Management of Hot Flashes in Hypogonadal Men

Diagnostic Confirmation and Treatment Rationale

• The American Urological Association recommends confirming the diagnosis of hypogonadism with repeat morning total testosterone measurement and measuring free testosterone by equilibrium dialysis, as normal total testosterone can mask low free testosterone in some cases 1, 4
• The Endocrine Society suggests verifying LH and FSH levels to differentiate between primary and secondary hypogonadism, with normal LH/FSH indicating secondary (hypothalamic-pituitary) hypogonadism 1, 4
• The European Association of Urology recommends measuring serum prolactin in all patients with low testosterone and normal/low LH to screen for prolactinoma or other pituitary disorders 4
• Hot flashes are a recognized symptom of male hypogonadism that should improve with testosterone normalization, according to the National Comprehensive Cancer Network 1, 2, 3, 4

Treatment Options

• The American College of Clinical Endocrinologists recommends testosterone replacement therapy (TRT) as first-line treatment for hot flashes in men with hypogonadism, with transdermal testosterone gel 1.62% as a recommended formulation 1, 2, 3
• The European Urology Association suggests that androgens (testosterone) are specifically indicated for relief of hot flashes in men with hypogonadism who are not on androgen deprivation therapy for prostate cancer 2, 3
• Gabapentin 900 mg daily at bedtime and venlafaxine 37.5-75 mg daily are recommended as non-hormonal options for hot flash management in men with hypogonadism, according to the National Comprehensive Cancer Network 6, 7

Monitoring and Safety Precautions

• The European Association of Urology recommends baseline monitoring of PSA, digital rectal exam, hematocrit/hemoglobin, liver function tests, and lipid panel before starting TRT, with follow-up monitoring at 3-6 months and annually 5, 4
• The American Urological Association suggests that TRT is contraindicated in men with known or suspected prostate cancer, male breast cancer, desire for fertility, severe untreated sleep apnea, and uncontrolled heart failure 5

Lifestyle Modifications

• The European Urology Association recommends weight loss if overweight/obese and regular physical activity as adjuncts to TRT, as they can improve endogenous testosterone production and yield better outcomes than either alone 5