Mylonakis et al developed a flow diagram for evaluating and managing HIV-infected men who present with symptoms suggestive of androgen deficiency. Androgen deficiency may occur in patients with HIV-disease and needs to be distinguished from other conditions that cause similar symptoms. The authors are from Massachusetts General Hospital and Boston University Medical Center in Boston.
Clinical evaluation for signs and symptoms of androgen deficiency:
(1) fatigue, loss of energy
(2) depressed affect
(3) change in pattern of hair growth (loss of pubic or axillary hair; decreased beard growth)
(4) testicular atrophy
(5) gynecomastia
(6) decreased libido
If a person has several of the findings, then the first step is to determine if there is an obvious explanation for the symptoms. If there are no obvious explanations for the findings, then the workup starts by ordering a free testosterone level. Free testosterone represents the bioavailable, non-protein bound hormone.
|
Free Testosterone Levels |
Additional Testing |
Diagnosis |
|
greater than the (mean for age) – (1 standard deviation, SD) |
NA |
hypogonadism unlikely. |
|
between the lower limit of normal for age and the mean minus 1 SD |
NA |
hypogonadism possible. |
|
less than the lower limit of normal for age |
(LH OR FSH elevated) AND (prolactin normal) |
primary hypogonadism likely. |
|
less than the lower limit of normal for age |
(LH AND FSH normal), OR (prolactin increased) |
rule out a mass lesion in pituitary or hypothalamus. |
where:
• The original algorithm uses the quartiles with the lower quartile having additional monitoring. Since this may not be readily determined, I used the mean and standard deviation.
|
Diagnosis |
Management |
|
Hypogonadism unlikely. |
Follow clinically. Evaluate patient for other conditions that may give a similar clinical picture. Repeat free testosterone levels if problems persist and no other diagnosis can be established. |
|
Hypogonadism possible. |
Follow clinically. Repeat free testosterone levels if problems persist and no other diagnosis can be established. |
|
Primary hypogonadism likely. |
Consider testosterone supplementation. Perform a workup for primary gonadal failure. |
|
Mass lesion in pituitary or hypothalamus, or hyperprolactinemia |
Refer to an endocrinologist. |
|
Decreased free testosterone with no lesion in pituitary or hypothalamus and no hyperprolactinemia. |
Consider testosterone replacement. |
Purpose: To evaluate an HIV-infected male for evidence of androgen deficiency using the method of Mylonakis et al.
Specialty: Urology
Objective: other testing, complications, differential diagnosis and mimics, red flags
ICD-10: B23.8,
