Conference of the
European Society of Antiaging Medicine
Monaco March 2007
Dr Perring was invited to
speak on the subject of Late Onset Hypogonadism
from which the following has been extracted:
Introduction
We may say that men are driven
sexually by three forces: male hormones, that drive what we call
'libido': sexual desire, the motivation for which in any individual, is
psychological and complex; and sexual self-image, the mental view men have
of themselves as sexual beings which is psychologically, but also
culturally, determined.
In my clinical experience
older men often have loss of both libido and desire, while retaining a
strong image of themselves as sexual beings. In the service of this
self-image they often welcome the opportunity of medical intervention, as
offered within the specialty of anti-aging medicine, to maintain or recover
sexual function.
This we do by androgen
replacement, following proper assessment and selection of patients, with the
addition of chemical aids to erection if necessary.
This presentation will focus on the diagnosis,
assessment and safe treatment of testosterone depletion in later life,
called Late Onset Hypogonadism.
Definition
The term Late Onset
Hypogonadism (LOH), now preferred to Andropause of Male Menopause, is
defined by the Society for the Study of the Ageing Male (ISSAM) as 'A
clinical and biochemical syndrome associated with advancing age and
characterised by typical symptoms and deficiency in serum testosterone
levels'.
Safety First!
The decision to institute testosterone replacement in older men with low
testosterone levels must be individualised and accompanied by a detailed
discussion of the potential risks and benefits.
Question:
Which older men should be given testosterone?
Answer: Those men who are significantly affected by
having low levels of testosterone, who want it and who would benefit from
its use. The risk of developing prostate cancer and other
contra-indications to its use should be taken into account.
Clinical Presentation
and Diagnosis
Clinically, symptoms of LOH
are:
-
Reduced lean body mass,
loss of muscle volume/strength
-
Reduced erection
strength (also nocturnal erections)
-
Increased visceral fat
-
Reduced bone mineral
density (osteopenia/osteoporosis)
-
Fatigue, depression and
irritability
-
Reduced cognitive
functions and spatial orientation
-
Reduced libido and
fantasies
-
Reduced body hair and
skin tone/thickness
(ISSAM 2002)
The depletion of
testosterone occurs gradually as measured in the Massachusetts Male Aging
Study:
Longitudinal Decline within Subjects by over 10 years:
The incidence of LOH in the
Baltimore Longitudinal Study on Aging 1997 was shown to be:
The diagnostic criteria
for diagnosing LOH biochemically are:
-
Total Testosterone (TT)
<12nmol/L (346ng/dL)
-
Free Testosterone Index
(TT/SHBG) 41-159%
Or
-
Free Testosterone <250
pmol/L (72pg/mL)
The actions of Androgens on
sexual functions in hypogonadal men are central and peripheral:
Androgens and Sexual
Function in (young) hypogonadal men:
Testosterone replacement increases
-
Sexual activity
-
Sexual daydreams,
thoughts and desires
-
Spontaneous and
nocturnal erections
-
Penile rigidity
-
Penile sensitivity
Orgasm and ejaculation are androgen dependent.
Other actions of androgens
include:
-
Maintenance of muscle
strength and mass
-
Reduced adipose tissue
-
Maintenance of bone
density
-
Action on neurones and
neuro-transmitters with effects on verbal fluency, memory and energy
The minimum tests to
assess the need for testosterone replacement are:
-
Serum Total
Testosterone, Sex Hormone Binding Globulin (SHBG) and Free Testosterone
Index (FTI) or Free Testosterone
-
Serum Luteinising
Hormone (LH)
-
Serum Prolactin
Optional Hormone tests
include:
-
Dehydrotestosterone (DHT),
Dihydroepiandrosterone (DHEA), Oestradiol (E2), IGF 1, thyroid and
cortisol
Assessment for Hormone
Replacement Therapy may also require:
-
Measurement of bone
density: Dexascan
-
Assessment of Prostate
Function: Phenotypic or genotypic disease, current urinary
symptoms, DRE, prostate specific antigen (PSA)
-
Rectal ultrasound
Testosterone Treatment
(NB 'testosterone' is used as a generic term)
In general a short-acting
natural testosterone to be preferred.
The therapeutic goal of treatment is the mid-range level of a young adult
male
(TT about 20 nmol/L or SHBG/TT ratio >60)
Specific forms of
testosterone are:
-
Testosterone gel (Testogel)
50mg bd
-
Transdermal Patch:
Testosterone 5mg/d (Andropatch)
-
Buccal Tablets:
Testosterone 30mg (Striant)
-
Orally:
Testosterone undecanoate (Restandol): 80mg twice daily
-
Intramuscular
injection: testosterone as proportionate 30mg, phenylpropionate 60mg,
isocaproate 60mg, decanoate 100mg (Sustanon): 250mg every two/three
weeks
-
Implant:
Testosterone <600mg every 3 months
Follow-up of patients
receiving HRT
-
PSA and DRE at 3, 6,
9,and 12months and then annually thereafter
-
Transrectal U/S with
biopsy only if above abnormal
-
Hb and hematocrit at
3,6,9,12 months and then annually thereafter
-
Bone density (dexascan)
may be advisable 2 yearly
Prostate cancer is not a
total bar to later treatment with testosterone following its successful
treatment - after one year or later.
Effects of Hormonal
Therapy (HT) on Sexual Function
Meta-analysis of male HRT
showed testosterone administration is associated with greater improvement in
sexual function compared to placebo treatment in men with sexual dysfuntion
and low testosterone levels.
Testosterone may also favourably affect partner interactions and intimacy
due to an overall increase in sexual desire and sense of well-being,
independent of the change in erectile function
Specifically:
Testosterone restores erectile response in 40 - 60% of hypogonadal patients.
The 'best' treatment is currently testosterone plus a PDE5 inhibitor (e.g.
Sildenafil, Vardenafil, Tadanafil) or Prostaglandin E1 (e.g. Caverject).
A Holistic View
For the maintenance of satisfying sex consider the whole person:
-
Hormones and other aids
to arousal are only part of a complex social/biological system
-
Consider also lifestyle
factors (nutrition, exercise, 'stress') and the relationship of the
couple (communication, intimacy and maturation towards autonomy)
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