Symptoms to Diagnosis

An obese 48-year-old man with progressive fatigue and decreased libido

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CASE RESUMED: FOLLOW-UP

The patient presents 3 months later for follow-up. He reports significant improvement in his presenting symptoms including energy, libido, and erectile function. He also reports some improvement in his mood and concentration. He has lost 12 lb (5.4 kg) and is still trying to improve his diet and exercise program. He is compliant with his testosterone gel therapy.

His serum calculated free testosterone level is 7.8 ng/dL (4.5–17), and his hematocrit is 46%. The patient is instructed to continue his treatment and to return after 9 months for further follow-up.

TAKE-HOME POINTS

  • Men with hypogonadism usually present with nonspecific manifestations, so clinicians should keep a high index of suspicion.
  • Both clinical and biochemical evidence of hypogonadism should be present to diagnose and start treatment for it.
  • Low levels of serum total testosterone do not necessarily reflect hypogonadism.
  • The hormonal profile of central hypogonadism reveals low serum testosterone with low or inappropriately normal serum LH and FSH levels.

Obesity can cause central hypogonadism and should be suspected after pituitary and other systemic causes are excluded.

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