Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • suspected pituitary tumour with concerning features including:
    • acute new visual field loss (usually temporal and classically bitemporal superior quadrantinopia/hemianopia)
    • thunderclap headache
    • symptomatic cortisol insufficiency

For clinical advice, please telephone the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network 

Southern Adelaide Local Health Network

Exclusions

  • unexplained fatigue without endocrine disorder

Triage categories

Category 1 - appointment clinically indicated within 30 days

  • arrested puberty (16 years and over)
  • suspected hypopituitarism

Category 2 — appointment clinically indicated within 90 days

  • azoospermia
  • confirmed hypogonadism with two morning testosterone levels less than 6nmol/l
  • delayed puberty (16 years and over)
  • male infertility

Category 3 — appointment clinically indicated within 365 days

  • symptoms of androgen deficiency with testosterone levels above 6nmol/l

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • past medical/surgical/reproductive history, including:
    • age and health
    • drug therapy, including previous prescribed or non-prescribed testosterone
    • testicular size
  • current medications and dosages
  • use/frequency of alcohol, tobacco, and other drugs, including:
    • history of marijuana use (including partner)
    • other relevant medications that contribute to infertility e.g. illicit drugs, steroids, chemotherapy
  • allergies and sensitivities
  • onset, duration, and progression of symptoms
  • management history including treatments trialled/implemented prior to referral
  • physical examination
  • height/weight
  • body mass index (BMI)

Pathology

  • morning sample on at least 2 separate days (7.00 to 9.00 am):
    • luteinizing hormone (LH)
    • follicle-stimulating hormone (FSH)
    • androgen profile
  • prolactin
  • morning cortisol (8.00 to 9.00 am)
  • thyroid stimulating hormone (TSH)
  • free thyroxine (FT4)
  • insulin-like growth factor-1 (IGF1)

If infertile

  • semen analysis
    • repeat in 4 to 6 weeks if abnormal

Suspected obstructive sleep apnoea

  • sleep study

Additional information to assist triage categorisation

  • bone mineral densitometry

Clinical management advice

Hypogonadism can be caused by issues with the testicles (primary hypogonadism), the pituitary gland or hypothalamus (secondary hypogonadism), or a combination of factors. Treatment may involve hormone replacement therapy to raise testosterone levels and alleviate symptoms. Reduced testosterone levels can be associated with obesity, sleep apnoea, analgesics, alcohol and depression.

  • Primary hypogonadism characterised by low testosterone, elevated luteinizing hormone and follicle- stimulating hormones, are indicative of primary testicular disease.
  • Secondary hypogonadism involving low testosterone without increases in luteinizing hormone and follicle-stimulating hormones, indicates pituitary or hypothalamic dysfunction.

Investigation should establish persistent biochemical testosterone deficiency (requires at least 2 serum testosterone levels at 0800-0900 on separate days) to establish a diagnosis/cause.

  • biochemical androgen deficiency, perform the recommended preliminary biochemical tests.

For testosterone treatment subsidised by the Pharmaceutical Benefits Scheme (PBS), an initial prescription should come from an endocrinologist, with patients having two morning testosterone levels below 6nmol/L in the presence of established pituitary or gonadal conditions. Treatment can be managed by a general paediatrician, endocrinologist, urologist, or a fellow of the Australasian Chapter of Sexual Health Medicine, or in consultation with one of these specialists.

Please ensure that recent pathology results are available. Consider providing the patient with a repeat pathology form at the time of referral.

Patients who have previously received care from a specialist should be encouraged to return to their care for additional assessment if needed.

Referrals are subject to the evaluation of the triaging clinician. If you believe your patient necessitates specialist assessment but may not meet the provided criteria, feel free to connect with the specialist team to discuss your concerns.

Clinical resources

Consumer resources

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

  • full name, including aliases
  • date of birth
  • residential and postal address
  • telephone contact number/s – home, mobile and alternative
  • Medicare number, where eligible
  • name of the parent or caregiver, if appropriate
  • preferred language and interpreter requirements
  • identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

  • impact on employment
  • impact on education
  • impact on home
  • impact on activities of daily living
  • impact on ability to care for others
  • impact on personal frailty or safety
  • identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery, where surgery is a likely intervention.
  • Choice to be treated as a public or private patient.
  • Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
  • A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.