Andropause

Andropause

1. ANDROPAUSE SPEAKER : DR PARMINDER PAL SINGH CHAIRPERSON : DR RAGHUVANSH SHARMA

2. DEFINITITION ‘ A CLINICAL AND BIOCHEMICAL SYNDROME ASSOCIATED WITH ADVANCING AGE AND CHARACTERISED BY A DEFICIENCY IN SERUM ANDROGEN LEVELS WITH OR WITHOUT A DECREASE IN GENOMIC SENSITIVITY TO ANDROGENS. IT MAY RESULT IN SIGNIFICANT ALTERATIONS IN THE QUALITY OF LIFE AND ADVERSLY AFFECT THE FUNCTION OF MULTIPLE ORGAN SYSTEMS’

3. SYNONYMS PADAM : Partial Androgen Deficiency In Ageing Male ADAM : Androgen Deficiency In Ageing Male MALE CLIMACTERIC VIROPAUSE RELATIVE HYPOGONADISM HYPOANDROGENEMIA MANOPAUSE LOH : Late Onset Hypogonadism

4. EPIDEMIOLOGY Prevalence is unknown Testosterone level decline by 1% per year after the age of 50 Some studies show 20% of men over age of 60 have abnormally low level of testosterone 50% have abnormally low level of bioavailable testosterone

5. EPIDEMIOLOGY cont.. By the age of 75, testosterone level are at 65% of young adults and 25% of these men have below normal level of bioavailable testosterone ( Vermeulen , 2000) Same study showed 25% of 75 year olds, had testosterone levels in the top quarter of those of young adults ( Vermeulen , 2000)

6. Variation in serum total testosterone concentrations Bremner, WJ, Vitiello, V, Prinz, PN, J Clin Endocrinol Metab 1983; 56:1278

7. Physiological effects of testesterone CNS → libido, energy, spatial cognition, well being, memory Larynx → lower voice Liver → lowers SHBG and HDL Kidneys → raises erythropoietin Prostate → increases size and secretion Genitals → development, erection, spermatogenesis

8. Physiological effects cont…… Skin → increases facial and body hair and sebum production Blood → increases hematocrit (PCV) Adipose tissue → increases lipolysis , ↓es abdominal fat Bone → increases bone mineral density Muscle mass → increases lean mass and strength

9. PATHOPHYSIOLOGY Decreasing levels of bioavailable testosterone due to : Decrease rate of production by testes Reduction in size and weight of testes Critical illness Increassed leval of stress Testicular trauma Genetic and metabolic disorder

10. Chronic illness ( DM, CRF, HIV, COPD) Medications : ( corticosteroids, opiates, estrogen, antiestrogen ) Obesity Malnutrition Chronic substance abuse Physical stress ( burn injury ) Previous surgery

11. SIGNS AND SYMPTOMS Reduced energy Decrease sense of well being Fatigue Decreased libido and erectile dysfunction Changes in ejaculation Decrease in strength and lean body mass Loss of height , body hair Increase in body fat

12. Hot flashes, sweating, insomnia, anxiety Irritable mood, tiredness, lethargy Lack of motivation, low mental energy Depression, low self esteem Less interest and desire for sex, less sexual activity, poor erection, reduced quality of orgasm and ejaculation

13. ERECTILE DYSFUNCTION Definition : inability to attain or maintain an erection sufficient to complete intercourse It is under neurogenic, arteriogenic and vasogenic control Atherosclerosis and reduced testosterone play a role in decreased oxygen saturation to tissues leading to fibrosis ( TGF-B1) Prevalence at ages 55, 65, 75, 80 was 8%, 25%, 55% and 75% respectively

14. Conditions in which testosterone should not be administered Very high risk of serious adverse outcomes Metastatic prostate cancer Breast Cancer Moderate to high risk of adverse outcomes Undiagnosed prostate nodule or induration Unexplained PSA elevation Erythrocytosis ( hematocrit >50%) Severe lower urinary tract symptoms associated with benign prostatic hypertrophy as indicated by AUA/IPSS > 19 Unstable severe congestive heart failure (class III or IV) Bhasin, S. et al. J Clin Endocrinol Metab 2006;91:1995-2010

15. Monitoring of Testosterone Therapy Clinical response/adverse effects After 3 months, then annually Testosterone levels After 2- 3months Hematocrit Baseline, 3 months, then annually Bone Mineral density After 1-2 yrs in men with osteoporosis/fx Bhasin, S. et al. J Clin Endocrinol Metab 2006;91:1995-2010

16. Monitoring of Testosterone Therapy DRE/PSA Baseline, 3 months, then in accordance with guidelines Urological consult if: PSA > 4 ng/ml Increase in PSA > 1.4 ng/dl within 12 months Rx Abnormal DRE Increase in IPSS prostate symptom score > 19 Bhasin, S. et al. J Clin Endocrinol Metab 2006;91:1995-2010

17. Summary of Risks and Benefits of Testosterone Replacement Decreasing Testosterone levels are associated with a decline in: libido and sexual function Bone Mineral Density lean body mass, and muscle strength Replacement studies in elderly men with mildly low Testosterone levels have not convincingly shown a benefit or reversal of these changes

18. However, in elderly men with very low T levels (< 200-300 ng/dl) improvement in libido and BMD Possible improvement in sexual function and the perception of physical well being Testosterone replacement mildly increases PSA levels and may exacerbate androgen dependent diseases (BPH and prostate cancer) which increase with age However, clinical studies to date are too small to determine an adverse effect Summary of Risks and Benefits of Testosterone Replacement

19. CONCLUSION THUS IT MAY BE STATED THAT THE MALE ANDROPAUSE DOES EXISTS. IT AFFECTS THE MEN OVER 40 YEARS OF AGE ( SOMETIMES EARLIER) EARLY DIAGNOSIS AND HORMONE REPLACEMENT THERAPY CAN IMPROVE SYMPTOMS. TESTERONE REPLACEMENT THHERAPY MUST BE ALWAYS ADMINISTERED ONLY BY VERY RESPONSIBLE PHYSICIANS AND UNDER STRICT CASE SELECTION CRITERION AND SUPERVISION.

20. THANK YOU