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.

The Fndings of this study dispel the notion that

a pure linear relationship exists between serum

testosterone and satisfaction levels.

In a recent

study Yeap et al observed a U-shaped association

between testosterone and cardiovascular mortal-

ity.

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.

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.

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.

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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