United Medical Network

12th April 2008, 16:53

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Andropause - Male Menopause
Testosterone replacement options: Guidelines Take New Look at Management of Hypogonadism in Men
By eInternal Medicine News: Michele G. Sullivan
Feb 16, 2003, 11:39am

Updated guidelines on diagnosis and treatment of hypogonadism in men reflect advances in treatment and more robust data about the short-term benefits of testosterone replacement therapy.

The guidelines, issued by the American Association of Clinical Endocrinologists (AACE), also urge additional research into the long-term use of the therapy and its possible effects on the risks of cancer and cardiovascular disease.

“Concern about long-term safety and efficacy remains an issue,” said Dr. Steven M. Petak, chair of the guidelines revision committee.

“Perhaps these new guidelines will stimulate some additional research into these issues,” said Dr. Petak, an endocrinologist at the Texas Institute for Reproductive Medicine and Endocrinology, Houston.

The National Institute on Aging has begun work on a 1-year study to evaluate the feasibility of conducting clinical trials of testosterone replacement therapy in older men. A task force will report on the known benefits and risks of the therapy, its potential public health impact, and the ethical issues involved in conducting such a clinical trial. The report is expected by November, said Dr. Stanley Slater, deputy director of the institute's geriatrics and clinical gerontology program.

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The new AACE guidelines include a detailed discussion of clinical and laboratory findings, plus a diagnosis and treatment algorithm based on testicular size, hormone levels, and semen analysis. The revision is the first since the guidelines were initially issued in 1996.

It's important to focus attention on the recognition and treatment of the disorder because many men are reluctant to discuss the symptoms of hypogonadism with their physicians. Symptoms usually include decreased libido, impotence, decreased muscle mass, fatigue, and decreased bone density.

“Many men don't seek out medical attention for health problems in the early stage,” Dr. Petak said. “And they don't feel comfortable talking about the major symptom, loss of libido.”

Even if patients do mention decreased sexual urge, physicians might be more likely to prescribe Viagra than to perform a full evaluation. “Lots of physicians don't delve into the matter too deeply, either for lack of time or because of the level of discomfort,” he said. A thorough evaluation is important because hypogonadism may arise from problems with the testes, pituitary, or hypothalamus, or by a genetic disorder.

The AACE guidelines are aimed at three target populations:

Men with primary testicular failure who require hormone replacement.

Men with gonadotropin deficiency or dysfunction who may have received testosterone replacement therapy or treatment for infertility.

Aging men whose could benefit from testosterone therapy.


United Medical Network - Diagnostic criteria

Diagnostic criteria are based on physical assessment, hormone levels, dynamic testing (GnRH and clomiphene stimulation tests), and semen analysis. Additional diagnostic studies include bone densitometry, pituitary imaging, genetic studies, testicular biopsy, and scrotal exploration.

No studies have clearly indicated that a particular testosterone level is associated with pituitary tumors. But a total testosterone level of less than 150 ng/dL should trigger a pituitary imaging study, even in the absence of other symptoms, the guidelines state.

The treatment goal is the same in each target population—to restore sexual function (including fertility, if desired and possible), libido, behavior, and physical well-being. In addition to decreased sex drive and sexual activity, men with low testosterone levels may exhibit anger, depression, fatigue, and confusion, as well as physical effects such as decreased muscle mass and bone density and associated osteoporosis.

Based on the results of recent studies, the new guidelines state that testosterone replacement often alleviates associated psychological conditions, increases virilization, and optimizes bone density. Recent studies also indicate that the therapy may normalize growth hormone levels in elderly men. Therapy also may decrease cardiac mortality in this population, but the guidelines make no specific recommendations in this area because the link between cardiovascular disease and low testosterone is not fully understood.


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The AACE guidelines evaluate testosterone replacement methods (injection, patch, gel, and oral agents) and stress that patients on testosterone replacement need to be carefully monitored for possible adverse effects. Careful monitoring of prostate-specific antigen is particularly important, and men with known prostate cancer should never use testosterone replacement therapy.

The full guidelines are available online at www.aace.com/clin/guidelines.



United Medical Network - Testosterone May Boost Endurance In Heart Failure

Andropause - Male Menopause
Testosterone May Boost Endurance In Heart Failure
By eInternal Medicine News: by Timothy F. Kirn
Dec 22, 2002, 8:55pm

Testosterone therapy was associated with a 95-meter improvement on the shuttle walk test in a double-blind study of 20 heart failure patients, Dr. T. Hugh Jones said at the annual meeting of the Endocrinology Society.

The patients, men with ejection fractions of around 35%, increased their distance walked during the test from an average 280 m to an average 375 m—an increase of 34%—after 12 weeks of testosterone therapy. In contrast, patients who received placebo increased their distance by an average of 2%. Testosterone was given as 100-mg injections delivered once every 2 weeks in the trial.

A larger, confirmatory trial is underway, Dr. Jones of the academic unit of endocrinology at the University of Sheffield (England) said in a press conference.

Low testosterone levels may contribute to exercise intolerance and general fatigue in men with heart failure. Testosterone can promote vasodilatation and may have some beneficial anti-inflammatory properties.

