To the Editor: We report the case of a patient with previously undiagnosed hypogonadism whose anxiety symptoms improved after he received testosterone injections.
Mr. A, a 34-year-old man, was diagnosed with generalized anxiety disorder. His symptoms included mental exhaustion, irritability, insomnia, poor concentration, and decreased libido. He unsuccessfully tried relaxation techniques and biofeedback before beginning treatment with buspirone, 30 mg/day. After noticing improvement, he discontinued the medication after 2 months but resumed taking it 6 months later, when his anxiety returned.
A review of his medical record indicated that Mr. A had undergone a right orchiectomy several years earlier for an undescended testicle. Blood samples were taken for laboratory analysis. His testosterone level was 185 ng/dl (normal=241–827), and his free testosterone level was 8.9 pg/ml (normal=18–39). His luteinizing hormone level was 18.7 mIU/ml (normal=2–12), and his level of follicle-stimulating hormone was 31.4 mIU/ml (normal=1–8). The results of a physical examination and laboratory tests were within normal limits. Mr. A tapered his buspirone treatment and elected not to begin treatment with paroxetine.
Mr. A was referred to an endocrinologist, who ruled out occult malignancy and prescribed testosterone enanthate, 200 mg i.m. every 2 weeks. He reported resolution of his anxiety symptoms after 1 month. His concentration and libido increased, and he reported better orgasms. He tried to decrease the frequency of his injections but remained on the bimonthly schedule after feeling his anxiety symptoms returning. He has been on the regimen for more than 18 months and has experienced no side effects. This treatment plan may be continued indefinitely.
Contraindications to androgen replacement therapy include androgen-dependent cancers, such as prostate and male breast cancer, and benign prostatic hypertrophy when obstructive symptoms are present (1). A patient’s hematocrit and low-density/high-density lipoprotein ratio should be monitored, since testosterone can elevate these as well (1).
The literature supports a connection between hypogonadism and depression, as evidenced by untreated hypogonadal men scoring significantly higher in ratings of depression, anger, fatigue, and confusion than infertile and normal comparison men (2) and by the improvement of depressive symptoms after the administration of testosterone to hypogonadal men with depression refractory to selective serotonin reuptake inhibitors (3). Another study (4) has shown that testosterone replacement therapy decreases anger, nervousness, and irritability in hypogonadal men. The temporal connection between the improvement of Mr. A’s anxiety symptoms and replacement testosterone suggests an association between anxiety and hypogonadism. With this case report, we suggest including anxiety in the list of psychiatric manifestations of hypogonadism that improve with testosterone replacement therapy.