What type of specialist treats hormone needs, particularly for conditions like hypogonadism or low testosterone?

Specialist Treatment for Hormone Needs in Hypogonadism

Patients with hypogonadism or low testosterone should be referred to an endocrinologist, particularly when there are complex hormonal issues, pituitary disorders, or persistently elevated prolactin levels. 1

Primary Care Evaluation and Referral Pathway

• Initial evaluation of testosterone deficiency is often conducted by primary care providers, urologists, or endocrinologists, with specific referral patterns determined by the underlying cause 1
• Patients should undergo comprehensive laboratory testing including:
  • Morning total testosterone levels (measured between 8-10 AM) 1
  • Luteinizing hormone (LH) levels to determine the etiology of testosterone deficiency 1
  • Free testosterone by equilibrium dialysis in patients with obesity 1

When to Refer to an Endocrinologist

Endocrinologist referral is indicated in the following scenarios:

• Patients with persistently elevated prolactin levels, which may indicate pituitary tumors such as prolactinomas 1
• Men with total testosterone levels <150 ng/dL combined with low/low-normal LH levels (requires pituitary MRI regardless of prolactin levels) 1
• Patients with elevated baseline estradiol measurements 1
• Cases of secondary hypogonadism (low testosterone with low/normal LH/FSH) requiring further evaluation of hypothalamic-pituitary dysfunction 1
• Complex cases requiring pituitary function testing and MRI of the sella turcica 1

When to Refer to a Urologist

Urologists often manage:

• Primary hypogonadism (testicular failure with elevated gonadotropins) 2
• Men with hypogonadism who have concerns about fertility 1
• Patients requiring testosterone replacement therapy without complex pituitary issues 2
• Men with severe oligospermia or non-obstructive azoospermia who need reproductive genetic testing 1

Treatment Considerations

• Testosterone replacement therapy is indicated for conditions associated with deficiency or absence of endogenous testosterone 2
• FDA-approved indications include:
  • Primary hypogonadism (congenital or acquired testicular failure) 2
  • Hypogonadotropic hypogonadism (congenital or acquired gonadotropin or LHRH deficiency) 2
• Treatment options include:
  • Transdermal testosterone preparations (gel, patch) - preferred for stable day-to-day levels 1
  • Injectable testosterone (enanthate or cypionate) - more cost-effective but with fluctuating levels 1
  • Implantable testosterone pellets - longer-term option requiring implantation procedure 1

Monitoring and Follow-up

• Testosterone levels should be tested 2-3 months after treatment initiation 1
• Hemoglobin/hematocrit should be measured at baseline and monitored during therapy 1
• PSA should be measured in men over 40 years before starting testosterone therapy 1
• Patients should be informed about potential improvements in erectile function, libido, anemia, bone mineral density, lean body mass, and depressive symptoms 1

Special Considerations

• Men interested in fertility should have reproductive health evaluation before testosterone therapy 1
• Alternative treatments like gonadotropins, clomiphene citrate, or tamoxifen may be considered for men wishing to preserve fertility 3
• Patients with obesity may have low total testosterone due to reduced sex hormone-binding globulin but normal free testosterone levels 1

By following this referral pathway, patients with hypogonadism can receive appropriate specialist care based on the underlying cause and complexity of their hormonal needs.