Endocrine Abstracts

Background: It is well known that care must be taken in initiating testosterone replacement in individuals with historically low androgen levels. However less is reported about the influence of restoration of normal endogenous testosterone production on behaviour.

Here, we report the how adverse sequelae of successful treatment of secondary hypogonadism were managed through a joint approach.

Case report: A 34-year-old Business Account Manager for a High Street Bank was diagnosed with a right antero-lateral pituitary macroadenoma (13 mm largest dimension), involving the adjacent right cavernous sinus. Serum prolactin was 96 500 mu/l (50–400). Testosterone was 2.8 nmol/l (10.0–35.0), LH 1.2 mu/l, FSH 1.9 mu/l. TFTs were normal. Formal perimetry revealed a visual field defect – bitemporal upper quadrantanopia. He was started on cabergoline, changed to quinagolide because of side effects.

Prolactin normalised and tumour size decreased. Testosterone normalised to 15.6 nmol/l (9–30). Energy level and strength improved as did lean body mass with a corresponding fall in weight (5 kg).

However major problems of personality change became manifest with increased irritability, moodiness, quickness to temper, verbal aggression towards partner and near flare-ups with clients. In his own words he ‘fed off people’s anger’.

Quinagolide 150 mcg od was continued after persuasion and referral made to a liaison psychiatrist. Cognitive Behavioural Therapy was commenced with a day-to-day event diary to identify precipitants to irritability and rage. Efforts were made to resolve the highlighted triggers. The focus was that this was a temporary problem that would resolve as his body adjusted to a higher level of testosterone. There has been no recurrence of these problems and his wife is expecting their first child.

Discussion: Restoration of physiological levels of testosterone in a hypogonadal patient can temporarily cause a shift in mental state. However biding time, psychotherapeutic intervention can be used to manage successfully these issues.