There was no evidence that testosterone increased skeletal muscle strength or bulk, or that it changed plasma levels of proinflammatory cytokines, Dr. Jones said.


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United Medical Network - HORMONES FOR MEN

By THE NEW YORKER : JEROME GROOPMAN
Nov 30, 2002, 11:32am

It goes by many names. "Male menopause" is perhaps the most popular, but "andropause" is the term that many doctors favor, and PADAM ("partial androgen deficiency in aging men") has its partisans, too. The condition may afflict millions of Americans, and, if they do not yet recognize the symptoms, a public-awareness campaign has been launched to help them. A two-page ad that ran in Time not long ago showed a car's gas gauge pointing to Empty and beside it the words "Fatigued? Depressed mood? Low sex drive? Could be your testosterone is running on empty." The ad explains that "as some men grow older, their testosterone levels decline," and that such men should consult their doctors about testosterone therapy. At the bottom of the page, the gas gauge points to Full.

Physicians have been targeted with similar ads. One that appeared in a recent issue of a primary-care journal calls on them to "identify the men in your practice with low testosterone who may benefit from clinical performance in a packet." The photographs are eye-catching: there's a well-built fellow in his middle years beside the words "improved sexual function"; a smiling man in shorts and a T-shirt who is standing next to a mountain bike ("improved mood"); a policeman directing traffic ("increased bone mineral density"). Doctors are told to "screen for symptoms of low testosterone" and "restore normal testosterone levels."

United Medical Network - AndroGel

These ads were paid for by Unimed, a division of the Belgian conglomerate Solvay. Unimed makes AndroGel, a drug that was approved by the F.D.A. two years ago, and is the fastest-growing form of testosterone-replacement therapy for men. Pills, introduced in the sixties, often caused liver damage. Intramuscular injections, particularly favored by bodybuilders and competitive athletes, produce a sharp spike of the hormone, and then a fall, and these fluctuations are often accompanied by swings in mood, libido, and energy. In the late eighties, a transdermal patch was developed, and its use is still widespread. The patch provides safer and steadier dosing, but often causes skin irritation, and sometimes falls off during exercise. AndroGel, by contrast, delivers testosterone in a colorless, drying gel that is simply rubbed on an area of the body—usually the shoulders—once a day. It has thus made testosterone available in a form that almost any man can use conveniently.


United Medical Network: Dr. Abraham Morgentaler

If hormone-replacement therapy for andropause becomes as common as such therapies have been for menopause—and this seems to be the ambition of some drug companies—the consequences, both medical and financial, could be dramatic. Given the popular desire to reverse human aging with a simple nostrum and the growing intimacy between commercial and clinical concerns, the trend may prove to be irresistible. The pharmaceutical industry is, of course, in the business of inventing treatments. Some people wonder whether it may help invent diseases, too.


To be treated for andropause, you first need physicians who can confidently make the diagnosis. One of them is Dr. Abraham Morgentaler, the director of Men's Health Boston. He is forty-six years old, with thick black hair and deep-set eyes. Trained as a urologist, he specializes in male sexual dysfunction and infertility. He views testosterone deficiency in older men as a silent epidemic, and worries that, of the perhaps five million American men who suffer from it, ninety-five per cent go undiagnosed. Replacing missing testosterone, he believes, will help restore youthful muscle tone, bone strength, potency, and general vigor. He recently put an ad in the Boston Globe urging men who were experiencing "low sex drive" or "low energy" to have their testosterone level tested at his clinic. The costs of both the ad and the tests were underwritten by a Unimed educational grant.

Men's Health Boston is in a modern brick-and-glass office building at a busy intersection in Brookline. It has a well-appointed waiting room with soft lighting and upholstered chairs; photographs of famous local athletes adorn the walls. The men who came to see Morgentaler on a recent afternoon had all been given a questionnaire provided by Unimed:

1. Do you have a decrease in libido (sex drive)?
2. Do you have a lack of energy?
3. Do you have a decrease in strength and/or endurance?
4. Have you lost height?
5. Have you noticed a decreased "enjoyment of life"?
6. Are you sad and/or grumpy?
7. Are your erections less strong?
8. Have you noticed a recent deterioration in your ability to play sports?
9. Are you falling asleep after dinner?
10. Has there been a recent deterioration in your work performance?

United Medical Network - my brain often feels foggy

Among the patients was a real-estate broker in his late fifties. He had answered "Yes" to questions 1, 2, 3, 5, 7, and 10. "I'm just exhausted by the end of the afternoon," he said, after Morgentaler gave him a physical. "And my brain often feels foggy." He likes to shoot pool, and he remarked that his game wasn't what it used to be.

"Have you noticed any change in sexual performance?" Dr. Morgentaler asked.

"Well, I'm not a kid anymore," the patient said, but he had no real complaints.
Morgentaler then showed the man the results from his blood assay. His testosterone levels were "somewhat low," Morgentaler said. "Now, if I had a magic wand and I could do anything for you, what would it be?"

"Fix the energy thing."
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