Management of male obesity-related secondary hypogonadism: A clinical update

Table 2 Cautions with testosterone replacement therapy and monitoring for adverse effects

High-risk population for TRT	Special considerations in monitoring
Very high risk of serious outcomes: prostate cancer; breast cancer	For patients who opt for prostate monitoring: Men aged 55-69 yr & those aged 40-69 yr who are at increased risk for prostate cancer and choose monitoring; perform DRE and measure PSA at baseline, at 3-12 months after starting treatment, and then as per local prostate cancer screening guidelines
Moderate to high risk of adverse outcomes	Urologic consultation should be sought if: (1) Increase in serum PSA > 1.4 ng/mL within 12 months of starting TRT; (2) PSA > 4 ng/mL at any time; (3) DRE detected new onset prostate abnormality; and (4) significant worsening of LUTS
Unevaluated prostate nodule or induration	To check Haematocrit at baseline, then at 3-6 months following TRT, and then annually. If Hct > 54%, stop therapy until it decreases to a safer level; evaluate for other causes of erythrocytosis (sleep apnoea, COPD), re-initiate at lower doses when Hct falls below normal
Baseline PSA > 4 ng/mL or > 3 ng/mL in men at high risk for prostate cancer
Severe lower urinary tract symptoms
Haematocrit > 48% (> 50% for men living at high altitudes)
Uncontrolled or poorly controlled heart failure
Myocardial infarction or stroke in the preceding 6 months
Untreated severe obstructive sleep apnoea
Wants fertility in the near future
Formulation-specific adverse effects (Table 1)

TRT: Testosterone replacement therapy; PSA: Prostate specific antigen; DRE: Digital rectal examination; Hct: Haematocrit; COPD: Chronic obstructive pulmonary disease; LUTS: Lower urinary tract symptoms.