary sex characteristics.
More informationHEADACHE MEDICINE NEW PATIENT QUESTIONNAIRE
1 HEADACHE MEDICINE NEW PATIENT QUESTIONNAIRE Name Date Age your headaches began (or how long ago did they start? ) Do you have more than one type of headache? Yes No If yes, answer the following questions
More informationCorporate Medical Policy Testosterone Pellet Implantation for Androgen Deficiency
Corporate Medical Policy Testosterone Pellet Implantation for Androgen Deficiency File Name: Origination: Last CAP Review: Next CAP Review: Last Review: testosterone_pellet_implantation_for_androgen_deficiency
More informationBrief Pain Inventory (Short Form)
Brief Pain Inventory (Short Form) Study ID# Hospital# Do not write above this line Date: Time: Name: Last First Middle Initial 1) Throughout our lives, most of us have had pain from time to time (such
More informationTestosterone Treatment: Myths Vs Reality. Fadi Al-Khayer, M.D, F.A.C.E
Testosterone Treatment: Myths Vs Reality Fadi Al-Khayer, M.D, F.A.C.E The Biological Functions of Testosterone in Men Testosterone is essential to the musculoskeletal and metabolic systems throughout a
More informationMale Menopause: Disease or Pseudoscience? March 4, 2015 story: FDA to require warning on labels of testosterone products.
Male Menopause: Disease or Pseudoscience? March 4, 2015 story: FDA to require warning on labels of testosterone products. 3-30-2015; web William E. Winter, MD University of Florida Departments of Pathology
More informationThe reality of LOH-symptoms
The reality of LOH-symptoms PRISM IV Bruges, Belgium September 25-26, 2014 Dr. Herman Leliefeld Androsmannenkliniek The Netherlands The reality of LOH symptoms male external & internal genitalia Testosterone
More informationThe Agony or the Ecstasy. Familiar?
The Agony or the Ecstasy Familiar? Snoring Related Complaints Drives wife from bedroom Girlfriend won t marry me Shakes entire house Ask me to leave movies and church Has had to leave boat so friends could
More informationAn Update on Men s Health and Sexual Function
An Update on Men s Health and Sexual Function Lawrence Jenkins, MD, MBA Assistant Professor Clinical Department of Urology The Ohio State University Wexner Medical Center Outline Testosterone Deficiency
More informationDoes TRT Induce Prostate Cancer?
Does TRT Induce Prostate Cancer? Prism VI, Bruges, Belgium 21-22November 2014 Herman Leliefeld, Urologist, Utrecht The Netherlands Does TRT Induce Prostate Cancer? Why is it a controversial topic? Is there
More informationAndrogen deficiency. Dr Rakesh Iyer Staff Specialist in Endocrinology Calvary hospital
Androgen deficiency Dr Rakesh Iyer Staff Specialist in Endocrinology Calvary hospital Outline Pathological androgen deficiency - Background, causes, interpretation - Indications for treatment Androgen
More informationo Normal Balanced Diet for your Age o High in Carbohydrates o High in Fats o High in Protein o Other Diet
HEALTH ASSESSMENT SCREENING FORM GO402 Welcome to G0438 First Annual G0439 Subsequent Other Code PATIENTS NAME: DATE OF BIRTH: DATE OF SERVICE: PLEASE LIST CURRENT MEDICATION, ALSO OVER THE COUNTER MEDICATIONS
More informationDate of Birth (mm/dd/year): 2. How much would you like to weigh (desired weight)?
