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artits
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et
al
.
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ev
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ssoc
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B
ras
2014; 60(4):286-294
older men. These may be useful, but are nonspecific al-
though being sensitive
1,20
(
A
).
Recommendation
It is recommendable to carry out a diagnosis of late-on-
set hypogonadism only in men with some of the main
signs and symptoms of hypogonadism and morning se-
rum testosterone level below the minimum reference va-
lues for young adults. The three ADAM, AMS and Smith
Scale questionnaires may be used as LOH (late-onset hypo-
gonadism) triage instruments.
W
hat
is
the
role
of
the
ADAM
questionnaire
?
Ten symptoms commonly observed in men with bioavai-
lable testosterone (BAT) were used to develop the ADAM
questionnaire
20
(
B
). Various studies with good evidence
have shown that the ADAM questionnaire has high sensi-
tivity for identifying ADAM, yet low specificity. Thus, it
cannot be used as a substitute for serum testosterone dose
in the diagnosis
21-23
(
A
). Studies have shown that the diag-
nosis of late-onset hypogonadism or ADAMmay be clini-
cally suspected when the symptoms of sexual dysfunction
are present
24
(
A
).
Recommendation
When analyzing the responses to the ADAM questionnai-
re, clinically suspected cases of LOH are those in which
the symptoms of sexual dysfunction are present.
W
hat
is
the
role
of
the
S
mith
scale
?
The Smith scale is based on men between 40 and 79 years
that participated in the Massachusetts Male Ageing Study
(MMAS). A questionnaire with eight items was developed
based on age, BMI, diabetes, asthma, headache, sleep pat-
terns, dominance preferences, and smoking status. The
questionnaire performed significantly better than chan-
ce in identifying men with low levels of testosterone and
encourages men at risk of low testosterone to seek pro-
fessional evaluation of their testosterone levels. It is a self-
-administered questionnaire for triage of the risk of tes-
tosterone deficiency
25
(
B
).
One study suggests that the ADAM and AMS ques-
tionnaires are superior to the MMAS questionnaire as
a triage instrument for late-onset hypogonadism, as
they have higher sensitivity. The Smith questionnaire is
more related to risk rather than being a questionnaire of
symptoms
20
(
A
).
Recommendation
The Smith questionnaire is considered a questionnaire
to assess the risk of LOH.
W
hat
is
the
role
of
the
AMS
scale
?
This measurement instrument was designed as a scale of
quality of life (QoL) connected to health and standardi-
zed to be self-administered, firstly to assess symptoms of
aging (regardless of being connected to the disease) among
groups of men under different conditions, secondly, to
assess the severity of symptoms/QoL over time, and thir-
dly, to measure changes before and after androgen repla-
cement therapy. The scale has been translated into 21 lan-
guages and is widely used.
The AMS scale measures similar phenomena to those
measured by the ADAM and Smith questionnaires, des-
pite not being designed as a triage instrument
26
(
B
). Com-
paring the three questionnaires in relation to sensitivity
for diagnosing hypogonadism in men, the result was 97%
for the ADAM, 83% for the AMS and 60% for the Smith
scale. In relation to specificity, the result was 30% for the
ADAM, 59% for Smith scale and 39% for the AMS. In con-
clusion, the ADAM and AMS can be useful instruments
for triage of male hypogonadism but are relatively uns-
pecific, therefore the diagnosis of hypogonadism should
depend on functional criteria and biochemistry
20
(
A
). A
promising triage instrument related to the AMS has been
described for the diagnosis of androgen deficiency. This
“AMS screener” is composed of the AMS scale + age + BMI.
It would be acceptable for triage of a large number of peo-
ple and for pre-selection of individuals for a fuller diag-
nostic assessment
27,28
(
A
).
Recommendation
It is recommendable for the AMS scale and ADAM ques-
tionnaire to be used as triage instruments, and the diag-
nosis of LOH should also depend on functional criteria
and biochemistry.
W
hat
is
the
role
of
the
serum
and
free
testosterone
levels
in
the
diagnosis
of
late
-
onset
hypogonadism
?
The diagnosis of late-onset hypogonadism is based both
on plasma levels of testosterone and clinical symptoms.
Almost all testosterone circulates in the blood (98%) bound
to serum proteins, mainly SHBG (sex hormone binding
globulin) and albumin, with only 1% to 2% of serum tes-
tosterone free from protein binding. SHBG binds to T
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