Andropause

1. 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

10. 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

11. 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)

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

15. 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

16. 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

17. 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

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

19. 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

20.  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

21. 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

44. 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

48. 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

49. 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

50. 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

51.  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

52. 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.