MFA Weight Management Practice Initial Consultation Survey Name: Date of Birth (mm/dd/year): I. Weight History 1. What is the main reason you want to lose weight? _ 2. How much would you like to weigh
More informationMedicare Annual Wellness Visit HEALTH RISK ASSESSMENT
Patient Name: Date of Birth: GENERAL HEALTH 1. How is your overall health? Excellent Good Fair Poor 2. How many different prescriptions are you taking? 0-3 4-6 7-10 10+ 3. Do you take all of your mediations
More informationSleep Health Center. You have been scheduled for an Insomnia Treatment Program consultation to further discuss your
Sleep Health Center You have been scheduled for an Insomnia Treatment Program consultation to further discuss your sleep. In the week preceding your appointment, please take the time to complete the enclosed
More informationRN Behavioral Health Care Manager in Primary Care Settings
RN Behavioral Health Care Manager in Primary Care Settings Integrated Care and the Expanding Role of Nurses Seattle Airport Marriott, SeaTac, WA Tuesday, January 9, 2018 The Healthier Washington Practice
More informationAn Idea Whose Time Has Come-Male Health Programs: An Opportunity For Clinical Expansion and Better Health
An Idea Whose Time Has Come-Male Health Programs: An Opportunity For Clinical Expansion and Better Health KEVIN R. LOUGHLIN MD,MBA Harvard Medical School Boston, MA THE WEAKER SEX-MALES LIFE EXPECTANCY
More informationRoy Zagieboylo, MD Assistant Professor University of Connecticut Family Medicine Department
Roy Zagieboylo, MD Assistant Professor University of Connecticut Family Medicine Department That weight gaining diet I put you on is really working! This won t hurt me a bit. You re in good shape for the
More informationWELCOME TO AGEWELL MEDICAL ASSOCIATES
WELCOME TO AGEWELL MEDICAL ASSOCIATES We offer the following checklist and suggestions to help make your first visit as easy and pleasant as possible. What to bring with you: [ ] All of your medications
More informationPOST-STROKE DEPRESSION
POST-STROKE DEPRESSION Stroke Annual Review March 7 th & 8 th, 2018 Justine Spencer, PhD, CPsych OVERVIEW What is Post-Stroke Depression (PSD)? Risk factors/predictors Impact of PSD Treatment and Management
More informationSTEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit.
PATIENT HEALTH HISTORY FORM DIRECTIONS AND VISIT DAY INSTRUCTIONS Prior to your Appointment: STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit. STEP
More informationProblem Summary. * 1. Name
Problem Summary This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question
More informationCBT Intake Form. Patient Name: Preferred Name: Last. First. Best contact phone number: address: Address:
Patient Information CBT Intake Form Patient Name: Preferred Name: Last Date of Birth: _// Age: _ First MM DD YYYY Gender: Best contact phone number: Email address: _ Address: _ Primary Care Physician:
More informationMedical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol
PRE-EVALUATION FORM Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol High Blood Pressure Obesity Heart Defect
More informationOutline. Classic Androgen deficiency. Cardiovascular Risk and Testosterone Fact vs Fiction. Professor Robert I McLachlan AM, FRACP, PhD
Health Ed Brisbane Saturday 27 th October 2018 Cardiovascular Risk and Testosterone Fact vs Fiction Professor Robert I McLachlan AM, FRACP, PhD Hudson Institute of Medical Research, Monash University Department
More informationHow Long Does It Take For Testosterone Replacement Therapy to Work?
How Long Does It Take For Testosterone Replacement Therapy to Work? When will I feel the effects? Dr Kevin J Meuret How Long Does it Take For Low Testosterone Treatment To Work? Great Question. New clients
More informationManaging Testosterone Deficiency: A Practical Guide. John Grantmyre MD Professor of Urology Dalhousie University
Managing Testosterone Deficiency: A Practical Guide John Grantmyre MD Professor of Urology Dalhousie University 1 2 Case Study #1 A 59-Year-Old Man with Erectile Dysfunction 3 Case History Robert is a
More informationHormone Replacement Therapy For Men Consultation Information
Hormone Replacement Therapy For Men Consultation Information www.urologyaustin.com Biological Aging and Hormones As we age, a natural degeneration and aging of organs causes the levels of our hormones
More informationMedicare & Dual Options Annual Comprehensive Exam FAX COMPLETED FORM TO: Patient Personal Information
FAX COMPLETED FM TO: 877-682-2216 All fields marked with an * are required to be completed in order to receive payment for the ACE Form, unless indicated otherwise. Please refer to the document titled
More informationWhere are the injections given? They are given in the upper outer hip.
