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andropause.pptx
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- 2. ALSO KNOWN AS… Androgendeficiency in ageing male Late onset hypogonadism Male menopause Male climacteric Androclise Androgen decline in ageing male (ADAM) Ageing male syndrome
- 3. DEFINITION • Defined asa syndrome associated with a decrease in sexual satisfaction or a decline in a feeling of general well-being with low levels of testosterone in older man • Investigators have generally taken two approaches; one is purely statistical (lower 2.5th percentile of testosterone adult value), whereas the other is clinical (use of questionnaires)
- 4. PATHOPHYSIOLOGY • Frequency ofthe condition in 40–79-year old community-dwelling men is 2.1% • Slow gradual decline in testicular testosterone (T) production as the man ages • The decline of T is usually small, 1–2% per year, but in some men it is more profound and may lead to clinical hypogonadism • Majority men fulfilling the strict criteria of andropause are overweight or obese. The lean men with andropause have often chronic health conditions (e.g. cardiovascular disease, diabetes, frailty)
- 5. DIAGNOSIS OF LOH CLINICALDIAGNOSIS • COMMON SYMPTOMS Loss of libido (most commonly reported) erectile dysfunction decreased muscle mass and strength increased body fat, decreased bone mineral density and osteoporosis decreased vitality and depressed mood • presence of three sexual symptoms (decreased libido, morning erections, and erectile dysfunction) combined with a total testosterone level of less than 11 nmol/l and a free testosterone level of less than 220 pmol/l, can be considered the minimum criteria for the diagnosis of LOH in aging men.
- 6. DIAGNOSIS OF LOH LABDIAGNOSIS • serum sample for total testosterone determination should be obtained between 0700 and 1100 h • Total serum testosterone = unbound T + protein bound T ( SHBG & Albumin) • Bioavailable testosterone = unbound T + Albumin-T • Free or bioavailable testosterone concentrations should be measured when total testosterone concentrations are close to the lower limit of the normal range and when altered SHBG levels are suspected • average testosterone threshold corresponded to the lower limit of the normal range for young men, that is, 300 ng/dl (10.4 nmol/l)
- 7. DIAGNOSIS OF LOH FURTHEREVALUATION • To differentiate between primary and secondary hypogonadism - • Estimation of serum FSH + LH • If low T is associated with elevated LH, the man has primary hypogonadism, and if LH is either low or inappropriately normal in the face of low T, hypogonadism is secondary, caused by a disturbance at the hypothalamic-pituitary level. Both conditions are observed in andropause • Depression, hypothyroidism, acute illness, chronic alcoholism, and use of medications such as corticosteroids, cimetidine, spironolactone, digoxin, opioid analgesics, antidepressants, antifungal agents should be excluded before making a diagnosis of LOH • Endocrinological diseases should be suspected with signs/symptoms & clinical evaluation accordingly
- 8. INDICATION FOR REPLACEMENT THERAPY SYMPTOMSOF LOH PRESENT TESTOSTERONE >350 NG/ML >12 NMOL/ML <230 NG/ML <8 NMOL/ML INBETWEEN NO SUBSTITUTION NECESSARY WILL BENEFIT WITH REPLACEMENT REPEAT TEST, CONSIDER BIOAVAILABLE TESTOSTERONE
- 9. POTENTIAL BENEFITS OFTESTOSTERONE REPLACEMENT BODY COMPOSITION, MUSCLE MASS & STRENGTH • Decrease in fat mass and increased lean body mass • No overall change of body weight • Inconsistant increase in muscle strength
- 10. POTENTIAL BENEFITS OFTESTOSTERONE REPLACEMENT BONE DENSITY AND FRACTURE RATE • Osteopenia, osteoporosis and fractures very common with LOS • Bone density consistently increased with therapy, specially lumbar spine BMD
- 11. POTENTIAL BENEFITS OFTESTOSTERONE REPLACEMENT SEXUAL FUNCTION • Erectile dysfunction +/- decreased libido with documented testosterone deficiency are candidates for replacement therapy. • Testosterone treatment moderately improved the number of nocturnal erections, sexual thoughts and motivation, number of successful intercourses, scores of erection function, and overall sexual satisfaction • consistent effect has been noted only on libido than on erection function
- 12. POTENTIAL BENEFITS OFTESTOSTERONE REPLACEMENT METABOLIC SYNDROME • obesity, hypertension, dyslipidemia, impaired glucose regulation, and insulin resistance - common symptoms • Low serum testosterone associated with cardiovascular morbidity • Low SHBG and/or androgen deficiency - early warning signs for cardiovascular risk and scope for early intervention in non obese men • Replacement shows no consistent effect seen on diabetes and hyperlipidemia • ANEMIA - stimulate erythropoiesis and increase reticulocyte count, hemoglobin, and bone marrow erythropoietic activity
- 13. POTENTIAL EFFECTS OFTESTOSTERONE REPLACEMENT COGNITIVE FUNCTION, MOOD, ENERGY, QOL • Decrease in testosterone leads to decline in verbal and visual memory and visuospatial performance - effects of replacement show mixed results • Beneficial effect with mood seen in studies with hypogonadism a/w AIDS
- 14. POTENTIAL BENEFITS OFTESTOSTERONE REPLACEMENT PROSTATE CANCER AND BPH • No conclusive evidence that Treatment increases risk of prostate cancer Converts subclinical CA prostate into clinically significant one • Proven deterioration of symptoms and stimulation of growth in known cases of locally advanced and metastatic cancer prostate • DRE + PSA essential before starting therapy, but blind biopsy not recommended
- 16. ASSESSMENT OF TREATMENTOUTCOME CONTINUATION OF TREATMENT • Acceptable time frame for improvement of symptoms - 3 to 6 months for sexual function, loss of libido, muscle strength and body fat, bone mineral density take longer time to improve • Failure to improve in desired time - discontinue treatment and evaluate further for other causes
- 17. ASSESSMENT OF TREATMENTOUTCOME MONITORING DURING THERAPY • Testosterone level should be checked every 3-6 months • Hematocrit checked as baseline and every 3-6 years. If HCT >54%, stop therapy till it decreases to normal level and then restart at lower dose • BMD after 1-2yrs of replacement • PSA at onset, 3-6 months and then according to screening protocol. Urology consultation necessary if rising PSA or deteriorating IPSS score • Psychiatric evaluation and formulation specific check-up at each visit
- 18. CONTRAINDICATIONS TO REPLACEMENT •Prostate or breast cancer • Guidelines from Endocrine Society recommend against starting testosterone therapy in 1. palpable prostate nodule or induration 2. prostate specific antigen greater than 4 ng/ml or greater than 3 ng/ml in men at high risk for prostate cancer 3. severe lower urinary tract symptoms with IPSS > 19. • Significant erythrocytosis with HCT >50%, untreated obstructive sleep apnoea, poorly controlled heart failure - replacement should not be started before resolution of comorbid condition
- 19. CONCLUSION • A relativelyimportant public health issue generally overlooked in our society • Awareness amongst doctors may help in early identification of at-risk individuals for cardiovascular disease, reduce fracture related morbidity
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