Endocrine Abstracts

44 years old gentleman referred to endocrinology clinic complaining of reduced libido. Initial blood test showed borderline low testosterone levels measuring 8.4 nmol/l (10–37) on 2016. SHBG 28. He has a past medical history of type 2 diabetes diagnosed March 2015, fibromyalgia, bilateral carpal tunnel syndrome, spinal osteoarthritis and asthma. medication includes Amitriptyline 30 OD, Buprenorphine 15 μg patches weekly and inhalers together with metformin and sitagliptin. He is not hypertensive, no history of CVD, non-smoker and drinks alcohol only occasionally. His BMI is 34. He is not using recreational drugs and never used anabolic steroids. He was found to have low sperm count in the past and underwent with his partner two cycles of IVF that were unsuccessful. He subsequently fathered two daughters, with natural conception, of 11 and 13 years old. He sometimes gets early morning and nocturnal tumescence. He gets partial tumescence with sudden detumescence. Sometimes, he is able to orgasm and ejaculate. He describes his libido as very poor and it has been for ten years. He is in the same relationship for 20 years. He has constant stresses in his life with illness and family problems. Prostate size around 30 gm of benign smooth outline His penis is normal. His testicular size around 10 ml bilaterally. HbA1c on diagnosis 88 mmol/mol on diagnosis, now measuring only 49. FSH and LH are inappropriately normal for the levels of testosterone measuring 10 and 3.6 respectively. Pituitary MRI normal. His hypogonadism is deemed as secondary to his diabetes, obesity and painkillers. A trial of testosterone replacement with Testogel 50 mg daily was considered to see if he will benefit from it. 8 months later, He hasn’t experienced an improvement in terms of his libido in any way. This was reiterated by his wife, who explained that intimate relations between the couple are rare. His testosterone came back as 6.7 nmol/l. Although he confirmed proper compliance and daily gel application. we agreed on Sustanon injection 250 mg 4 weekly. 6 months later, latest testosterone was 4.8. He wanted to try another form of injection. Started Nebido 1 g injection every 12 weeks. Sildenafil and Tadalafil, prescribed were also unhelpful. Referred to ED clinic. His last testosterone in Feb 2018 was 11.6 and in June came back as 25.4. The patient and his wife mentioned that there is no difference in terms of libido. Injections stopped for 6 months, testosterone 10.3.