Androgen deficiency in the aging male, or andropause is being diagnosed with increased frequency.Agrowing body of literature supports the view that a true testosterone decrease develops in some men around the age of 45 which can be associated with a broad spectrum of deficiency symptoms.
Manifestations associated with andropause include:
Vasomotor/ nervous system
- Episodes of sweating
- Hot flushes
- Decreased vigour and physical energy
- Diminished muscle mass and strength
- Abdominal obesity
- Loss of lean muscle mass
- Decreased libido
- Reduced sexuality
- Poor erectile function
- Limited quality of orgasm
- Reduced volume of ejaculate
- Weakness of ejaculation
It is obvious that testosterone affects many body systems, including male sexual development, sexual behaviour, sexual and erectile function, bone mineralization, lipid and carbohydrate metabolism, muscle mass, muscle strength and hematopoiesis.
Prominent among the manifestations of andropause are mood disorders and decreased libido.Androgen administration renders men more vigorous when the hypogonadal state is corrected.The increased sense of wellbeing experienced by this persons can be dramatic.
Self reported changes include: more relaxed feelings, improved sleep pattern, decreased fear and/or sadness, renewed sexual desire, increased sexual interest, partial correction in sexual dysfunction and a decline in lethargic episodes.
In clinical practice we make use of the following hormonal score sheet to ask patients to grade their symptoms. We than repeat the procedure after a course of androgen administration and have found without exception an improvement of two points in most of the categories.
Hormonal score sheet:Rate the following as they apply to you; use numbers one to four, with one being rare and four being frequent or severe.
- Fatigue, tiredness, loss of energy
- Decrease in physical stamina
- Feelings of depression
- Decreased sex drive
- Erection and/or potency problems
- Loss of morning erections
- Dry skin on face or hands
- Increase in waist size
- Loss of motivation
- Increase in aches in joints and muscles
- Frequent use of alcohol- now or in past
- Decrease in muscle mass
- The age you are?
- The age you feel?
Management of Andropause
Male hormone therapy has been shown to be dramatically effective in relieving symptoms and restoring drive, health, potency and a sense of renewed vitality. Management includes:
- Reduce oestradiol levels and increase testosterone levels through dieting, exercise and nutritional supplements such as zinc and vitamin C. Testosterone is converted to oestradiol through the aromatase enzyme. Oestrogen is stored in fatty tissue and speeds up aromatase activity, therefore diet and exercise are important. A weight loss programme can cut down oestradiol build-up.
- Zinc supplementation in amounts of 100mg. per day is believed to decrease testosterone conversion to oestrogen, possibly by affecting the number of androgen receptor sites.
- Vitamin C has been used also to decrease aromatase activity in doses of 1-3 gram per day.
This is a conservative approach which may be useful in a man with borderline results and symptoms, or someone who wishes to forestall the onset of andropause.
Another approach is more appropriate when laboratory values and symptoms are more definitive and in such men, increasing testosterone levels is more clearly a major goal.
Testosterone replacement therapy
Testosterone replacement is an important and highly effective means of addressing andropause. It is extremely important that a clinical examination should be done before initiation of therapy. Values should be measured for cholesterol, FBC, haematocrit, PSA, testosterone, oestradiol, FSH and LH.There are several efficient ways to administer testosterone.
- Oral preparations
- Intramuscular injection therapy
- Implanted pellets
- Topical preparations
Patients receiving supplemental therapy testosterone therapy should have clear indications based on clinical symptoms and/or physical manifestations. Proper laboratory assessment is mandatory.
Patients affected by androgen deficiency usually require testosterone administration therapy on a long term basis.Testosterone replacement may result in increased oestrogen levels and is therefore contraindicated in men with breast cancer.
Known prostate cancer is a contraindication for testosterone treatment. Known existence of sleep apnoea remains a contraindication for androgen administration.Initially patients should be followed on a three monthly basis.
At these visits the following should be undertaken:
- Clinical assessment of response to therapy
- PSA if patient is older than 40 years of age.
Patients who remain stable may subsequently be followed every six months, at which time a lipid profile, haemoglobin and haematocrit may also be considered.
Serum levels in treated patients will fluctuate considerably, particularly if testosterone is given by intramuscular injection. Regardless of serum levels, clinical response is a better guide to the dose required.
Andropause and testosterone replacement therapy can be complicated, and it is wise to refer these patients to a medical practitioner with sufficient experience and knowledge.