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ANDROPAUSE, TESTOSTERONE &
MALE MENOPAUSE
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Frequently Asked Questions (FAQs)
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This information is under
copyright by Harvey S. Bartnof, M.D. and California Longevity and Vitality
Medical Institute®.
It may be copied only for individual, personal use and is not for distribution
or publication of any type without the explicit written permission of Dr.
Bartnof.
Andropause is a state of lowered “androgen”
(male-type) hormone levels in men, particularly testosterone. It also has been
referred to as “ADAM” or androgen deficiency (decline) in aging men, “PADAM” or
partial androgen deficiency (decline) in aging men, “male menopause” (similar to
the decline in female hormones in women in middle age or older), male
“climacteric,” and even “viropause” (decline in virility).
Common symptoms include (not all are always
present): decreased libido (less or loss of interest in sex), weakness/ fatigue/
tiredness, memory changes (may be subtle), and erectile dysfunction (“ED”).
Other symptoms may include (not all are always present): decreased stamina
(workouts, etc.), decreased mental “sharpness,” decreased productivity,
decreased cognition (thinking, ability to understand), decreased concentration,
irritability, nervousness, depression, moodiness, night sweats, “hot flashes,”
and “palpitations” (sensation of abnormal heart beating). Note that several of
these symptoms may be non-specific, meaning they may be due to causes other than
andropause. Also note that there is increasing research that low testosterone
may be a co-factor for Alzheimer’s disease (brain disease) in men and possibly
women.
Common signs include (not all are always
present): decreased muscle mass, decreased muscle strength, increased fat mass,
decreased axillary (armpit) hair, decreased pubic hair, possible decreased size
of testicles, decreased bone mass (possible osteopenia and even osteoporosis),
decreased sperm count with possible infertility and dry skin. Note that some of
these symptoms may be non-specific, meaning they may be due to causes other than
andropause.
Just as in any other medical condition, a
diagnosis is made based upon a patient’s history (symptoms), physical
examination, laboratory tests and possibly other additional tests.
After a diagnosis is made, the benefits and risks
are discussed by Dr. Bartnof with the patient. If treatment is indicated, a
decision is made, based upon the preference of the patient and his informed
consent, to begin treatment. Treatment is almost always with replacement
testosterone.
Androgens refer to the male-like hormones,
although women also have androgens—but lower levels than men. The main
androgens are: testosterone, dihydrotestosterone (DHT), androstenedione, and
DHEA (dehydroepiandrosterone, from the adrenal glands on top of each kidney).
Testosterone increases libido (interest in sexual activity), is anabolic
(will build body tissues, including muscles and bones), helps
maintain normal oil secretion in the skin and hair, and has effects, directly or
indirectly on the brain, that are partly responsible for normal cognition
(thinking), mental sharpness and concentration, visual-spatial abilities, sense
of well-being, sense of stamina, sense of energy and normal mood. Androgens
are necessary for normal erectile functioning, while testosterone is a
necessary co-factor for sperm production and fertility. Androgens lead to
male sexual characteristics, including facial (and in many men) body
hair and a deeper voice. Testosterone has beneficial benefits on the
heart and arteries—it was used to treat angina (heart pain due to
artery blockage) in the 1940s. Several studies have shown that testosterone
dilates the heart and other arteries, although the effects may be due to its
conversion to estradiol. Several modern studies have shown beneficial effects
of testosterone on results of exercise treadmill testing, reducing abnormal
changes on electrocardiograms (ST depression improves) and improving angina.
Low testosterone levels in men are associated with “atherosclerotic” (blockages)
disease in the heart arteries. Testosterone will decrease total and LDL (“bad”)
cholesterol, but, in some men, will also decrease the HDL (“good”)
cholesterol somewhat. This decrease is counterbalanced by increased clearance
(decrease in blood level of) of total cholesterol. Low HDL can be treated with
lifestyle intervention and/or prescriptive and non-prescriptive medication.
Usually, testosterone is prescribed as a periodic
injection (every 7 or 10 days) or as a topical cream or gel, either once or
twice daily. A less commonly-used formulation is pellets implanted under the
skin every few months. Other formulations include skin patches, a small patch
used in the mouth on the gums and a sublingual (under the tongue) tablet. There
are advantages and disadvantages and benefits/ risks for each of the
formulations. Oral testosterone as a sole medication is not available in the
US.
The purpose of testosterone therapy is to treat
the symptoms and body changes listed under questions 2 and 3 above. However, as
with any treatment, there are potential side effects. They are often
manageable; however, if a side effect cannot be managed or begins to outweigh
potential benefits, then a decision may be made to stop treatment. Side effects
include: more natural oil on the skin (particularly the head) that when
excessive may lead to oily skin or hair and even acne; increased red
cell counts (treatable or avoidable); excessive libido; and possible
prostate growth. The prostate issue in testosterone therapy is a
controversial one. It appears that the hormones that testosterone converts into
(DHT and probably estradiol) are the ones involved in prostate growth.
