Endocrine Abstracts

70yrs male was referred to endocrinology due to an abnormal blood test showing hypogonadotropic hypogonadism. Initial investigations were done due to bilateral gynecomastia worsening over 20 years, by the breast team. He did not go through puberty as a child and was given a testosterone injection at the age of 12yrs for a year. This was discontinued due to sexual arousal since then he did not have any further endocrine follow-ups. He had symptoms of tiredness, reduce libido, and erectile dysfunction. He had no sense of smell. There was no facial, axillary, or pubic hair growth. Tanner stage 1 testicles were noted with a very small penis. He underwent a mastectomy for gynecomastia. He has a background history of COPD, hypothyroidism, and BPH. His usual medications include thyroxine, Omeprazole, finasteride, and tramadol. No significant family history of endocrine problems. No history or evidence of anabolic steroids.

Investigation and Results: FBCs, renal, and liver profiles are Unremarkable. FSH<1.0 (1-10 unit/litre), LH <1, prolactin 150microunit per litre, Estradiol <37pmol/l, Testosterone <0.5(6.7-25.8 nmol/l), random Cortisol adequate, IGF-1 normal, HbA1c 37, PSA <0.050, TSH ranging between upper end of normal up to 10mu/l. MRI head/pituitary; normal pituitary gland. Further high-resolution images showed the absence of the olfactory bulb and olfactory sulci. Bone scan was organized for him but didn’t attend. Xray pelvis for lower back pain reported as markedly osteopenic bone.

Treatment: Investigations and MRI findings suggestive of Kallman syndrome. Testosterone were low all his life. He was offered testosterone therapy in the form of tostran gel 2% 2 squirts/day. Treatment will help with generalized tiredness and sexual symptoms along with osteoporosis. He was informed that his gynecomastia can get worse on this replacement ad given the diagnosis of BPH we need to monitor FBC and PSA. He was further referred to a geneticist for genetic testing for Kallman syndrome.

Conclusion and discussion: Patient was unhappy with testosterone. Not much difference noted in general well-being but he experienced erections on and off which he felt embarrassed about. He also noticed an increased breast size. He had discontinued the treatment on his own and declined any further testing including genetic workup. Case was unusual due to age of presentation. It was further complicated due to BPH diagnosis with negligible testosterone and very low PSA. Offered treatment has more implications than just improving secondary sexual characteristics. Subphysilogical doses were causing significant side effects.