1 How do you diagnose low Testosterone in men? Low Testosterone can be diagnosed if you have 3 or more of the following symptoms: lack of libido fatigue insomnia erectile dysfunction (ED) depression loss
More informationSoutheastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire Name: MR#:_ Date: Date of Injury: Referred By: Age: Date of Birth: Handed: R L Ambidextrous Male Female **** Mark
More information66 M with erectile dysfunction and abnormal labs RAJESH JAIN ENDORAMA 10/29/2015
66 M with erectile dysfunction and abnormal labs RAJESH JAIN ENDORAMA 10/29/2015 HPI 66 M presenting as a referral for erectile dysfunction and abnormal labs Has been seeing a facility specializing in
More informationCERTIFIED MEN S HEALTH COUNSELOR ONLINE COURSE: SESSION 7 Male Menopause and Testosterone
CERTIFIED MEN S HEALTH COUNSELOR ONLINE COURSE: SESSION 7 Male Menopause and Testosterone Andropause: Dealing With Male Menopause Hormonal changes that occur as a result of aging are generally associated
More informationHORMONE THERAPY IN AGING MALE ATHLETES
DISCLOSURES HORMONE THERAPY IN AGING MALE ATHLETES No relevant affiliations or financial interests When, Why and is it Safe? OBJECTIVES Summarize the benefits of optimizing hormone balance Examine the
More informationClinical Practice Guideline: Management of Major Depression in Primary Care
Clinical Practice Guideline: Management of Major Depression in Primary Care Approved, CHP Quality Improvement Committee 3/27/01, 10/22/02, 10/28/03, 11/2/04, 11/1/05, 9/8/09, 5/10/11, 5/14/13, 5/12/15,
More informationProgramme. Why bother? The effects of sleep loss. Common Sleep Disorders, Identification and investigation Treatments
Programme. Why bother? The effects of sleep loss. Common Sleep Disorders, Identification and investigation Treatments Brief (but important ) questions. Why bother? The three Pillars of health: - Nutrition
More informationIndex. urologic.theclinics.com. Note: Page numbers of article titles are in boldface type.
Note: Page numbers of article titles are in boldface type. A Acquired hypogonadism, prevalence of, 165 167 primary, 165 secondary, 167 Adipose tissue, as an organ, 240 241 Adrenal hyperplasia, congenital,
More informationNew Patient History Questionnaire
New Patient History Questionnaire For office use only: Height: Weight: NC: WC: BMI: Name: Age: How did you hear about us? Who referred you? Who is your primary care physician? What are your weight loss
More informationAlternative management of hypogonadism Tamoxifen. Emmanuele A. Jannini, MD Tor Vergata University of Rome ITALY
Alternative management of hypogonadism Tamoxifen Emmanuele A. Jannini, MD Tor Vergata University of Rome ITALY eajannini@gmail.com What hypogonadism is? What hypogonadism is? It is an empty glass The two
More informationWestminster IAPT Primary Care Psychology Service. Opt-In Questionnaire
Westminster IAPT Primary Care Psychology Service Opt-In Questionnaire In order to get a better idea of your difficulties, we would be grateful if you could complete the attached registration form and questionnaire.
More informationEPWORTH SLEEPINESS SCALE
EPWORTH SLEEPINESS SCALE Name: Sponsors last 4 of SSN#: DOB: Today s Date: Age (years): Gender (circle): MALE FEMALE How likely are you to doze off or fall asleep in the following situation, in contrast
More informationJessica Gifford, LICSW Mental Health Educator Jessica Gifford, LICSW Mental Health Educator
Alleviating Depression and Anxiety through Wellness Promotion Jessica Gifford, LICSW Mental Health Educator Jessica Gifford, LICSW Mental Health Educator Public Health Approach Mental Health is a public
More informationConscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND (701)
Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND 58078 (701) 478-7199 INTAKE FORM BIRTH DATE: / / Age: Email: YOUR NAME FIRST: MIDDLE INITIAL: LAST: YOUR ADDRESS COMPLETE
More informationSleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118
Sleep Questionnaire *Please complete the following as accurate as possible. Please bring your completed questionnaire, insurance card, photo ID, Pre-Authorization and/or Insurance referral form, and all
More informationANDROGEN DEFICIENCY Update on Evaluation and Management
ANDROGEN DEFICIENCY Update on Evaluation and Management Kristen Gill Hairston, MD, MPH Associate Professor of Internal Medicine Section of Endocrinology and Metabolism Wake Forest University School of
More informationI would like for my patient to be seen in Sleep Medicine consultation and managed by the sleep physician. Yes No
701 E. COUNTY LINE ROAD, SUITE 207. GREENWOOD, IN. 46143 OFFICE317-887-6400 FAX 317-887-6500 indianasleepcenter.com REFERRAL FOR SLEEP EVALUATION Patient Name:_ Phone: I would like for my patient to be
More informationNebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY
Nebraska Bariatric Medicine 8207 rthwoods Dr., Suite 101 Lincoln, NE 68505 MEDICAL HISTORY Name Today s Date The following page allows you to complete what we call a weight timeline. This is a very valuable
More informationADULT QUESTIONNAIRE. Date of Birth: Briefly describe the history and development of this issue from onset to present.
