Therapeutic goals of t treatment: part 2

So, the goals of T therapy in adults with male hypogonadism are to:

  • restore libido and improve erectile function;
  • stimulate male hair growth;
  • increase muscle mass and strength;
  • increase BMD, potentially reducing the risk of fractures;
  • improve energy, mood, and motivation;
  • increase hematocrit into the normal adult male range.
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In most men with ED, T treatment alone is insufficient to restore complete erectile function and permit satisfactory intercourse. Because spermatogenesis requires high local T concentrations that cannot be achieved by exogenous androgen administration, T replacement therapy does not stimulate sperm production and testis size, nor does it restore fertility. Treatment of infertility in hypogonadal men is usually only possible in men with secondary hypogonadism and gonadotropin deficiency, using gonadotropin or gonadotropin-releasing hormone (GnRH) therapy.

The normal “physiological” range of serum T concentrations in adults is broad and usually established in healthy young men. In young hypogonadal men, T treatment produces beneficial clinical effects when serum T concentrations are increased into this normal range. With increasing age, serum T levels decline gradually and progressively, but the physiological significance of this decline is not clear. Initial studies in older hypogonadal men have also demonstrated some beneficial effects of T treatment that increase serum T levels into the normal range. Therefore, the goal of T treatment of male hypogonadism, irrespective of age, is to restore serum T concentrations to within the normal adult range.
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An important consideration in the clinical use of T therapy is the dose–response effect of T on different target organs. Recent studies suggest that some actions of T demonstrate continuous dose-response effects as T levels are increased from below normal to within and above the physiological range—e.g., muscle mass. In contrast, other T actions exhibit threshold effects—e.g., libido—that are stimulated near maximal levels at relatively low T concentrations. In some patients—e.g., elderly men with severe prostate disease—low-dose T supplementation may be more prudent than full T replacement. Although not demonstrated in clinical trials, low doses of T may be sufficient to induce some beneficial effects such as the stimulation of libido and, to a limited extent, anabolic actions on muscle and bone, while minimizing adverse stimulatory effects on prostate growth.