From the Guidelines
Testosterone supplementation is not contraindicated in patients with partial empty sella syndrome. A partial empty sella is a condition where the pituitary gland appears partially flattened or smaller than normal within the sella turcica, with cerebrospinal fluid filling the remaining space. This condition can be congenital or acquired and is often found incidentally during brain imaging. Most cases of partial empty sella are asymptomatic and require no treatment. However, some patients may experience hormonal imbalances if the pituitary function is affected, including potential testosterone deficiency in men.
Key Considerations
- If laboratory testing confirms low testosterone levels along with appropriate clinical symptoms (fatigue, decreased libido, erectile dysfunction, reduced muscle mass), testosterone replacement therapy can be safely administered using standard protocols, as supported by recent guidelines from the American College of Physicians 1.
- The typical options include testosterone injections (50-100 mg weekly or 200 mg every 2 weeks), daily transdermal gels (50-100 mg), or patches (2-6 mg), with patient preferences often leaning towards injectable testosterone due to lower cost or topical gels for convenience and ease of use 1.
- Before starting therapy, a complete hormonal evaluation should be performed to assess overall pituitary function, as other hormones might also be affected.
- Regular monitoring of testosterone levels, hematocrit, PSA (in men over 40), and clinical response is essential during treatment, considering the potential for discontinuation rates between 30% and 62% due to various reasons including side effects or lack of perceived benefit 1.
Approach to Treatment
- The presence of an empty sella itself does not change the approach to testosterone replacement, though the underlying cause of the empty sella should be investigated if not already known.
- The decision to start testosterone therapy should be based on symptoms and laboratory confirmation of low testosterone, rather than the presence of a partial empty sella alone.
- Patient education on the benefits and risks of testosterone replacement therapy, including the potential impact on quality of life, is crucial for informed decision-making, as patients often report bothersome symptoms such as lack of energy, decreased strength and endurance, and deterioration in work performance 1.
From the Research
Definition of Partial Empty Sella
- Partial empty sella occurs when less than 50% of an enlarged or deformed sella turcica is filled with cerebrospinal fluid in the setting of unidentified etiologic pathological conditions 2.
- It is characterized by the herniation of the subarachnoid space within the sella, which is often associated with some degree of flattening of the pituitary gland 3.
Testosterone Supplementation in Partial Empty Sella
- There is no direct contraindication of testosterone supplementation in patients with partial empty sella, but it is essential to evaluate the clinical and hormonal profile of these patients 3.
- In some cases, patients with partial empty sella may have endocrine dysfunction, including hypogonadism, which may require hormone replacement therapy, including testosterone supplementation 2, 4.
- However, it is crucial to identify and address any underlying pituitary hormone deficiencies, as testosterone supplementation may not improve fertility, but it can help produce and maintain virilization and prevent future complications of hypogonadotropic hypogonadism 2.
Importance of Hormonal Evaluation
- Patients with partial empty sella should undergo a thorough hormonal evaluation to detect any deficiencies early and institute appropriate replacement therapy 3, 5.
- The evaluation should include serum thyroid-stimulating hormone, T4, cortisol, prolactin, total testosterone, follicle-stimulating hormone, and luteinizing hormone levels 3.
- Regular follow-up and revaluation are necessary to monitor the progression of the condition and adjust treatment accordingly 5.