Therefore these other hormones also generally require monitoring and natural
supplements or prescriptive medications may be used to keep those hormones in a
normal range. Regular monitoring of the PSA (prostate specific antigen) blood
test, red cell counts and examination of the prostate is necessary. A man who
has had a history of prostate cancer or breast cancer (yes, men do sometimes get
breast cancer) has a relative contraindication to (should not take) testosterone
replacement therapy. However, if a man with either of those cancers has been
cured and enough time has passed, he may be a candidate for testosterone
replacement. DHT (made from testosterone) may induce scalp hair loss in
susceptible men, unless the DHT is blocked or inhibited with specific
treatments. A few men are susceptible to subtle, female-type breast
appearance, but this is preventable and treatable with specific therapies. Some
men may notice a slight decrease in the size of their testicles, but this
can be avoided with specific treatments, if necessary. The decrease occurs
because of a feedback loop that shuts off the normal brain signal to the
testicles. This same mechanism may decrease sperm counts and decrease
fertility—if a man still desires to father a child, there are treatments to
allow for normal sperm counts. Sometimes, testosterone can worsen “sleep
apnea,” a condition whereby breathing temporarily stops during sleep—this is
more likely to occur in men who are overweight or obese. In some men,
testosterone may decrease the HDL (“good”) cholesterol somewhat. This
decrease is counterbalanced by increased clearance (decrease in blood level of)
of total cholesterol. Low HDL can be treated with lifestyle intervention and/or
prescriptive and non-prescriptive medication. When testosterone levels are
within normal limits, “rhoid rage” (excessive anger) does not occur—but may
occur when levels are too high or “supraphysiologic,” as when it is abused by
some “body-builders.” Oral testosterone is not available in the US as a sole
drug, and certain types can cause liver problems.
Hypogonadism in men is a strict medical
definition primarily based on a blood testosterone level that falls below a
specified level that varies from laboratory to laboratory. A patient’s symptoms
and physical examination is also used to make that diagnosis. Andropause refers
more generally to a state of declining androgens or male-like hormones. Also, a
patient’s history, physical examination and laboratory results are used to make
the diagnosis. However, not all physicians even believe that andropause exists
(more and more of them will in the future as they and the public become more
educated). Also, some physician researchers may include a decline of other
hormones in their definition of andropause, specifically DHEA (dehydroepiandrosterone
from the adrenal glands) and somatotropin (growth hormone). Yet other
physicians will use other “-pause” terms to refer to those hormones that are
declining, specifically adrenopause for the decline in DHEA and
somatopause for the decline in somatotropin.
Several research studies have shown a
significant association between low testosterone levels in men and Alzheimer’s
disease of the brain. In the January 27, 2004 issue of the journal Neurology,
574 men were followed for an average of 19 years in the Baltimore Longitudinal
Study of Aging. The results showed that higher free (unbound)
testosterone levels in men predicted a decreased future risk of
developing Alzheimer’s. Put another way, for every 50% increase in free
testosterone at baseline, there was a 26% decreased risk of developing the
disease. This “dose-response” relationship is something that statistics
researchers use to add credence to the results and significantly adds weight to
the conclusions. At the end of the study, those men with Alzheimer’s had about
half the level of free testosterone as those men who did not have the disease.
For more information about this study,
CLICK HERE
.The same researchers had reported previously that older
men with higher levels of free testosterone have better visual memory, better
verbal memory and better performance on “spatial” tasks than those men with
lower levels.
Robert S. Tan, MD, of the University of
Texas at Houston, reported in 2003 in the journal Aging Male his results of a
pilot study of 10 men with dementia (loss of brain function, a prominent finding
in Alzheimer’s) and who had low testosterone blood levels (hypogonadal). After
testosterone replacement therapy, quarterly measurements for 1 year revealed
significant improvements in thinking abilities (MMSE, Mini-Mental State
Examination) and visual-spatial abilities (Clock-Drawing test). This is only a
pilot study and additional research is necessary. For more information about
this study,
CLICK HERE
.
To see more references about testosterone
and Alzheimer’s/ memory loss,
CLICK HERE
The effects on man by subcutaneous injections of a liquid
obtained from the testicles of animals.
Sequard
B. The Lancet 1889 July 20:105-107 (not available on PubMed).
1944-1946
(JAMA)
The male climacteric, its symptomatology,
diagnosis and treatment.
Heller CG and Myers G. Journal of the American Medical
Association 1944; 126(8):472-477 (not available on PubMed).
The male climacteric: report of 273 cases.
Werner AA. Journal of the American Medical Association
1946; 132:188-194 (not available on PubMed).
by Robert S. Tan, MD; publisher AMRED Publishing, 2001.
(Paperback , 186 pages) Available for purchase at Amazon.com
“The Testosterone Syndrome”
by Eugene Shippen, MD; publisher M. Evans & Co,
1998. (Paperback, 220 pages)
Current References of Interest-General Medical
Is it andropause? Recognizing androgen deficiency in aging men.
