MON-154 - Do It Yourself (DIY) Testosterone: A Unique Case of Testosterone Replacement Therapy

Introduction
Testosterone (T) has a long record of safety and efficacy for its prime role of androgen replacement therapy in men with hypogonadism (Hypogonad). Recently, there has been a rise in off-label T use and misuse, as well as thyroid, growth and adrenal supplements. Male patients often take T for low energy, low libido, erectile dysfunction, weight gain, and other symptoms. People often use these symptoms as indicators to verify their suspicion of hypogonadism. Some patients prefer to self-medicate since the black market is perceived as much quicker, easier and less expensive to obtain T, than the medical system.

Case Presentation
We present the case of a 55-year-old male who presented to the endocrine clinic for evaluation and continuing medical management of Hypogonad. He states that from 2013 until 2017, he was prescribed Nandrolone Decanoate therapy from an outside clinic, for a testosterone level of 158 with symptoms of low libido, difficulty sleeping, and depression. This medication was stopped after left shoulder replacement. Following the 4 yr. period of clinic prescriptions, he admitted to currently making up T solution through testosterone kits from China. After stopping the unknown form of testosterone for 3 months, labs showed a low total testosterone level of 29 ng/dL(Nl 264-916).
One month later, after taking the unknown solution, levels of total Testosterone = 986 ng/dL (Nl 250-1100), free Testosterone of 273.6 pg/mL (Nl 35-155), FSH < 0.3 mIU/mL (Nl 1.4-18.1), LH < 0.07 mIU/mL (Nl 1.5-9.3), Prolactin 14.5ng /mL (Nl 2.1-17.7). Labs off of testosterone replacement showed low Free testosterone 11.5 pg/mL (Nl 35-155), low total Testosterone 62 ng/dL (Nl 250-1100), low FSH < 0.3 mIU/mL, low LH 0.11 mIU/mL, low Sex Hormone Binding Globulin 15.14 nmol/L (Normal 10-57 for adult males) , normal Prolactin 5.6 ng/mL (Nl 2.1-17.7) confirming the diagnosis of hypogonadism. It is unclear whether the patient has low FSH and LH due to chronic testosterone pituitary suppression or secondary hypogonadism. MRI pituitary was ordered to rule out secondary hypogonadism.

Conclusion
Unsupervised testosterone use carries significant potential risks including cardiovascular disease, erythrocytosis, fluid retention, benign prostatic hyperplasia, prostate cancer, hepatotoxicity, infertility, worsening sleep apnea, breast cancer and mental health disorders, and unsafe ingredients, as well as lack of monitoring, incorrect dosing and misuse. Our case aims to educate providers that some patients may obtain unsafe testosterone from non-medical sources. Therefore, it is important to inquire about off-label use of testosterone and supplements when evaluating patients for hypogonadism.

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