Editor – The informative article by Offord et al highlights thedetrimental impact of age-related frailty and sarcopenia onmobility, fracture risk, quality of life, and NHS resources. 1 Wewere, however, surprised to find no mention of hypogonadismamong the recognised causes of sarcopenia (and anaemia) inolder males. The anabolic benefits of androgens on skeletalmuscle mass are well-documented, albeit also observable withsupraphysiological levels achieved by athletes as well as in thecontext of medically justifiable T replacement. 2 The EuropeanMale Ageing study found that hypogonadism affects 2–5% ofcommunity-dwelling older men. 3 Hypogonadism is either caused by deficient testicularfunction (ie primary hypogonadism) or reduced pituitaryluteinising hormone (LH) and follicle stimulating hormone(FSH) secretion (ie secondary hypogonadism). Secondaryhypogonadism (low LH, FSH and T) is challenging to diagnose,particularly in the acute setting, as similar biochemicalresults may be observed in relation to non-gonadal illness,and in healthy men in the evening or post-prandially (T levelshave diurnal variation and are suppressed acutely by foodintake). 4 By contrast, the biochemical fingerprint of primaryhypogonadism is unambiguous, even in the setting of anacute medical or geriatric-rehabilitation ward; serum levels ofLH and FSH are elevated, and serum T is low or low-normal.Furthermore, it is important to consider that patients mayalso present with microcytic anaemia caused by reducedT-dependent haematopoeisis. T treatment may be given topically or by depot injection.T treatment is not recommended for men with physiologicalsuppression of T secretion as a result of either frailty or obesityof old age. 3–5 However, for older men with true hypogonadism,T replacement is an inexpensive, safe and effective therapy thatcan reverse sarcopaenia, osteopaenia and anaemia, with expertconsensus defining no upper age limit for the initiation oftherapy in these individuals. 6 Thus, when diagnosing sarcopaenia in older men, we urgephysicians not to reflexively ascribe this to ‘old age’, andto also recognise that unexplained anaemia may sign-posthypogonadism. If the patient is subsequently found to haveelevated LH and FSH, a trial of T replacement should beconsidered following an expert review.
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