Tan RS, Pu SJ. Postgraduate Medicine 2004 Jan; 115(1): 62-6.
http://www.postgradmed.com/issues/2004/01_04/tan.htm
(PubMed abstract:)
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14755879
An integrative review on current evidence of
testosterone replacement therapy for the
andropause.
Tan RS, Culberson JW.
Maturitas. 2003 May 30; 45(1): 15-27 (review).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12753940
Andropause:
an old concept in new clothing.
Morley JE, Perry HM. Clinics in Geriatric Medicine
2003 August; 19(3): 507-528 (review).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14567004
Andropause:
clinical implications of the decline in serum testosterone levels with aging in
men.
Matsumoto AM. Journals of Gerontology Series A: Biological Sciences and
Medical Sciences. 2002 Feb; 57(2): M76-99 (review, no abstract available on
PubMed).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11818427
Andropause,
testosterone therapy, and quality of life
in aging men.
Morley JE. Cleveland Clinic Journal of
Medicine. 2000 Dec; 67(12): 880-2.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11127982
Urologic aspects of
andropause.
Stas SN,
Anastasiadis AG, Fisch H, Benson MC, Shabsigh R.
Urology.
2003 Feb; 61(2): 261-6 (review, no abstract available on PubMed).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12597927
Andropause:
is it time for the geriatrician to treat it?
Morley JE. Journals of Gerontology Series A: Biological Sciences and Medical
Sciences. 2001 May; 56(5): M263-5 (editorial, no abstract available on
PubMed)
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11320104
Andropause:
introducing the concept of 'relative hypogonadism' in aging males.
Tan RS. International Journal of Impotence
Research 2002 Aug; 14(4): 319 (no abstract available on PubMed).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12152125
Andropause:
endocrinology, erectile dysfunction, and prostate pathophysiology.
Hafez B, Hafez ES. Archives of Andrology.
2004 Mar-Apr; 50(2): 45-68 (review).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14761837
Perceptions of and risk factors for
andropause.
Tan RS, Philip PS.
Archives of Andrology. 1999 Nov-Dec; 43(3): 227-33.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10624507
Current References of Interest-
Alzheimer’s, memory loss,
other
Low Free
Testosterone Levels Linked to
Alzheimer's Disease in Older Men
(National Institute of Aging)
http://209.70.85.166/cgi-bin/s.cgi?cs=&q=Testosterone&ch=http:%2F%2Fwww.alzheimers.org%2Fnianews%2Fnianews62.html&fm=off
Free testosterone and risk for
Alzheimer disease in older men.
Moffat SD, Zonderman AB, Metter EJ, Kawas C,
Blackman MR, Harman SM, Resnick SM.
Neurology. 2004 Jan 27; 62(2): 188-93.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14745052
A pilot study on the effects of testosterone
in hypogonadal aging male patients with
Alzheimer's disease.
Tan RS, Pu SJ.
Aging Male. 2003 Mar; 6(1): 13-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12809076
Role of androgens in mild
cognitive [thinking] impairment and
possible interventions during andropause.
Tan RS, Pu SJ, Culberson
JW. Medical Hypotheses. 2004; 62(1): 14-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14728998
Longitudinal assessment of serum free
testosterone concentration predicts memory
performance and cognitive [thinking] status
in elderly men.
Moffat SD, Zonderman AB, Metter EJ, Blackman MR,
Harman SM, Resnick SM.
Journal of Clinical Endocrinology and Metabolism. 2002
Nov; 87(11): 5001-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12414864&dopt=Abstract
Plasma testosterone levels in
Alzheimer and
Parkinson diseases.
Okun MS.and
others. Neurology. 2004 Feb 10; 62(3): 411-3.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14872022
Low androgenization index in
elderly women and elderly men with
Alzheimer's disease.
Paoletti AM and others.
Neurology. 2004 Jan 27; 62(2): 301-3.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14745075
Effects of transdermal testosterone on
bone and muscle in older men with low
bioavailable testosterone levels.
Kenny AM, Prestwood KM, Gruman CA, Marcello KM, Raisz LG.
Journals of Gerontology Series A: Biological Sciences and Medical Sciences.
2001 May; 56(5): M266-72.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11320105
Impact of
obesity on hypogonadism in the
andropause.
Tan RS, Pu SJ.
International Journal of Andrology 2002 Aug; 25(4): 195-201.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12121568
Official guidelines of the International
Society for the Study of the Aging Male (ISSAM)
Cuzin B, Giuliano F, Jamin C, Legros JJ, Lejeune H, Rigot JM,
Roger M. Prog Urology. 2004 Feb; 14(1): 1-14.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15098744
American Association of Clinical
Endocrinologists Medical Guidelines for Clinical Practice for Evaluation and
Treatment of Hypogonadism [classical testosterone deficiency] in Adult Male
Patients—2002 Update
http://www.aace.com/clin/guidelines/hypogonadism.pdf
Institute of Medicine Report: Testosterone
and Aging (November 12, 2003)
http://www.iom.edu/report.asp?id=16398
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