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CPE-006 · synthetic case TESTO-FX-11
Chronic opioid use
Testosterone 210 and 200 with a low-normal LH.
Purpose: Testosterone 210 and 200 with a low-normal LH.
Inputs the engine received
Testosterone and hormones
- Total testosterone, sample 1
- 210 ng/dL
- Total testosterone, sample 2 (separate day)
- 200 ng/dL
- SHBG
- 30 nmol/L
- LH
- 1.9 IU/L
- Prolactin
- 10 ng/mL
Symptoms and findings
- Age
- 50 years
- Low libido
- Yes
Possible reversible contributors
- Opioid use
- Yes
What the engine reports
Detected clinical pattern
Criteria for Testosterone Deficiency Met
Symptoms with low total testosterone on two samples (210 and 200 ng/dL). Secondary pattern. The cause still has to be found.
- Axis: Secondary (hypogonadotropic) pattern
Why this pattern was identified
- Low testosterone on two samples. 210 and 200 ng/dL are both below 300 ng/dL (AUA). With compatible symptoms, the criteria for testosterone deficiency are met.
- Secondary pattern. LH 1.9 IU/L is not elevated despite low testosterone: the problem is above the testes (hypothalamus or pituitary) or functional.
Calculations
- Calculated free testosterone (Vermeulen)
- 4.2 ng/dL
No threshold is applied: cutoffs are assay-specific.
Recommended next steps
For physician consideration. Urgent review always comes first.
- 1Address the contributor(s) (opioid use) and repeat testosterone.Endocrine Society 2018.
Differentials, pitfalls and contradicting signals
- Functional suppression (obesity, opioids, illness) and pituitary disease look alike on these values.
Evidence and rule trace · 4 rules
HG-CALC-01Calculated free testosterone
Inputs: total testosterone 210 ng/dL · SHBG 30 nmol/L · albumin 4.3 g/dL
Calculated free testosterone 4.2 ng/dL.
HG-03Low testosterone confirmed on two samples
Inputs: 210 ng/dL · 200 ng/dL
Biochemically low testosterone on two samples.
HG-06Secondary (hypogonadotropic) pattern
Inputs: LH 1.9 IU/L (upper limit 9) · total testosterone 210 ng/dL
Pattern of secondary (hypogonadotropic) hypogonadism.
HG-08Reversible contributors present
Inputs: low testosterone · opioid use
Reversible contributors are present.
Evidence
- EV-ES-TRT-2018 · Bhasin S, Brito JP, Cunningham GR, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(5):1715-1744.
- EV-AUA-2018 · Mulhall JP, Trost LW, Brannigan RE, et al. Evaluation and Management of Testosterone Deficiency: AUA Guideline. J Urol. 2018;200(2):423-432.
- EV-TRAVISON-2017 · Travison TG, Vesper HW, Orwoll E, et al. Harmonized reference ranges for circulating testosterone levels in men of four cohort studies in the United States and Europe. J Clin Endocrinol Metab. 2017;102(4):1161-1173.
- EV-VERMEULEN-1999 · Vermeulen A, Verdonck L, Kaufman JM. A critical evaluation of simple methods for the estimation of free testosterone in serum. J Clin Endocrinol Metab. 1999;84(10):3666-3672.
Physician adjudication required. Clinical decision support for physician review. This output identifies laboratory patterns and cautions. It does not diagnose, find the cause, or recommend starting, stopping or dosing testosterone therapy. Physician adjudication is required.
Change the values
The same engine, starting from this case. Change any value and watch the pattern and the rule trace react.
Against typical adult male reference intervals
Testosterone and hormones
- <264
- 264–299
- 300–350 borderline
- >350
4.3 g/dL is assumed when left empty.
Symptoms and findings
Possible reversible contributors
Testosterone therapy context
More testosterone cases
TESTO-FX-01
Low libido and erectile dysfunction, testosterone never measured
A 48-year-old with sexual symptoms and fatigue.
TESTO-FX-02
One low testosterone
Total testosterone 218 ng/dL on a single morning sample.
TESTO-FX-03
Low on two samples with a primary pattern
Testosterone 205 and 190 with LH 22 and FSH 31.
TESTO-FX-04
Secondary pattern with obesity and diabetes
LH 1.2 and FSH 2.0 with BMI 36.
TESTO-FX-05
Raised prolactin with low testosterone
Prolactin 95 ng/mL.
TESTO-FX-06
Headache, visual field loss and prolactin 310
Possible pituitary mass effect.
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