testosterone for evaluating the efFcacy of TST in an
individual.
Most patients are treated with testosterone gels
or injections for symptomatic hypogonadism. ┬▒ewer
men currently receive CC as an alternative treat-
ment for hypogonadism. Overall in the current
study men who received CC reported hypogonadal
symptom resolution rates via qADAM that were
equal to those of men prescribed testosterone in-
jections or gels. This evidence suggests that there
may be a larger role for CC as treatment for symp-
tomatic hypogonadism as an alternative to testos-
terone gels or injections, especially in younger men
interested in preserving fertility. Of concern is that
up to 20% of urologists prescribe exogenous testos-
terone, a medication known for its contraceptive
potential, in men with infertility.
24
The Fndings of this study dispel the notion that
a pure linear relationship exists between serum
testosterone and satisfaction levels.
4
In a recent
study Yeap et al observed a U-shaped association
between testosterone and cardiovascular mortal-
ity.
25
Men with serum testosterone in the highest
quartile were at higher risk for mortality than men
in the middle quartiles. With studies indicating
an association between serum testosterone and car-
diovascular risk practitioners should target symp-
tom improvement rather than simply increased
testosterone as the end goal.
Interestingly, when components of the qADAM
questionnaire
were
analyzed
separately,
men
receiving testosterone injections reported higher
libido than men receiving CC and testosterone
gels. ┬▒urthermore, serum estradiol was higher in
men on testosterone injections than in men on CC
or testosterone gels. These associations between
increased serum estradiol and higher libido corrob-
orate the recent study by ┬▒inkelstein et al showing
an important role for estrogen in the regulation of
sexual function in men treated with testosterone
gels.
26
The current study has strengths and limitations.
The ability to capture men on the same day that
serum hormones were evaluated allowed for accu-
rate comparisons between serum hormone levels
and perceived symptomology. Also, the age matched
design removed age as a confounding variable,
which is especially important since younger men
report increased satisfaction with TST.
27
In addi-
tion, CC was typically prescribed for young men
with infertility and age matching would potentially
eliminate this bias.
We sought to identify differences, if any, among
TST modalities by evaluating symptoms from
the patient perspective. Using a control group of
eugonadal men not on TST and the standardized,
validated qADAM questionnaire to evaluate satis-
faction and hypogonadal symptoms add further
strength to our Fndings.
The study was limited by its retrospective, cross-
sectional design and the fact that pretreatment
qADAM values were not available. A limitation of
qADAM is poor speciFcity. The lack of speciFcity is
due not only to the fact that many positive ques-
tionnaire responses may indicate other conditions,
such as depression, but also because scores derived
from these questionnaires do not predict or correlate
well with measured free and total testosterone.
28
Moreover, while we could not control the timing of
testosterone injection, which could have confounded
the results, the fact that average testosterone levels
were signiFcantly increased compared to those in
patients who received CC and testosterone gels
suggests that most patient data were captured
within 3 or 4 days after injection. In addition, only
1 serum testosterone measurement was included in
analysis since we sought to evaluate the relation-
ship between qADAM score and serum testosterone.
CONCLUSIONS
Men on CC for symptomatic hypogonadism reported
hypogonadal symptoms similar to those of age
matched men on testosterone injections and gels.
These comparable hypogonadal symptoms among
the different treatment regimens suggest that CC
could be as effective for hypogonadism as other
well established treatment modalities. Because CC
has fewer potential side effects than testosterone
injections or gels and it is more affordable, it may
have a larger role in treating men with symptomatic
hypogonadism.
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