ADULT QUESTIONNAIRE Name: Address: Preferred phone number to reach you: Is it okay to leave a message? Yes No (Please check one) Date of Birth: Reason(s) for seeking treatment at this time? Briefly describe
More informationPlease complete this form before your Doctor visit. We will review this together and make any changes needed.
1 Medical History Please complete this form before your Doctor visit. We will review this together and make any changes needed. Name Date of Birth Date of visit What is your height? weight? Medical History,
More informationLambeth Psychological Therapies
Complaints procedure: If you are not happy about your experience with our service, you can speak to a member of staff directly; alternatively, you can contact the PALS Office. To make a formal complaint,
More informationLate onset Hypogonadism. Dr KhooSay Chuan Department of Urology Penang General Hospital
Late onset Hypogonadism Dr KhooSay Chuan Department of Urology Penang General Hospital Late onset hypogonadism(loh) Definition LOH age associated testoteronedeficiency syndrome (TDS) Male menopause, andropause,
More informationPATIENT NAME: DATE OF DISCHARGE: DISCHARGE SURVEY
PATIENT NAME: DATE OF DISCHARGE: DISCHARGE SURVEY Please indicate whether you feel Living Hope Eating Disorder Treatment Center provided either Satisfactory or Unsatisfactory service for each number listed
More informationDiagnosis and Clinical Evaluation of Hypogonadism in Adult Patients with Obesity and Diabetes
Diagnosis and Clinical Evaluation of Hypogonadism in Adult Patients with Obesity and Diabetes Adrian Dobs, M.D., M.H.S. Professor of Medicine and Oncology The Johns Hopkins University School of Medicine
More informationTestosterone Replacement Therapy for Hypogonadism: Learning Objectives. What Is the Evidence? Is It Safe? Case Study. Case Study contd.
4 4:4pm Testosterone Therapy: Examining the Evidence SPEAKER Culley Carson, MD Presenter Disclosure Information The following relationships exist related to this presentation: Culley Carson, MD: Consultant
More informationANDROGEN DEFICIENCY/MALE HYPOGONADISM
ANDROGEN DEFICIENCY/MALE HYPOGONADISM 1. Medical Condition Hypogonadism in men is a clinical syndrome that results from failure of the testes to produce physiological levels of testosterone (androgen deficiency)
More informationChristina Pucel Counseling 416 W. Main St Monongahela, PA /
ADULT INTAKE Name: Gender: M F DOB: Address: City: State: Zip: Telephone: Home Mobile Highest Level Education: Occupation: Emergency Contact: Relationship: Phone: Referred by: Family Members: Name Gender
More informationANDROGEN DEFICIENCY/MALE HYPOGONADISM
Medical Information to Support the Decisions of TUE Committees 1. Medical Condition Hypogonadism in men is a clinical syndrome that results from failure of the testes to produce physiological levels of
More informationMale New Patient Package
Male New Patient Package The contents of this package are your first step to restore your vitality. Please take time to read this carefully and answer all the questions as completely as possible. Thank
More informationSleep Disorders and their management
Clinical Stream Sleep Disorders and their management Dr Alex Bartle Programme. What happens in sleep, and why bother? The effects of sleep loss. Common sleep disorders Brief (but important ) questions.
More informationPeer Support / Social Activities Overview and Application Form
Peer Support / Social Activities Overview and Application Form What is Peer Support? Peer support is when people use their own experiences to help each other. What happens during peer support sessions
More informationSleep Disorders and the Metabolic Syndrome
Sleep Disorders and the Metabolic Syndrome Tom V. Cloward, M.D. Intermountain Sleep Disorders Center LDS Hospital Objectives Describe how sleep disorders impact your daily medical practice Don Don t do
More informationDiscussion Questions WHAT ARE SOME POSSIBLE CAUSES OF HER PAIN? WHAT ELSE WOULD YOU LIKE TO KNOW
CLINICAL CASES Case: Ms. FM Case: Ms. FM Ms. FM is a 37-year-old school teacher Under your care for 10 years Unremarkable past history Was in minor car accident 4 months ago Has had progressive generalized
More informationPATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
More informationWHAT YOU NEED TO KNOW ABOUT SLEEP APNEA
WHAT YOU NEED TO KNOW ABOUT SLEEP APNEA Wayne Driscoll Clinical Education Specialist 2 SLEEP APNEA IN THE NEWS Carrie Fisher died from sleep apnea, other factors, coroner says USA Today NJ Transit engineer
More information