Endocrine Abstracts

A 33-year-old rehabilitated intravenous drug abuser was referred in view of bilateral gynaecomastia. The gynaecomastia developed gradually over a year with the left breast greater than right, and associated with intermittent tenderness but no galactorrhoea. He was found to have a low total testosterone and elevated oestradiol level. The patient claimed to have had undergone normal puberty with normal secondary sexual characteristics. He was able to maintain a beard, and had normal muscle strength. He admits to snoring at night, however denied excessive lethargy. He also lost his morning erections and complained of decreased libido. At presentation, his Methadone dose was being down-titrated. He denied use of over-the-counter medication and denied use of testosterone or anabolic steroids. On examination, the patient was normotensive with an obese body habitus. He was at Tanner Stage V but had evident gynaecomastia. Visual fields were normal to confrontation.Investigations:Breast Ultrasound showed bilateral gynaecomastia and MR Pituitary showed a normal pituitary gland. Bone Density showed a Hip T score -1.1 and Spine T score -2.3 in-keeping with osteopenia. Sleep study showed mild OSA for which he was being followed-up by Sleep Clinic. The diagnosis of hypogonadotrophic hypogonadism, possibly secondary to obesity and long-standing opiate abuse as well as methadone treatment, was explained to the patient. He was offered testosterone replacement in an attempt to improve his sexual symptoms, prevent progression to osteoporosis, and possibly reduce gynaecomastia. However, plastic surgery may be required in the future to correct the latter. It was explained that testosterone replacement does not induce fertility, and if family planning is being considered in the future, the treatment regime would need to be modified to human choriogonadotropin (hCG). To this end, he was started on testosterone undecanoate 1000 mg IM every 12 weeks with a plan to sample trough testosterone levels prior to the third dose.