Hypogonadism

Draft … My original question in PICOT format was: In men, ages 45-65, with low testosterone levels, how does using intramuscular testosterone alone compare to using intramuscular testosterone in combination with subcutaneous human chorionic gonadotropin (hCG) in increasing serum testosterone levels after a 6-month treatment period. However, since creating it last week, I have decided to redefine it to: In men, ages 45-55 who present with symptoms of hypogonadism, how does using intramuscular testosterone alone compare to using intramuscular testosterone in combination with subcutaneous hCG in reducing reported symptoms after a 6-month treatment period.
Symptoms associated with hypogonadism are fatigue, loss of muscle mass, increased body fat, depression, decreased libido, and loss of night time erections. Granted, these symptoms alone may not result in a diagnosis of hypogonadism as comorbidities, such as obesity, hypertension and diabetes, must be considered (Lawrence, Stewart, & Larson, 2017).
Background questions are looking to answer general knowledge questions that often can be located in textbooks. They typically have a root question of who, what, when, where, how and why followed by the outcome of the intervention or area of interest (Colorado State University, n.d.). Foreground questions, as defined by Lawrence, Stewart, & Larson (2017), are “those that can be answered from scientific evidence about diagnosing, treatment, oe assisting patients in understanding their prognosis” (p.27).
Background questions would likely deal with the type of symptoms the patient initally reported that encouraged them to seek medical attention. Examples would be what causes fatigue and loss of energy in the aging man? What are the symptoms of low testosterone? What causes low testosterone? The symptoms associate with hypogonadism are easily located in textbooks and on the internet. The foreground questions pose the more clinical questions. An example may be, what other diagnoses may cause similar symptoms as hypogonadism? What does hCG do in the role of treating low testosterone?
Much of the evidence located initially was related to infertility in younger men. As I varied my key words for the searches, my results began to increase. The additional results were more specific to testosterone replacement in various ages and several were specific to older men. There are even fewer results that discuss the use of hCG with testosterone. The most specific article was “A Double-Blind, Placebo-Controlled, Randomized Clinical Trial of Recombinant Human Chorionic Gonadotropin on Muscle Strength and Physical Function and Activity in Older men with Partial Age-Related Androgen Deficiency”, but it was from 2002 and did not use testosterone in combination with the hCG (Liu, Wishart, & Handelsman, 2002). I feel confident that with time and varying the key words in the searches that I will generate more appropriate results