Sex steroids

Male hypogonadism

Low androgen levels in HIV-infected men appear relatively common, often in the setting of low or inappropriately normal gonadotrophin levels. The cause of this is not completely understood, however contributors include the usual causes of hypogonadism in men. There appears to be an association with HIV wasting and lipodystrophy (48).

Androgen deficiency in men leads to lean tissue and bone loss, fatigue and mood disturbance. Other symptoms may include a loss of body hair, testicular atrophy, reduced pubic hair and reduced libido. Clinical confirmation includes the findings of gynaecomastia, reduced secondary sex characteristics and small, soft testicles. Clinical signs that may suggest a secondary cause, including the presence of a goitre and thyrotoxicosis, a testicular mass, signs of chronic liver or pituitary disease. Biochemical confirmation is undertaken by measuring two early morning testosterone levels (at 8-9am), along with FSH and LH levels, prolactin and TSH levels. Diagnosis and examination for causes of testicular failure are detailed elsewhere (49).

PBS prescribing of androgens in Australia require two early morning testosterone levels <8.0 nmol/L and endocrinologist evaluation. Treatment options include injectable testosterone (testosterone esters, 200-250 mg every 2-3 weeks, or long-acting testosterone undecanoate 1000mg IMI every 10-12 weeks), transdermal testosterone by patch, gel or lotion applied daily. Men receiving androgen supplementation require annual digital rectal examination of the prostate and annual measures of plasma prostate specific antigen levels.

Female hypogonadism

Secondary amenorrhoea is common in women with HIV infection, affecting about one in four women (50). The prevalence of amenorrhea is higher among women who have lost significant amounts of weight in the setting of HIV-related wasting (50).  Evaluation should exclude pituitary disease (by measuring prolactin, LH and FSH), thyrotoxicosis, premature menopause, polycystic ovary syndrome, in addition to rare causes of hyperandrogenism.

Treatment in women with premature menopause (ie age <45 years) usually takes the form of the oral contraceptive pill or hormone replacement therapy, to alleviate symptoms of oestrogen deficiency and maintain bone mass. Therapy should be offered until the age of 50-53 years, that is, about the usual age of menopause. The presence of a past history of stroke, deep vein thrombosis or pulmonary embolism, or current cigarette smoking may alter recommendations for hormonal therapy.